Kelly’s (1894) principal innovation in cystoscopy was developing a technique that provided adequate bladder distention. The Kelly cystoscope, a hollow tube without a lens, was not innovative, but his technique was. The cystoscope was introduced using an obturator, with the patient in knee-chest position. The negative intra-abdominal pressure created by this position allowed air to distend the bladder when the cystoscope was introduced. A head mirror was used to reflect an electric light into the bladder for illumination. The technique was simple but provided an excellent view. Its simplicity dramatically enhanced the accessibility of cystoscopy to all physicians. Kelly’s fame as a genitourinary surgeon, and as the founder of the Johns Hopkins Hospital residency training program in gynecology, the first in the nation, established cystoscopy as a gynecologic technique.

The twentieth century provided many innovations in the cystoscope. Hopkins and Kopany (1954) introduced both a fiber-optic telescope and, later, a rod lens system, which dramatically improved light transmission and resolution. This rod lens design is the system used in today’s rigid cystoscopes. Replacement of the air chamber with a series of glass rods with optically finished ends, separated by intervening air spaces, provides a wider viewing field and permits a change in the viewing angle. The innovation of angled telescopes improved the extent of visualization and facilitated more invasive procedures. Increasingly complex instruments were developed to perform operative procedures through a cystoscope, and, gradually, general surgeons developed the subspecialty of urology around this new technology. The development of the subspecialty of urology coincided with changes in gynecology. The combination of gynecology and obstetrics into a single training program deemphasized cystoscopy in gynecologic training, and gynecologists gradually became less skilled in the technique, whereas urologists continued to develop it.

The most recent development in cystoscopy is the flexible cystoscope. A flexible cystoscope takes advantage of the flexibility of the fiber-optic lens system to create a cystoscope that bends, thereby increasing the range of the field of view. Some authors report an improved view of the bladder neck using a flexible fiber cystoscope, whereas others advocate flexible cystoscopy to limit the necessary instrumentation and improve patient tolerance.

Robertson (1973), the father of urogynecology, reintroduced cystoscopy to gynecology with the development of the Robertson urethroscope. He addressed the deficiencies of the cystoscope for viewing the urethra by applying the rods lens technology of the Hopkins cystoscope to a shorter straight-on telescope with a nonfenestrated sheath designed specifically for viewing the urethra. He subsequently outlined a technique—dynamic urethroscopy—for evaluating incontinent women using the Robertson urethroscope. Dynamic urethroscopy offered a simple office procedure that considerably improved the diagnostic evaluation of the lower urinary tract over the alternatives of the time.

INDICATIONS

Cystourethroscopy, an invaluable procedure for today’s urogynecologist, has both diagnostic and operative indications. Diagnostic indications include hematuria, lower urinary tract symptoms, urinary incontinence, urethral diverticula, and urogenital fistulas.

The differential diagnosis of hematuria is extensive but falls into conditions that are primarily renal or post-renal in origin. Endoscopy is useful in the diagnosis of the post-renal conditions, including neoplasms of the bladder and urethra, urethral polyps, chronic cystitis, recurrent cystitis, interstitial cystitis, urolithiasis, and foreign bodies.

The differential diagnosis for lower urinary tract symptoms is extensive, including many nebulous conditions. Possible causes include acute cystitis, chronic cystitis, trigonitis, radiation cystitis, urethral pain syndrome, urethral diverticula, urethritis, and interstitial cystitis. Other conditions that may cause similar symptoms include detrusor overactivity, urolithiasis, partial urinary retention, and moderate to severe pelvic organ prolapse. Cystourethroscopy is indicated when the presenting symptoms strongly suggest a diagnosis of urethral diverticulum, interstitial cystitis, urolithiasis, or tumor, and for patients who do not respond to initial therapy. Endoscopy should be avoided in the presence of an active urinary tract infection.

The general agreement is that cystoscopy is indicated for patients complaining of persistent incontinence or voiding symptoms following incontinence surgery, but less agreement exists about the role of cystoscopy in the baseline evaluation of patients with urinary incontinence. The refinement of urodynamic evaluation over the last three decades has demonstrated the superiority of this modality for diagnosing the common causes of urinary incontinence, such as urodynamic stress incontinence and detrusor overactivity. However, although urodynamic testing excels at providing an objective assessment of lower urinary tract function, it provides little information about lower urinary tract anatomy. Cystourethroscopy contributes an anatomic assessment of the urethra and bladder that is not achieved by urodynamic tests alone. Anatomic abnormalities, such as urethral diverticula, urogenital fistulas, and intravesical foreign bodies causing detrusor overactivity, might be suspected based on history or urodynamic tests but require an anatomic assessment for confirmation. Cystourethroscopy can also reveal unsuspected neoplasia in the incontinent patient. However, in women with stress incontinence, bladder lesions are found in only about 1% of patients. The Clinical Practice Guidelines of the Agency for Health Care Policy and Research in 1996 noted that the evidence does not support the routine use of cystoscopy in the evaluation of women with simple symptoms of incontinence (Fantl et al., 1996).

For many urogynecologists, cystourethroscopy also has a role in the diagnosis of intrinsic sphincteric deficiency, a condition that does not have standardized diagnostic criteria. Some advocate a single urodynamic parameter to make the diagnosis. However, in the absence of validated standard criteria for diagnosing intrinsic sphincteric deficiency, an approach that combines clinical measures of severity, urodynamic evidence of poor urethral resistance, and an anatomic evaluation of urethral coaptation seems to be warranted. Cystourethroscopy is perhaps the simplest way to achieve such an anatomic evaluation of the urethrovesical junction (UVJ).

Operative indications of cystourethroscopy in the female lower urinary tract include minor operative procedures performed through an operative cystoscope and intraoperative uses. Cystoscopy is an important adjuvant to surgery of the female genitourinary system and is commonly used to (1) perform and judge coaptation during periurethral injections and suburethral sling procedures, (2) facilitate surgical repair of urinary tract fistula and urethral diverticula, (3) ensure the safe placement of suprapubic catheters, and (4) evaluate the ureters and bladder mucosa for inadvertent damage at the time of surgery.

INSTRUMENTATION

Rigid Cystoscopy

The three components of the rigid cystoscope include the telescope, the bridge, and the sheath (Fig. 9-1). Each component serves a different function and is available with various options to facilitate its role under different circumstances.

Figure 9-1 Rigid endoscopes in urology and urogynecology. (Top to bottom) Catheter-deflecting bridge; 30-degree telescope; 70-degree telescope; cystoscope sheath with bridge; obturator.

The telescope transmits light to the bladder cavity and an image to the viewer. Telescopes designed for cystoscopy are available with several viewing angles, including 0-degree (straight), 30-degree (forward-oblique), 70-degree (lateral), and 120-degree (retro view). The different angles facilitate the inspection of the entire bladder wall. Although the zero-degree lens is ideal for adequate urethroscopy, it is insufficient for cystoscopy. The 30-degree lens provides the best view of the bladder base and posterior wall, and the 70-degree lens permits inspection of the anterior and lateral walls. The retro view of the 120-degree lens is not usually necessary for cystoscopy of the female bladder but can be useful for evaluating the urethral opening into the bladder. For many applications, a single telescope is preferable. In diagnostic cystoscopy, the 30-degree telescope is usually sufficient, although a 70-degree telescope may be required in the presence of elevation of the UVJ. For operative cystoscopy, the 70-degree telescope is preferable. The angled telescopes have a field marker, visible as a blackened notch at the outside of the visual field opposite the angle of deflection, that helps facilitate orientation.

The cystoscope sheath provides a vehicle for introducing the telescope and distending medium into the vesical cavity. Sheaths are available in various calibers, ranging from 17 to 28 French for use in adults and smaller calibers for use in pediatrics. When placed within the sheath, the telescope, which is 15 French, only partially fills the lumen, leaving an irrigation-working channel. The smallest sheath is better tolerated for diagnostic procedures, whereas the larger calibers provide space for the placement of instruments into the irrigation-working channel. The proximal end of the sheath has two irrigating ports, one for introduction of the distending medium and another for removal. The distal end of the cystoscope sheath is fenestrated to permit use of instrumentation in the angled field of view. The cystoscope is also beveled, opposite the fenestras, to increase the comfort of introduction of the cystoscope into the urethra. Bevels increase with the diameter of the cystoscope, and larger sheaths may require an obturator for atraumatic placement.

The bridge serves as a connector between the telescope and sheath and forms a watertight seal with both. It may also have one or two ports for introduction of instruments into the irrigation-working channel. The Albarran bridge is a variation that has a deflector mechanism at the end of an inner sheath (Fig. 9-2). When placed in the cystoscope sheath, the deflector mechanism is located at the distal end of the inner sheath within the fenestra of the outer sheath. In this location, elevation of the deflector mechanism assists the manipulation of instruments within the field of view.

Figure 9-2 Deflector at the tip of an Albarran bridge.

Rigid Urethroscopy

The rigid urethroscope is a modification of the cystoscope designed exclusively for evaluation of the urethra (Fig. 9-3). Because it is primarily a diagnostic instrument, it does not have a bridge. The telescope is shorter and has a 0-degree viewing angle, which provides a circumferential view of the urethral lumen as the mucosa in front of the urethroscope is distended by the distention medium. The 0-degree lens is essential for adequate urethroscopy.