• A cystoscopy is performed to visualize and examine the inner surface of the urethra and bladder; it is an endoscopic procedure.
• The cystoscope is either flexible or rigid and is inserted into the urethra. The distal end has either a lens or fiberoptic apparatus to allow visualization via a proximal eyepiece or monitor, respectively.
  • To enhance visualization, sterile fluid is used to distend and stretch the bladder.
  • The cystoscope has extra channels that allow for instruments to be inserted in order to perform biopsies, stent placement, dilation, laser procedures, stone removal, or intravesical administration of medications (e.g., Bacillus-Calmette-Guérin (BCG): A live, attenuated strain of Mycobacterium bovis as adjuvant treatment for nonmuscle invasive bladder cancer).
• Modifications/enhancements of this endoscopic procedure include transurethral resection of bladder tumor (TURBT) and transurethral resection of the prostate (TURP). A resectoscope is utilized to remove the tissue.
• Indications include frequent urinary tract infections (UTIs), hematuria, unusual cells seen in urine samples, chronic pelvic pain, cystitis, dysuria, blockage from the prostate, stones, or abnormal growth/tumor/polyps.
• A ureteroscope is a longer, thinner instrument that can be used to visualize and examine the ureters and upper urinary tract structures.

• Lithotomy
• Often requires the Trendelenburg position

Natural orifice procedure via the urethra

5 minutes to 1 hour

Minimal

Pathology dependent. Many procedures are performed on an outpatient basis.

• Cystoscope
• Ureteroscope
• Resectoscope

Incidence

Approximately 67,000 new cases of bladder cancer per year.

Prevalence

Bladder cancer is three times more common in males than females; more common in patients >55 years old; and twice as common in Caucasians as African Americans.

• Pain
• Urinary tract infection
• Urinary tract obstruction
• Bladder, urethral, or urethra perforation or injury

History

• Hematuria
• Calculi
• Bladder tumor/cancer
• UTI
• Urinary tract obstruction
• Hydronephrosis

Signs/Physical Exam

• Tachycardia or fever may suggest an infectious process
• Cardiopulmonary exam

Labs/Studies

• Metabolic panel if acute kidney injury is suspected
• CBC and coagulation factors if hematuria
• Urinalysis and urine culture, if UTI
• EKG and chest x-ray as per standard criteria
• Renal ultrasound for urinary tract obstruction and hydronephrosis
• Abdominal plain film or CT scan may show calculi

• Anxiolysis as appropriate; use cautiously in elderly patients.
• Opioids as appropriate

Patients undergoing monitored anesthesia care or a regional technique plus MAC should still be consented for general anesthesia as a backup.

• First line: Fluoroquinolone within 1 hour of the procedure
• Second line: Trimethoprim–sulfamethoxazole, or gentamicin with ampicillin
• Escherichia coli is most common organism

• Local anesthesia is often used for flexible diagnostic cystoscopy.
• Monitored anesthesia care should be considered for diagnostic flexible cystoscopy in patients unable to tolerate local anesthesia.
• Neuraxial anesthesia with a T10 level is adequate for most urologic procedures. However, it does not reliably block the obturator nerve. An awake patient is the best monitor for mental status changes in TURP syndrome.
• Regional anesthesia. An obturator nerve block may be considered in conjunction with neuraxial techniques if inferolateral bladder wall resection is anticipated. It prevents patient movement if the nerve is stimulated and decreases the risk of bladder perforation (2) [A].
• General anesthesia is commonly used.

• Standard ASA monitors
• Invasive monitoring is dictated by the patient's comorbidities

• General anesthesia with a laryngeal mask airway (LMA) or endotracheal tube (ETT).
• LMA can be used if the patient is NPO, not at risk for aspiration, and has an "adequate" FRC. Supraglottic devices may decrease the incidence of airway reactivity in patients with asthma or chronic obstructive pulmonary disease (COPD). Muscle relaxation for the procedure may still be utilized.
• ETT should be used if the patient is not NPO, possesses risk factors for aspiration, or if the lithotomy and Trendelenburg positions may hinder spontaneous ventilation (e.g., truncal obesity, decreased pulmonary compliance).
• In patients with renal failure or hyperkalemia, succinylcholine may be contraindicated. If a rapid sequence induction is indicated, consider rocuronium (drawback = duration may be prolonged) or cisatracurium (drawback = longer time to onset).

• Balanced anesthetic with volatile or IV medications.
• Surgical irrigating fluids may be absorbed in some cases. TURP procedures pose the highest risk due to open prostatic venous sinuses; thus irrigating time should be kept as short as possible.
• Hemodynamics should be maintained close to baseline values, particularly in patients with end-organ damage.
• Hypothermia may occur due to cold irrigating fluids. Normothermia can be maintained with increased ambient room temperature, upper body forced air warming blanket, or warm IV fluids.
• Narcotics. In patients who are spontaneously breathing with an LMA, titrate to respiratory rate.
• Duration of action of nondepolarizing muscle relaxants may be prolonged if gentamicin is given or the patient is hypothermic.
• Radiation safety precautions should be implemented if fluoroscopy is used.
• Laser protective goggles should be implemented for the patient and OR staff if laser therapy is utilized.

• Antiemetic prior to emergence
• Ensure complete akinesis until legs are out of lithotomy.
• Awake extubation after reversal of muscle relaxation and when routine respiratory parameters are met.