Uro instruments- cystoscopy & fibreoptics

Uro instruments- cystoscopy & fibreoptics

1. Fibreoptics
and
Cystoscopy
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical
College
Chennai

1

2. Moderators:
Professors:
•Prof. Dr. G. Sivasankar, M.S., M.Ch.,
•Prof. Dr. A. Senthilvel, M.S., M.Ch.,

Asst Professors:
•Dr. J. Sivabalan, M.S., M.Ch.,
•Dr. R. Bhargavi, M.S., M.Ch.,
•Dr. S. Raju, M.S., M.Ch.,
•Dr. K. Muthurathinam, M.S., M.Ch.,
•Dr. D. Tamilselvan, M.S., M.Ch.,
•Dr. K. Senthilkumar, M.S., M.Ch.
Dept Of Urology, KMC and GRH, Chennai 2

3. “No Aladdin’s cave was ever so beautiful or so full of surprises
as the human bladder.”
-John P Blandy, Operative Urology Textbook

Dept Of Urology, KMC and GRH, Chennai 3

4. Even though we take for granted the
present cystoscopy instruments, it is
only through the efforts of many
pioneers we enjoy them.

Our present day equipment is merely
a forerunner of what the future will
bring.
Dept Of Urology, KMC and GRH, Chennai 4

5. Cystoscopy-Evolution
Dept Of Urology, KMC and GRH, Chennai 5

6. First Generation Cystoscopes
•How to light a cave?
•How to see the light from
outside?
Dept Of Urology, KMC and GRH, Chennai 6

7. Phillip Bozzini- ‘Leichleiter’ or Guide light
1806
Dept Of Urology, KMC and GRH, Chennai 7

8. Bozzini Cystoscope-Optics
Dept Of Urology, KMC and GRH, Chennai 8

9. Vienna Faculty of Medicine-Perverse Curiosity
•Wax candle with chimney
•Shark skin
•Concave lens

Dept Of Urology, KMC and GRH, Chennai 9

10. Pierre Segalas –Urethro cystique-1826
Dept Of Urology, KMC and GRH, Chennai 10

11. John Dix Fisher - 1826
Dept Of Urology, KMC and GRH, Chennai 11

12. Antonie Desormeaux-1853
Dept Of Urology, KMC and GRH, Chennai 12

13. Desormaeux-Optics
•Kerosene Light
•Adjustable mirror
Dept Of Urology, KMC and GRH, Chennai 13

14. Desormaeux-Father of Cystoscopy
•First Endosurgery-
Urethral Papilloma
excision
•Coined the term
‘Endoscope’.
Dept Of Urology, KMC and GRH, Chennai 14

15. Second Generation Cystoscopes
•Advent of Electricity
•Intracorporeal Light sources
•Increased Field of vision
Dept Of Urology, KMC and GRH, Chennai 15

16. Maximilian Nitze-1877
Father of Modern Urology
“In order to light up
the Room, you have
to carry the light
inside”
Dept Of Urology, KMC and GRH, Chennai 16

17. Problems with 1
st
Gen Cystoscopes
•Poor Illumination – Use Bruck’s Platinum wire
•Minuteness of Image – Use Prisms and Lenses (in collaboration with
Joseph Leiter from Vienna)
Dept Of Urology, KMC and GRH, Chennai 17

18. Bruck’s Apparatus – Hot light source
When electricity is passed through a
platinum wire, it produced intense heat and
white glow, which can be used as light
source.
Dept Of Urology, KMC and GRH, Chennai 18

19. Nitze Cystoscope-With Platinum Wire
Dept Of Urology, KMC and GRH, Chennai 19

20. Nitze Endoscope – Minuteness of Image
Dept Of Urology, KMC and GRH, Chennai 20

21. Nitze-Leiter Cystoscope-1879
Dept Of Urology, KMC and GRH, Chennai 21

22. ‘Box Phantom’ of Valentine
Dept Of Urology, KMC and GRH, Chennai 22

23. Problems with 2
nd
Gen Cystoscopes
•Heavy equipment
•Burns to the patient and the surgeon
•Platinum is easily fused
•Mirrored and inverted image

Dept Of Urology, KMC and GRH, Chennai 23

24. Third Generation Cystoscopes
•Cold light source
•Unmirrored erect image

Dept Of Urology, KMC and GRH, Chennai 24

25. Third generation Cystoscope-Cold Light
•In the Year 1878
•Electric current passed
through carbon fibre in
vacuum will produce
light.
•It will neither produce
much heat nor will burn
out.

Dept Of Urology, KMC and GRH, Chennai 25

26. Nitze-Leiter Cystoscope-1900s
Dept Of Urology, KMC and GRH, Chennai 26

27. Air cystoscopy-Howard Kelly-1892

Dept Of Urology, KMC and GRH, Chennai 27

28. Air distension cystoscopes-American Standard
Dept Of Urology, KMC and GRH, Chennai 28

29. Problems
•Irritates the bladder mucosa
•Urine collected during procedure cause air bubbles and false images
•Air embolism in rare cases

Any reason?
Early endoscopes had no way to instill water through separate channel
Sterlising urological instruments was difficult.
Getting sterile water for irrigation was very difficult.
Dept Of Urology, KMC and GRH, Chennai 29

30. Fourth Generation Cystoscope
•Hopkins Rod lens
•Fibre Optics
Dept Of Urology, KMC and GRH, Chennai 30

31. Harold Hopkins-SEFLOC glass lens
Dept Of Urology, KMC and GRH, Chennai 31

32. Hopkins Vs Older Lens systems
Dept Of Urology, KMC and GRH, Chennai 32

33. Total Internal Reflection
Dept Of Urology, KMC and GRH, Chennai 33

34. Optical Fibre Principle
Dept Of Urology, KMC and GRH, Chennai 34

35. Heinrich Lamm-1903-Medical Student
•Light can be bent as it pass through the glass
fibre.
•Bunch of glass fibres can be used to transmit
an image and reproduce again at a distance.
•Applied for patent but denied because of
poor image quality.
Dept Of Urology, KMC and GRH, Chennai 35

36. Hopkins and Narinder Kapany-1948
•Physicist Harold Hopkins and his graduate
student Narinder Kapany improved image
resolution by increasing the number of
fibers in a bundle and got patent for the
same.
•Father of Fibreoptics-Dr.Narinder Kapany
Dept Of Urology, KMC and GRH, Chennai 36

37. Combining Hopkins and Optic fibre –
Karl Storz – German Company with American Brain
Dept Of Urology, KMC and GRH, Chennai 37

38. Hopkins And Van Heel
Dept Of Urology, KMC and GRH, Chennai 38

39. Fifth Generation Cystoscope
•Video Imaging
Dept Of Urology, KMC and GRH, Chennai 39

40. Photoelectric effect
Dept Of Urology, KMC and GRH, Chennai 40

41. RGB and Photoelectric Effect
Dept Of Urology, KMC and GRH, Chennai 41

42. Charged Couple Device-CCD-1969
Dept Of Urology, KMC and GRH, Chennai 42

43. Recent Advances
•Narrow Band Imaging
•Photodynamic diagnosis/Blue light imaging
•Confocal Laser endomicroscopy
•Optical Coherence Tomography
Dept Of Urology, KMC and GRH, Chennai 43

44. Narrow Band Imaging
•This optical technology uses a CCD chip and a special filter.
•Basic Principles:
•Used primarily for identifying superficial lesions.
•Blue light has less penetration.
•Hemoglobin absorbs blue and light avidly.
•Malignancy are more vascular hence more hemoglobin.
Dept Of Urology, KMC and GRH, Chennai 44

45. Narrow Band Imaging Technique
Dept Of Urology, KMC and GRH, Chennai 45

46. Colour Coding
Dept Of Urology, KMC and GRH, Chennai 46

47. Narrow Band Imaging
Dept Of Urology, KMC and GRH, Chennai 47

48. Photodynamic diagnosis/Blue light imaging
•Based on the concept of Flourescence.
Dept Of Urology, KMC and GRH, Chennai 48

49. Flourescence Principle
Dept Of Urology, KMC and GRH, Chennai 49

50. Visible Light Spectrum
•Wavelengh of Blue higher
than Red.
•Blue is higher energy wave
and Red is lower energy.
Dept Of Urology, KMC and GRH, Chennai 50

51. Blue light Cystoscopy
•Amino levulinic acid is a fluorescent agent.
•It is absorbed by dysplastic tissue but not by normal tissue.
•If blue light is used for illumination, ALA will absorb blue and it will
emit red light.
•So against a blue background, the tumour will be red.
Dept Of Urology, KMC and GRH, Chennai 51

52. Blue light imaging
Dept Of Urology, KMC and GRH, Chennai 52

53. Confocal Laser Endomicroscopy
•Based on Flourescence.
•Flourescein dye is used and images are
taken 30 sec to 8 minutes after the
procedure.
•It permeates the lamina propria and
extracellular matrix.
•Architectural distortion noted.
•Also known as Optical Biopsy.
Dept Of Urology, KMC and GRH, Chennai 53

54. Confocal Laser Endomicroscopy
Dept Of Urology, KMC and GRH, Chennai 54

55. Optical Coherence Tomography (OCT)
•Non-invasive optical technique to see below the surface of tissues (up
to 1–3 mm).
•This technology is similar to ultrasound except that OCT provides
much higher resolution images.
•It measures reflected waves of near infrared light.
•Does not require direct contact with the tissues.
Dept Of Urology, KMC and GRH, Chennai 55

56. Resolution and Penetration-Comparison
Dept Of Urology, KMC and GRH, Chennai 56

57. Optical Coherence Tomography
•Lamina propria has a “bright, distinct
signal” while the muscularis had a
“darker, spindled appearance”.
•Muscle invasion can be detected
with OCT.
Dept Of Urology, KMC and GRH, Chennai 57

58. OCT-Limitations
•Steep learning curve for interpretation by the surgeon
•False positives that can occur with other conditions that disturb the
urothelial layers such as scarring or inflammation.
Dept Of Urology, KMC and GRH, Chennai 58

59. Rigid
Cystoscopy
Dept Of Urology, KMC and GRH, Chennai 59

60. Rigid Cystoscope Components
1. Cystoscope sheath
2. Cystoscope obturator
3. Bridge
4. Light cable
5. Telescope
Dept Of Urology, KMC and GRH, Chennai 60

61. Cystoscope Sheath
•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).
Dept Of Urology, KMC and GRH, Chennai 61

62. Cystoscope Sheath
•Adult sheath-22 cms. Cross section-Oval
•No markings for distal 10cm, later marking every 1 cm for 13 cms.
•Useful for measuring Prostatic urethral length.
•Vesical end of 17Fr is different from all others.
Dept Of Urology, KMC and GRH, Chennai 62

63. Cystoscope Sheath
•At the level of inlet/outlet channel –Sheath size
•Behind sheath size, largest size of the catheter, two
of which can be passed simultaneously.
•Behind the above - single largest catheter, which
can be passed through the sheath.
•The above catheter size are the maximum size with
scope and Albarrans lever in situ.
•If simple bridge is used maximal permissible
catheter size will increase by 1 Fr.
Dept Of Urology, KMC and GRH, Chennai 63

64. Albarran’s Lever
•It is Bridge with a deflecting lever, which can be used to deflect the
ureteric catheter to align the catheter with the ureteric orifice.
•It has two channels through which two catheters can be passed
simultaneously.
Dept Of Urology, KMC and GRH, Chennai 64

65. Cystoscope Bridge
•Adult cystoscope bridges are universal and can fit into all sizes of
sheaths. Length of bridge is 6 cm.
•Telescope channel: It accommodates the telescope.
•Accessories’ channel: It is meant to pass the accessories such as
ureteric catheter, wires forceps, etc.
Dept Of Urology, KMC and GRH, Chennai 65

66. Obturators
•They are specific 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.
Dept Of Urology, KMC and GRH, Chennai 66

67. Obturator-Parts
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.

Dept Of Urology, KMC and GRH, Chennai 67

68. Obturator-Differentiation
Dept Of Urology, KMC and GRH, Chennai 68

69. Telescopes
•The telescopes are classified depending on the viewing angle. They
are available as 0°, 30°, 70°, 120° and 12°.
•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, this is the most commonly
used telescope.
•Lateral telescope (70°) to view the bladder dome.
Dept Of Urology, KMC and GRH, Chennai 69

70. Telescope-Colour Coding
Dept Of Urology, KMC and GRH, Chennai 70

71. Positioning
•Lies flat with legs supported
on rests so that the thigh
makes an angle of 10 to 20
degrees with the horizontal.
•If the angle is steep, it is
difficult to examine trigone or
ureter catheterization.
•Supine with legs placed apart
on a padded rest is an
alternative.
Dept Of Urology, KMC and GRH, Chennai 71

72. Preparation
•Skin preparation can be done with
betadine or chlorhexidine solution.
•Urethra is gently injected with
anaesthetic lubricant gel.
•Penile clamp is applied
transversely proximal to the glans
penis.
Dept Of Urology, KMC and GRH, Chennai 72

73. Technique
•In introducing cystoscope, under direct
vision, with irrigation on flow, follow the
curve of the urethra, swinging the
instrument downwards round the bulbar
urethra.
•Force is never needed.
Dept Of Urology, KMC and GRH, Chennai 73

74. Physiological Narrowings
1.Internal Meatus
2.Navicular fossa to penile urethra
proper transition
3.Penile urethra
4.Bulbar urethra to membranous
urethra transition
Dept Of Urology, KMC and GRH, Chennai 74

75. Urethra Curvatures
1.Penoscrotal angle (Straighten the
Penis)
2.Curvature in the bulb (Swing the
scope downwards)
3.Ventral curvature of due to median
lobe (Inconsistent)
Dept Of Urology, KMC and GRH, Chennai 75

76. Anterior and Bulbar urethra
•Anterior urethra may have few
openings of urethral glands,
sometimes more prominent near
bulb.
•Bulbar urethra becomes wider,
shows helical submucosal rings
like the barrel of a rifle.
•Follow the roof of the urethra and
swing the urethroscope down
gently until the external sphinter
is seen.

Dept Of Urology, KMC and GRH, Chennai 76

77. External Sphincter
•External sphincter looks like the
anus, occluding the lumen.
•But it easily dilates before
advancing the endoscope.
•If the patient is frightened, it may
be difficult to relax.
•Ask the patient to breathe in and
out deeply or pretend to urinate.
Dept Of Urology, KMC and GRH, Chennai 77

78. Prostatic Urethra
•Normal prostatic urethra is red and
granular.
•Verumontanum is the salient feature
of prostatic urethra. It has a central pit
called Utriculus masculinus.
•Opening on either side of the utriculus
are the orifices of the ejaculatory
ducts.
•On the proximal end is the bladder
neck, once crossed, it reaches bladder.
Dept Of Urology, KMC and GRH, Chennai 78

79. Ureteric Orifices
•The cystoscope is advanced 2 cm inwards from the bladder neck and
then rotated 45 degrees first on one side and then on the other.
•Interureteric ridge is a useful landmark.
Dept Of Urology, KMC and GRH, Chennai 79

80. Flexible
Cystoscopy
Dept Of Urology, KMC and GRH, Chennai 80

81. Cross section Image
•Two light guide
•bundles
•One image guide bundle
•Working channel

Dept Of Urology, KMC and GRH, Chennai 81

82. Technique
•Supine position with legs apart.
•Penis cleaned with antiseptic solution.
•Anaesthetic jelly injected.
•Flexible endoscope is advanced while sterile water flows through it
under direct vision.
•As the external sphincter is approached, the tip is slightly bent up.
•Patient is asked to pretend to void.
•Sphincter relaxes and the scope slides into prostatic urethra.
Dept Of Urology, KMC and GRH, Chennai 82

83. Technique
•The scope is advanced after examining the prostatic urethra into the
bladder.
•All bladder walls are examined systematically.
•Finally, by curving the tip fully open itself, retrograde view of the
bladder neck can be achieved.

Dept Of Urology, KMC and GRH, Chennai 83

84. Advantages
•Ease in patient positioning resulting in better patient comfort.
•It is useful in manipulation across difficult curves and high bladder
necks and median lobes.
•The ability to flex the endoscope helps in complete visualization of
the bladder easily.
Dept Of Urology, KMC and GRH, Chennai 84

85. Thank You
Dept Of Urology, KMC and GRH, Chennai 85