Cystoscopy

Cystoscopy is the direct examination of the urethra and bladder using a cystoscope, a thin tube with a light and a camera. It shows tumours, stones, inflammation, strictures, diverticula, fistulae, and bleeding sites, and it allows biopsy and some treatment during the same procedure.

Two types of instrument are used. A flexible cystoscope is passed with local anaesthetic gel, with the patient awake, in an outpatient clinic, and takes 5 to 10 minutes. A rigid cystoscope gives a wider channel for biopsy and treatment, and is used under general or regional anaesthesia in an operating theatre, with a duration of 10 to 30 minutes.

The bladder is filled with sterile saline or water to give a clear view. Blue light (photodynamic) cystoscopy and narrow band imaging improve detection of flat tumours and carcinoma in situ.

Cystoscopy is the reference test for bladder cancer. In a patient with visible haematuria, a bladder cancer is found in about 10 to 15%, and in patients over 60 years with a smoking history this rises to 20% or more. Flexible cystoscopy has a sensitivity of about 90% for papillary tumours, and enhanced imaging raises detection of flat lesions by 10 to 20%.

Indications.

• Visible haematuria at any age, and persistent non-visible haematuria in patients at risk (over 40 years, smokers, occupational exposure).
• Surveillance after treatment of bladder cancer.
• Bladder lesions seen on ultrasound or CT, and abnormal urine cytology.
• Recurrent urinary infection, persistent irritative symptoms, or pelvic pain (including suspected interstitial cystitis).
• Suspected bladder stones, foreign bodies, fistula, or urethral stricture.
• Lower urinary tract symptoms in men with suspected outlet obstruction, and before prostate surgery to assess the urethra.
• Retrograde ureteric catheter placement, stent insertion, or removal.
• Chronic catheter users with symptoms, and bladder involvement from schistosomiasis, tuberculosis or radiation.

Not indicated during an acute urinary tract infection, except to relieve obstruction.

Contraindications and precautions.

• Untreated urinary tract infection: the procedure is delayed.
• Bleeding disorder or anticoagulant treatment: balance the risk, and correct where biopsy is planned.
• Acute prostatitis or epididymitis, severe urethral stricture, or recent urethral injury.
• Antibiotic cover is considered in patients at risk (recent infection, indwelling catheter, immunosuppression, heart valve disease, joint prosthesis), and is not given routinely.
• Pregnancy: used only when needed.
• Patients with spinal injury at T6 or higher are at risk of autonomic dysreflexia.

Preparation and technique.

A urine culture is checked before the procedure, and consent covers the possibility of biopsy. The patient lies supine, with legs apart, and the genitalia are cleaned and draped. Local anaesthetic gel is applied to the urethra and held for 5 minutes or more.

The scope is passed through the urethra under vision, examining the whole length of the urethra, the prostatic urethra, bladder neck, and then the bladder, where all walls, the dome, trigone, ureteric orifices and the ureteric jets are inspected. The bladder is emptied at the end, and the patient is allowed to pass urine before leaving.

Normal appearances.

The urethra is smooth and pale pink. The bladder mucosa is pale pink with fine vessels, with clear views of the ureteric orifices, which are slit like and eject clear urine at intervals. The trigone is smooth and the bladder wall is without folds, tumours or stones. The bladder neck is closed in a woman and symmetrical in a man, and the prostatic urethra is free of obstruction.

Interpretation.

• Papillary tumour: a frond like growth, which may be single or multiple, with a stalk. Biopsy or resection gives the grade and depth.
• Flat red velvety areas: possible carcinoma in situ, confirmed by biopsy.
• Sessile solid tumour: higher risk of invasive disease.
• Stones: single or multiple, with associated trabeculation, diverticula or outlet obstruction.
• Trabeculation, cellules and diverticula: chronic outlet obstruction or neurogenic bladder.
• Inflammation: erythema, ulcers (Hunner lesions in interstitial cystitis), bullous oedema, haemorrhagic cystitis, and radiation damage with telangiectasia.
• Schistosomiasis: sandy patches, nodules and calcification.
• Tuberculosis: ulcers, granulomas and a contracted bladder.
• Prostatic enlargement: lateral lobe or median lobe enlargement, and a high bladder neck.
• Stricture: narrowing of the urethra with scarring, which stops the scope.
• Fistula or foreign body: abnormal openings and migrated material.
• Bleeding from the ureteric orifice: suggests an upper tract source.

Critical values and findings needing immediate action.

• A suspected malignant tumour: biopsy or transurethral resection with specialist referral.
• Clot retention or heavy bleeding: irrigation, drainage and transfusion.
• Bladder perforation (fluid not returning, abdominal pain or distension): urgent assessment, catheter drainage and surgical repair if needed.
• Fever with rigors after the procedure: urgent treatment for urosepsis.
• Obstructing stones or hydronephrosis: urgent drainage.

Limitations and artefacts.

• Visualisation is poor with blood, clots, debris, an overfull or empty bladder, or a very tight stricture.
• Small or flat lesions (carcinoma in situ), diverticulum tumours, and anterior wall lesions can be missed, particularly with a flexible scope, and the dome can be difficult to view.
• Normal looking mucosa does not exclude disease, and urine cytology or biopsies may be needed.
• Erythema from catheter trauma, infection or recent instrumentation resembles carcinoma in situ.
• Cystoscopy does not examine the upper urinary tract or the kidney.
• Discomfort and anxiety limit the examination, particularly in men.

Complications.

• Dysuria, frequency, and mild haematuria for 24 to 48 hours (common).
• Urinary tract infection (about 2 to 5%, lower with sterile technique).
• Urinary retention (especially in men with a large prostate), and urethral injury, stricture or false passage (rare).
• Bladder perforation during biopsy or resection (about 1%).
• Bleeding that needs treatment, and, rarely, bacteraemia.
• Complications of anaesthesia with rigid cystoscopy.
• Autonomic dysreflexia, in at risk patients.

Special groups.

• Women: a short urethra and easy passage, though women with atrophy may have discomfort. Look for urethral diverticulum and fistula.
• Men: pain on passage through the prostatic and bulbar urethra is more frequent, and local anaesthetic gel and relaxation help.
• Children: general anaesthesia and a paediatric scope are used.
• Patients with a long term catheter, spinal cord injury or radiation history: regular surveillance for bladder cancer is needed.
• Bladder cancer follow up: schedules depend on grade and stage, from 3-monthly in the first year to yearly in low risk disease.
• Regions: schistosomiasis is an important cause of haematuria and bladder cancer in endemic areas, and cystoscopy with biopsy helps to confirm it. Flexible cystoscopy is not available in many centres, and rigid cystoscopy under spinal or general anaesthesia is the main method. Sterilisation of instruments must be strict.

Follow up tests.

• Histology of biopsies or resected tissue.
• Urine cytology and urine culture.
• Renal and bladder ultrasound, CT urography or MRI to examine the upper tracts and stage.
• Examination under anaesthesia and bimanual palpation.
• Ureteroscopy for upper tract lesions.
• Repeat cystoscopy at set intervals for cancer surveillance.
• Urodynamic studies in bladder dysfunction.