Cystoscopy

Cystoscopy is a method of endoscopic examination of the bladder using a special device - the cystoscope. There are cystoscopy: a sight for examination of the bladder (Fig. 1); catheterization - to conduct ureteric catheter into the renal pelvis with the purpose of receiving and examination of the urine from each kidney separately (Fig. 2); operational - for extraction of foreign bodies, electrocautery papillomas, biopsy (Fig. 3); fotosistemy. The cystoscope has the form of metal catheter with the short beak in the gallbladder end, which is mounted an electric lamp.
viewing the cystoscope


Fig. 1. Viewing the cystoscope: 1 - endoscopic light; 2 - tube; 3 - pavilion optical tube.
catheterization cystoscope
Fig. 2. Catheterization cystoscope: 1 - endoscopic light; 2 lifts of Albarrana for directions ureteric catheter; 3 - tube; 4 - valve to supply washing liquid; 5 - pipe with valve to introduce ureteric catheter; 6 - control mechanism lift of Albarrana; 7 - pin rings; 8 - valve; 9 - pavilion optical tube; 10 - the pavilion of the cystoscope.
operational cystoscope
Fig. 3. Operational cystoscope with the included biopsy forceps: 1 - tongs, 2 - tube; 3 - pavilion optical tube.


In the channel of the instrument is a complex optical system, with the help of which the image of a wall bladder is passed researcher's eye through the eyepiece. There are cystoscopy larger caliber for adults and a smaller one for children.
Cystoscopy is held with hematuria to identify the source of bleeding, disorders of urination, chronic inflammatory diseases of kidneys and mochevyvodyashih ways, suspected bladder tumors.
Cystoscopy is contraindicated in acute inflammatory diseases of the urinary tract and genital organs.
Prior studies of the cystoscope is sterilized: optical system is removed, the metal parts are dismantled and carefully washed the current stream of warm soapy water. All parts are wiped dry, channels tool blown through the air with a rubber balloon. The tool without the optical system is placed in pairs formalin on the day.
Immediately before use cystoscope wipe wine alcohol (to avoid irritation of the urethra and the bladder from formalin) and liberally smeared with glycerin. If necessary, cystoscopy on the same day, another patient cystoscope after washing place for 15-20 minutes in a solution of oxycyanide mercury 1:1000 or alcohol. The optical system is wiped with gauze soaked in wine alcohol. Ether, benzene, phenol to cleanse the cystoscope and its optical system cannot be applied. Before the examination, you must ensure that the bulb shines and optics transparent.
Usually cystoscopy performed without anesthesia. The patient with a heightened sensitivity to pain before the examination in the urethral lumen syringe without pressure imposed 15-20 ml 1-2% solution novokaina or 15 ml dikaina in solution 3 : 1000.
Patient is placed in a special chair with norderallee. A cystoscope is carried out in the bladder, the optical system of extract and produce washing cavity bladder weak antiseptic solution of oxycyanide mercury 1 : 5000 or solution etakrydina (rivanol) 1 : 3000 to those holes, until the liquid flowing from the bubble, is clear. In total, the bladder should be introduced 200-250 ml of liquid. For the filling of the bladder in one of the above solutions in a tube of cystoscope enter the optical system and, turning cystoscope-axis, examine the bladder wall. Normal mucosa has a pinkish-yellow, shining, smooth, with gentle Grabovetskaya vessels - arteries and veins. The mucous membrane in the field of cystic triangle more red, vessels bigger and more. The mouth of the ureters can take different forms: a slit-like, oval, round and centered on small cylinders.
Chromatotherapy - functional test with Indigo Carmine to determine the functions of the right and left kidney. After insertion of the cystoscope into the bladder and inspection patient is injected with 5 ml of 0.4% solution of Indigo Carmine and watch the gallbladder holes ureters. Monitoring should start with the alleged healthy side. At normal function of the kidneys in 3-5 minutes after the introduction of Indigo Carmine simultaneously from both ureters starts to separate painted blue urine. Lag selection colored urine and the weakening of its color indicates the inhibition of renal function or the presence of obstacles to the flow of urine from the upper urinary tract.

Cystoscopy (from the Greek. kystis - bladder and skopeo - examine, investigate) - method research bladder by direct inspection of the cavity with the help of special device - the cystoscope. The design principle of the cystoscope is that the light source is introduced into the stretched liquid cavity bladder, allowing to consider its walls through a special optical system. Non-leaching model observation of the cystoscope is a metal catheter with curvature Mercier, bill which placed a light bulb, and in the cavity of a catheter - optical system consisting of lenses and prisms (Fig. 1). In most modern cystoscopy optical part is mounted separately from the case of a cystoscope, allowing you to retrieve it during the research for change wash liquid, without removing the case of the cystoscope. The optical system of the cystoscope consists of a lens is placed on the cystic the end of the cystoscope, a rectangular prism reflecting hypotenuse face and kit lenses for the transmission of images and eyepiece, through which, as through a magnifying glass, the doctor examines the image itself.
In modern cystoscopy used prisms, built according to the law of total internal reflection. Developed system of cystoscopy with vnepolozhnym light source, which is used as a special svetodiodnye. The use of optical fibers and powerful light sources allows to achieve a good light, sufficient to fotoritocco and even kinematicheskaya.
Cystoscopy with otvlekayasj optics (flush or irrigation) is equipped with a crane wash system and automatic valve opens when the introduction of the optical system and closed immediately after removing it, preventing reverse leakage of liquid from the bladder (Fig. 2). Anterior to the valve on the body of the cystoscope is located nest to turn on the electric current, consisting of two bushings, separated by an insulating plate, which is attached pin plug connecting cord from the electrical source. The current source can be urban electricity network connectivity special step-down transformer and batteries or dry batteries. From one sleeve inside sleeve of the cystoscope is a stand-alone guide to the core cartridge light bulbs, the second conductor is the building of the cystoscope.
Washing cystoscopy allow to conduct research by introducing into the bladder, the patient one of the tool and provide the ability repeatedly during cystoscopy to flush the bladder, without introducing new instruments. For washing and filling of the bladder remove the optics of the cystoscope into the cartridge through the valve enter a tip or special two-way valve through which fill or empty the bladder. Having cavity bladder transparent environment, crane from the cystoscope is removed and enter the optical system. There are cystoscopy, which lets you shoot the image seen in the bladder. In developed VNIIMP fotoritocco (Fig. 3) at the time of shooting is created increased illumination due to the supply of the device with additional voltage electric current. This allows you to take pictures with short exposures and to use the film medium sensitivity. Catheterizationa cystoscopy (Fig. 4) have the channel, intended for catheters. In the hole, located near the lens lies special metal plate (lever Albarrana), seamed steel thrust with cremalleras. The rotation of the latter rope pulls up and down, due to the changing optional investigating an angle relative to the longitudinal axis of the cystoscope raise the lever by which in the bladder is given the right direction ureter the catheter.
There are cystoscopy with two moves for simultaneous handling of both ureters immediately and unilaterally catheterizationa cystoscopy, which allows to use tubes of large diameter, which is necessary in some cases for therapeutic and diagnostic procedures.
Operating cystoscopy for intravesical operations (Fig. 5), structurally different from catheterization, have a greater diameter of the channel to conduct endovascular instruments (the biopsy forceps and extraction of foreign bodies, scissors, electrodes for electrocoagulation).


Preparation tool. All parts of the instrument wipe with gauze soaked in the solution of green soap and washed under running water. After that, the tool must be dry wiped out all of its channels purged with air by means of a rubber balloon. Thus purified tool (without optical system) store in pairs formalin. Before the introduction into the bladder cystoscope should be spolocnost sterile water (to avoid irritation from formalin), rubbed dipped in wine alcohol Marley and lubricated with glycerin. If necessary, enter the cystoscope on the same day, another patient should be immersed tool for 15-20 minutes in a solution oxycyanides mercury 1 : 1000 or ethyl alcohol.
Technique cystoscopy. Cystoscope when applied to women does not cause sharp pain, and anesthesia during cystoscopy is not required. Men conducting the observation of the cystoscope is also does not require anesthesia. Conducting catheterizationa cystoscope and long term manipulations with him should, as a rule, produce under anesthesia. To do this before it in the lumen of the urethra install without pressure 5-10 minutes 15-20 ml 2-3% solution novokaina or 15 ml dikaina in solution 3 : 1000. Very sensitive patients or painful processes in the bladder should be installed in the cavity bladder through a thin catheter another 20-30 ml anesthetic solution.
A study is made on special rentgenologicsky the table (Fig. 6) after filling of the bladder clear liquid. In the production cystoscopy for catheterization ureters and subsequent retrograde pielografii cystoscope is introduced into the bladder (Fig. 7) by the usual rules (see Catheterization), men always with an optical system or of the obturator. Then make irrigation of the bladder weak antiseptic solution (oxycyanides mercury of 1 : 5000, boric acid 2%, etakrydina 1 : 3000 and so on) until then, until the liquid flowing from the bubble, is crystal clear. Then fill the bladder 200 ml of one of these solutions, introducing the optical system of the cystoscope include electric current, and start direct inspection cavity bladder. More than the specified quantity of the liquid to enter into the bladder does not follow, as in most cavity lighting created by the cystoscope, will be insufficient for a good orientation. Cystoscopy is recommended always with the same filling of the bladder, as depending on the degree of stretching walls zitostaticescoe picture could change (difference of color appearance and disappearance of wrinkles on the walls of the bladder, etc). A necessary condition cystoscopy is completely transparent and calm behavior of the patient. Therefore, if you have acute effects on the urinary bladder in the form of increased painful craving for urinating cystoscopy can be made only by the subsidence of the pains.

Fig. 2. Irrigation cystoscope: 1 - automatic valve; 2 - valve flushing system with dual shock.
Fig. 3. Fotoritocco with the camera "Narcissus" design VNIIMP.
Fig. 5. Operational cystoscope design VNIIMP.
Fig. 6. Rentgenologicsky Desk. The position of the patient for cystoscopy.

Modern cystoscope consists of two parts: external and internal.
The outer part is called the body of the cystoscope is a metal tube in the bill which is screwed light bulb in a metal frame (Fig. 21), and in the outer end is inserted automatic spring valve that prevents the leakage of fluid from it (Fig. 22).
In the case of the cystoscope along its walls runs thin insulated wire that connects the bulb with a contact near the opposite end (pavilion) catheter. This contact is put the plug is connected to a light source. The light source can serve ordinary electric current lighting network, voltage is through a step-down transformer is brought to 4-5 volts, or dry battery pocket lantern.
The inner part of the optical tube is a thin metal hollow cylinder, which is freely inserted into the body of the cystoscope. In the lumen of the optical tube mounted optical system: some distance 1 cm from the gallbladder to the end that is inserted prismatic lens, and centrally her lens. Over the prism in the wall of the tube is made a hole, covered with a thin glass. When the optical system is inserted into the lumen catheter, this hole is at the level of the window catheter (Fig. 23).
Rays of light falling on the mucous membrane of the urinary bladder, recorded it and get into the prism optical tube, where are refracted and sent along the long axis of optics. The image of a part of the mucous membrane, stone, tumors, and so on, which is facing at this moment prism, the result in reduced lens, mirror and back. At different distances from each other in the lumen of the tube is placed a few lenses, the latest of which is a Lupu - the eyepiece. The lens system transforms the image coming from the lens, actual, direct, and increased up to 2-5 times, depending on the degree of approximation of a prism to the site. The greater the distance between them, the smaller the image size.
On the rim of the eyepiece there is a button that indicates where currently facing prism.
This is basically a device least complicated, so-called observation, the cystoscope, allowing you to explore the cavity bladder.
Using catheterization cystoscope is possible not only to examine the bladder, but also to perform urethral catheterization. Along the rear of the cystoscope laid one or two thin channel for conducting ureteric catheter (unilateral and bilateral catheterizationa cystoscopy). In the window near the beak of the cystoscope is mounted a metal plate - tongue of Albarrana. This disk is connected to the cable, taking place in the body of the cystoscope. The cable is driven screw cremallera located in the pavilion of the cystoscope. Movement cremallera the tab Albarrana can be rejected from the long axis of the cystoscope different angles up to direct (Fig. 24). Thus the tip ureteric catheter attached to the corresponding direction that allows you to enter it in the mouth of the ureter (see Fig. 36).

Fig. 21. The housing inspection irrigation cystoscope.
Fig. 22. Automatic valve of the cystoscope.
Fig. 23. Optical tube cystoscope.
I, a prism; b - eyepiece; in - button indicating the direction of the prism. II - optic tube is introduced into the body of the cystoscope. Prism optical tube turned to the window casing.
Fig. 24. Catheterization cystoscope.
A - one-way; - bilateral; and - cremallera cystoscope; b - reed of Albarrana omitted; the tongue of Albarrana raised, giving the right direction ureter the catheter.

Operational cystoscope is a unilateral catheterization cystoscope, optical tube which is thinner than usual, and catheterization channel wider. Through him you can enter into the bladder various tools on the long, flexible metal hose, such as pliers to remove foreign bodies, double sharp spoon biopsy, scissors. Such indonesienne instruments depicted in Fig. 25.
Cystoscope-the device is intended for kamnedrobilniy under the control of the eyes. By design, it differs from the usual cystoscopy the fact that the optical system is mounted together with lighting system in the same tube. Instead of the light bulb on the end of the catheter are two branches with teeth. Turns cremallera pushing the branches, seize and crushed stones (Fig. 26).
Sterilization cystoscopy boiling invalid because it violates the wire and dissolve the glue, which are fixed lenses. Boiling subject only to the circle, which is filled with cleansing liquid, rubber tube, which connects it with the crane, and the faucet. A cystoscope is sterilized by immersion individual parts - metal body, optics, the valve - in a solution oxycyanides mercury of 1 : 1000 for 15-20 minutes. After drinking the cystoscope is washed with running water, then every detail wipe with a cotton ball moistened with alcohol, again immersed in a solution oxycyanides mercury for 15 minutes and drain ether. Disassembled the cystoscope is better to store in the closet between two dry towels.
Cystoscopy is in urological or gynaecological chair. Before it the patient produces the urine. After processing the external opening of the urethra in the urethra men with the help a syringe with a cone-shaped rubber tip enter 10-20 ml 1-3% solution novokaina, who are detained for 5-10 minutes in the urethra through a special clip, superimposed on the penis back of the head in the transverse direction. Women cystoscopy is performed without anesthesia urethra. Injection technique cystoscope is the same as the metal of the catheter. After insertion of the cystoscope into the bladder optical system removed and instead enter the two-way valve, enabling quick and easy to fill and to empty the bladder (Fig. 27). The bladder is entered warm wash liquid until the urge to urinate and presented back to the substituted graduated glass. This determines the capacity of the bladder. Bladder washed and filled with a solution of rivanol (1 : 10000) or oxycyanides mercury (1:10000), then wash tap delete.
To conduct cystoscopy is necessary to fill the bubble wash fluid was transparent. Sometimes at considerable admixture in urine, blood or pus requires multiple laundering bubble to get at least 1-2 minutes relatively transparent environment. When hematuria, due to a bleeding tumor or ulcer, urinary bladder, you should make the laundering hot (42 degrees) liquid in small portions, not letting the entire washing fluid from the bladder. Hot solution helps to stop bleeding, incomplete removal of fluid from the bladder when washing prevents significant reduction of the detrusor and creates favorable conditions to stop the bleeding. When a cluster in a bubble of a large number of blood clots need to remove them using a special emergency catheter large calibre (Fig. 28).
After laundering bubble injected wash liquid to the physiological capacity it, i.e. 200-250 ml. At reduced capacity of bubble liquid is injected until the urge to urinate. If capacity is below 30-40 ml cystoscopy is often impossible.

Fig. 25. Tools for endovascular operations.
a - double acute stomach biopsy; b - scissors; in - tongs; g - electrode.
Fig. 26. Cystoscope-lithotripter (A), branches (B), optical and lighting system (In), rod (G).
Fig. 27. Two-way valve for the cystoscope.
Fig. 28. Evacuation catheter.
a - catheter; b - rod to the catheter.

Removing the crane, the cystoscope is injected optical tube, connect to the contact, and proceed to the examination of the mucous membrane of the bubble.
First, inspect the front wall, and then, slowly turning the cystoscope around its axis clockwise and moving it from the neck to the top of the bubble and back, examining the side walls, the bottom of the bladder, mouth ureters and transitional fold.
Normal mucosa of the bladder has a light pink color, it is smooth and slightly shiny. On the background of it is visible to the network of small blood vessels (Fig. 29).
When viewed from the front wall is visible bubble or group of air bubbles (Fig. 30), penetrating from the lumen of the cystoscope in the washing of the bubble. When the status buttons for 5 hours conditional dial you can see the mouth of the left ureter, and the 7-hour - right. The mouth of the ureters are located in the corner of the cystic triangle at the ends of the muscle rollers, obliquely converging down to the middle line, to the inner opening of the urethra (Fig. 31).
In the field of cystic triangle mucosa more intensively painted in red, because the vascular network here is more dense than in the other areas (Fig. 32).
The mouth of the ureters are slit-like shape. In the cystoscope is possible to see their periodic expansion, accompanied by throwing a trickle of urine, colorless normal, colored red in renal bleedings (Fig. 33), blue with indigocarmina the sample (Fig. 34).
Obstacles to the flow of urine, such as the narrowing of the urethra, prostate hypertrophy, violation of innervation of the bladder, causing the hypertrophy of the muscle fibers in the form of bars, lifting over a mucous membrane of the bubble - trabecular or log bubble (Fig. 35, Fig. 29-32 see inset between pages 64-65; Fig. 33-35 see inset between pages 80-81).
Description cystoscopies paintings cystitis, tuberculosis, tumors, diverticula, atony bladder and other diseases is given in appropriate sections. Contraindications to cystoscopy are acute infectious diseases, acute inflammation of the urethra, bladder and sexual glands - prostate, testicles and their appendages, traumatic damage to the urethra and bladder.


Fig. 29. Normal mucosa of the bladder.

Fig. 30. Air bubble to the top of the bubble.

Fig. 31. Cystic triangle and the mouth of the ureters (polythematic).

Fig. 32. Thick vascular network in the region of the left half of the gallbladder triangle. At the apex of the triangle shows the mouth of the left ureter.

Fig. 33. The discharge bloody urine from the mouth of the right ureter.

Fig. 34. The selection of the urine stream, dyed Indigo Carmine, from the mouth of the left ureter.

Fig. 35. Trabecular (log) bladder wall.