CHAPTER 45: Surgeries for Pelvic Floor Disorders

Diagnostic and Operative Cystoscopy and Urethroscopy

During gynecologic surgery, the lower urinary tract may be injured. Thus, diagnostic cystoscopic evaluation is often warranted following procedures in which the bladder and ureters have been placed at risk. Additionally, operative cystoscopy is within the scope of many gynecologists for the passage of ureteral stents, lesion biopsy, and foreign-body removal. Of these, ureteral stenting may be indicated to delineate the ureter’s course during cases with abnormal pelvic anatomy or to assess ureteral patency following gynecologic surgery.

Rigid and flexible cystoscopes are available, although in gynecology, a rigid scope is typically used. A cystoscope is composed of an outer sheath, bridge, endoscope, and obturator. The sheath contains one port for fluid infusion and a second port for fluid egress. For office cystoscopy, a sheath measuring 17F affords greater comfort. However, for operative cases, a 21F or wider-diameter cystoscope is preferred to allow rapid fluid infusion and easier instrument and stent passage. The sheath’s end tapers, and in women- with a narrow urethral meatus, an obturator can be placed inside the sheath to create a rounded tip for smooth introduction. In selected instances, gentle dilation of the external urethral opening using narrow cervical dilators is needed prior to sheath introduction. The next piece, the bridge, attaches to the proximal portion of the sheath and allows coupling between the endoscope and sheath. Additional ports are present on the bridge and are generally used to introduce stents or instruments.

Several endoscope viewing angles are available and include 0-, 30-, and 70-degree optical views (Fig. 45-1.1). Zero-degree endoscopes are used for urethroscopy. For cystoscopy, a 70-degree endoscope is superior for providing the most comprehensive view of the lateral, anterior, and posterior walls; trigone; and ureteral orifices. To achieve a comparable view, a 30-degree endoscope requires additional manipulation. However, a 30-degree endoscope does offer advantages and allows surgeons greater flexibility as it can be used for either urethroscopy or cystoscopy during a given examination. For operative cystoscopic cases in which instruments are passed down the sheath, a 30-degree endoscope should be used because with 0- and 70-degree endoscopes, operative instruments generally lie outside the field of view.

PREOPERATIVE

Prior to office cystoscopy, urinary tract infection (UTI) is excluded to avoid upper tract infection. If diagnostic cystoscopy is performed properly, complications are rare. Of these, infection is the most common and results from the significant incidence of bacteriuria following cystoscopy.

INTRAOPERATIVE

Surgical Steps

Anesthesia and Patient Positioning

Cystoscopy may be performed in low or standard lithotomy position with the legs positioned in stirrups. For office cystoscopy, 2-percent lidocaine jelly is instilled into the urethra 5 to 10 minutes prior to cystoscope insertion. ...