Cystoscopy

Cystoscopy

1. Cystoscopy Presented by---- Mrs. Usha Rani Kandula , MSc.Nursing , Assistant professor, Department of Adult Health Nursing, College of Health Sciences, Arsi University, Asella , Ethiopia.

2. Introduction - Cysto-scopy is a visual examination of the urinary bladder.

3. cystoscope size as per age - Cystoscopes from 9.5 Fr through 16 Fr are used for infants and children. -Adults- it ranges 17 to 30 Fr for adults.

4. Parts of cystoscope -Each type of procedure requires specific endoscopic equipment. -All rigid urologic endoscopes have the same basic components,

5. Sheath -The hollow sheath, through which the urologic endoscope passes, may be concave, convex, or straight in configuration at the distal end (the end inserted into the urethra)

6. - The other end has a stopcock attachment for irrigation. -Sheath sizes range from 11 Fr for infants to 30 Fr for adults.

7. -Space is provided within the sheath to accommodate instruments for work in the bladder or urethra.

8. -Other instruments and catheters can be inserted through the sheath into the ureters and/or kidneys for diagnostic or therapeutic procedures.

9. Obturator -The stainless steel obturator , which is inserted into the sheath, occludes the opening of the sheath and facilitates introduction into the urethra without trauma to the mucosal lining.

10. Telescope -Telescopes are complex precision optical systems; they are costly, delicate instruments that are handled gently at all times.

11. -Each telescope contains multiple finely ground optical lenses that relay the image from the distal end inside the bladder or urethra to the ocular (eyepiece) used by the urologist to view internal structures.

12. Indications for cystoscopy - For routine examination of the urinary bladder. -Biopsy of a tumor. - Cystogram for diagnostic x-rays. -Diagnostic evaluation and therapeutic removal of obstructions within the structures of the genitourinary tract.

13. - Fulguration of a tumor(Tissue destroy). -Incision into a bladder neck by observation. -Coagulation of a hemangioma . -Removal of a foreign body.

14. Con- Hematuria , frequent cystitis other urinary tract infections, Urinary incontinence, urinary retention, Calculi (stone) discovered on incidental x-ray.

15. Con-- - Cystoscopy may also be performed to Catheterize the ureters , to treat lesions or tumours , To follow up the examination of an operative or endoscopic procedure.

16. Patient Preparation for a Cystoscopic Examination

17. Preparation of the Patient - Antiembolitic hose are applied when requested. -When general or spinal anesthesia is employed, it is administered before the skin prep.

18. - Local anesthetic may be inserted into the urethra of the male patient and applied to the urethral meatus of the female patient following the skin preparation.

19. - The patient is usually on the cysto scopy table (in the “ cysto ” room) in lithotomy position. -The customized “ cystoscopy ” table has special built-in padded crutch supports for the knees that should be padded.

20. General or regional anesthesia, -1.The procedure will be performed with the patient under general or regional anesthesia, -The patient may be encouraged to drink fluids before coming to the cystoscopy room. -Fluids ensure rapid collection of a urine specimen from the kidneys.

21. - Some tests require the ability to void for bladder strength studies or while contrast medium passes through the urinary system. -Electro myo graphic (EMG) data may be gathered during the process.

22. 2. Intra urethral procedures are often performed with topical agents or local infiltration anesthetics. -The patient should be reassured that the procedure usually can be performed with only mild discomfort.

23. PRIVACY OF THE PATIENT -Respect the patient’s modesty by providing appropriate drapes and keeping the cystoscopy room door closed.

24. position of the patient- lithotomy 3 . The patient is assisted into the lithotomy position with the knees resting in padded knee supports or stirrups. -Gel pads behind the legs and knees help avoid undue pressure in popliteal spaces.

25. - Velcro straps are used to secure the patient’s legs. -Some cysto scopic procedures are performed with the male patient in the supine position.

26. 4.The drainage pan is pulled out of the lower break of the urologic bed after the patient’s legs have been positioned on knee supports and the foot of the bed has been lowered.

27. Skin preparation 5.The pubic region, external genitalia, and perineum are mechanically and chemically cleansed with an antiseptic agent according to routine skin preparation procedure.

28. - A sterile screen is placed over the drain or a drain is incorporated into disposable drapes following the skin preparation. -The table may be tilted downward to permit easy drainage of preparation solution.

29. - Irriation of the skin and to avoid burns when using the ESU. -Extend the preparation from umbilicus to mid-thighs.

30. Males. Cleanse entire pubic area, including the penis, scrotum, and perineum. Discard each sponge after wiping the anus. Females. See skin and vaginal preparation for D&C, .

31. Draping Drape sheet under the buttocks and a “ cystoscopy ” drape (drain and screen incorporated), or drape sheet under the buttocks, leggings, a laparotomy sheet, and a sterile screen and drain.

32. -Scrub soaps can be diluted with warmed sterile saline or water for the comfort of the patient.

33. 6.Topical anesthetic agents are instilled into the urethra at the end of the preparation of the procedure. -A viscous liquid or jelly preparation of lido caine hydrochloride, 1% or 2%, may be used.

34. -This medium remains in the urethra rather than flowing into the bladder.

35. For the female For the female: -The female urethra is most sensitive at the meatus . -A small, sterile cotton-tipped applicator dipped into the anesthetic gel and placed in the meatus is sufficient anesthesia for local urethral procedures.

36. The applicator is removed when the urologist is ready to introduce an instrument. -Cone-shaped syringes are commercially available for intra urethral instillation of local lidocaine 2% jelly.

37. For the male b. For the male: -A disposable cylinder with an acorn tip can be used for intraurethral insertion. -The agent is injected into the urethra, and the penis is compressed with a noncrushing spring-loaded penile clamp for a few minutes to retain the drug.

38. 7. A sterile stainless steel filter screen is placed over the drainage pan. -The patient is draped as for other perineal procedures in the lithotomy position. -The urologist may need to have access to the rectum.

39. - The perineal sheet has two fenestrations: one exposes the genitalia, and the other fits over the screen on the drainage pan. -A gauze filter is incorporated into this latter fenestration to capture resected tissue.

40. - The urologist may prefer to wear a sterile disposable plastic apron over his or her gown. -One style of this apron is attached to the bed, which provides a sterile field from the urologic bed to the urologist’s shoulders.

41. - A receptor kit that attaches to the apron eliminates the need for the drainage pan. -Tissue specimens are collected as irrigating fluid passes through a collecting basket.

42. - Most surgical facilities have a “ cystoscopy room” complete with a “ cysto ” table with built-in knee holders useful for placing the patient in lithotomy position; -The table has x-ray capabilities to deliver fluoroscopy, as needed.

43. - When resection is to be performed, a resecto scope with a working element (electrical wire loop) is used to cauterize and coagulate tissue.

44. - If a “ cysto scopy ” table is unavailable, padded stirrups (e.g., Allen) are used. -All bony prominences and areas vulnerable to skin and neurovascular pressure or trauma are padded.

45. - When a procedure in addition to cysto scopy is performed requiring electro surgery, application of an electrosurgical dispersive pad is necessary.

46. A brief description of the procedure follows: 1. A sheath and obturator are lubricated and inserted into the urethra. 2. An obturator is removed and the cystoscope is inserted.

47. 3. Irrigation tubing is attached, and the bladder is filled with solution for visualization. 4. A light cord is attached to the fiber optic unit.

48. Procedure - Insertion of a well-lubricated cysto scope into the urethra is attempted. -In the presence of a stricture, the urethra may be dilated with filiform sounds.

49. - Once the stricture has been cleared, the urethra is inspected and the cysto scope is advanced into the bladder.

50. - The obturator is removed, and a urine specimen is obtained. -The bladder is filled with irrigation fluid, and under direct visualization, the bladder, ureteral orifices, bladder neck, and urethra are examined.

51. - A pan endoscope, a resecto scope, and/or a ureteral catheterizing endoscope may be required depending on the procedure to be performed.

52. Equipment -Padded “ cystoscopy ” table crutch leg holders or padded stirrups (e.g., Allen) on OR table -Extra IV standard/pole for hanging irrigation fluid -Fiber-optic light source, e.g., Xenon 300 W -ESU

53. Instrumentation -Sterile screen unless cystoscopy drape used (sterile screen incorporated) -Rigid fiber-optic cystoscope (Brown-Berger) and panendoscope (McCarthy) or - cystourethroscope ( Wappler ) for bladder visualization

54. -Lateral and foroblique fiber-optic telescopes (interchangeable with all sheaths) and (power) cord - Resectoscopes , e.g., Iglesias, Nesbit, Baumrucher , and Stern-

55. -McCarthy (sheath, Timberlake obturator , telescope [composed of Bakelite], and working element (cutting electrode) to cut and coagulate -Bridge (e.g., short, Alberran ) required for telescope to fit into the sheath

56. -Stopcock, hemostat, and catheter nipples Penile clamp (used following local anesthetic instillation in males) -Urethral sound

57. Add - Resectoscope (for bladder fulguration) - Ureteral lithotrite and corresponding scope (for lithopaxy )

58. -Catheterizing telescope (for catheterization of the ureters ), add ureteral catheters Note: A flexible fiber-optic cystoscope is employed for patients unable to tolerate the lithotomy position.

59. Supplies - Antiembolitic hose -Sterile screen (“ cysto ” drape has sterile screen incorporated) -Medicine cup, syringe (20 ml)

60. -Topical anesthetic (e.g., lidocaine hydrochloride/ Anestacon 1% or 2%) for males -Medicine cup, syringe, and dye (optional) ESU cord (for procedures in addition to cystoscopy )

61. -Water-soluble lubricant -Irrigation solution, usually sterile water (available in 2000- or 3000-ml bags) -Disposable cystoscopy tubing

62. - Filiform urethral sounds, available -Graduated pitcher -Test tubes with screw tops (for urine specimen collections)

63. Special Notes Apply Special Notes from Abdominal Laparotomy , p. 134. • Ensure and verify that all x-ray, IVP, etc. reports are in the room and that they belong to the correct patient.

64. -For the female patient, local anesthetic is placed into the urethral meatus with a cotton-tipped applicator (or cone-shaped syringe) following the skin and vaginal prep.

65. -The applicator stick is to remain in the meatus until the surgeon inserts an instrument.

66. -Reminder: Assess and document patient’s anxiety level and level of knowledge regarding the intended procedure.

67. -Circulator can provide a measure of comfort by clarifying misconceptions by answering the patient’s questions in a knowledgeable manner when possible or redirect the question to the physician.

68. - Reminder: All medications used in the sterile field must be labeled. -Scrub person should use a sterile marking pen to identify all solutions. -Avoid medication errors,.

69. -Reminder: All medication containers should be kept in the room until the completion of the procedure. -Follow all safety precautions to avoid medication errors;.

70. - A flexible fiber-optic cysto scope is used for patients who cannot tolerate the lithotomy position (e.g., patients with arthritis, etc.); the patient may not require an anesthetic. -Position patient carefully to avoid injury.

71. -An imaging system is an integral part of the “ cystoscopy ” table; often fluoroscopy is incorporated into the table.

72. -Employ x-ray safety protection, as necessary, e.g., the room should be lead-lined, personnel should wear lead aprons (donned before scrubbing) and stand behind lead walls during x-ray exposure;.

73. - Care must be taken to position patients on the “ cystoscopy ” table correctly; -particular care should be taken for patients with hip problems or arthritis (if they can tolerate the lithotomy position at all).

74. -The built-in knee crutch supports on the “ cysto scopy ” table help to avoid pressure damage on neurovascular structures in the popliteal space when legs are padded adequately and positioned correctly.

75. - Customized gel pads with Velcro® are available. -When using a standard OR table, employ the same considerations; -use padding for the Allen stirrups.

76. - in stirrups preoperatively and postoperatively for patient safety and medico legal reasons. -When positioning patient, prevent employees straining muscles by showing them how to employ ergo dynamic techniques.

77. • Lift both legs at the same time when putting the patient’s legs in stirrups to prevent postoperative lumbo sacral strain.

78. -This is best done by two persons; however, one person can do this by placing one leg on his/her shoulder while placing the other foot in the stirrup.

79. - Raise and lower legs slowly to prevent cardiovascular disturbances, e.g., rapid alterations in venous return.

80. -The “ cysto scopy ” table has a drainage pan that can be pulled out of the lower break in the table after the patient is positioned.

81. -When the standard OR table must be used instead, a kick bucket is used to catch the irrigation fluid.

82. -The scrub person or the circulator prepares the instrument table from which the surgeon works. -A Mayo stand is not used; a scrub person is not required during the procedure.

83. - The surgeon usually dons a sterile disposable plastic apron that is worn under the sterile gown or a gown with an impermeable inset is worn when working in the “ cystoscopy ” room to prevent (strike-through) contamination.

84. -Sterile water is the solution of choice when only cystoscopy will be performed.

85. -When a procedure in addition to cystoscopy is performed, the irrigation solution should be nonelectrolytic and isotonic (e.g., glycine , sorbitol ) to prevent burning the patient.

86. - Observe the level of irrigation as it is used and replace irrigation bags, as necessary. -Always be prepared with a new bag of irrigation, as necessary.

87. • Special care is taken not to damage the fragile lensed telescopes and fiber-optic light cords by placing a pad in the sink before cleaning them.

88. - High end disinfection is the minimal requirement (of the Centers for Disease Control) for processing endoscopic instrumentation.

89. - Cystoscopes are usually disinfected using a 2% aqueous glutaraldehyde solution (e.g., Cidex ™). -As Cidex is very irritating, rinse instruments well.

90. - Many facilities prefer to sterilize the instrumentation; aqueous glutaraldehyde (e.g., Cidex ), peracetic acid, and/or hydrogen peroxide gas plasma, in addition to ethylene oxide,may be used.

91. - Each disinfection or sterilization process has particular time restraints; see methods of disinfection and sterilization,.

92. - Instruments that have blood on them need to be scrubbed with a brush. -The inside channel of tubular instruments must be cleaned. Instruments cannot be left soaking longer than necessary, as the seals will be affected.

93. - Moving parts of the instruments should be lubricated with an instrument “milk.”

94. - When a “ cysto ” drape is available, a screen is incorporated into it. -Otherwise, a sterile screen is required to capture resected tissue.

95. - Depending on the procedure performed, a urinary drainage unit may be attached to the Foley catheter.

96. - The unit should be placed below the level of the bladder to prevent a reflux of urine; this may prevent a potential urinary tract infection.

97. - When the ESU is used (for procedures in addition to cystoscopy ), an electrosurgical dispersive pad is required.

98. - It should be placed on skin that is relatively hair-free (the area may require shaving) and as close to the area of the surgery as possible, without being in the sterile field.

99. -The power control settings of the ESU should be set as low as possible while still being effective.

100. -Check and replace the wire loops (disposable) used with resectoscopes as necessary for breakage, as they are malleable and fragile.

101. Thanking you