CYSTOSCOPE & URETEROSCOPES.pptx

instruments in urology

1. CYSTOSCOPEs AND URETEROSCOPEs Dr. Manoj Kumar Deepak Urology Resident

2. HISTORY Maximilian Carl Nitze is credited with the invention of modern cystoscope, He used an electrically heated platinum wire for illumination, a cooling system which used flowing ice water and telescopic lens for visualization. In 1887, following the invention of the light bulb by Thomas Edison, Nitze constructed a cystoscope that did not require the cooling system.

3. CYSTOSCOPES FLEXIBLE RIGID

4. Difference - Apart from the obvious The image and optical image transmission differs. Rigid relies on a rod lens system In the flexible endoscopes rely on fiberoptic / digital system.

5. RIGID CYSTOSCOPES All cystoscopes are made of stainless steel alloy. The cystoscope sheath is calibrated in French (Fr), this is considered to be the outer circumference of the instrument in millimeters (mm). Fr is same as Charriere (Ch).

6. The parts of a rigid cystoscope assembly. 1. Cystoscope sheath 2. Cystoscope obturator 3. Bridge 4. Light cable 5. Telescope

7. Cystoscopic Sheath

8. Cystoscopic Sheath Length of an adult cystoscope sheath regardless of size is 22 cm . The cross section of the sheath is not round but oval. Markings on the shaft - The proximal 10 centimeters from the vesical end devoid of any markings. Markings are engraved on the sheath at every 1 cm thereafter for the next 13 cm. The markings help in estimation of prostatic urethral length

9. Method to measure prostatic urethral length: The cystoscope is introduced along the entire length. The cystoscope is withdrawn under endoscopic vision till the bladder neck. The marking on the external meatus is noted (Point A). Thereafter, the cystoscope sheath is withdrawn till the verumontanum and a note of the marking is done (Point B). The number of markings on the sheath between point A and point B is noted, this is the length of the prostatic urethra.

10. Beak of the sheath The distal end of the sheath is bulbous dorsally and smooth without sharp edge. –atraumatic. Hence can be passed without an obturator. If the beak is not of such design then that instrument should be passed through the meatus with obturator, e.g. VIU sheath, resectoscope sheath. 17 Fr sheath is short beak sheath this is used for female cystourethroscopy.

11. Numbering on the sheath Size of the sheath is indicated by a number written on the sheath at the level of inlet/outlet channel. The numbers written in two circles behind the above indicate the largest size of the catheter, two of which can be passed simultaneously through the sheath. Behind the above is a single circle with a numerical value, denoting the single largest catheter, which can be passed through the sheath.

12. Bridges

13. Bridges A re universal and can fit into all sizes of sheaths. Length of bridge is 6 cm. Specially designed cystoscopes(the bridge and the telescope cannot be detached) - 'integrated cystoscopes’.

14. Integrated Vs Detachable bridges The advantages of detachable bridge are: 1. It helps in emptying the bladder efficaciously. 2. It helps in passing larger size catheter after detaching the bridge. 3. It helps in attaching the Elick’s evacuator for evacuation of stone fragments/ clots/chips, etc. Types of Bridges (Classification) 1. Without side channel 2. With one side channel 3. With two side channel.

15. Parts of Bridge Telescope channel : It accommodates the telescope. Accessories’ channel : It is meant to pass the accessories such as ureteric catheter, wires forceps, etc. It has a rubber shod which help in easy passage of the instrument.

16. OBTURATORS

17. Obturators S pecific for a given sheath. Once attached to the sheath it makes the tip of the sheath smooth thereby snuggly fitting to it. The length of the obturator is 26 cm. Parts of obturator are as follows: Vesical end knob : This helps in smooth atraumatic insertion of the cystoscope. Shaft : Connects the vesical end knob and the locking mechanism. Locking mechanism : Zero (0) should correspond to zero (0) of the sheath when locked.

18. Points which differentiate a cystoscope, Sachse’s and resectoscope obturator. The differentiation is based on size of the knob and the presence and absence of groove

19. The telescopes

20. The telescopes Classified depending on the viewing angle. Namely : 0°, 30°, 70°, 120° and 12° Size of telescopes available – 4 mm, 30 cm (fits in all cystoscope sheaths and VIU sheaths, resectoscope sheaths).

21. Straight forward telescopes (0°) is focused to view straight ahead, is usually used for urethroscopy. Forward oblique telescopes (30°) best affords visualization of the base and anterolateral aspect of the bladder, Lateral telescope (70°) to view the bladder dome. Retrospective telescopes (120°) help to visualize the anterior bladder neck from inside. With the use of flexible cystoscopes on the rise the 70° and 120° telescopes have become obsolete

22. Hopkins rod-lens system employs special glass rods with customized finished ends. The rod-lens system reduced the air spaces between lens with long rods of glass which were ground, contoured, and polished at both ends, there are short gaps of air in between Rod-lens are glued with special adhesive cement which is a special alloy, effectively making it water proof. Hence Auto- Clavable .

23. Conventional Vs Hopkins rod lens system

24. Basic structure of telescope Parts of Telescope Shaft : Angulation at the tip varies depending on the viewing angle Eyepiece : It is typically black in color, the size is universal and adapts to any camera head.

25. Special Types of Cystourethroscopes and its Uses Extended length cystoscope- urethroscope : The working length is 29 cm. It is 22 Fr, the color code is blue. The compatible telescope bridge has one instrument channel; it is for use of 10 Fr instruments.

26. Continuous flow laser cystoscope. The round tip configuration of the sheath and an 8 Fr working channel helps for easy urethral manipulation and insertion of laser with its accessories.

27. SEMI RIGID URETEROSCOPES

28. SEMI RIGID URETEROSCOPES All modern ureteroscopes are semirigid and have optical fibers. The first endoscope specifically for ureteroscopy was designed by Richard Wolf Medical Instruments in 1979 The first ureteroscope with fiber optic imaging system was introduced by ACMI in 1985.

29. SEMI RIGID CLASSIFICATION All semirigid URS have size described as 2 digits, e.g. 7/8.5 Tip is 7 Fr and shaft is 8.5 Fr. Common size of a URS are 6/7.5, 7/8.5, 8/9, 8 etc. Length of URS can be short or long . Short are generally 35 cm(females) ; Long are generally 45 cm (males).

30. Semirigid ureteroscopes can be classified based on size, make and channel. 1. According to make (Storz, Wolf, Olympus, Scholly ) 2. Depending on channel. Most ureteroscopes have a straight or oblique channel. Straight channel : Allows use of rigid pneumatic lithotripsy probes. Oblique channel : Also called as uretero-laser scopes.

31. Parts 1. Eyepiece : Straight, oblique or lateral offset. 2. Body : It has a light post and working channels. 3. Working channels : Ureteroscopes have either a single larger channel or two separate channels. 4. Sheath : 7/8.5 Fr-Tip is 7 Fr (length varies) and shaft is 8.5 Fr 5. T wo irrigation ports at right angles to instrument.

32. FLEXIBLE SCOPES

33. FLEXIBLE SCOPES Advantage Patient positioning resulting in better patient comfort. Ease of manipulation across difficult curves and high bladder necks and median lobes. Ability to flex the endoscope helps in complete visualization of the bladder easily.

34. F lexible cystourethroscope have generally three fiberoptic bundles— two noncoherent bundles of fibers that transmit light and a single coherent bundle of glass fibers that constitutes the imaging bundle. The image is not a single image, but a composite matrix of each fiber within the bundle. The image obtained is analogous to a newspaper photograph—that is, it is composed of multiple dots merging into a single reconstructed image known as ‘ honeycomb ’ effect . Mauire effect . Mauire effect

35. Types of flexible scopes Conventional : It is a fiberoptic flexible ureteroscope. The light is carried to the tip by a set of noncoherent fiberoptic bundles and image is carried back by a set of coherent fiberoptic bundles. Digital : The newer generation of flexible ureteroscopes have replaced the image carrying fiberoptic bundles with a camera sensor at the tip of the instrument. The image is thus carried as electronic signals. This technology is called as the chip at the tip technology.

36. Advantages of Digital Flexible Ureteroscope The image transfer is better since the chip at the tip directly receives it. Image quality is equivalent to ten times the pixel resolution of standard fiberoptic endoscopes. Since there is no need for attaching a camera The instrument becomes light and easy to manipulate. The wear and tear is lower as there is no fiberoptic bundle in this ureteroscope. Disadvantages of Digital Flexible Ureteroscope Since tip size increases because of chip at the tip, patients require more ureteric dilatation with larger access sheaths and there is an increased chance of staging the procedure if ureter could not be adequately dilated. Even the smallest digital flexible ureteroscope is 8.5 Fr in size. Further, these ureteroscopes are more expensive.

37. The accessories which are compatible with flexible cystoscope Grasping forceps—5 Fr, 73 cm Biopsy forceps—5 Fr, 73 cm Stone basket—5 Fr, 60 cm Ball electrode—4 Fr, 73 cm. The flexible cystourethroscope can be sterilized with gas sterilization .

38. Parts of a flexible scope Body : The body is attached to an integrated cable containing wires to carry electronic signals of image and fiberoptic bundles to carry light. It has a working channel port and deflection lever. Shaft : The shaft has a slightly larger diameter than those of fiberoptic ureteroscopes. Tip DIGITAL Eye piece / Objective lens Hand Piece Working channel Seal Light post Shaft Tip CONVENTIONAL

39. Parts of a Conventional Fiberoptic Flexible Ureteroscope 1. Eye piece (ocular lens) and focusing component : The eyepiece magnifies the virtual image and makes the image visible for the viewer. 2. Hand piece : Hand piece has the following components: – – Deflecting lever : Based on the direction of deflection of the tip of ureteroscope with respect to the direction of movement of deflecting lever, the deflection mechanism has been classified into two types

40. LOGIC (intuitive, positive or American) type, direction of deflection of tip corresponds to that of the lever, i.e. down is down and up is up. In ANTI-LOGIC (counter-intuitive, contrapositive or European) type, direction of deflection of tip is opposite to that of the lever.

41. – – Working channel : Working channel is used to insert graspers, baskets, wires and laser fibers. The inner diameter of working channel is 3.6 Fr. Irrigation port is connected to the working channel port at a right angle. – – Seal : The seal is fitted on the inlet channel. – – Light post : The fiberoptic light cable is attached to the light post.

42. 3. Shaft : The shaft encases fiberoptic bundles for image and light transmission, working channel and wires for deflection mechanism. The size of flexible ureteroscope is quoted by its tip diameter, which is 7.5 Fr in the case of Storz flex X2. The working length of the instrument is 67 cm 4. Tip : The objective lens is made of 2–9 lenses as well as a prism The direction of view is 0° and angle of view is 88°. The tip can be deflected 270° in either direction.

43. THANK YOU