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Objective To determine whether flexible cystoscopy with a prototype slim flexible instrument is less uncomfortable than flexible cystoscopy using a standard flexible cystoscope. Patients and methods In all, 200 men scheduled to undergo flexible cystoscopy for the follow-up of transitional cell carcinoma of the bladder were randomized in equal groups to flexible cystoscopy using the standard instrument or using the prototype slim-scope. Each patient had 11 mL of 2% lignocaine gel instilled intraurethrally 5 min before the procedure. At the end of the procedure the patient was asked to complete a 100-mm non-graphical visual analogue scale to rate how uncomfortable the procedure was. Results The slim-scope was very significantly less uncomfortable than the conventional instrument (anovaP

Objectives To investigate the value of narrow-band imaging (NBI) flexible cystoscopy in the detection of urothelial carcinoma (UC) of the bladder. Materials and methods Clinical data of 179 patients with suspected UC, who presented with gross hematuria, were collected at China PLA General Hospital from January 2009 to August 2010. These patients underwent white-light imaging (WLI) cystoscopy followed by NBI. The tumors were visualized, imaged, and recorded. Suspected UCs were biopsied or treated by transurethral resection, and then sent for pathologic examination. Detection results for NBI and WLI were compared. Results WLI and NBI confirmed UC in 143 patients; a total of 285 tumors were detected. The patient-level detection rates for NBI and WLI were 97.9% (140/143) and 88.8% (127/143), respectively ( P = 0.002). The patient-level false-positive detection rates for NBI and WLI were 21.8% (39/179) and 29.1% (52/179), respectively ( P = 0.12). NBI detected a total of 59 additional tumors (17.2%; 34pTa, 17pT1, 3pT2, and 5pTis) in 44 of 143 patients (30.8%). NBI found 1 additional tumor in 34 cases, 2 additional tumors in 6 cases, 3 additional tumors in 3 cases, and 4 additional tumors in 1 case. The mean ± SD (range) number of identified UCs per patient was 1.97 ± 0.67 (1–5) for NBI and 1.78 ± 0.53 (1–4) for WLI ( P = 0.01). The tumor-level detection rates for NBI and WLI were 96.8% and 79.3%, respectively ( P Conclusions Compared with WLI, NBI improves UC detection. It has a higher rate of detection and a comparative rate of false-positive detection. NBI is simple and requires no dyeing. It can be conveniently applied to complement WLI.

The collection techniques used to obtain urinary specimens include voided and catheterized urine, bladder, ureteric and renal pelvic washings and brushings, retrograde catheterization of ureters, renal pelves, and ileal conduit (described in detail in Chap. 1). These collection techniques, particularly instrumentation, have a significant effect on the makeup of the urinary sediment. Catheterization of the bladder, retrograde catheterization of the ureter and renal pelves and brushings, virtually always, result in removal of urothelial cell clusters that may be mistaken for fragments of urothelial papillary tumors. Thus, a thorough knowledge of the cytologic features observed in the various collection techniques is very important in diagnostic interpretation. Tables 4.1 and 4.2 indicate the advantages and disadvantages and the cytologic appearance of urothelial cells in various specimen-collection methods.

To assess the impact on visual analog scale (VAS) pain scores of allowing male patients to view the procedure of flexible cystoscopy.A total of 86 male patients admitted to our hospital for flexile cystoscopy by a single urologist between 2010 and 2011 were randomized to two equal groups. Group 1 included 43 patients who were allowed to watch the video screen with the urologist. Group 2 included 43 patients who were unable to view the video monitor. All patients received the same real-time explanation during the cystoscopy. Patients recorded their pain feeling on a VAS ranging from 0 to 10 after the physician completed the cystoscopy. The pulse and respiratory rate were also recorded 5 minutes before the procedure and immediately after the procedure.There was no statistically significant difference in the postprocedure pulse rate and respiratory rate between groups. The mean pain score on the VAS in group 1 was statistically significantly lower than that in group 2 (1.12±0.96 vs 3.33±2.50, P0.001, Mann-Whitney U test). Patients who were allowed to watch the video screen experienced less discomfort at cystoscopy.Real-time visualization of flexible cystoscopy with simultaneous explanation improves male patients' comfort.

Hematuria is the presence of red blood cells in the urine and can be visible to the naked eye (macroscopic), detectable with microscopic analysis or found by dipstick testing of urine. Around 40% of patients with hematuria have a significant underlying cause regardless of the quantity of blood in the urine. As the presence of hematuria is common and there are often no clues as to the underlying cause, this condition comprises a large amount of the urological workload and should be regarded as a manifestation of urological malignancy until proven otherwise.1 While it is recognized that the contemporary urological approach for the investigation of hematuria may not always be evidence-based medicine,1 there are numerous high-quality studies confirming the prevalence of disease within patients with this condition.

Nd:YAG laser irradiation and flexible cystoscopy were used in the outpatient management of 16 cases (21 sessions) with superficial bladder tumors. Irradiation of tumors was accomplished in all cases except 3 in which the visual field was affected by bleeding after the cup biopsy of tumors. Tumors at the bladder neck were easily irradiated through the flexible cystoscope. No tumor recurred at or near the previously irradiated site. This method provided a safe and cost-effective means to treat superficial bladder tumors in selected cases.

PURPOSE: To determine the prevalence of different approaches to the difficult urethral catheterization (DUC) among urology residents (UR) in the United States (US). MATERIALS AND METHODS: An email invitation to participate in an online survey regarding DUC was sent to 267 UR and to 22 urology program coordinators for them to forward to their residents. 142 UR completed the survey. RESULTS: After the initial unsuccessful attempt by a nurse, 92% of UR attempted a catheter prior to resorting to other modalities. The most common choice of the first catheter was a Coude (76%) size 18F (51%). For situations where multiple sizes and types of catheters (12 - 20F) were used without success, 3 scenarios were proposed: 1) Catheter passed the bulbomembranous urethra (BMU) and patient had previous history of transurethral resection of the prostate or radical retropubic prostatectomy, 2) Catheter passed the BMU and no urologic history, 3) Catheter did not pass the BMU and no urologic history. Flexible cystoscopy was used in 74%, 62% and 63%; blind passage of a glidewire was second with 15%, 23% and 20%; and blind use of filiforms and followers was chosen in 7%, 9% and 9% of the scenarios respectively. CONCLUSIONS: The most common approach to the DUC among UR in the US involves using an 18F Coude catheter first. After trying one or more urethral catheters, UR most commonly resort to flexible cystoscopy as opposed to the blind placement of glide wires or filiforms/followers.

To investigate the difference in pain score of patients allowed to view their flexible cystoscopy procedure compared with those who have not viewed the procedure on the video monitor.It is a prospective, randomized, controlled study. A total of 76 patients with different clinical indications for flexible cystoscopy were enrolled in the study. Patients were divided into 2 groups; group A and group B with 38 patients each. Group A patients viewed the procedure on a video monitor, whereas group B, the control group, did not. Statistical analyses were performed using a χ(2) test, Student's t test, and paired t test. A P value of0.05 was considered to be statistically significant.There were no statistically significant differences in demographic characteristics between the 2 groups. Mean age, duration of the procedure, and indications for the procedure were also comparable in the 2 groups. There was, however, a statistically significant difference in pain scores between the 2 groups (P.001). The numbers of patients reporting pain in the study group (group A) were lower than in the control group (group B). There was a statistically significant difference in the postprocedural pulse rate; however, the systolic blood pressure pre- and postprocedure remained the same.Patients' who viewed the cystoscopic procedure on a video monitor reported less pain on a visual analog scale compared with the control group.

Flexible cystoscopy is well established in urological practice. We present a unique image obtained during bladder inspection, illustrating visual refractive distortion, which highlights the potential difficulty in optical interpretation.

Flexible cystoscopy has revolutionized the field of diagnostic urology. It can be done under local anaesthesia in the outpatient setting and is thus a highly useful tool. Its role in therapeutic urology is more limited but it still has a place in the management of certain conditions.

Pain relief is one of the most essential aspects of the successful management of postoperative care. In recent years, great emphasis has been laid on ensuring that adequate pain relief is coupled with minimal side effects. Furthermore, in the era of modern surgery, increasing numbers of minor operations are performed under local anesthesia, as this helps to reduce the operative costs and minimize postoperative complications. In this chapter we provide an overview of analgesic drugs and their role in pain relief in urological practice, with emphasis on the local anesthetic procedures in urology.

Contains fulltext : 70759.pdf (Publisher’s version ) (Closed access) OBJECTIVE: To confirm the recently published positive effect on visual analogue pain (VAS) scale levels for men watching their flexible cystoscopy. PATIENTS AND METHODS: From June 2007 to September 2007, 154 men had a flexible cystoscopy for various indications, all carried out by one urologist. Patients were randomized into two groups; those in group 1 were allowed to watch the video screen together with the urologist during the procedure; those in group 2 were not allowed to watch the procedure on the video screen. All patients received the same real-time explanation during the cystoscopy. After the cystoscopy procedure the patients were asked to record their experience of pain on the 100 mm VAS as soon as they left the room. The two groups were further stratified by the number of previous cystoscopies experienced to evaluate the possible modifying effect of their previous experience. RESULTS: Although the results suggested a small decrease in perceived pain there were no statistically significant differences between the groups, regardless of cystoscopy experience. CONCLUSIONS: Our results show that, in contrast to an earlier report, the pain experienced by men undergoing a first or repeated flexible cystoscopy is not strongly influenced by watching the procedure.

Objectives To evaluate the diagnostic value of a new photodynamic diagnosis (PDD) system using 5-aminolevulinic acid (ALA) for the diagnosis of bladder tumors. To validate whether false-positive findings caused by tangent effects in PDD can be resolved, we compared diagnostic accuracies between the new PDD system and a conventional PDD system. Patients and Methods Among 30 transurethral bladder biopsies, 15 cases received ALA-PDD using rigid fluorescence cystoscopy (conventional PDD system), and flexible fluorescence cystoscopy with a twin mode monitor (new PDD system) was used in a separate set of 15 cases. To evaluated the usefulness of ALA-PDD, diagnostic accuracies were retrospectively compared between the conventional PDD system and the new PDD system. Results Of 207 specimens from 30 cases, we obtained 110 specimens using the conventional PDD system and 97 specimens using the new PDD system. Of these samples, we selected 30 distal bladder specimens each from both the conventional PDD system and the new PDD system. The overall sensitivity, specificity and false-positive rate for the new PDD system were 100%, 82.6%, and 17.4%, respectively. Those of the conventional PDD system were 83.3%, 66.2% and 33.8%, respectively. The overall false-positive rate of the new PDD system improved to 16.4% when compared with the conventional PDD system. Furthermore, the false-positive rate of the new PDD system in distal bladder samples improved to 11.8%. The overall AUC of the new PDD system was significantly greater compared with that of the conventional PDD system (P

An experienced urology nurse observed that patients seemed to tolerate the procedure better when allowed to see the monitor in real time during office based cystoscopy. We assessed the impact of this on visual analog scale pain scores.A total of 100 consecutive male patients underwent flexible cystoscopy, as performed by a single surgeon during the study period. Patients were randomized into 2 groups. Patients in group 1 were allowed to visualize the video screen with the surgeon, while patients in group 2 had the screen positioned so that only the surgeon could visualize the procedure. Water soluble lubricant was used on all endoscopes and all men received 10 cc 2% viscous lidocaine intraurethral before cystoscopy. No sedatives or analgesics were administered. All patients provided consent before the procedure and they were asked to record their pain experience on a 100 mm visual analog pain scale as soon as the surgeon left the room.Men who were allowed to visualize the cystoscopy had lower visual analog scale pain scores than those who were unable to visualize the screen (14 vs 23, Wilcoxon rank sum test p=0.02).To our knowledge no study has shown the impact of distraction of cystoscopic findings on procedure pain levels. Men viewing cystoscopy on the video monitor experienced an approximately 40% decrease in the pain level compared to those who did not view the procedure on the monitor. We encourage office urologists to incorporate this useful point of technique during flexible cystoscopy.

Purpose of review To review the recent literature on the use of fluorescence cystoscopy in the diagnosis and management of bladder cancer. Recent findings Recent advances have been made in fluorescence cystoscopy with the use of newer fluorescence agents (hexylester aminolevulinate and hypericin) and their application to flexible cystoscopy. Within several hours of intravesical administration of these agents, bladder tumors can be detected using fluorescence cystoscopy resulting in improved cancer detection and lower short-term recurrence rates than white light cystoscopy. Preliminary results with flexible fluorescence cystoscopy suggest that this technique can be used for office-based cystoscopy. Summary Significant advances have been made in the field of fluorescence cystoscopy. The currently available fluorescence agents in recent phase II and III trials outperform white light cystoscopy in terms of cancer detection and recurrence-free survival. Fluorescence cystoscopy should be considered as an adjunctive tool for the diagnosis and management of superficial bladder cancer.

To examine the incidence of urinary tract infection (UTI) after flexible cystoscopy (FC) and determine whether prophylactic norfloxacin reduces this incidence compared with placebo.A double-blind trial was performed, randomizing 234 patients to either 400 mg of norfloxacin or placebo prior to FC. All patients provided a midstream urine specimen (MSU) before the procedure, as well as at day 3 and day 7 after FC. In addition, a telephone questionnaire was performed to correlate the nature and severity of any symptoms associated with UTI.Interim analysis was performed because of the low recruitment rate, and a significantly lower infection rate than expected meant that the trial was discontinued. There was one symptomatic UTI in the placebo group (0.82%) and one in the norfloxacin group (0.89%). The UTI in the placebo group was de novo, while the infection in the norfloxacin group was secondary to pre-FC bacteriuria. There was no difference in the infection rates in the two groups. The overall infection rate (de novo and secondary to existing bacteruria) after FC was 0.85%.Infection after flexible cystoscopy is rare and not associated with significant morbidity. A much larger study would be required to determine whether antibiotic prophylaxis significantly reduces the rate of postprocedure UTI.

OBJECTIVE To correlate urine cytology findings before and after flexible cystoscopy. PATIENTS AND METHODS A total of 153 patients undergoing surveillance for bladder tumour provided voided urine for cytology before and immediately after flexible cystoscopy. RESULTS Of the 153 patients, 116 had negative urine cytology before and after (96%) a visibly normal cystoscopy and 37 had positive urine cytology before and after cystoscopy that showed recurrent tumour. CONCLUSIONS Urine cytology immediately after flexible cystoscopy correlates well with results of urine cytology before cystoscopy.

Whether urethral injection of anesthetic and lubricating gel prior to outpatient flexible cystoscopy is worthwhile with regard to pain tolerance has been investigated only in a parallel randomized study. A crossover study was thus designed for further elucidation.Each of 33 male patients underwent three flexible cystoscopic examinations with intraurethral instillation of 11 mL of cold anesthetic gel (group 1), plain lubricating gel (group 2), or no gel (group 3). In every examination, 2% lidocaine gel was applied to the cystoscope. Although the cystoscopy was performed by two urologic surgeons, each patient underwent the three consecutive examinations with the same urologist. All the patients separately recorded pain levels during gel instillation, cystoscope insertion, and intravesical observation on a 100-mm visual analog scale after every cystoscopy.From the median scores, the degree of pain resulting from gel injection was 77.0% and 98.0% of those for cystoscope insertion and intravesical observation, respectively. For each group stratified by anesthetic method, there was no significant difference in the pain score during either cystoscope insertion or intravesical observation.The pain caused by intraurethral gel instillation is significant compared with that from cystoscope insertion and intravesical observation. Anesthetic gel instillation appears to have no significant advantage over anesthesia-free flexible cystoscopic examinations.

At present, the gold standard for the detection of bladder carcinoma is cystoscopy, often as part of the investigation of haematuria. There has been substantial research into the development of a non-invasive test for voided urine that would obviate the requirement for flexible cystoscopy. If such a test was 100% sensitive and 100% specific, and was cost-effective, it could represent a way of separating patients who required tumour resection from those with no bladder carcinoma development. This article reviews the development of non-invasive tests for the detection of bladder carcinoma, with emphasis on the most recent developments in fields such as microsatellite analysis, telomerase, and matrix metalloproteinase detection, in addition to the more widely researched tests such as NMP22 and BTA.

AIM: To investigate if music reduces anxiety and pain in the Veterans Affairs population undergoing flexible cystoscopy.

Objectives To validate a flexible cystoscopy simulator by determining if it could differentiate between expert and novice cystoscopists. Subjects and methods Seventeen subjects (10 novices with no previous endoscopic experience and seven urologists who had all carried out > 1000 flexible cystoscopies each) were asked to undertake a flexible cystoscopy task on the URO Mentor (Simbionix, Israel) virtual reality (VR) machine. In the task used the bladder mucosa has 10 flags (numbered 1–10) at key positions in the bladder; by visualizing each of the 10 flags and photographing them the subject will have indirectly visualized the entire mucosa. Subjects were asked to carry out the task 10 times, to allow their rate of acquisition of skill to be assessed. The total time taken for the task and the number of flags visualized were used as measures of performance. Results The experienced urologists were significantly better at flexible cystoscopy than the medical students on the first trial for the mean number of flags seen (9.57 vs 8.0, P = 0.01) and the mean time to complete the task (2.33 vs 4.89 min, P = 0.03). At the 10th trial there was still a significant difference for the time taken, between the medical students and the urologists (2.33 vs 0.81 min, P = 0.01) but not for the number of flags seen (9.2 vs 9.6, P = 0.46). The medical students improved between the first and the 10th attempt, being significantly quicker for trial 10 than trial 1 (P = 0.005). However, although the medical students appeared to see more flags (8.0 vs 9.2) this was not significant (P = 0.05). The urologists did not differ in the number of flags visualized between the first and 10th trial, although they were significantly quicker in completing the task (P = 0.02). The urologists were significantly faster in trial 2 than trial 1, but no faster thereafter (P = 0.04). Conclusions Using the URO Mentor simulator, it was possible to assess the level of experience of flexible cystoscopy, and therefore the system has construct validity. As in the real situation there is a period of learning during which the subject becomes familiar with the computer/machine/human interface, the task and the handling of the instruments. These results support the view that there is a role for VR simulators in urological training.

Objective To examine the instructional effectiveness of a course for nurses wishing to learn flexible cystoscopy, using a virtual reality flexible cystoscopy simulator to measure the outcome. Subjects and methods Fourteen urology nurse practitioners with no previous experience of cystoscopy were taught the basic techniques of flexible cystoscopy. They then had supervised group instruction during which they practised flexible cystoscopy on an inanimate latex model, and were taught how to handle the cystoscope, followed by unsupervised practice, including use of the virtual reality (VR) simulator (URO Mentor, Simbionix, Israel). They then undertook a cystoscopy task on the simulator; within the bladder there were 10 flags (numbered 1–10) at key positions. By visualizing and photographing each of the flags the subject would have visualized the entire bladder mucosa. The number of flags seen was thus used as a measure of how much of the bladder mucosa was examined. The VR simulator also measured the total procedure time. After a day of training the subjects were reassessed and the changes in performance evaluated. Subjects were also asked their opinion of the use of VR for flexible cystoscopy. Results The median (range) time to complete the procedure before the course was 3.33 (2–5.5) min and the number of flags seen 7 (6–9). After the course, the median time decreased to 2.85 (1.5–4.42) min and the number of flags seen increased to 8 (6–9). The change in time was significant (P = 0.03) but the difference in the number of flags was not (P = 0.12). All 14 subjects enjoyed the use of VR for learning flexible cystoscopy; they all reported that they were more confident in handling a flexible cystoscope and in undertaking flexible cystoscopy. Conclusion The virtual reality simulator was an effecctive tool for teaching flexible cystoscopy.

A 64-year-old woman with a history of a Stamey procedure for stress incontinence 20 years previously, underwent a diagnostic flexible cystoscopy to investigate recurrent urinary sepsis. Cystoscopic examination demonstrated a large vesicular calculus. When traction was applied to the calculus it was shown to be attached to a 10 cm length of non-absorbable suture material. The suture was attached to two further calculi, apparently originating from outside the bladder wall. All visible calculi and the suture were removed. In the following weeks the patient reported passage of air and faeculent material per-urethra. A repeat cystoscopy revealed an opening in the posterolateral bladder wall and CT confirmed the presence of an enterovesical fistula. Laparoscopy demonstrated a fistula between the terminal ileum and bladder wall. A further 10 cm length of non-absorbable suture material was removed from the terminal ileum and omentum. Laparoscopic repair of the fistula was performed successfully and the patient has remained symptom free following the procedure.

The aim of this study was to determine whether single-dose parenteral antibacterial therapy significantly alters the rate of infection in patients undergoing flexible cystourethroscopy.162 patients were studied prospectively having either received parenteral antibacterial chemoprophylaxis prior to flexible cystourethroscopy or not. Pre- and postprocedure mid stream samples of urine (MSSU) were obtained to objectively evaluate the presence of infection.Gentamicin prophylaxis reduced the rate of post-cystoscopy-positive MSSUs from 21 to 5%.The surprisingly high rate of infection after flexible cystoscopy was significantly reduced by a single dose of gentamicin.

77-year-old female was referred to the haemaology department with asymptomatic anaemia Hb 8 g/dL). An initial diagnosis of warm antiody autoimmune haemolytic anaemia (WA-AIHA) as made. The patient started oral prednisolone 0mg while investigations were carried out to xclude an underlying cause—–in particular lymhoma. Three weeks after commencing steroids he patient underwent a contrast enhanced comuterised tomogram (CT). The CT (Fig. 1) showed xtensive gas within the wall of the bladder consisent with emphysematous cystitis (EC), with normal reters and kidneys. The patient was referred o the urological outpatient and seen 7 days ater. Urological assessment confirmed a 10-year hisory of intermittent self-catheterisation (ISC) for etrusor failure. The patient had not noticed

Summary— Ancillary procedures associated with extracorporeal Shockwave lithotripsy (ESWL) include placement and subsequent removal of double pigtail ureteric stents. A simple new technique has been developed for the insertion of these stents. Using the flexible cystoscope, the procedure is performed on an out-patient basis under local anaesthesia. Placement of the stents was successful in 30/34 patients and removal was successful in 14/14 patients.

For how long after flexible cystoscopy do artifactual cytological changes of urine persist?

Objective: To determine whether the use of video during flexible cystoscopy affects patient experience and understanding of investigation findings. Patients and methods: One hundred thirty five consecutive patients, listed for flexible cystoscopy, were randomised to two groups; cystoscopy with or without video viewing. Levels of patient anxiety, pain on scope insertion, pain during examination and understanding of examination findings were assessed by questionnaire. Results: Pain scores during examination were significantly lower in the video group. There was a highly significant difference in patient's ability to correctly describe the findings favouring the video group. Conclusion: Use of video during flexible cystoscopy improves patient understanding of examination findings and helps to alleviate pain during the examination.