Cystoscopy

CYSTOSCOPY. Cystoscope. Cystoscopy is a method of examining the urinary bladder by direct visual inspection of its cavity using a special instrument—the cystoscope. The first attempts to examine the cavities of the urinary tract with the eye date to the beginning of the 19th century (Bozzini). The endoscope of Grünfeld (1874) saw wider application. In these instruments, the light source was located outside the cavity being illuminated, and the light rays were directed through it via a narrow and long tube, which greatly complicated the examination. In 1879, Nitze proposed his cystoscope, which, with a series of modifications and improvements, is still used to this day. The principle of construction of the modern cystoscope is that light is introduced into the bladder cavity, which is distended with fluid, and this cavity is viewed through an optical system. The cystoscope (Fig. 1) View cystoscope. has the shape of a metal sound with a curvature of Mercier, at the end of which is mounted an Osram electric cold lamp, giving full incandescence at 0.35 A and a light intensity of 8.1 candles (Ringlet). Inside the instrument passes an optical system, which consists of: 1) an objective lens, placed at the bladder end of the cystoscope, giving a reversed image of the object; 2) a lens placed at half the length of the cystoscope with a focal length equal to one-quarter of the tube length; the purpose of this lens is to transfer the image given by the objective to the outer part of the tube; 3) a magnifying system—the eyepiece, through which the observer's eye views the image itself, as with a magnifying glass. Modern optics define the cystoscope system as a complex microscope with weak magnification and an immersion system, since between the object and the objective there is water filling the bladder and changing the conditions ft in the cystoscope with a reversed image. Figure 3. Path of rays in a cystoscope with direct image. Fig 2 Fig 3 path of rays relative to _{Fig 2}/ _th' _{eir i} n their path in air (Figs. 2 and 3). The optics that thus transmit a doubly inverted, i.e., correct in terms of its position on the plane, image, are complicated by the fact that in front of the objective is placed a rectangular prism with a silvered hypotenuse, one leg of which is adjacent to the objective, and the other forms the glass in the window at the base of the cystoscope's beak. This device allows one to see the image of the plane not perpendicularly, but parallel to the long axis of the cystoscope. The latest instruments (Kolmorgen, Ringleb) are improved in two directions. Their optics have great light-gathering power, which is achieved by increasing the number of intermediate reversing lenses in the middle of the cystoscope tube, and in them the mirror inversion of the image, dependent on reflection in the hypotenuse of the prism, is eliminated. This is achieved by using the Amici prism, which differs in that its hypotenuse forms a gabled roof. The hypotenuse of the Amici prism is not silvered, as it satisfies the laws of total internal reflection. The amalgam of simple prisms often becomes dull

Figure 4. Irrigation cystoscope and faucet for washing.

and peels off, which greatly shortens the working life of ordinary cystoscopes. Cystoscopes with an Amici prism are significantly more practical. At the outer end of the cystoscope there is an eyepiece, looking into which one can see the image of objects located in the bladder in the area of the beak opposite the objective located there. For orientation, the eyepiece is equipped with a button, the position of which corresponds to the prism of the objective. Immediately behind the eyepiece there is a contact for the cystoscope handle, with which the electric light is turned on. The thickness of the cystoscope for examination should not exceed No. 18 on the Charrière scale. For children, thinner instruments (up to No. 8) have been constructed, whose field of vision is, however, significantly smaller than that of cystoscopes for adults. The most commonly used modification is the irrigation washing cystoscope, consisting of a metal catheter-sheath with a lamp and an automatic shutter and op- Washing cystoscopes allow examination by introducing only one instrument to the patient and provide the possibility of repeatedly washing the bladder during cystoscopy without introducing new instruments into the urethra. There exist cystoscopes that allow photographing the image visible in the bladder (Küttner, Ringleb) (Fig. 5). The idea is that during the examination a photographic plate can be brought to the place where the actual image viewed in the eyepiece is formed and fixed it as a photograph. After development, the photograph is enlarged. Cystoscopic photography has not found wide application. Photography does not convey the colors and shades that constitute an important aspect in cystoscopy, and therefore cannot replace even a moderately executed hand-drawn drawing. (Gagman). The diagnosis and therapy of surgical diseases of the kidneys have developed greatly since Casper and Albarran almost simultaneously proposed their attachment to the cystoscope, using which one can introduce catheters into the renal pelvis under visual control and collect urine separately from each kidney. Catheterization cystoscopes differ from ordinary ones in that a channel runs along them, intended for the passage of catheters (Fig. 6). In the hole located near the objective lies a special metal plate, the Albarran flap, which by means of a screw located near the eyepiece can be bent to a right angle and then straightened again. There exist cystoscopes with two passages for simultaneous catheterization of both ureters at once, but they usually only pass a catheter No. 4 or 5, which are too thin for collecting urine, therefore greater use

Figure 6. Catheterization cystoscope.

Unilateral catheterization cystoscopes have become widespread. In the market there is a very practical set consisting of one optical system and two sheaths - a viewing and a catheterization cystoscope with accessories (G. Wolf). Cystoscopes for intravesical operations are built on the type of catheterization cystoscopes with a wide channel, which allows instruments to be passed into the bladder on flexible steel cables and operated from the outside: forceps for grasping foreign bodies, forceps for biting off tissues for biopsy, scissors for incisions, and thick conductors for electrocoagulation of tumors (see Urological Instruments). For examination of the bladder with a cystoscope, it is necessary that the urethra be freely passable and the bladder hold at least 100 cm³ of fluid. The examination is performed by distending the bladder with a transparent fluid and thus creating a cavity where the instrument's tip can rotate freely. The patient is placed in a gynecological chair or a special high table with leg supports. A catheter or the sheath of an irrigating cystoscope is introduced according to standard rules, and the bladder is washed with physiol. solution, boiled water, or a solution of mercuric cyanide 1:5,000 until the fluid exiting the bladder becomes completely clear. After filling the bladder with 150 g of fluid in men and 200 g in women, the optical system is introduced, current is turned on, and direct examination of the bladder cavity is begun. More than the specified amount of fluid should not be introduced into the bladder, as in a larger cavity the illumination will be insufficient for good orientation. It is recommended to always perform cystoscopy with the bladder equally filled, as depending on the degree of stretching of the walls, the cystoscopic picture can change in terms of color differences, appearance and disappearance of folds, etc. A necessary condition for cystoscopy is complete transparency of the medium and calm behavior of the patient. Therefore, it is clear that in the presence of acute conditions of the bladder in the form of frequent painful urges, cystoscopy can only be performed after the pain has subsided. Usually, cystoscopy itself does not cause sharp pain sensations and does not require anesthesia for its application. In very sensitive patients, it is recommended to inject into the lumen of the urethra before introducing the cystoscope with a syringe under pressure 20 cm³ of a 1% solution of novocaine or to inject 0.01 of morphine under the skin. When there is a large amount of pus in the urine, it is necessary to wash the bladder for a long time until a transparent medium is obtained. Sometimes the washing fluid, which has already become clear, suddenly becomes cloudy again. This is explained by the entry of cloudy urine from the renal pelvis into the bladder in the presence of pyonephrosis. In such cases, after obtaining clear fluid, one should quickly proceed to examination of the bladder so that when the medium becomes cloudy, the examination is temporarily interrupted for new washing of the bladder cavity, and thus perform cystoscopy in parts, examining the bladder wall section by section. In these cases, the cystoscope described above with a washing attachment is of invaluable service, as using it, washing can be done quickly without removing the entire instrument from the urethra. The presence of blood in the urine is not only not a contraindication to cystoscopy, but, on the contrary, in all cases of hematuria, patients should be immediately cystoscoped as a rule, since here it is possible to visually determine the source of bleeding, which is especially important in bleeding from the kidney in the initial stage of its disease. In cases of profuse bleeding from the bladder, it is not always technically possible to perform cystoscopy, as blood mixing with the washing fluid does not make it possible to achieve a transparent medium. In such cases, one should try to reduce the bleeding by washing the bladder with hot water, adding adrenaline to it. Iozef proposed to fill the bladder with sterile vaseline oil, in which blood does not dissolve. It should be remembered that with any one position of the cystoscope, we do not see the entire inner surface of the bladder, but only that part opposite the objective. To examine the entire bladder, a series of movements with the cystoscope should be made, rotating it around its axis and at the same time advancing and withdrawing it. In this case, the cystoscope should not be moved randomly, but should be moved sequentially according to a certain scheme, otherwise it is easy to miss insignificant but often important changes in the bladder wall (tumor, ulcer). First, the anterior-superior and lateral walls of the bladder are examined in three directions of the cystoscope's tip (fig. 7), rotating it around its axis, advancing and withdrawing it into the depth of the bladder. Then they proceed to examination of the posterior wall of the bladder, and in men with an enlarged prostate gland, it is necessary to strongly tilt the eyepiece downward. When wishing to better examine any part of the bladder, the central part of the cystoscope's objective should be brought closer to it. The object being examined then appears enlarged and the details of the cystoscopic picture become clearer. One should generally take into account the circumstance that the resulting image is always magnified 1¹/₂-2 times. When beginning the examination, the cystoscope should be checked: the optics must be clear and the bulb must light well. If the bulb does not light, one must determine whether it has burned out. A bulb unscrewed from the cystoscope is tested by touching one part of the fork of the lamp frame and the other - the thin platinum spiral at the base of the bulb, emerging from the insulating mass (fig. 8). Cystoscopes before introduction into the bladder should be thoroughly wiped with cloth soaked in rectified spirit, and the taps should be boiled. The lumen of the sheath should be washed with a solution of mercuric cyanide. The indications for the use of cystoscopy are very wide and can be said to be constantly expanding, since the safety of this method is absolute when observing known preventive measures, and the need to verify by examination

Figure 7. Schema of cystoscopic examination of the bladder.

Figure 8. Testing the cystoscope bulb.

that which can be assumed through reasoning, is obvious. Contraindications are not often encountered and are reduced to the presence of acute inflammatory processes of the bladder wall. Furthermore, contraindications for cystoscopy are acute epididymitis, purulent prostatitis. Chronic inflammatory processes of the bladder not only are not contraindications to cystoscopy, but, on the contrary, in them cystoscopy is directly indicated. Very often there are obstacles and difficulties for performing cystoscopy. First of all, free passability of the urethra for the cystoscope is necessary. Congenital narrowing of the external opening can be eliminated by dissection. Acquired strictures are previously dilated by bouginage. The complications observed after cystoscopy, in general, do not differ from the complications observed after the introduction of metal bougies and catheters into the urethra (see Catheterization). Patients sometimes experience burning during urination after cystoscopy, which usually lasts no more than a day and has no special significance. Minor traumatic injuries to the urethra, giving independently quickly ceasing bleeding, are often observed after cystoscopy, especially in hypertrophics; not so rarely in patients with purulent urine after cystoscopy the temperature rises with chills (Katheterfieber). To prevent this, patients should be prepared for cystoscopy for 2-3 days by taking urotropin or salol orally, and also prescribe a warm bath and aspirin (0.5) orally after cystoscopy. More severe complications of cystoscopy have also been described: purulent prostatitis, epididymitis and orchitis. The cause of such should be sought in insufficient technique of research-rough traumatic introduction of instruments. The normal mucous membrane of the bladder appears in the cystoscope as whitish-yellow or light-rose in color, its surface is smooth and slightly shiny. The mucous in the area of the triangle is always redder, often individual arteries and veins visible through the mucous membrane can be seen. The greatest attention of the researcher should be concentrated on the area of exit from the bladder and the area of the ureteral openings. To examine the first, the cystoscope is slowly pulled out of the bladder under visual control, until the field of vision is divided into two parts: on one the usual picture of the bladder mucosa will be visible, on the other a dark red colored semicircle will appear, which as the cystoscope is withdrawn will increase-the sphincter of the bladder (see Bladder, tab., fig. 1). The edge of the sphincter should be smooth, even; sometimes it is covered with transverse folds. To find the triangle, the cystoscope should be directed strictly along the median line with the beak downward, and then, slowly withdrawing and inserting it, turn it 45° to the left to find the right ureter and vice versa. The ureteral openings appear in the form of a slit or round opening of various sizes. Observing them in the cystoscope, one can see the process of excretion of urine from them-observe their movements. At this time, the wall of the bladder in the area of the ureteral opening comes into a state of peristaltic contraction, then the ureteral opening suddenly protrudes, opens and a stream of urine is forcefully excreted from it, which dissolves in the irrigation fluid filling the bladder. The examination of the bladder with the aid of a cystoscope with the modern improvement of the latter appears to be a very simple matter. Using a cystoscope, one can not only determine the nature of the disease and the degree of its spread, but also indicate indications for surgical intervention. The first thing that strikes the eye in a diseased bladder is the change in color of its mucosa in the form of the appearance of b. or m. sharp focal hyperemia, which can sometimes occupy the entire inner surface of the bladder (see illustration to the article Cystitis). The presence of hyperemia indicates the presence of an inflammatory disease of the mucosa. Sometimes simultaneously with hyperemia one has to observe also edema of the mucosa in the form of formation on a limited space of numerous, closely adjacent to each other vesicles filled with serous fluid-cystitis bullosa (see Cystitis). In other cases on the hyperemic mucosa deposits of fibrin, the product of secretion of the inflamed membrane, in the form of loose white films (cystitis fibrinosa-see illustration to the article Cystitis) are visible. Finally with abundant desquamation of the upper layers of epithium, ulcers can form on the surface of the bladder (cystitis ulcerosa) (see Bladder). For the cystoscopic picture of tbc- see Bladder, tuberculosis, and the figure on the table to this article. To recognize stones and foreign bodies in the bladder by means of cystoscopy usually presents no difficulty. Using this method of research, we obtain the possibility to judge the size of the stones, their quantity and finally, what is most important, their chemical composition. The stone appears as a spherical body, prominently standing out due to its color and structure against the general background of the mucosa. Stones from phosphoric and carbonic salts appear as a piece of white chalk with a smooth surface. Stones from oxalic acid lime have a rough, studded with spines surface of dark brown color. Urate stones are brownish-yellow in color and smooth (see Bladder, tab., fig. 3, 4 and 5). Due to their weight, stones should be sought on the posterior, resp. lower surface of the bladder. Finding them on the lateral or anterior walls indicates their location in a diverticulum. Simultaneously with the presence of stones, more or less deep inflammatory phenomena from the side of the bladder mucosa can be observed, which complicates the research. Deposition of fibrin on the concrement in the form of films can simulate a malignant tumor, therefore it is recommended, especially to persons not too experienced in cystoscopy, to always 'tap' on the stone with the cystoscope. Tumors of the bladder are usually located on the bottom of the bladder, on the sphincter and in the area of the ureteral openings. With the cystoscope one can distinguish in the bladder tumors of two kinds-sitting on a pedicle, histologically b. c. benign, and sitting on a broad base, usually malignant. The first have the appearance of granulation growths ('cauliflower'), hang into the cavity of the bladder and always cast a shadow on the wall of the bladder. Sometimes it is possible to clearly see the bleeding spot of the tumor. Malignant tumors are uneven, infiltrate the bladder wall itself, are dark red in color, covered with a white dense coating, are ulcerated and bleed in the center (see Bladder, tab., fig. 12). The capacity of the bladder is usually at this time diminished. The surface of a cancerous tumor can simulate in the cystoscope a stone-phosphate. To recognize the nature of the tumor in the presence of a concomitant cystitis is not always easy, since it is not possible to establish the border of the tumor. Therefore such patients have to be repeatedly cystoscoped, subjecting the bladder between researches to local treatment. The increase of the tumor during this time at the periphery indicates its malignancy, growth into the cavity of the bladder-benignity. In the presence of hypertrophy of the prostate gland, with long-existing narrowing of the urethra, finally with various diseases of the spinal cord, the inner surface of the bladder appears in the cystoscope not smooth, but on it appear crossbars_u ridges in the form of a grid, crossing each other and going in different directions (see Bladder, fig. 16). The picture of such a trabecular bladder develops as a result of hypertrophy of individual muscle fibers, which appear in the form of light-colored ridges. The mucous between these ridges appears in the form of a series of diverticula, pockets, depressions of a darker color as a result of their insufficient illumination. The entrance to a diverticulum with a large volume of it appears as a round or oval dark hole with clearly illuminated thick edges (see Bladder, tab., fig. 9). In women one has to observe quite often changes in the walls of the bladder as a result of diseases of neighboring organs in the form of pressure on the posterior or lower wall of the bladder with incorrect positions of the uterus, in the form of pulling of the wall in the presence of scar processes in the vicinity of the bladder, finally in the form of edema and hyperemia of individual areas of the mucosa with adhesions of the bladder walls to malignant tumors of female pelvic organs. Therefore one should proceed to cystoscopy in women only after internal gynecological examination. In the recognition of surgical diseases of the kidneys, the appearance of the ureteral opening of the bladder and the excretion of urine from them play an important role. Sometimes it is possible to observe with the eye the appearance from the ureteral opening of blood in the form of a stream of red liquid or in the form of emerging blood clots-worms. Such bleeding can be caused by tbc, kidney tumors, stones of the renal pelvis or ureter. In the presence of purulent processes in the kidney (pyonephrosis, pyelitis, infected stones, tbc) one can see the excretion from the ureter corresponding to the diseased side of turbid, purulent urine. Sometimes in pyonephroses it is visible how pus emerges, like paint from a tin tube, in a dense mass from the ureter and deposits on the bottom of the bladder.

In very rare cases, when there are new growths in the lower third of the ureter, individual villi of the tumor can be seen appearing in the ureteral opening during periods of its dilation. The ureteral opening itself may also change its external appearance. In long-lasting purulent processes in the kidney and renal pelvis, maintained by the presence of stones in them, the mucous membrane near the ureteral opening becomes hyperemic and contains a considerable number of blood vessels. The swelling of the opening may also depend on the incarceration of a stone in the intramural part of the ureter. The differential diagnosis with tuberculous edema should be based on the patient's history. In some cases, it is possible to see in the opening itself an incarcerated 'forming' stone (see Urinary Bladder, table, fig. 2).-Finally, the ureteral opening with a portion of the bladder wall may protrude above its surface, bulging into the bladder cavity. In such diseases-ureteral hernias (ureterocele)-one can see at the site of the normal ureteral opening a spherical bulging of the bladder wall with a pinpoint opening. This bulging, representing a sac-like dilation of the ureter, periodically, depending on the function of the kidney, alternately contracts and dilates. If the location of the ureter with the bladder wall in its normal state presents no difficulty, then in pathological processes it is not always easy to find it, and one has to inject a solution of indigo carmine into the vein of the patient, in order to, guided by the appearance of urine colored blue, find the ureteral opening (chromocystoscopy). In some cases, the ureteral openings seem to gape, their contractions are weak and very slow. In this case, there is a lesion of the neuromuscular apparatus of the ureters, their atony, usually accompanied by inflammatory processes in the ureter, renal pelvis, and bladder with purulent, infected urine. Catheterization of the ureters is performed for diagnostic and therapeutic purposes with the aid of cystoscopes for catheterization (see Catheterization).