Pre‐procedure

ActionRationale

1. 1.Show
   Check the environment and equipment to ensure that everything is properly prepared for the procedure, including that the irrigation is attached and run through the scope, and awareness of the location and availability of emergency equipment.
   To ensure the procedure will take place without delay for the patient and to ensure that the safety of the patient is addressed (BAUS and BAUN [16], [17], C; Skills for Health [151], [152], [153], [154], C).
2. 2.Show
   Ask assistant to set up trolley with sterile urology pack and prepare scope.
   To ensure that the safety of the patient is addressed (BAUS and BAUN [16], [17], C; Skills for Health [151], [152], [153], [154], C).

   To maintain infection control standards and minimize cross‐infection and contamination (Fraise and Bradley [50], E; RCN [132], C).
3. 3.Show
   Read the patient's notes, referral letter, patient history and relevant investigation results and identify any special instructions, investigations or items for which you need to seek advice prior to the procedure, including any metal prosthesis.
   To ensure that the safety of the patient is addressed (BAUS and BAUN [16], [17], C; Skills for Health [151], [152], [153], [154], C).
4. 4.Show
   Ensure that pre‐procedure criteria have been met:

   • urine sample tested for infection, the results interpreted and a sample sent for further analysis if required
   • urine cytology obtained if required
   • pre‐procedure medication has been taken as required, such as prophylactic antibiotic
   • patient has emptied bladder
   • observations within normal limits
   • check medications and anticoagulation have been reviewed or withheld.
   Requisite pre‐procedure tests are performed to ensure patient safety addressed (BAUS and BAUN [16], [17], C; Skills for Health [151], [152], [153], [154], C) and timely sampling of urine. E
5. 5.Show
   Accurately identify the patient and introduce yourself and any colleagues present to the patient.
   To ensure that the safety of the patient is addressed (BAUS and BAUN [16], [17], C; Skills for Health [151], [152], [153], [154], C). To ensure the patient is aware who is present during the procedure. E
6. 6.Show
   Assess the patient's suitability for the procedure, including any changes to health since referral, medication or allergy status, and seek advice or refer if necessary.
   To ensure that the safety of the patient is addressed and to ensure relevant history is recorded (BAUS and BAUN [16], [17], C; Skills for Health [151], [152], [153], [154], C).
7. 7.Show
   Explain the procedure and potential complications to the patient and accurately answer any questions at a level and pace that is appropriate to:

   • their level of understanding
   • their culture and background
   • their preferred way of communicating their needs.
   To ensure informed consent has been obtained and also that patient's needs are appropriately addressed during procedure (DH [34], C).
8. 8.Show
   Ensure the patient's informed consent to the procedure has been given and, if not, obtain it.
   To ensure informed consent has been obtained and also that patient's needs are appropriately addressed during procedure (DH [34], C; NMC [116], C).
9. 9.Show
   Ensure that the cystoscope is diathermy compatible.
   To ensure cystodiathermy is undertaken safely (BAUS and BAUN [17], C).
10. 10.Show
    Ensure that irrigation fluid is diathermy compatible, for example 1.5% glycine or normal saline.
    To ensure cystodiathermy is undertaken safely (BAUS and BAUN [17], C).
11. 11.Show
    Ask the patient to remove any metal jewellery or to cover with non‐conductive tape.
    To ensure that the safety of the patient is addressed (BAUS and BAUN [17], C).
12. 12.Show
    Ask the patient to remove clothing below the waist. Offer a gown to cover the patient.
    To provide privacy and comfort for the patient. E.

    To minimize the risk of a hospital acquired infection (BAUS and BAUN [17], C).
13. 13.Show
    Assist the patient to position themselves onto an incontinence sheet on the trolley correctly for the procedure (supine), respecting their dignity and ensuring their comfort within the constraints of the procedure. Males lay flat and females with legs apart.
    To enable easy passage of the cystoscope (BAUS and BAUN [16], [17], C; Skills for Health [151], [152], [153], [154], C) and maintain patient comfort and dignity. E
14. 14.Show
    Ensure the patient is not in contact with any metal surface.
    To ensure no adverse events occur with subsequent burns while using cystodiathermy (BAUS and BAUN [17], C).
15. 15.Show
    Prepare the area for the diathermy plate by shaving excessive hair (usually the patient's thigh) while avoiding bony prominences, wet skin, scar tissue, metal prosthesis or tattoos.
    To ensure no adverse events occur with subsequent burns while using cystodiathermy (BAUS and BAUN [17], C).
16. 16.Show
    Wash hands with soap and water and dry, followed by alcohol rub, and apply non‐sterile gloves and apron.
    To maintain infection control standards and minimize cross‐infection and contamination (Fraise and Bradley [50], E; RCN [132], C).
17. 17.Show
    Identify, clean with cleansing solution such as chlorhexidine solution and examine the urethral orifice and surrounding area. In females open the labia, and in males retract the foreskin.
    Initial examination of the patient and first findings, appropriate cleansing to minimize cross‐infection/contamination (Reynard et al. [136], E).
18. 18.Show
    Insert local anaesthetic gel topically into the urethra, leaving for 5–10 minutes.
    To maintain patient comfort E and allow smooth passage of the cystoscope (BAUS and BAUN [17], C).

    Appropriately applied lidocaine gel reduces pain in males during flexible cystoscopy (Aaronson et al. [1], R1a).
19. 19.Show
    Remove gloves and apron and discard in clinical waste.
    To ensure correct disposal of clinical waste (DH [35], C; HSE [68], C).
20. 20.Show
    Wash hands with soap and water, followed by alcohol rub, and apply sterile gloves and gown.
    To maintain infection control standards and minimize cross‐infection and contamination (Fraise and Bradley [50], E; RCN [132], C).
21. 21.Show
    Apply sterile drape over patient's lower body.
    To maintain infection control standards and minimize cross‐infection and contamination (Fraise and Bradley [50], E; RCN [132], C).

Procedure

1. 22.Show
   Maintain communication with the patient throughout the procedure, monitor and respond to any questions or needs.
   To ensure ongoing informed consent (DH [34], C; NMC [116], C); patient comfort, safety and dignity maintained. E
2. 23.Show
   Ensure the labia are held open in females or the foreskin is retracted in males. This should be done either by an assistant or with your non‐dominant hand.
   To ensure thorough and accurate examination (Reynard et al. [137], E).
3. 24.Show
   Introduce the cystoscope into the urethra and advance it gently under direct vision using deflection (Action figure 19a) and inflection (Action figure 19b) (change in angle) of the tip to avoid trauma to the urethral wall and ensure that the correct irrigation fluid is running (normal saline if washings are required to preserve the cells).
   To maintain patient safety and comfort. To ensure thorough and accurate examination (Reynard et al. [137], E).
4. 25.Show
   If insertion is difficult, or problems occur, seek advice or decide to terminate the procedure and record your findings.
   To maintain patient safety. E
5. 26.Show
   Fill bladder sufficiently with irrigation fluid to facilitate systematic examination of the internal structure of the bladder and to identify anatomical landmarks using tip deflection and inflection, instrument rotation and gentle advancement and withdrawal of the cystoscope.
   To ensure a thorough and accurate examination (Smith et al. [156], C) of the bladder (Figure 20.14).
6. 27.Show
   Identify all abnormal lesions or bleeding areas throughout the examination. Record images throughout procedure using the video stack, external printer or software connected to the stack and scope.
   To ensure a thorough and accurate examination (Smith et al. [156], E).
7. 28.Show
   Improve visualization, if necessary, by aspirating fluids from the bladder.
   To ensure a thorough and accurate examination (Smith et al. [156], E).
8. 29.Show
   Select the diathermy compatible biopsy forceps and ensure they are in working order.
   To avoid an adverse event if cystodiathermy is required during the procedure and biopsy forceps are functional (BAUS and BAUN [17], C).
9. 30.Show
   Insert biopsy forceps through the channel of the cystoscope using dominant hand while keeping the cystoscope tip in the straight position.
   To ensure damage to the cystoscope does not occur (BAUS and BAUN [17], C).
10. 31.Show
    Visualize the biopsy forceps as they enter the bladder and field of vision.
    To ensure the biopsy forceps are in the correct position and not opened while within the cystoscope to avoid damage to both devices (BAUS and BAUN [17], C).
11. 32.Show
    Use the cystoscope controls to orientate the biopsy forceps over the tissue to be sampled.
    To ensure the biopsy forceps are in the correct position and not opened while within the cystoscope to avoid damage to both devices (BAUS and BAUN [17], C).
12. 33.Show
    Open the jaws of the biopsy forceps or instruct an assistant to operate the biopsy forceps.
    To ensure grasping forceps are operated correctly and safely. E
13. 34.Show
    Close the biopsy forceps jaws, taking an adequate tissue sample.
    To provide an adequate specimen for histopathological analysis while minimizing patient discomfort (BAUS and BAUN [17], C).
14. 35.Show
    While biopsy forceps are closed, pull sharply from the bladder tissue.
    To provide an adequate specimen for histopathological analysis while minimizing patient discomfort (BAUS and BAUN [17], C).
15. 36.Show
    Withdraw the biopsy forceps via the cystoscope channel while keeping the jaws closed, or instruct the assistant to do so.
    To ensure the sample is removed (BAUS and BAUN [17], C).
16. 37.Show
    Deposit all of the tissue sample into the specimen pot or instruct the assistant, making sure the biopsy forceps do not touch the sterile pot.
    To ensure the sample is maintained for histopathological analysis (BAUS and BAUN [17], C).
17. 38.Show
    Clean the forceps between each sample in sodium chloride 0.9%.
    To ensure biopsy forceps are clean and ready for additional sampling. E
18. 39.Show
    Visualize biopsy sites for excessive bleeding and perform cystodiathermy if required (see Procedure guideline 20.7 Cystoscopy with APC/cystodiathermy.
    To minimize the risk of clot retention of urine and haemorrhage (BAUS and BAUN [17], C).
19. 40.Show
    Repeat steps 32–39 for subsequent samples.
     
20. 41.Show
    Once complete, fully withdraw cystoscope, maintaining irrigation until withdrawal of cystoscope is almost complete.
    To ensure cystoscope is fully withdrawn. E

Post‐procedure

1. 42.Show
   Reassure patient that the examination has been completed.
   To maintain patient comfort and safety. E
2. 43.Show
   Assist the patient to reposition, wipe surplus lubricant and dry.
   To maintain patient comfort and safety. E
3. 44.Show
   Remove gloves and dispose of all used single‐use equipment. Return cystoscope for washing according to local guidelines.
   To maintain infection control standards and minimize cross‐infection and contamination (BAUS and BAUN [16], [17], C; Fraise and Bradley [50], E; RCN [132], C; Skills for Health [151], [152], [153], [154], C).
4. 45.Show
   Label specimens and send to laboratory for histopathological analysis.
   To ensure correct identification and correct analysis is undertaken (BAUS and BAUN [17], C).
5. 46.Show
   Ask the patient to pass urine before leaving the department.
   To ensure the patient is able to pass urine (BAUS and BAUN [17], C).