What is a cystoscope?

What is a Cystoscope

A cystoscope is a specialized endoscopic instrument designed to visualize the interior of the urethra, bladder mucosa, and ureteral orifices for diagnostic and therapeutic purposes. 1

Instrument Design and Types

Rigid vs. Flexible Cystoscopes

• Flexible cystoscopes are now preferred for most diagnostic procedures because they cause less pain, produce fewer post-procedure symptoms, simplify patient positioning, reduce procedure time, and demonstrate at least equivalent (and sometimes superior) diagnostic accuracy compared to rigid instruments, particularly for lesions at the anterior bladder neck 1

• Modern flexible cystoscopes feature actively deflectable tips with 180-degree two-way thumb-directed deflection, removable light bundles, outer sheaths of 16F or less, and working channels large enough (≥6F) to admit standard endoscopic instruments 2

• Rigid cystoscopes remain useful for specific therapeutic applications but have been largely supplanted by flexible instruments for routine diagnostic office-based procedures 1, 3

Technical Components

• The instrument utilizes fiberoptic technology (first applied to cystoscopy in 1973) that transmits light and images through flexible glass fibers, allowing complete examination of the urethra and bladder with a single-lens system 3, 4

• Current digital imaging technology provides unparalleled image quality compared to early models that used reflected candlelight and produced inverted, backwards images 4

Clinical Applications

Diagnostic Uses

• Cystoscopy provides complete visualization of the bladder mucosa, urethra, and ureteral orifices, which is necessary to exclude bladder cancer 1

• The procedure demonstrates very high diagnostic accuracy for detecting bladder cancer, with sensitivity ranging from 87-100% and specificity from 64-100%, exceeding the diagnostic value of any imaging test 1

• Cystoscopy is the cornerstone diagnostic tool and current standard for inspecting the entire bladder for malignancy or other abnormalities in patients presenting with hematuria 1

Therapeutic Applications

• Beyond diagnosis, flexible cystoscopes can be used for treating urethral strictures, bladder neck contractures, placing ureteral catheters under direct vision, removing ureteral stents and foreign bodies, treating small bladder tumors with Nd:YAG laser, and fragmenting bladder calculi with pulsed-dye laser 2

Procedure Characteristics

Patient Positioning and Anesthesia

• Initial diagnostic cystoscopy can be performed under local anesthesia using either rigid or flexible instruments 1

• Patient positioning is simplified with flexible instruments—males are positioned supine and females in frog-leg supine position 5

• The procedure can be performed at the bedside in many settings using local anesthesia alone 2

Equipment Requirements

• Standard equipment includes the flexible cystoscope, irrigant, lubricating gel, sterile gloves, and towels/drapes 5

• A treatment cart containing light source, endoscopic instruments, irrigating supplies, and the endoscope facilitates office-based procedures 2

Clinical Context and Indications

• Cystoscopy is recommended as part of the initial office evaluation for microscopic hematuria in all adults over 40 years of age and in patients under 40 with risk factors for bladder cancer (including tobacco use, occupational exposures, or other high-risk features) 1

• The procedure may be deferred in select low-risk patients (men and women younger than 40 with no risk factors), though urinary cytology should still be performed 1

• Patients with non-muscle-invasive bladder cancer undergo routine surveillance cystoscopy to assess for recurrence and progression 1

Limitations and Complications

• Fiberoptic cystoscopy is limited in patients who are actively bleeding or have blood clots in their bladders, as withdrawal of irrigant or bladder drainage is cumbersome 3

• Possible complications include pain and discomfort, hematuria, dysuria, and urinary tract infection 1

• Active urinary tract infection with symptoms, urethral stricture, and inability to position the patient appropriately are contraindications to the procedure 6