Paraplegia 32 (1994) 454-462 © 1994 International Medical Society of Paraplegia Flexible cystoscopy in spinal cord injury. Review article 2 D A Rivas MD, 1 M B Chancellor MD I Fellow, Neuro-Urology, 2 Assistant Professor of Urology, Department of Urology, Iefferson Medical College, 1025 Walnut St, Philadelphia, PA 19107, USA. Endoscopy of the urinary tract remains the cornerstone of urological therapy. Over the years, continued refinement of the endoscopic instruments has per­ mitted a progressive increase in the number and methods of their application. The development of the smaller diameter, flexible endoscopes represents the greatest advance in urological endoscopy. Their characteristics permit greater versatility with less traumatic procedures, increasing patient comfort and mini­ mizing iatrogenic injury. Spinal cord injury (SCI) patients are a select group, which require special attention when undergoing endoscopic procedures. Often a contracted bladder or poorly controlled muscle spasms make the SCI patient difficult to endoscope using conventional rigid instruments. Furthermore, auto­ nomic dysreflexia is a significant concern during traumatic urinary tract in­ strumentation. This communication will discuss the applications of flexible cystoscopy, including novel techniques, which can be useful in SCI patients. Keywords: spinal cord injuries; cystoscopy; flexible cytoscopes; urodynamics; bladder; urethra. Introduction flexible imaging bundles allowed for a truly flexible, actively deflectable endoscope. 1 The ability to directly visualize the features This new generation of instruments ini­ of the urinary tract is of paramount import­ tially met with a poor reception, as illumina­ ance when urological dysfunction develops. tion and visualizing power were somewhat The limitations of urological endoscopy decreased when compared to traditional have largely been determined by the in­ rigid instrumentation.2 The ability to reach strumentation itself. Initially, incandescent convoluted areas of the urinary tract, bulbs provided illumination which was however, provided a strong impetus for barely adequate for visualization. Once further development. Over the past two cold-source lighting via fiberoptic cords was decades, continued refinement of flexible developed, image conduction using the rod/ urological endoscopes has resulted in the lens system further enhanced endoscopic development of increasingly smaller instru­ capabilities. ments of superior quality, with exceptional With superior ability to illuminate and illumination, visualization, and working visualize the internal bodily cavities, the capabilities.3 next most significant development came in the form of flexibility. Prior to the advent of flexible endoscopes, rigid instrumentation Basic endoscopy could often not adequately reach convolu­ Endoscopic examination of the urethra and tions of the lumenal surfaces. This limitation bladder is the most elementary urological was compensated for by adjusting the angle procedure. It may be included in the evalu­ of the rigid lens, but was not remedied until ation of a patient with urinary tract dysfunc­ tion, symptomatology, or hemorrhage. In Correspondence to David A Rivas MD. Suite 1112 addition, it is the initial step towards gaining College Bldg, 1025 Walnut St, Philadelphia, PA access to the urinary tract for other diag­ 19107, USA. nostic and therapeutic maneuvers, such as Paraplegia 32 (1994) 454-462 Flexible cystoscopy in spinal cord injury 455 ureteral stenting and ureteroscopy for stone graphy.8 The need to perform cystoscopy disease.4 may arise intraoperatively when the surgeon Traditionally, basic cystoscopy has been least expects it. The use of a rigid cysto­ performed using rigid instruments, which scope, necessitating the lithotomy position, require the dorsolithotomy position in order may require patient repositioning, reprep­ to permit adequate endoscopic inspection. ping, and redraping, resulting in the loss of Often those with spinal or hip joint arthritis valuable time, increasing expense, and in­ experience some discomfort with such posi­ creasing the risk of iatrogenic infection. The tioning. flexible cystoscope, however, may be util­ Several lens angle systems (0°, 30°, 70°, ized without such extensive maneuvers, 120°) may be required to completely visual­ provided that the urethra is accessibleY ize the entire urothelial surface, including Flexible cystoscopy is a valuable pro­ the urethra and bladder neck, because of cedure which can be used under many the often convoluted angles of the urinary different circumstances. Even retrograde bladder. Due to the rigid nature of the ureteropyelograms can be performed, if instrument and the stress it imposes on necessary, under what may be less than urogenital tissues, anesthesia is often re­ ideal conditions.8 Male and female patients quired in order for the patient to tolerate a have been examined in both the prone and thorough examination. supine positions.lO Flexible instrumentation can be used in the outpatient, office setting, essentially replacing rigid cystoscopy for Flexible cystoscope development diagnostic purposes.ll Clayman has des­ Flexible cystoscopy was first introduced by cribed its versatility during percutaneous Tsuchida & Sugarawa in 1973.5 Since that procedures.6 time, the usefulness of the technique has Flexible endoscopy of the urinary tract been greatly extended (Table J). Flexible has facilitated the diagnosis and treatment cystoscopy has been used as an adjunct in of urological di<;'"ase for both the patient percutaneous stone extraction,6 for ureteral and the physician.3 Early reports of flexible catheterization,? and retrograde uro- endoscopy were elementary, and limited to examinations of the b!adder.5 Refinements Table I Applications of flexible cystoscopy in of techniques and advances in technology spinal cord injured patients have enabled investigators to perform tasks previously reserved for rigid endoscopes. 1-4 Diagnostic The working port permits biopsy, fulgura­ Evaluate for tumor, stones, stents, strictures, tion, laser therapy, the retrieval of foreign and bladder neck obstruction bodies and calculi, and ureteral guidewire Endourodynamic placement for catheterization or further Retrograde urethrogram, cystogram, and pyelo­ instrumentation.12 Several series comparing gram flexible with rigid endoscopy have uni­ Bedside endoscopy of acute and spinal unstable SCI versally shown less patient discomfort, decreased anesthetic requirements, and Therapeutic equivalent diagnostic capabilities with flex­ Bladder biopsy 1,12 Placement and removal of ureteral guidewire ible cystoscopy. and stents The advent of flexible cystoscopy has Laser fiber and electrohydraulic fibers for treat­ permitted a more comfortable routine ment of bladder stone, tumor, and obstruc­ examination, eliminating the need for the tion lithotomy position. The flexibility of the Assist in ESWL: retrograde imaging shaft of the instrument is less stimulating, Deflate jammed Foley catheter balloon therefore sedation is rarely necessary. The Bedside diagnosis of urinary tract bleeding and actively deflectable tip of the endoscope assist in difficult ureteral catheter insertion may be angled up to 220°, permitting a Ureteral stent insertion for decompression of thorough examination without the need for hydronephrosis the interchanging of different lenses. Taken 456 Rivas and Chancellor Paraplegia 32 (1994) 454-462 together, these flexible characteristics allow needed with flexible cystoscopy; topical a complete examination of the patient in lidocaine (2% jelly) is our anesthetic of either the supine, prone, sitting or oblique choice. Although the patient with complete positions.4 suprasacral SCI does not perceive pain with cystoscopy, topical anesthesia is helpful in diminishing noxious stimuli in those suscept­ Flexible cystoscopy: general considerations ible to the development of autonomic dys­ A patient with a spinal cord injury may reflexia (AD). We will detail below particu­ require endoscopic evaluation for several lar precautions required for such patients. different reasons. In general, such patients Universal precautions should be practiced often have muscle spasms and limb contrac­ by all personnel performing and assisting tures, making them difficult to be placed in with the procedure. Eye protection and a the lithotomy position. The flexibility of the mask to cover the mouth and nose are nonrigid instrumentation permits endoscopy essential, as splashing of urine that may be in the supine position in those in whom rigid contaminated with blood and semen may endoscopy might not otherwise be possible. transmit the human immunodeficiency and Indeed, in the case of outpatient, in-office the hepatitis viruses. examinations, the endoscopic procedure Sterile water or saline irrigation improves may be performed while a male patient is visibility and allows bladder distention to seated in his wheelchair, avoiding the need maximize the surface area to be inspected. to transfer to an examining table. Dilute sterile radiographic contrast may be Described below are flexible cystoscopy used if a fluoroscopic cystogram is to be techniques which facilitate endoscopic combined with flexible endoscopy. This examination of the lower urinary tract in dilute contrast solution does not impair nearly every situation which we have en­ visual acuity. countered at the Regional Spinal Cord In patients in whom we anticipate the Injury Center of the Delaware Valley, possibility