Background
Cystoscopy is endoscopy of the urinary bladder via the urethra. It may employ either a rigid or a flexible cystoscope and may be performed for either diagnostic or therapeutic purposes.
The first instrument used for visualizing the body from inside was developed by Philipp Bozzini (1773-1809), a German army surgeon, who invented the Lichtleiter (the ancestor of modern endoscopes) in 1807. Bozzini used this innovation for viewing the bullets in his patients. [1] The cystourethroscope has been greatly improved by the introduction of cold light, the enhancement of the optical system, and the development of videoendoscopy, flexible instruments, and virtual endoscopy. [2, 3]
Relevant anatomy
The adult bladder is located in the anterior pelvis and is enveloped by extraperitoneal fat and connective tissue. It is separated from the pubic symphysis by an anterior prevesical space known as the retropubic space (of Retzius). The dome of the bladder is covered by peritoneum, and the bladder neck is fixed to neighboring structures by reflections of the pelvic fascia and by true ligaments of the pelvis.
The body of the bladder receives support from the external urethral sphincter muscle and the perineal membrane inferiorly and the obturator internus muscles laterally (see the image below).
Indications and Contraindications
Diagnostic indications for cystoscopy include the following:
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Evaluation of patients with voiding symptoms (storage or obstructive)
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Evaluation of urologic fistulas
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Evaluation of urethral or bladder diverticula
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Congenital anomilies in pediatric population
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Retrieval of samples (for cytologic and histologic studies)
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Intraoperative evaluation of the urethra, bladder, and ureters after some incontinence or prolapse procedures
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Retrograde pyelography for upper urinary tract evaluation
Therapeutic indications include the following:
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Treatment of urethral strictures
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Bladder neck procedures [5]
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Intravesical procedures (eg, for treatment of bladder stones, bladder ulcers, or bladder tumors; removal of foreign bodies in the bladder; botulinum toxin injection; and ureteral catheterization in association with some gynecologic problems)
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Reflux treatment in pediatric population
Cystourethroscopy is contraindicated in febrile patients with urinary tract infections (UTIs) and those with severe coagulopathy.
Technical Considerations
There is level Ib, III, and IV evidence to suggest that antibiotic prophylaxis before simple cystourethroscopy should be administered only in the presence of risk factors for UTI, such as advanced age, anatomic anomalies of the urinary tract, poor nutritional status, smoking, long-term corticosteroid use, immunodeficiency, fixed catheters, coexisting infection, and prolonged hospitalization.
For those who have any of these risk factors, the recommended antibiotic prophylaxis includes a single dose of either a fluoroquinolone or trimethoprim-sulfamethoxazole. Alternatively, an aminoglycoside (with or without ampicillin), a first- or second-generation cephalosporin, or amoxicillin-clavulanate may be given. Patients with negative urine cultures and those without any of these risk factors do not need antibiotic prophylaxis before cystourethroscopy.
The above recommendations hold true for simple cystourethroscopy; however, all patients who are scheduled to undergo cystourethroscopy with manipulations should receive antibiotic prophylaxis. [6] According to the American Heart Association (AHA), antimicrobials are no longer recommended solely to prevent infectious endocarditis in association with genitourinary procedures. [7, 8, 9] However, guidelines from the European Society of Cardiology state that antibiotic prophylaxis may be considered for high-risk patients who undergo invasive genitourinary procedures. [10]
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Rigid cystoscope with connections to irrigation and light source.
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Flexible cystoscope.
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Bladder distention in patient with interstitial cystitis.
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Large supratrigonal vesicovaginal fistula, showing tip of vaginal clamp.
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Cystoscope assembly, part 1. Video courtesy of Michel Rivlin, MD, and G Rodney Meeks, MD.
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Cystoscope assembly, part 2. Video courtesy of Michel Rivlin, MD, and G Rodney Meeks, MD.
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Cystoscopy, part 1. Video courtesy of Michel Rivlin, MD, and G Rodney Meeks, MD.
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Cystoscopy, part 2. Video courtesy of Michel Rivlin, MD, and G Rodney Meeks, MD.
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Cystoscopy supplies. Image courtesy of Michel Rivlin, MD, and G Rodney Meeks, MD.
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Cystolithotripsy, part 1. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
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Cystolithotripsy, part 2. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
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Cystolithotripsy, part 3. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
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Gross anatomy of the bladder.
