Cystoscopy (urethrocystoscopy) is a medical procedure that allows doctors to examine the inside of the bladder and urethra using a cystoscope. This procedure helps diagnose and treat conditions such as bladder tumors, stones, infections, and urinary tract abnormalities. It can be performed under local or general anesthesia and may involve taking tissue samples or performing minor surgeries.

What is cystoscopy and urethrocystoscopy?

Cystoscopy is a medical procedure that involves examining the inside of the bladder and urethra using a cystoscope, a specialized thin tube equipped with a camera and light. During a cystoscopy, the cystoscope is inserted through the urethra into the bladder, allowing the doctor to view the internal structures in detail and, if necessary, take tissue samples or perform minor surgical interventions. Cystoscopy has not therapeutic effect, its only diagnostic endoscopic method.

Since the urethra is also evaluated during this procedure, it is more accurate to call it “urethrocystoscopy.” In other words, “urethrocystoscopy” is an endoscopic procedure that assesses both the urethra and the bladder.

What are the types of cystoscopy?

There are two types: Cystoscopy performed with normal light and photodynamic cystoscopy. In the photodynamic method, special substances such as 5-aminolevulinic acid (5-ALA) and its ester derivative, hexaminolevulinic acid (HAL), are introduced into the bladder. These substances are absorbed by cancer cells and appear blue, unlike normal tissue. This helps prevent small tumors from being missed.

Types of cystoscope

There are two main types of cystoscopes used in cystoscopy:

• Flexible Cystoscope: A thin, flexible tube that can bend and navigate through the urethra more comfortably. Often used for diagnostic purposes and minor procedures. It is typically more comfortable for the patient and can often be done under local anesthesia in an outpatient setting.
  • Rigid Cystoscope: A straight, rigid tube that provides a clearer, more detailed view of the bladder and urethra. Preferred for more complex procedures, such as taking biopsies, removing bladder stones, or performing surgeries. It may require general or regional anesthesia due to the discomfort it can cause.

How to do cystoscopy?

Cystoscopy is a procedure performed by a healthcare professional, usually a urologist, to examine the bladder and urethra. Here’s how it is typically done:

Preparation:

• Consent and Explanation: The patient is informed about the procedure, its purpose, and any risks. Consent is obtained.
• Anesthesia: Depending on the complexity of the procedure and the patient’s comfort, local, regional, or general anesthesia may be administered. Local anesthesia is often used for outpatient cystoscopies.

Positioning:

• The patient lies on their back on an examination table, with their knees bent and feet in stirrups, similar to the position used during a gynecological exam.

Cleaning and Lubrication:

• The physian cleans the genital area with an antiseptic solution to reduce the risk of infection.
• A lubricating jelly, often containing a local anesthetic, is applied to the cystoscope to ease its insertion and minimize discomfort.

Insertion of the Cystoscope:

• The cystoscope is gently inserted into the urethra and slowly advanced into the bladder.
• The procedure is carefully monitored, and the patient may be asked to describe any discomfort.

Examination:

• Once the cystoscope is in place, the healthcare provider examines the lining of the bladder and urethra by viewing the images on a monitor.
• The bladder may be filled with sterile water or saline to expand it, providing a better view of the bladder walls.

Biopsy or Treatment (if necessary):

• If any abnormal tissue is found, the doctor may take a biopsy using instruments passed through the cystoscope.
• Minor treatments, such as removing small bladder stones or tumors, can also be performed during the procedure.

Completion:

• After the examination or treatment is complete, the cystoscope is carefully withdrawn.
• The patient may be asked to urinate to check for any immediate discomfort or difficulty.

Post-Procedure Care:

• The patient is monitored briefly after the procedure, especially if general anesthesia was used.
• Mild burning or bleeding during urination may occur for a day or two, which is normal.
• The patient is usually advised to drink plenty of water to flush the bladder and prevent infection.
• If a biopsy was taken or a treatment performed, specific aftercare instructions are provided.

Indications of cystoscopy

Cystoscopy is indicated for the diagnosis, evaluation, and treatment of various conditions affecting the bladder, urethra, and lower urinary tract. Key indications include:

• Hematuria (Blood in Urine)
• Recurrent Urinary Tract Infections (UTIs)
• Bladder Cancer Diagnosis and Monitoring
• Lower Urinary Tract Symptoms
• Intermittent or Chronic Pelvic Pain
• Urinary Incontinence
• Unexplained Urinary Symptoms
• Bladder Stones
• Bladder neck insertion (high bladder neck)
• Foreign Bodies
• Urethral Stricture Diagnosis
• Vesicoureteral Reflux
• Pre-Surgical Evaluation

Contraindications

Cystoscopy has several contraindications, both absolute and relative, that should be considered before performing the procedure:

Absolute Contraindications:

• Acute Urinary Tract Infection (UTI): Performing a cystoscopy in the presence of an active UTI can exacerbate the infection and lead to complications.
• Severe Urethral Stricture: If the urethra is significantly narrowed, attempting to pass a cystoscope may cause trauma or worsen the condition.

Relative Contraindications:

• Coagulopathy or Anticoagulation: Patients with bleeding disorders or those on anticoagulant therapy are at increased risk of bleeding during or after cystoscopy. The procedure may be delayed or modified until the bleeding risk is minimized.
• Recent Urethral or Bladder Surgery: Recent surgical interventions in the urinary tract can make the tissues fragile, increasing the risk of injury or complications from cystoscopy.
• Severe Cardiovascular or Respiratory Disease: Patients with significant cardiovascular or respiratory conditions may not tolerate the procedure well, particularly if anesthesia is required.
• Pregnancy: While not an absolute contraindication, cystoscopy during pregnancy should be carefully considered due to potential risks to the fetus, particularly in the first trimester.
• Urinary Retention or Obstruction: In cases of severe urinary retention or obstruction, there is a risk of trauma or perforation during the procedure.

Complications

While cystoscopy is generally safe, there are potential complications associated with the procedure:

• Urinary Tract Infection (UTI)
  • Bladder Infection (Cystitis)
  • Bleeding (Hematuria)
  • Pain or Discomfort (Urethral Pain)
  • Bladder Spasms
  • Urethral Injury
  • Perforation (Bladder or Urethral Perforation)
  • Allergic Reaction (Anesthesia Reaction)
  • Blood Clots (Formation of Clots)

Summary

Cystoscopy (urethrocystoscopy) is a medical procedure used to examine the inside of the bladder and urethra with a cystoscope. It helps diagnose and treat urinary tract conditions, such as bladder tumors, stones, infections, and structural abnormalities. It is generally safe, though it may cause temporary discomfort and carries minor risks like infection or bleeding.

Prof. Dr. Emin ÖZBEK

Urologist

Istanbul- TURKIYE