Endoscopic Diagnosis and Treatment in Urinary Bladder Pathology: Handbook of Endourology

Endoscopic Diagnosis and Treatment in Urinary Bladder Pathology

Handbook of Endourology

Edited by

Petrişor A. Geavlete

Table of Contents

Cover

Title page

Copyright

Contributors

Preface

Acknowledgments

Chapter 1: Cystoscopy and Urinary Bladder Anatomy

Abstract

1.1. Generalities

1.2. Urinary Bladder Anatomy

1.3. History

1.4. Indications

1.5. Contraindications

1.6. Technique of Cystoscopy

1.7. Complications of Cystoscopy

Chapter 2: Fluorescence Cystoscopy

Abstract

2.1. Immunofluorescence

2.2. Fluorescence Cystoscopy

Chapter 3: Endoscopic Approach in Bladder Inflammatory Pathology

Abstract

3.1. Generalities

3.2. Endoscopic approach in nonspecific bladder infections

3.3. Endoscopic approach in encrusted cystitis

3.4. Endoscopic approach in bladder tuberculosis

3.5. Endoscopic approach in interstitial cystitis

Chapter 4: Endoscopic Treatment of Bladder Tumors

Abstract

4.1. History

4.2. Generalities

4.3. The aims of endoscopic resection in noninvasive bladder tumors

4.4. Indications of endoscopic resection in the treatment of bladder tumors

4.5. Preoperative considerations

4.6. Instruments

4.7. Anesthesia

4.8. Patient positioning

4.9. Bimanual palpation

4.10. Urethrocystoscopy

4.11. Endoscopic resection technique

4.12. Biopsy of the bladder mucosa

4.13. Biopsy of the prostatic urethra

4.14. End of the procedure

4.15. General principles

4.16. Technical aspects of endoscopic resection of bladder tumors in particular situations

4.17. Incidents and complications of endoscopic resection of bladder tumors

4.18. Assessing the quality of endoscopic resection

4.19. The results of endoscopic resection in the treatment of noninvasive bladder tumors

4.20. Improving the quality and results of TURV

4.21. Assessment of the prognosis of noninvasive bladder tumors

4.22. Protocol for the postoperative follow up of patients with noninvasive bladder tumors

4.23. Complementary treatment in noninvasive bladder tumors

4.24. Alternatives to the endoscopic resection of bladder tumors

4.25. Endoscopic resection of infiltrative bladder tumors

4.26. Conclusions

Chapter 5: Endoscopic Approach to Bladder Stones

Abstract

5.1. History

5.2. Classification

5.3. Indications for endoscopic treatment in bladder stones

5.4. Transurethral cystolitholapaxy

5.5. Percutaneous suprapubic cystolithotomy (cystolithotripsy)

5.6. Combined endoscopic treatment

5.7. Alternatives to the endoscopic treatment of bladder stones

5.8. Endoscopic treatment particularities in urinary diversion lithiasis

Chapter 6: Endoscopic Approach to Intravesical Foreign Bodies

Abstract

6.1. Introduction

6.2. Classification

6.3. Indications

6.4. Preoperative assessment

6.5. Surgical technique

6.6. Complications

6.7. Results

Chapter 7: Endoscopic Approach to Bladder Diverticula

Abstract

7.1. Generalities

7.2. Indications

7.3. Preoperative assessment

7.4. Preoperative measures

7.5. Instruments

7.6. Technique

7.7. Results

7.8. Complications

7.9. Other congenital malformations

Chapter 8: Endoscopic Management of Vesical Fistulas

Abstract

8.1. Generalities

8.2. Vesicovaginal fistula

8.3. Enterovesical fistula

Chapter 9: Endoscopic Approach to Intramural Ureter Pathology

Abstract

9.1. Anatomy of the intramural ureter

9.2. Endoscopic approach of intramural lithiasis

9.3. Endoscopic treatment of vesicoureteral reflux

9.4. Endoscopic approach of the ureterocele

9.5. Other malformations of the intravesical ureter

9.6. Intramural ureter stenosis

Chapter 10: Endoscopic Approach to the Intramural Ureter During Total Nephroureterectomy

Abstract

10.1. Generalities

10.2. History of the procedure

10.3. Indications

10.4. Ureteral stripping technique

10.5. Pluck technique

10.6. Complications

10.7. Results

Subject Index

Copyright

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Contributors

Petrişor A. Geavlete (Editor), MD, PhD,     Professor of Urology, Academician (Corresponding member) – Romanian Academy of Medical Sciences, Head and Chairman of Urological Department, Saint John Emergency Clinical Hospital, Bucharest, Romania

Emanuel Alexandrescu MD,     Saint John Emergency Clinical Hospital, Bucharest, Romania

Mihai Drăguţescu MD,     Saint John Emergency Clinical Hospital, Bucharest, Romania

Bogdan Geavlete MD, PhD,     Lecturer of Urology, Saint John Emergency Clinical Hospital, Bucharest, Romania

Dragoş Georgescu MD, PhD,     Associate Professor, Chief of Urological Department, Saint John Emergency Clinical Hospital, Bucharest, Romania

Marian Jecu MD, PhD,     Assistant-Professor of Urology, Saint John Emergency Clinical Hospital, Bucharest, Romania

Victor Mirciulescu MD, PhD,     Researcher grade III, Saint John Emergency Clinical Hospital, Bucharest, Romania

Cristian Moldoveanu MD, PhD,     Saint John Emergency Clinical Hospital, Bucharest, Romania

Răzvan Mulţescu MD, PhD,     Saint John Emergency Clinical Hospital, Bucharest, Romania

Gheorghe Niţă MD,     Assistant-Professor of Urology, Saint John Emergency Clinical Hospital, Bucharest, Romania

Florin Stănescu MD, PhD,     Saint John Emergency Clinical Hospital, Bucharest, Romania

Preface

The treatment of bladder tumors currently represents a continuously changing, dynamic field of urologic pathology, with an impressive variety of diagnostic methods and a wide palette of endoscopic therapeutic options.

Modern technology has made its mark on novel assessments, especially on the therapeutic possibilities.

Prestigious urologic centers currently apply a new methodology for their approach to bladder tumors. While the evolution of infiltrative bladder tumor methodology has not been spectacular, there are numerous ongoing protocols for noninvasive bladder tumors, and the controversies surrounding choosing the most minimally invasive therapy, as well as their limits, continue. All these modern preoccupations are widely addressed in the wealth of modern urologic literature.

We have written this third volume of the Handbook of Endourology, dedicated to bladder tumors: Endoscopic Diagnosis and Treatment in Urinary Bladder Pathology based on significant experience; approximately 500 patients have been operated on each year in our clinic (constantly over the last 10 years) and have undergone novel endoscopic approaches specific for noninvasive bladder tumors. In this volume, we have covered current practices regarding the complexity of choosing the most efficient methods, both for assessment and for the correct oncologic treatment of the urologic condition.

Rigid and flexible cystoscopy (in visible light and fluorescence); the endoscopic treatment of bladder tumors with techniques for improving the results of endoscopic resection; plasma vaporization in the treatment of bladder tumors; laser for minimally invasive treatment of bladder tumors, bladder lithiasis, bladder malformations, and disorders of the ureteral orifice (endoscopic treatment of intramural lithiasis, endoscopic treatment of ureterocele, vesicoureteral reflux); the endoscopic approach to the intramural ureter in nephroureterectomy for upper urinary tract tumors; and the endoscopic approach to intravesical foreign bodies are examples of modern methods or bladder conditions with minimally invasive treatment.

With many years’ experience, we now consider that we can describe significant, unanimously recognized results that can orient the modern urologist with regards to the multiple aspects related to the diagnosis and treatment of noninvasive bladder tumors. Initial findings from our clinic were published in the most important journals several years ago. One example is fluorescence cystoscopy, which is currently a common method of assessment in most reference centers around the world.

On the other hand, plasma vaporization (button) in noninvasive bladder tumors was first described by our clinic, while its results have been presented and published many times. En bloc resection is also a novel technique introduced by our clinic as an efficient therapeutic alternative.

Another example is the technique of endoscopic ureteral disinsertion using the button electrode, which was also introduced worldwide by our clinic, with published results.

This volume is a quintessence of a vast experience, sometimes of pioneering value, combining classic and modern approaches, comparing results, and orienting the modern urologist toward a more correct and complete modality of endoscopic diagnosis and treatment of noninvasive bladder tumors.

Within this volume, the reader will find over 700 full-color images that are intended to materialize a relevant collection of images, our exceptional casuistics, and real-life experiences from a center of excellence in this field.

It is essential for all urologists to review world-class, updated experience so that, in the end, the modern urologist can establish an algorithm for the diagnosis and minimally invasive treatment of noninvasive bladder tumors.

Editor

Professor Petrişor Aurelian Geavlete MD, PhD

Acknowledgments

Great appreciation for the wonderful support of Karl Storz Endoskope GmbH & Co. KG. Also, many thanks to the Olympus Medical System Europe GmbH and especially to Sanador Hospital for its major scientific contribution with regard to the publication of the handbook.

Chapter 1

Cystoscopy and Urinary Bladder Anatomy

Dragoş Georgescu

Emanuel Alexandrescu

Răzvan Mulţescu

Bogdan Geavlete

Abstract

The ability to approach the urinary tract without requiring surgical incisions has differentiated and continues to differentiate urology from many other surgical specialities. Endourology has permanently evolved over the last decades under the impulse of technological progress that has allowed the approach of the entire urinary tract and the development of modern, advanced endoscopes. Moreover, throughout the history of surgery, urology has had a leading role in the discovery and implementation of minimally invasive techniques.

Keywords

endourology

urethrocystoscopy

hematuria

urethra

cystoscopy

1.1. Generalities

The ability to approach the urinary tract without requiring surgical incisions has differentiated and continues to differentiate urology from many other surgical specialities. Endourology has permanently evolved over the last decades under the impulse of technological progress that has allowed the approach of the entire urinary tract and the development of modern, advanced endoscopes. Moreover, throughout the history of surgery, urology has had a leading role in the discovery and implementation of minimally invasive techniques.

Cystoscopy is a technique that allows direct visualization of the bladder, and is currently the most frequently performed urological endoscopic procedure, having both diagnostic and therapeutic indications. The endoscopic evaluation of the bladder is frequently accompanied by the concomitant examination of the urethra and, in consequence, can provide a comprehensive evaluation of the lower urinary tract, a procedure known as urethrocystoscopy.

1.2. Urinary Bladder Anatomy

1.2.1. Descriptive Anatomy

The urinary bladder is a musculomembranous cavity organ located in the anterior part of the pelvic cavity, superior and posterior to the pubis (Crafts, 1985).

The shape, position, size, and relationships of the bladder vary according to its degree of filling. When empty, the bladder is shaped like a tetrahedron, with an apex, a superior face, two inferolateral faces, a base (the posterior face), and a bladder neck (Carter and Chan, 2007). The bladder apex is oriented superiorly, and is the origin of the urachus, a fibrous structure that is a reminiscence of the allantois from the fetal period. It forms the middle umbilical ligament, which ascends from the bladder apex, on the posterior face of the anterior abdominal wall, between the peritoneum and the transversalis fascia, up to the navel, and fixes the bladder to the abdominal wall (Crafts, 1985).

The superior face of the bladder has a relatively triangular shape, is oriented anterosuperiorly, and is covered by the peritoneum. Anteriorly, the peritoneum is reflected on the anterior abdominal wall (parietal peritoneum). Bladder distension leads to the displacement of the peritoneum away from the abdominal wall and makes it possible to perform suprapubic cystostomy without the risk of intercepting the peritoneal cavity (Carter and Chan, 2007). Through the peritoneum, this portion of the bladder has relationships with the ileal loops and the sigmoid colon in men and with the ileum and uterus in women (Crafts, 1985).

The base of the bladder is oriented posteriorly, and in men, it has relationships with the seminal vesicles, the vas deferens ampoules and the terminal ureter, and inferiorly with the base of the prostate. The part that remains free of these structures is covered by the peritoneum, which is continuous with that located on the anterior rectal wall, forming the rectovesical pouch. In women, the bladder has posterior relationships with the uterus and upper part of the vagina, structures which separate it from the rectum (Crafts, 1985). The peritoneal reflection on these structures forms the vesicouterine and rectouterine pouches, respectively.

The inferolateral faces of the bladder, as well as the inferior part of the superior face, are separated anteriorly from the pubic bones by the connective tissue and perivesical fat of the retropubic space (the space of Retzius). Posteroinferiorly, the urinary bladder comes into contact with the fascia covering the levator ani and the internal obturator muscles (Crafts, 1985).

The bladder neck is the lowest part of the bladder, located approximately 3–4 cm behind the symphysis pubis, and continues with the prostatic urethra. The degree of bladder filling has very little influence on the position of the bladder neck, which is fixed to the pelvic fascia with the urethra and the prostate (Carter and Chan, 2007).

When distended, the urinary bladder has an oval shape with the maximum diameter oriented anteriorly and superiorly, where it comes into contact with the anterior abdominal wall. Apart from the modifications in shape and position described earlier, the other relationships of the bladder remain unchanged.

The bladder wall consists of four layers: serous, muscular, submucosal, and mucosal. The serous layer (tunica serosa) is derived from the peritoneum and is incomplete, only covering the superior face, the upper parts of the lateral faces, and a small area at the base of the bladder, in men (Crafts, 1985).

The muscular tunic (bladder detrusor) consists of three layers of smooth muscle fibers with different orientations: the external and internal layers are longitudinal, while the middle layer has circular fibers. The muscle layers do not follow this orientation throughout the bladder, and have a tendency to overlap and form a network (Crafts, 1985). Thus, in the upper part of the bladder, there is no clear delimitation of muscle layers, whereas as it approaches the trigone and the bladder neck, there is a clear separation between the three types of fibers of the detrusor (Carter and Chan, 2007).

The fibers of the external longitudinal layer have a maximum thickness at the base of the bladder where, on the midline, they are inserted on the apex of the trigone and merge with smooth muscle fibers from the prostate in men and from the vaginal wall in women. This ensures that the trigone has a strong muscular support. Laterally, the fibers of the posterior plane pass anteriorly and loop around the bladder neck, thus being involved in the continence mechanism at this level. Some muscle fibers of the external muscular layer are involved in the formation of the puboprostatic ligament in men and pubourethral ligament in women (Carter and Chan, 2007). The middle muscular layer is poorly represented with an irregular disposition of the fibers, which have an oblique and circular orientation.

The fibers of the internal layer are thin and arranged in a reticular manner, without losing their tendency for longitudinal orientation. Muscle fibers located in the periureteral bladder wall surround the ureteral orifice from the same side, then merge with fibers from the lateral and posterior ureteral wall and descend in order to be inserted in the bladder neck and the prostatic median lobe (Carter and Chan, 2007). These fibers constitute the so-called ureteral muscle, described by Sir C. Bell, which acts during bladder contraction in order to maintain the oblique path of the ureteral orifices and thereby to prevent vesicoureteral reflux (Dyson, 1995).

In the trigone, there are three different muscle layers. The superficial layer includes smooth muscle fibers that originate in the ureters, which descend through the trigone in order to enter the verumontanum. The deep layer stems from Waldeyer’s sheath and enters the bladder neck, while the middle layer consists of urinary bladder fibers (external longitudinal and middle circular) (Carter and Chan, 2007).

The submucous tunic serves to connect the muscular layer with the mucosa, and it intimately adheres to the latter (Crafts, 1985). It consists of a relatively thick layer of fibroelastic connective tissue that allows for considerable bladder distension, and it is crossed by numerous blood vessels (Carter and Chan, 2007).

The internal surface of the bladder is covered by transitional epithelium (urothelium) consisting of six cell layers and a basal membrane. This epithelium continues with the epithelium of the ureters and the renal tubular membrane, as well as that of the proximal urethra (Crafts, 1985).

1.2.2. Endoscopic Anatomy

The normal endoscopic anatomy is a prerequisite for the correct endoscopic assessment of the urinary tract. When properly distended using irrigation fluid, both the bladder and the entire upper urinary tract are accessible to an endoscopic approach.

When it is sufficiently distended, the bladder is shaped like a sphere with smooth, regular mucosa (Fig. 1.1); while when partially filled or empty, numerous mucosal folds can be observed at endoscopy (Fig. 1.2). The color of the bladder mucosa is usually yellow or pale pink, while its translucent nature allows endoscopic visualization of the submucosal vascular network (Fig. 1.3) (Cundiff, 2001).

Figure 1.1   Distended bladder wall.

Figure 1.2   Aspect of depleted bladder wall.

Figure 1.3   Endoscopic visualization of the submucosal vascular network.

The bladder neck (Fig. 1.4) represents the distal (lower) limit of the bladder and remains the major landmark and point of reference for its endoscopic anatomy. The term bladder neck refers not only to an anatomical region, but at the same time defines a functional entity. At this level, the urethral lumen and the bladder muscles converge. At present, there is a tendency to consider the bladder neck as a separate structure both from the bladder and the urethra, due to its unique functional characteristics.

Figure 1.4   Endoscopic aspect of the bladder neck in men.

Another landmark of endoscopic anatomy is represented by the bladder trigone. It defines a portion located on the posterior wall of the bladder, delimited by the two ureteral orifices and the bladder neck. The name derives from the relatively triangular shape of this area, where the ureteral orifices delimit the base, while the bladder neck marks the tip of the trigone. The interureteral bar (Fig. 1.5) extends between the two ureteral orifices and appears endoscopically as an elevated part of the mucosa. The identification of the interureteral bar during cystoscopy helps locate the ureteral orifices. The ureteral orifices may have a variety of endoscopic aspects (Fig. 1.6) but, in general, they appear as small circular or oval openings situated on top of a mucosal fold. The intramural part of the ureters can often be visualized endoscopically as a bump in the bladder mucosa, which descends obliquely from the sidewalls toward the trigone and the ureteral orifices (Cundiff, 2001). With the peristaltic outflow of urine, the ureteral orifices open and the mucosa that delimits them retracts toward the intramural part of the ureters (Fig. 1.7).

Figure 1.5   Endoscopic aspect of the interureteral bar.

Figure 1.6   Various aspects of ureteral orifices.

Figure 1.7   Open ureteral orifice, evacuating urine.

Visualization of the trigone is achieved by aligning the tip of the cystoscope inferiorly (caudally), immediately after passing the bladder neck, while the ureteral orifices are identified by directing the instrument laterally and posteriorly. The bladder base is located behind the trigone, while the sidewalls extend superiorly, toward the dome. The bladder dome (anterior wall) is identified by locating the air bubble that enters the bladder during cystoscopy (Fig. 1.8).

Figure 1.8   The gas bubble that marks the bladder dome.

1.3. History

The concept of exploring the inside of the human body and its various organs date back to antiquity. The Hippocratic Corpus describes probably the first rudimentary attempts at endoscopy using a rectal speculum. Most historians attribute the first attempt of an endoscopic maneuver to Philipp Bozzini (1773–1809) (Fig. 1.9), a German army surgeon, who attempted to study the cavity organs of the human body. In 1806, he designed the Lichtleiter device that consists of a system of angled mirrors, positioned to project the image of different internal structures of the body toward the examiner’s eye. Bozzini’s device consists of two aluminum tubes that were inserted into the body orifice that was to be examined, and used a candle as a light source (Natalin and Landman, 2009).

Figure 1.9   Philipp Bozzini.

This device is considered to be the first endoscope of modern medicine (Verger-Kuhnke et al., 2007).

In 1826, Pierre Salomon Segalas (1792–1875), a French urologist, presented an improved variant of the Lichtleiter device by adding an additional light source (candle) and a cannulated catheter that was meant to evacuate the bladder content. The new device was made of an elastic material similar to rubber, with the purpose of improving the safety and comfort of the procedure (Natalin and Landman, 2009).

However, the term endoscope is attributed to the French urologist Antonin Jean Desormeaux (1815–1894) and was introduced in 1853 in order to describe an extensively modified version of Bozzini’s Lichtleiter device. He replaced the light produced by the Lichtleiter’s candle with the flame obtained by burning a solution of 96% alcohol and turpentine in a lamp. Also, he reconfigured the mirror angles so that the light may be focused more accurately, leading to a superior visualization of the region that was examined (Verger-Kuhnke et al., 2007). Desormeaux performed the first endoscopic surgical intervention, reporting the excision of a urethral polyp and the incision of a urethral stricture; these procedures being made possible due to new technology (Léger, 2004). The German urology professor Maximilian Carl Friedrich Nitze (1848–1906) (Fig. 1.10) noted two major shortcomings of the endoscopes used at that time: a poor visual field and poor illumination. Based on these observations, Nitze created an innovative optical system using prisms and lenses that provide a much improved visual field, and introduced the first intracorporeal light source, using a platinum filament electric lamp (1878) (Herr, 2006). These changes led to the creation of what most historians consider to be the first successful modern cystoscope. The device with prisms and lenses allowed the transurethral visualization of the urinary bladder, while the light source was incorporated into the tip of the endoscope. The shortcomings of the instrument were related to the lamp’s complicated water cooling system, the difficulties in transurethral insertion, and the fact that the displayed image was inverted (Natalin and Landman, 2009). Nitze’s discovery revolutionized endoscopy and paved the way for minimally invasive surgery (Verger-Kuhnke et al., 2007).

Figure 1.10   Maximilian Carl Friedrich Nitze.

In 1910, Christian Jacobaeus used Nitze’s cystoscope to perform the first endoscopically guided laparoscopy (Herr, 2006).

In 1879, the development of cystoscopes was influenced by the appearance of incandescent electric lamps (light bulbs) that consisted of a carbon filament incorporated into a vacuumed glass envelope. In 1883, David Newman adapted this type of lamp so that it could be used as a light source incorporated into the cystoscope. This greatly simplified the production of cystoscopes, reduced the production cost, and led to the widespread use of these instruments (Natalin and Landman, 2009).

Another significant advance in the field of endourology was achieved with the creation of the first resectoscope by Maximilian Stern (1877–1946) in 1926. Subsequently, in 1931, the addition of a mobile resection loop made this instrument appropriate for transurethral resections, procedures that were to become standard interventions for most cases of benign prostatic hyperplasia and noninvasive bladder tumors (Reuter and Reuter, 1999).

Subsequently, the physicist Harold Hopkins (Fig. 1.11) attempted, in turn, to improve the optical system of cystoscopes. Hopkins discovered optical fibers with a thickness of 0.1 mm, which he merged into coaxial fascicles, creating a new means of transmitting light and images. In 1960, this technology led to the creation of the first flexible endoscope (Gow, 1998).

Figure 1.11   Harold Hopkins.

Furthermore, Hopkins developed a telescope consisting of cylindrical lenses separated by sections of air; this modification allows light to be transmitted more than 80 times faster at the same diameter (1959) (Shah, 2002). The Hopkins telescope with cylindrical lenses and the use of optical fibers are the foundation for the design of current cystoscopes.

The development of optical fiber technology at the beginning of the 1970s led to the appearance of flexible cystoscopes. In 1973, Tsuchida and Sagawara described the first bladder exploration using a cystoscope that, although requiring a rigid sheath for insertion, had a mobile distal extremity (Quayle et al., 2005). Subsequently, continuous technological progress turned flexible cystoscopy into an integral part of modern urological practice. Major disadvantages of optical fibers were excessive fragility and poor image resolution. This was solved by the use of cystoscopes equipped with distal sensors (distal chip technology) consisting of millions of photodiodes. The sensor is capable of converting light particles (photons) into electrical impulses and subsequently into a digital image (Natalin and Landman, 2009). This technology significantly improved the reliability of flexible cystoscopes and provided an excellent image resolution and the possibility of storing these images (Quayle et al., 2005). The development of fluorescence cystoscopy also represented an important progress in the diagnosis of noninvasive bladder tumors using agents with an affinity for cancer cells, which can be visualized using this technique.

Endocystoscopy is a recent technique, currently under assessment, that uses an imaging device similar to a catheter, which can be inserted through the working channel of most endoscopes (Anandasabapathy, 2008). This device achieves a 450- to 1125-fold amplification of the image, while histological level resolutions are generated with the concomitant use of tissue coloring agents, allowing the in vivo differentiation between benign and malignant superficial lesions of the bladder mucosa (Ohigashi et al., 2006; Sasajima et al., 2006). The images allow the observation of the cellular components, similar to conventional histological samples, and in most cases, the correct assessment of tumor grade. However, there are plenty of controversial aspects to be overcome before this technology can be effectively used for the in vivo clinical diagnosis of bladder tumors (Ohigashi et al., 2006).

Virtual endoscopy uses computer-assisted three dimensional reconstruction of anatomic information provided by computerized tomography and magnetic resonance imaging in order to generate images that provide a detailed endoscopic perspective of the studied organ. This type of reconstruction was applied to most cavity organs of the human body, including the bladder (Allan and Tolley, 2001), and may represent an inexpensive and noninvasive method for evaluating the urinary tract. However, virtual cystoscopy does not yet provide sufficient sensitivity for it to replace standard cystoscopy in diagnosis of bladder tumors and detection of recurrences after transurethral resection (Babjuk et al., 2008). Currently, virtual cystoscopy is a feasible method for the diagnosis of bladder tumors larger than 5 mm. Moreover, it allows for a 360° evaluation of the bladder in multiple planes, including areas that are difficult to approach by standard cystoscopy. Presently, this method has a major application only in patients in whom standard cystoscopy cannot be performed or is contraindicated (Kivrak et al., 2009).

Wireless capsule endoscopy (WCE) represents the most recent technique in the field of lower urinary tract endourology. This method uses a miniaturized video camera and a wireless radio transmitter integrated into a small capsule, which is inserted into the urinary tract. The system is also composed of an external device that receives the signal, a data storage unit, and a computer for data interpretation. The capsule has two main components: the optical system and the guidance system. The optical system consists of a short focus lens, a narrow external slot to increase the depth of the field, and a dual light-emitting diode illumination system. The guidance system is based on a set of magnets that enable manipulation of the capsule inside the examined organ (Natalin and Landman, 2009).

WCE was initially used in 2001 and its main indication is the exploration of the digestive tract when classic endoscopy is unsuccessful (occult bleeding, reflux disease, Crohn’s disease, etc.) (Saurin, 2007). In 2009, at the American Urology Association Congress in Chicago, the first use of such a perfected device was reported – Cellvizio, for the examination of the bladder. The study, which included 27 patients, was the first in vivo microscopic evaluation of the bladder and allowed real-time differentiation between cancer cells and normal bladder mucosa.

However, there are some potential obstacles to be considered for the clinical application of this method. Unlike the gastrointestinal tract, the introduction and mobilization of the WCE inside the bladder is performed in a nonphysiological manner, requiring additional handling capabilities. The bladder has a relatively small capacity compared with the gastrointestinal tract and is easily accessible to conventional endoscopic exploration. Moreover, tissue sampling is much more difficult when using the WCE. Finally, the size of the WCE raises issues regarding placement, mobility, and recovery of the device from the urinary tract (Gomella, 2009).

1.4. Indications

The primary indication of cystoscopy is represented by the diagnosis of lower urinary tract disorders.

Urethrocystoscopy achieves a direct and complete visualization of the urethra, bladder neck, and bladder. The main indications of cystoscopy are imposed by clinical manifestations that require detailed information regarding the structural anatomy and macroscopic pathology of the bladder. Moreover, cystoscopy enables tissue sampling for the histological (Fig. 1.12) or cytological examination, as well as endoscopic access to the upper urinary tract (Fig. 1.13).

Figure 1.12   Bladder biopsy.

Figure 1.13   Insertion of a ureteral catheter in order to perform retrograde pyelography.

A major indication of cystoscopy is represented by the diagnosis of microscopic or macroscopic hematuria. In the protocol for evaluating hematuria, the endoscopic exploration is preceded by other investigations (radiological, ultrasound), but cystoscopy remains the only direct method of diagnosing bladder lesions (Manyak and Scherr, 1996). Moreover, in case of ongoing total hematuria that presents as the only symptom, cystoscopy becomes the first method of investigation (Proca, 1978). Thus, the causes of hematuria can be directly diagnosed as originating in the bladder or upper urinary tract (Fig. 1.14).

Figure 1.14   Bleeding through the ureteral orifice.

Bladder tumors clinically manifest through hematuria in 80% of cases, while diagnosis through imaging investigations (radiological) is possible in approximately 60% of these. Accordingly, cystoscopy represents the primary diagnostic method, allowing to assess the location, number, and size of bladder tumors, as well as to take tissue samples for histological examination (Manyak and Scherr, 1996). Any bladder tumor, papillary (Fig. 1.15) or sessile (Fig. 1.16), requires a biopsy (Fig. 1.17). Biopsy samples must include samples of the muscle layer for a correct tumor staging (Fig. 1.18).

Figure 1.15   Different aspects of papillary bladder tumors.

Figure 1.16   Solid, infiltrative bladder tumors.

Figure 1.17   Bladder tumor biopsy using forceps.

Figure 1.18   Tumor biopsy that includes the muscle layer.

Another indication of cystoscopy is the assessment of irritative or obstructive micturition disorders, in order to establish the etiology: inflammatory (Fig. 1.19), neurological, tumoral, or other.

Figure 1.19   Pseudotumoral edema of the bladder mucosa.

The approach of the upper urinary tract by cystoscopy allows to examine the entire upper urinary tract using a contrast medium (retrograde pyelography), to obtain samples for cytological or histological examination, as well as to perform therapeutic maneuvers (placement of ureteral catheters) (Fig. 1.20) (Carter and Chan, 2007).

Figure 1.20   Insertion of an autostatic ureteral catheter under cystoscopic control.

In cases of recurrent or persistent urinary tract infections, cystoscopy may identify the presence of predisposing factors such as bladder outlet obstruction, cancers, fistulas (Fig. 1.21), malformations, etc. (Boos, 2001).

Figure 1.21   Vesico-vaginal fistula observed at cystoscopy.

The diagnosis of interstitial cystitis is based on clinical and endoscopic criteria. Modifications specific to this condition (Fig. 1.22) are revealed during cystoscopy in over 90% of cases (Porru et al., 2003; Hanno et al., 1999).

Figure 1.22   Characteristic aspect of interstitial cystitis (Hunner’s ulcer).

Traumatic injuries of the lower urinary tract are the result of different types of accidents involving the pelvis, or they may be iatrogenic. Both the bladder and the ureters may be injured during abdominal or pelvic surgical procedures. Statistically, gynecological interventions are responsible for over 75% of these injuries. Urethrocystoscopy has an important role in the diagnosis and minimally invasive treatment of these conditions (Fig. 1.23) (Hurt, 1999).

Figure 1.23   Transfixiant intravesical thread extracted during cystoscopy.

Cystoscopy may be performed as a diagnostic or a therapeutic procedure.

1.4.1. Diagnostic Indications

The diagnostic indications of cystoscopy include (Leyh and Paul, 2005):

• to establish the etiology of macroscopic or microscopic hematuria

• the diagnosis and follow-up of bladder tumors (primary, metastases, or by local invasion) (Fig. 1.24)

• the assessment of patients with recurrent or persistent urinary infections, interstitial cystitis

• to establish the etiology and therapeutic protocol in patients with urinary incontinence, neurogenic bladder, etc.

• the diagnosis of stones (Fig. 1.25) and intravesical foreign bodies

• the assessment of patients with urinary fistulas (vesicovaginal fistula, vesicoenteral fistula, etc.)

• the diagnosis of ureteral orifice conditions (vesicoureteral reflux, ureterocele, etc.)

• the assessment of patients with lower urinary tract symptoms, with etiology that could not be determined by other diagnostic methods

• endoscopic access to the upper urinary tract

• the following results of surgical interventions performed on the lower urinary tract

Figure 1.24   Invasion of the bladder trigone by extension of a cervical cancer.

Figure 1.25   Solitary (a) and multiple (b) bladder stones.

1.4.2. Therapeutic Indications

The therapeutic indications of cystoscopy include (Mantorani et al., 1993):

• extraction of intravesical foreign bodies (Fig. 1.26)

• treatment of bladder stones (litholapaxy)

• insertion or extraction of ureteral catheters

• bladder biopsy

• intravesical injection of therapeutic agents (anti-incontinence, overactive bladder)

Figure 1.26   The endoscopic extraction of intravesical foreign bodies.

1.5. Contraindications

The contraindications for the endoscopic evaluation of the lower urinary tract are represented by:

• acute urethritis

• acute prostatitis

• acute epididymitis

• fever caused by urinary tract infections

• severe coagulopathies

• urethral strictures

• urethral or bladder ruptures (abdominal or pelvic trauma) (Carter, 1992)

1.6. Technique of Cystoscopy

1.6.1. Instruments

The endoscopic assessment of the urinary bladder is performed using cystoscopes. Endoscopic equipment is measured according to the external diameter, expressed in French units (1 F = 0.33 mm) (Carter and Chan, 2007).

Currently used cystoscopes are of two types:

• rigid

• flexible

1.6.1.1. Rigid cystoscopes

Rigid cystoscopes (Fig. 1.27) were the first endoscopic instruments used in urological practice, and for a long time, the endoscopic exploration and treatment of lower urinary tract disorders was based exclusively on this type of instruments. The diameter of rigid cystoscopes varies between 6 F and 27 F; the most commonly used in adults having a diameter ranging between 15 F and 25 F (Akornor et al., 2005).

Figure 1.27   Rigid urethrocystoscope.

The size of the cystoscope is chosen according to the indication of the endoscopic procedure, the general rule being to use the instrument with the smallest diameter that is suitable for the intervention that needs to be performed (Manyak and Scherr, 1996).

Existing rigid cystoscopes, regardless of size, are composed of three main parts (Fig. 1.28):

• external sheath with obturator

• intermediate piece (bridge)

• telescope (optical system)

Figure 1.28   Components of the rigid cystoscope.

The external sheath has the role of protecting the telescope and at the same time, of introducing the telescope and the irrigation fluid into the bladder. The diameter of the sheaths varies between 6 F and 27 F; the ones with 21–22 F diameters being the most frequently used for standard diagnostic cystoscopy in adults. When a therapeutic maneuver is expected, 24–27 F sheaths are preferred because they allow for an easy insertion of various instruments through the working channel (Carter and Chan, 2007). The sheath is fitted at its proximal end with two connectors (ports), flow and return, for the introduction and the evacuation of the irrigation fluid, respectively.

The obturator is connected to the sheath and facilitates the atraumatic urethral passage of the sheath when choosing to introduce it in a blind manner, without the help of a video camera.

The intermediate piece serves to connect the sheath to the telescope and is fitted with one or two ports that enable the introduction of various instruments into the bladder (Cundiff, 2001). Thus, depending on the diameter of the sheath’s working channel, several types of instruments may be used: biopsy forceps, guidewires, laser fibers, lithotripsy probes, injection needles, etc. There are variants of cystoscopes in which the sheath and the telescope are connected directly, without the intermediate piece. The Albarran sheath is an intermediate piece variant that is fitted with a distal deflecting system, which facilitates the handling of instruments that are introduced through the working channel in areas with difficult access. The use of the Albarran sheath is avoided by some urologists because of the traumatic risk (mucosal lesions or perforations).

The telescope is designed to transmit the light inside the bladder, and at the same time, to transmit the image to the examiner. Modern rigid cystoscopes are based on the lens system created by Harold Hopkins, and have various viewing angles that enable a full examination of the bladder (Cundiff, 2001). Thus, cystoscopes with 0° optical angle (forward view) are used particularly for urethroscopy; whereas, those with 12–30° angles (forward and oblique view) are used especially for the examination of the base, posterior wall, and sidewalls of the bladder; and those with 70° (side view) enable the examiner to view the anterolateral walls and the bladder dome. Cystoscopes with 120° angles (retrograde view) are used to inspect the anterior area of the bladder neck (Carter and Chan, 2007). Telescopes with different viewing angles are fitted with a mark at the periphery of the visual field, with the role of facilitating orientation during cystoscopy. This marker is usually located directly opposite to the viewing angle. In common practice, the 30° telescope is the most widely used, allowing both diagnostic cystoscopy as well as handling of various intravesical instruments, while the 70° telescope is preferred for a complete bladder inspection.

The advantages of rigid cystoscopes include (Leyh and Paul, 2005):

• large visual field, superior telescopes

• wide working channel for auxiliary instruments

• irrigation channel with a large caliber and hence, better visualization

• the possibility to evacuate blood clots or other bladder debris

• easy handling and orientation during the procedure

1.6.1.2. Flexible cystoscopes

Flexible cystoscopes (Fig. 1.29), unlike the rigid ones, combine both the optical system and the working/irrigation channel into a single unit. The optical system is composed of a bundle of optical fibers that are responsible for the transmission of images and two similar fascicles responsible for transmitting light. The optical fibers are isolated, parallel, can transmit light (the image) even if bent, and are connected to a lens system that serves to magnify and focus the image. Because of the way the optical fibers are arranged, a small space remains between them, causing the granular, honeycomb aspect of the image (Cundiff, 2001). However, this drawback has been corrected in the last-generation cystoscopes. Similar to rigid cystoscopes, the optical system features a mark in the visual field (often located at 12 o’clock) that is meant to facilitate orientation during cystoscopy.

Figure 1.29   Flexible urethrocystoscope.

The properties of the optical fibers and their parallel layout have enabled to develop a distal deflecting mechanism that is controlled by a button located near the viewfinder. The degree of distal deflection in a single plane varies between 220° and 350°, while the maximum deflection in a single direction ranges from 180° to 220° (Table 1.1).

Table 1.1

Technical Characteristics of Different Models of Conventional Flexible Cystoscopes