Introduction Cystoscopy (cystourethroscopy) is a diagnostic procedure that uses a cystoscope, which is an endoscope especially designed for urological use

to examine the bladder, lower urinary tract, and prostate gland. It can also be used to collect urine samples, perform biopsies, and remove small stones. Purpose Cystoscopy is performed by urologists to examine the entire bladder lining and take biopsies of any questionable areas. Cystoscopy may be prescribed for patients who display the following conditions:
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blood in the urine (hematuria) inability to control urination (incontinence) urinary tract infection signs of congenital abnormalities in the urinary tract suspected tumors in the bladder bladder or kidney stones signs or symptoms of an enlarged prostate pain or difficulty urinating (dysuria) disorders of or injuries to the urinary tract symptoms of interstitial cystitis

Blood and urine studies, in addition to x rays of the kidneys, ureters, and bladder, may be performed before a cystoscopy to obtain as much diagnostic information as possible. During the cystoscopy, a retrograde pyelogram may also be performed to examine the kidneys and ureters.

Description There are two types of cystoscopes used to carry out the procedure, a rigid type and a flexible type. Both types are used for the same purposes and differ only in their method of insertion. The rigid type requires that the patient adopt the lithotomy position, meaning that the patient lies on his or her back with knees up and apart. The flexible cystoscope does not require the lithotomy position.

A cystoscopy typically lasts from 1040 minutes. The patient is asked to urinate before surgery and advised that relaxing pelvic muscles will help make this part of the procedure easier. A well-lubricated flexible or rigid cystoscope (urethroscope) is passed through the urethra into the bladder where a urine sample is taken. There may be some discomfort as the instrument is inserted. Fluid is then injected to inflate the bladder and allow the urologist to examine the entire bladder wall. The cystoscope uses a lighted tip for guidance and enables biopsies to be taken or small stones to be removed through a hollow channel in the cystoscope. During a cystoscopy, the urologist may remove bladder stones or kidney stones, gather tissue samples, and perform x-ray studies. To remove stones, an instrument that looks like a tiny basket or grasper is inserted through the cystoscope so that small stones can be extracted through the scope's channel. For a biopsy, special forceps are inserted through the cystoscope to pinch off a tissue sample. Alternatively, a small brush-like instrument may be inserted to scrape off some tissue. To perform x-ray studies such as a retrograde pyelogram, a dye is injected into the ureter by way of a catheter passed through the cystoscope. After completion of all required tests, the cystoscope is removed.

Preparation Patients may be asked to give a urine sample before cytoscopy to check for infection and to avoid urinating for an hour before this part of the procedure. They wear a hospital gown during the procedure and the lower part of the body is covered with a sterile drape. A sedative may be given about one hour prior to the operation to help the patient relax. The region of the urethra is cleansed and a local anesthetic is applied. Spinal or general anesthesia may also be used for the procedure. Distension of the bladder with fluid is particularly painful, and if it needs to be done, as in the case of evaluating interstitial cystitis, general anesthesia is required. A signed consent form is necessary for this procedure.

Aftercare After removal of the cystoscope, the urethra is usually sore, and patients should expect to feel a burning sensation while urinating for one to two days following the procedure. To alleviate discomfort or pain, patients may be prescribed pain

medication, and antibiotics may also be required to prevent infection. Minor pain may also be treated with over-the-counter, nonprescription drugs such as acetaminophen . To relieve discomfort, patients may be advised to drink two 8oz glasses of water each hour for two hours and to take a warm bath to relieve the burning feeling. If not able to bathe, they may be advised to hold a warm, damp washcloth over the urethral opening.

Patients who have undergone a cystoscopy are instructed to:

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Take warm baths to relieve pain. Rest and refrain from driving for several days, especially if general anesthesia was used. Expect any blood in the urine to clear up in one to two days. Avoid strenuous exercise during recovery. Postpone sexual relations until the urologist determines that healing is complete.

Risks As with any surgical procedure, there are some risks involved with a cystoscopy. Complications may include profuse bleeding, a damaged urethra, a perforated bladder, a urinary tract infection, or an injured penis. Patients should contact their physician if they experience any of the following symptoms after the procedure, including pain, redness, swelling, drainage, or bleeding from the surgical site; signs of generalized infection, which may include headache, muscle aches, dizziness, or an overall ill feeling and fever; nausea or vomiting; or difficult or painful urination. Cystoscopy is a commonly performed procedure, but it is an invasive technique that involves small yet significant risk. If anesthesia is required, there is additional risk, particularly for people who are obese, smoke, or are in poor health. Those undergoing anesthesia must inform the doctor of any medications they are taking.

Normal results A successful cystoscopy includes a thorough examination of the bladder and collection of urine samples for cultures. If no abnormalities are seen, the results are indicated as normal. In this case, the bladder wall appears smooth and the bladder is seen to be of normal size, shape, and position, without obstructions, growths, or stones. The treating physician can tell the patient what was seen inside the bladder right after the procedure. If a biopsy sample was taken, this will take several days to be examined and tested. Cystoscopy allows the urologist to detect inflammation of the bladder lining, prostatic enlargement, or tumors. If these are seen, further evaluation or biopsies may be needed. Cystoscopy with bladder distention can also evaluate interstitial cystitis. Bladder stones, urethral strictures, diverticula, or congenital abnormalities can also be detected. Alternatives There are procedures that can provide some information about the lining of the bladder, for example, x rays; however, none of these provide as much information to the doctor as a cystoscopy.

When to Seek Medical Care Do not hesitate to call your doctor if you experience problems after the procedure.
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It is common to experience some burning with urination, but this should go away quickly. You may also see blood in the urine off and on for a couple of weeks. You need to call your doctor if you experience fever, excessive bleeding, urinary retention, ortesticular pain. At times, some of these situations could be managed at home but frequently will require immediate evaluation.

Fever after an operation such as cystoscopy can signal the onset of infection. Most often, either the urine or the kidneys or both will become infected. Urinary burning and frequency of urination are common symptoms of urinary tract infections. Some people may have only fever and vomiting. Pneumonia is a less frequent source of fever.Thrombophlebitis, an infection of the vein used for IV access during surgery, can also occur. Your doctor needs to be notified immediately if you develop a fever, even if you are already taking antibiotics. If the office is closed, you will frequently be referred to the Emergency Department for an evaluation. Bleeding after cystoscopy is common. When you notice bleeding, rest and increase your fluid intake (unless you have a medical condition in which you should not). Notify your doctor at once if you feel that you are experiencing too much bleeding. An Emergency Department visit is generally necessary if your urine becomes so bloody that you could not read a newspaper through it or if you are passing blood clots in the urine. Your bladder may need to be washed out to remove the clots. You may need to be hospitalized to control the bleeding. Blood clots can block the flow of urine, causing urinary retention. Acute urinary retention is a medical emergency. You should see your doctor or go to the Emergency Department. Do not wait long for your doctor to call you back because this condition can continue to become increasingly uncomfortable until the bladder is drained with a catheter. Your doctor should be notified immediately if you experience testicular pain and swelling. You will likely need to be evaluated by a physician. Although this will usually reveal testicular inflammation or infection, torsion (a twisting of the testicle) needs to be ruled out.

Transurethral resection of the prostate

Transurethral resection of the prostate (TURP) is a surgical procedure by which portions of the prostate gland are removed through the urethra.

Purpose The prostate is a gland that is part of the male reproductive system. It consists of three lobes, and surrounds the neck of the bladder and urethra (tube that channels urine from the bladder to the outside through the tip of the penis). The prostate weighs approximately one ounce (28 g), and is walnut-shaped. It is partly muscular and partly glandular, with ducts opening into the urethra. It secretes an antigen called prostate-specific antigen (PSA), and a slightly alkaline fluid that forms part of the seminal fluid (semen) that carries sperm. A common prostate disorder is called benign prostatic hyperplasia (BPH) or benign prostatic enlargement (BPE). BPH is due to hormonal changes in the prostate, and is characterized by the enlargement or overgrowth of the gland as a result of an increase in the number of its constituent cells. BPH can raise PSA levels two to three times higher than normal. Men with increased PSA levels have a higher chance of developing prostate cancer. BPH usually affects the innermost part of the prostate first, and enlargement frequently results in a gradual squeezing of the urethra at the point where it runs through the prostate. The squeezing sometimes causes urinary problems, such as difficulty urinating. BPH may progress to the point of generating a dense capsule that blocks the flow of urine from the bladder, resulting in the inability to completely empty the bladder. Eventually, this could lead to bladder and kidney malfunction. Transurethral resection of the prostate (TURP) is the treatment of choice for BPH, and the most common surgery performed for the condition. "Transurethral" refers to the procedure being performed through the urethra. "Resection " refers to surgical removal.

Demograhics Prostate disease usually occurs in men over age 40. BPH eventually develops in approximately 80% of all men. Prostate cancer occurs in one out of 10 men. In the United States, more than 30,000 men die of prostate cancer each year.

Description TURP is a type of transurethral surgery that does not involve an external incision. The surgeon reaches the prostate by inserting an instrument through the urethra. In addition to TURP, two other types of transurethral surgery are commonly performed, transurethral incision of the prostate (TUIP), and transurethral laser incision of the prostate (TULIP). The TUIP procedure widens the urethra by making small cuts in the bladder neck (where the urethra and bladder meet), and in the prostate gland itself. In TULIP, a laser beam directed through the urethra melts the tissue. The actual TURP procedure is simple. It is performed under general or local anesthesia. After an IV is inserted, the surgeon first examines the patient with a cystoscope, an instrument that allows him or her to see inside the bladder. The surgeon then inserts a device up the urethra via the penis opening, and removes the excess capsule material that has been restricting the flow of urine. The density of the normal prostate differs from that of the restricting capsule, making it relatively easy for the surgeon to tell exactly how much to remove. After excising the capsule material, the surgeon inserts a catheter into the bladder through the urethra for the subsequent withdrawal of urine.

Preparation BPH symptoms include:

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increase in urination frequency, and the need to urinate during the night difficulty starting urine flow a slow, interrupted flow and dribbling after urinating sudden, strong urges to pass urine

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a sensation that the bladder is not completely empty pain or burning during urination

In evaluating the prostate gland for BPH, the physician usually performs a complete physical examination as well as the following procedures:
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Digital rectal examination (DRE). Recommended annually for men over the age of 50, the DRE is an examination performed by a physician who feels the prostate through the wall of the rectum. Hard or lumpy areas may indicate the presence of cancer. Prostate-specific antigen (PSA) test. Also recommended annually for men over the age of 50, the PSA test measures the levels of prostate-specific antigen secreted by the prostate. It is normal to observe small quantities of PSA in the blood. PSA levels vary with age, and tend to increase gradually in men over age 60. They also tend to rise as a result of infection (prostatitis), BPH, or cancer.

Pre-operative Management: 1. Inform the patient about the procedure and the expected postoperative care, including catheter drainage, irrigation and monitoring of hematuria. 2. Discuss the complications of surgery which include: 3. Incontinence or dribbling of urine up to 1 year after surgery and that Kegels exercise will help alleviate this problem 4. Retrograde ejaculation 5. Bowel preparation is given. 6. Optimal cardiac, respiratory and circulatory status should be achieved to decrease risk of complications. 7. Prophylactic antibiotics are ordered. Post-operative Management: 1. Urinary drainage is maintained and observed for signs of hemorrhage. 2. Maintain patency of urethral catheter. 3. Avoid overdistention of bladder, which could lead to hemorrhage. 4. Administer anti-cholinergic medications to reduce bladder spasms. 5. Maintain bed rest for the first 24 hours. 6. Encourage early ambulation, thereafter to prevent embolism, thrombosis and pneumonia. 7. Wound care is provided to prevent infection.

8. Administer pain medications. 9. Promote comfort through proper positioning. 10. Administer stool softeners to prevent straining that can lead to hemorrhage. 11. Reduce anxiety by providing realistic expectations about postoperative discomfort and overall progress. 12. Encourage patient to express fears related to sexual dysfunctions and to discuss with partner. 13. Teach measures to regain urinary control.

The initial recovery period lasts approximately one week, and includes some pain and discomfort from the urinary catheter. Spastic convulsions of the bladder and prostate are expected as they respond to the surgical changes. The following medications are commonly prescribed after TURP:
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B&O suppository (Belladonna and Opium). This medication has the dual purpose of providing pain relief and reducing the ureteral and bladder spasms that follow TURP surgery. It is a strong medication that must be used only as prescribed. Bulk-forming laxative. Because of the surgical trauma and large quantities of liquids that patients are required to drink, they may need some form of laxative to promote normal bowel movements. Detrol. This pain reliever is not as strong as B&O. There may be wide variations in its effectiveness and the patient's response. It also controls involuntary bladder contractions. Macrobid. This antibiotic helps prevent urinary tract infections. Pyridium. This medication offers symptomatic relief from pain, burning, urgency, frequency, and other urinary tract discomfort.

When discharged from the hospital, patients are advised to:

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Refrain from alcoholic beverages. Avoid sexual activities for a few weeks. Avoid driving a car for a week or more. Keep domestic activities to a minimum. Avoid weight lifting or strenuous exercise.

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Check their temperature and report any fever to the physician. Practice good hygiene, especially of the hands and penis. Drink plenty of liquids.

Risk Serious complications are less common for prostate surgery patients because of advances in operative methods. Nerve-sparing surgical procedures help prevent permanent injury to the nerves that control erection, as well as injury to the opening of the bladder. However, there are risks associated with prostate surgery. The first is the possible development of incontinence, the inability to control urination, which may result in urine leakage or dribbling, especially just after surgery. Normal control usually returns within several weeks or months after surgery, but some patients have become permanently incontinent. There is also a risk of impotence, the inability to achieve penile erection. For a month or so after surgery, most men are not able to become erect. Eventually, approximately 4060% of men will be able to have an erection sufficient for sexual intercourse. They no longer ejaculate semen because removal of the prostate gland prevents that process. This effect is related to many factors, such as overall health and age. Other risks associated with TURP include:
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blood loss requiring transfusion postoperative urinary tract infection unsatisfactory long-term outcome

TURP syndrome effects 26% of TURP patients. Symptoms may include temporary blindness due to irrigation fluid entering the bloodstream. On very rare occasions, this can lead to seizures, coma, and even death. The syndrome may also include toxic shock due to bacteria entering the bloodstream, as well as internal hemorrhage.

Normal Results

Normal post-operative symptoms include:

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urination at night and reduced flow mild burning and stinging sensation while urinating reduced semen at ejaculation bladder control problems mild bladder spams fatigue urination linked to bowel movements

To eliminate these symptoms, patients are advised to:

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Exercise. Retrain their bladder Take all medications that were prescribed after TURP Inform themselves via support groups or pertinent reading Get plenty of rest to facilitate the post-surgery healing process

Transurethral Resection of Bladder Tumor Transurethral bladder resection is a surgical procedure used to view the inside of the bladder, remove tissue samples, and/or remove tumors. Instruments are passed through a cystoscope (a slender tube with a lens and a light) that has been inserted through the urethra into the bladder.

Purpose Transurethral resection is the initial form of treatment for bladder cancers. The procedure is performed to remove and examine bladder tissue and/or a tumor. It may also serve to remove lesions, and it may be the only treatment necessary for noninvasive tumors. This procedure plays both a diagnostic and therapeutic role in the treatment of bladder cancers. Description Cancer begins in the lining layer of the bladder and grows into the bladder wall. Transitional cells line the inside of the bladder. Cancer can begin in these lining cells. During transurethral bladder resection, a cystoscope is inserted through the urethra into the bladder. A clear solution is infused to maintain visibility, and the tumor or tissue to be examined is cut away using an electric current. A biopsy is taken of the tumor and muscle fibers in order to evaluate the depth of tissue involvement, while avoiding perforation of the bladder wall. Every attempt is made to remove all visible tumor tissue, along with a small border of healthy tissue. The resected tissue is examined under the microscope for diagnostic purposes. An indwelling catheter may be inserted to ensure adequate drainage of the bladder postoperatively. At this time, interstitial radiation therapy may be initiated if necessary.

Diagnosis and Preparation If there is reason to suspect a patient may have bladder cancer, the physician will use one or more methods to determine if the disease is actually present. The doctor first takes a complete medical history to check for risk factors and symptoms, and does a physical examination . An examination of the rectum and vagina (in women) may also be performed to determine the size of a bladder tumor and to see if, and how far, it has spread. If bladder cancer is suspected, the following tests may be performed:
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biopsy cystoscopy urine cytology bladder washings urine culture intravenous pyelogram retrograde pyelography bladder tumor marker studies

Most of the time, the cancer begins as a superficial tumor in the bladder. Blood in the urine is the usual warning sign. Based on how they look under the microscope, bladder cancers are graded using Roman numerals 0 through IV. In general, the lower the number, the less the cancer has spread. A higher number indicates greater severity of cancer. Because it is not unusual for people with one bladder tumor to develop additional cancers in other areas of the bladder or elsewhere in the urinary system, the doctor may biopsy several different areas of the bladder lining. If the cancer is suspected to have spread to other organs in the body, further tests will be performed. Because different types of bladder cancer respond differently to treatment, the treatment for one patient could be different from that of another person with bladder cancer. Doctors determine how deeply the cancer has spread into the layers of the bladder in order to decide on the best treatment. Standard with any surgical procedure, the patient is asked to sign a consent form after a thorough explanation of the planned procedure.

Post-operative Care As with any surgical procedure, blood pressure and pulse will be monitored. Urine is expected to be blood-tinged in the early postoperative period. Continuous bladder irrigation (rinsing) may be used for approximately 24 hours after surgery. Most operative sites should be completely healed in three months. The patient is followed closely for possible recurrence with visual examination, using a special viewing device (cystoscope) at regular intervals. Because bladder cancer has a high rate of recurrence, frequent screenings are recommended. Normally, screenings would be needed every three to six months for the first three years, and every year after that, or as the physician considers necessary. Cystoscopy can catch a recurrence before it progresses to invasive cancer, which is difficult to treat.

Risk All surgery carries some risk due to heart and lung problems or the anesthesia itself, but these risks are generally extremely small. The risk of death from general anesthesia for all types of surgery, for example, is only about one in 1,600. Bleeding and infection are other risks of any surgical procedure. If bleeding becomes a complication, bladder irrigation may be required postoperatively, during which time the patient's activity is limited to bed rest. Perforation of the bladder is another risk, in which case the urinary catheter is left in place for four to five days postoperatively. The patient is started on antibiotic therapy preventively. If the bladder is lacerated accompanied by spillage of urine into the abdomen, an abdominal incision may be required. Normal Results The results of transurethral bladder resection will depend on many factors, including the type of treatment used, the stage of the patient's cancer before surgery, complications during and after surgery, the age and overall health of the patient, as well as the recurrence of the disease at a later date. The chances for survival are improved if the cancer is found and treated early.

Suprapubic Cystolithotomy

Cystolithotomy (sectio alta) is the surgical removal of bladder stones via a lower abdominal incision. The term sectio alta refers to the historical techniques of bladder stone surgery, since in former times perineal surgery was common (sectio lateralis and sectio mediana).

Indications
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Removal of foreign bodies in the urinary bladder Treatment of bladder tamponade and severe bladder bleeding, which cannot be managed via transurethral surgery

Contraindication Contraindications for planned surgery are: coagulation disorders, untreated urinary tract infection, bladder cancer.

Pre-operative Care
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Exclusion or treatment of a urinary tract infection Perioperative antibiotic prophylaxis Supine position with slight hyperextension of the lumbar spine Disinfection and draping Insert a transurethral catheter and fill the bladder with 200300 ml

Post operative Care

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Wound drainage 12 days Foley catheter for 5 days, do cystography before catheter removal

Complications Urinary tract infection, bleeding, wound infection, urinoma, thrombosis, pulmonary embolism.

Pathophysiology of Kidney Stones Formation

Decrease in Urine Volume Ingestion of meal high in insoluble salt Decrease Fluid Intake

Increase in Concentration of the Urine

Precipitation Occurs

Stones are formed and grow

Obstruction in the urinary tract from the calyces of the kidney and urethers

Possible Renal Failure

Suprapubic pain after voiding Urethral spasm Cloudy or blood tinged urine Excessive sweating Nausea as well as vomiting

Cystoscopy And its Sub-topic

Submitted by: Michael Angelo Pangiligan BSN-IV Group 2

Submitted to: Mr. Tiopianco