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.
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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”
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17. Problems with 1st Gen Cystoscopes
• Poor Illumination – Use Bruck’s Platinum wire
• Minuteness of Image – Use Prisms and Lenses (in collaboration with
Joseph Leiter from Vienna)
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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.
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22. ‘Box Phantom’ of Valentine
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23. Problems with 2nd 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
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.
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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.
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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.
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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
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.
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50. Visible Light Spectrum
• Wavelengh of Blue higher
than Red.
• Blue is higher energy wave
and Red is lower energy.
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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.
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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
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.
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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.
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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.
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60. Rigid Cystoscope Components
1. Cystoscope sheath
2. Cystoscope obturator
3. Bridge
4. Light cable
5. Telescope
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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).
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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81. Cross section Image
• Two light guide
• bundles
• One image guide bundle
• Working channel
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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.
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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.
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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.
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