Cystourethroscopy

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Chapter 240 Cystourethroscopy

DESCRIPTION

Cystourethroscopy is a technique for visualizing the interior of the urethra or bladder. This may also serve as a portal for other diagnostic or therapeutic measures.

INDICATIONS

To diagnose urinary tract disorders such as bleeding, pain, or dysfunction (e.g., interstitial cystitis). Cystourethroscopy can be a part of the evaluation of abnormal symptoms, signs, or laboratory findings; intraoperatively during gynecologic or urogynecologic surgery to rule out bladder, urethral, or ureteral trauma; and as part of staging or surgery for gynecologic malignancy.

CONTRAINDICATIONS

Active urinary tract infection. Known or suspected allergy to cleansing solutions or local anesthetics to be used.

REQUIRED EQUIPMENT

• Skin (or vaginal) preparation materials (iodine-based antibacterial solution [e.g., Betadine] or other suitable cleansing agents)

• Sterile gloves, antiseptic solution and sterile cotton balls, or skin preparation swabs

• Sterile urine specimen cup (with graduations)

• 1 liter of sterile saline (intravenous fluid without glucose is generally used) at room temperature (low-pressure carbon dioxide may also be used with suitable equipment) (If electrocautery is to be performed, a nonconducting solution, such as glycine, should be used.)

• Absorbent underpads

• 2% Xylocaine jelly in mushroom-tipped syringe (optional) or tube with conical delivery cap

• Cystoscope (rigid or flexible, direct viewing or with a 30-degree or greater down-angle view; the latter is better for visualizing the bladder trigone and ureteral openings)

• Fiber-optic light source (compatible with type of cystoscope used)

• Fiber-optic light cord

• An assistant is advantageous

TECHNIQUE

Shortly before the procedure, a single dose of prophylactic antibiotics is recommended to prevent urinary tract infection or septicemia for patients at moderate or high risk of endocarditis, those who are neutropenic, and those with preoperative bacteriuria or an indwelling catheter.

Immediately prior to starting the procedure, the patient is asked to empty her bladder (in private and in her usual manner). The patient is placed in the dorsal lithotomy position and the external urinary meatus and surrounding vulvar vestibule are cleansed with antiseptic solution. One to three milliliters of topical anesthetic such as 2% Xylocaine are introduced into the urethra.

With sterile technique, the patient is catheterized by use of a straight catheter, and any residual urine is caught, measured for volume, and sent for culture (if appropriate). With the catheter left in place, the bladder is slowly (to avoid inducing bladder spasm) filled with 100 to 200 mL of sterile saline, and the catheter is then removed.

After the light guide is attached to both the cystoscope and light source, the tip of the cystoscope is placed at the external meatus and gently inserted under direct (or video) guidance. The cystoscope should initially be inserted with a slight downward angle and then gently rotated under the symphysis. A direct (forward-looking) cystoscope may be used to facilitate inspection of the internal sphincter (urethral–vesical junction) and the urethra itself. The entire lumen of the urethra, bladder wall, the trigone, and ureteral openings should be examined systematically. If problems are encountered viewing the trigone, using a cystoscope with a downward-viewing angle facilitates the process.

If the goal is to examine for ureteral patency, 5 mL of indigo carmine can be given intravenously 10 to 15 minutes before the cystoscopy, followed by observation of blue-stained urine from the ureteral orifices.

At the completion of the procedure, the patient may empty her bladder or the bladder may be drained by catheter, as desired.

COMPLICATIONS

Infection, bleeding, dysuria, and urinary retention are possible, although unlikely. Perforation or bladder rupture possible (more likely with biopsy).

FOLLOW-UP

Based on indications.

CPT CODE(S)

52000 Cystoscopy

Gilmour DT, Das S, Flowerdew G. Rates of urinary tract injury from gynecologic surgery and the role of intraoperative cystoscopy. Obstet Gynecol. 2006;107:1366.

American College of Obstetricians and Gynecologists. The role of cystourethroscopy in the generalist obstetrician–gynecologist practice. ACOG Committee Opinion 372. Obstet Gynecol. 2007;110:221.

Cundiff GW, Bent AE. Endoscopic evaluation of the lower urinary tract. In: Walters MD, Karram MM, editors. Urogynecology and reconstructive pelvic surgery. 3rd ed. Philadelphia: Mosby Elsevier; 2007:114.

Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. JAMA. 1997;277:1794.

Olson ES, Cookson BD. Do antimicrobials have a role in preventing septicemia following instrumentation of the urinary tract? J Hosp Infect. 2000;45:85.

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