What are the risks and benefits of cystoscopy?

Risks and Benefits of Cystoscopy

Cystoscopy is a critical diagnostic procedure for detecting bladder cancer with high sensitivity (87-100%) and should be performed in all patients with hematuria who are over 40 years of age or have risk factors for bladder cancer. 1

Benefits of Cystoscopy

• Cystoscopy provides complete visualization of the bladder mucosa, urethra, and ureteral orifices, which is necessary to exclude the presence of bladder cancer 1
• High diagnostic accuracy with sensitivity ranging from 87% to 100% and specificity from 64% to 100% for detecting bladder malignancies 1
• Flexible cystoscopy has largely replaced rigid cystoscopy in outpatient settings, offering several advantages:
  • Causes less pain and discomfort compared to rigid cystoscopy 1, 2
  • Associated with fewer post-procedure symptoms 1
  • Simplified patient positioning and preparation 1
  • Reduced procedure time 1
  • At least equivalent diagnostic accuracy to rigid cystoscopy 1
  • Superior visualization of certain lesions, particularly those at the anterior bladder neck 1
• Outpatient flexible cystoscopy is cost-effective, with one study showing savings of approximately €1,211 per patient compared to inpatient procedures 3
• Avoids risks associated with general anesthesia when performed as an outpatient procedure 3

Risks and Complications of Cystoscopy

• Potential complications include:
  • Pain and discomfort during and after the procedure 1
  • Urinary tract infections 1, 3
  • Hematuria (bleeding) 1, 4
  • Dysuria (painful urination) 1
  • Bladder perforation (rare) 1
  • Scar tissue formation 1
  • Urinary retention, more common in men with pre-existing urination problems 1
• Despite these potential complications, outpatient cystoscopy is generally considered a low-risk procedure 3
• In a recent study of 77 women undergoing outpatient flexible cystoscopy, no post-procedure complications were observed 3

Indications for Cystoscopy

• Recommended for all adult patients over 40 years of age with microscopic hematuria 1
• Recommended for patients under 40 years with risk factors for bladder cancer 1
• Indicated even when upper tract imaging reveals a potentially benign source of bleeding 1
• Common indications include:
  • Evaluation of hematuria (visible or non-visible) 1
  • Recurrent urinary tract infections 3
  • Bladder pain syndrome 3
  • Overactive bladder symptoms 3
  • Surveillance of patients with previous bladder cancer 2

Risk Stratification for Cystoscopy

• High-risk patients (requiring both cystoscopy and upper tract imaging):
  • Patients over 40 years of age 1
  • Patients with persistent microscopic hematuria on repeat testing 1
  • Patients with additional urothelial cancer risk factors such as:
    • Irritative lower urinary tract symptoms 1
    • Prior pelvic radiation therapy 1
    • Prior cyclophosphamide/ifosfamide chemotherapy 1
    • Family history of urothelial cancer or Lynch Syndrome 1
    • Occupational exposures to benzene chemicals or aromatic amines 1
    • Chronic indwelling foreign body in the urinary tract 1
• Low-risk patients (cystoscopy may be deferred initially):
  • Men and women younger than 40 years with no risk factors for bladder cancer 1
  • However, urinary cytology should still be performed in these patients 1
  • If microscopic hematuria persists on repeat testing, these patients should be reclassified as intermediate or high-risk and undergo cystoscopy 1

Practical Considerations

• Flexible cystoscopy is now considered the standard tool for performing cystoscopy in outpatient settings 2
• Initial diagnostic cystoscopy can be performed under local anesthesia 1
• For patients with persistent hematuria and negative initial evaluation, additional evaluation including repeat cystoscopy may be warranted 1
• Follow-up is important as some patients with negative initial evaluation for asymptomatic microhematuria may eventually develop significant urologic disease 1

Limitations of Cystoscopy

• While highly sensitive for detecting bladder cancer, cystoscopy is an invasive procedure 1
• Cannot provide information about extravesical extension of tumors, requiring additional imaging modalities for complete staging 4
• CT cystography combined with virtual cystoscopy may be useful when conventional cystoscopy is inconclusive or cannot be performed 4