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Pre‐procedural considerations

To prevent an unnecessary invasive procedure, ensure that flexible cystoscopy is indicated and that the results required cannot be achieved by diagnostic imaging. In most cases appropriate diagnostic imaging will precede flexible cystoscopy.
Consideration of concurrent treatment such as chemotherapy, anticoagulants or other medications is required. A confirmation of allergy status must be obtained. In order to exclude a urinary tract infection a dipstick test should be performed prior to a flexible cystoscopy and/or MSU at least one week prior to the procedure. If the patient has an artificial urinary sphincter implanted, this must be deactivated prior to the procedure (BAUN and BAUS [16], [17]).

Equipment

Flexible cystoscopes and stack

As there are several different types of flexible cystoscope (Figure 20.12), it is essential that the practitioner familiarizes themselves with the equipment prior to use. A video stack is required to enable visualization and recording (Figure 20.13). Equipment familiarization should include:
  • the function, specification and performance characteristics of the equipment to be used in cystoscopy, including how to record and store images
  • the impact of equipment controls on the visual image
  • the safe operation of cystoscopy equipment
  • the importance of timely equipment fault recognition and local procedures for dealing with these
  • equipment capabilities, limitations and routine maintenance.
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Figure 20.12  Flexible cystoscope.
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Figure 20.13  Video stack.

Emergency equipment

Emergency equipment should be easily accessible in the rare event of a major complication. In addition, equipment required for urethral catheterization should be available in the event of a complication such as urinary retention.

Pharmacological support

A local analgesic such as a 2% lidocaine gel is inserted topically into the urethra 5–10 minutes prior to the procedure commencing. In males up to 11 mL and in females up to 6 mL are normally prescribed and applied (Peyronnet et al. [122]). If washings are required during the procedure, intravesical sodium chloride 0.9% is used to irrigate the bladder rather than sterile water to improve cell preservation during storage and transfer to the lab (BAUN and BAUS [16], [17]).
Procedure guideline 20.4

Flexible cystoscopy

Table 20.7  Prevention and resolution (Procedure guidelines 20.4, 20.5, 20.6, 20.7) (BAUS and BAUN [16], [17]; Skills for Health [151], [152], [153], [154])
ProblemCausePreventionAction
Urethral bleeding.Urethral trauma.Careful advancement of the cystoscope under direct vision during the procedure.
The procedure should be stopped and direct finger pressure must be applied to clamp the urethra.
In the case of continuous bleeding, the patient should be transferred to the recovery area and escalated to the senior clinician (usually the responsible consultant).
A three‐way 18 Fr Foley catheter should be inserted, with gentle traction applied over the bladder neck.
Haematuria.Underlying abnormality, intra‐procedure bladder trauma, bladder biopsy.Careful advancement of the cystoscope under direct vision during the procedure.A 22 Fr three‐way silicone Foley catheter should be inserted, followed by bladder washout and continuous bladder irrigation with normal saline. In case of severe bleeding, formal washout in theatre may be required.
Urinary retention.Underlying abnormality.All patients must spontaneously void before being discharged.If a patient complains of abdominal pain with inability to void or has no pain but a full bladder (confirmed on ultrasound) a 12–18 Fr Foley catheter should be inserted on free drainage. A trial of voiding without catheter should be booked to take place in 7–10 days.
Vasovagal syncope.Acute anxiety/fear.Addressing patient anxiety pre‐procedure, informing patient of what to expect. Recognizing acute anxiety pre‐procedure.
Immediately stop the procedure. Remove the scope and position the patient in dorsal decubitus with a 30° Trendelenburg (on back, head down) position. Vital signs should be recorded.
In case of complete loss of consciousness or sustained instability, escalate to the emergency response team and inform the lead clinician.
Urinary tract infection.Contamination or cross‐infection.Adherence to infection control guidelines.Recognize symptoms and treat according to local guidelines or microbiology result.
Pain.Urethral trauma.Use of 2% lidocaine gel.In case of acute pain, the procedure should be discontinued and if incomplete it should be re‐booked under a general anaesthetic. Pain should stop within a short period of the scope being withdrawn. If it does not, systemic analgesia should be administered and further investigations should be requested in discussion with the lead clinician.
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Figure 20.14  Male internal bladder structure. Source: Adapted from Tortora and Derrickson (2011). Reproduced with permission of John Wiley & Sons.
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