Flexible cystoscopy: a revolution in urological practice

Prospective Randomized Trial of Single-Use vs Reusable Cystoscope for Ureteral Stent Removal

Background: Reusable cystoscopes are associated with risks of cross-contamination, need for chemical reprocessing, mechanical breakdown, maintenance costs, and labor for cleaning. A sterile, single-use cystoscope may reduce or eliminate the source of these infections while also decreasing exposure to reprocessing chemical agents. In this multicenter, randomized trial, we sought to compare single use with reusable endoscopes for ureteral stent removal. Methods: A three-center, randomized, dual-arm postmarket clinical trial was performed to compare the single-use cystoscope (Ambu A/S) with standard-of-care flexible reusable cystoscopes for outpatient ureteral stent removal. A total of 102 patients were randomized and evaluated from baseline through day 10 postprocedure. Primary endpoint was successful stent removal. Secondary endpoints were time from preparation to disposal/reprocessing, adverse events (AEs), and clinician satisfaction. Results: A total of 102 subjects were randomized in a 1:1 manner. The successful stent removal rate was 51/51 (reusable) and 50/51 (single use). One patient required the conversion to reusable cystoscope owing to grasper passage issue. Median time from prep for the procedure to disposal/prep for reprocessing was 10.2 minutes for the single use and 18.4 minutes for the reusable (p < 0.001). There was no difference in clinician satisfaction between both arms. There was no difference in AEs between arms and no device causal attribution for any AE reports. There was one serious AE necessitating hospitalization for infection in the reusable arm. Conclusion: The randomized-controlled trial of single-use cystoscopes vs reusables showed comparable device success with significant time savings for single use and equivalent clinician satisfaction. The study was registered on clinicaltrials.gov database (NCT04829461) on April 2, 2021.

Music reduces patient-reported pain and anxiety and should be routinely offered during flexible cystoscopy: Outcomes of a systematic review

Objective: To conduct a systematic review of the literature to assess whether music reduces the use of analgesics and anxiolytics during flexible cystoscopy.

Methods: The systematic review was performed in line with the Cochrane guidelines and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. The databases searched included the Medical Literature Analysis and Retrieval System Online (MEDLINE), Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Clinicaltrials.gov, the Excerpta Medica dataBASE (EMBASE), Cochrane library, Google Scholar, and Web of Science from inception of the databases to February 2020. The primary outcome measure was the effect of music on pain and anxiety, and secondary outcome measures were patient heart rate and blood pressure.

Results: The initial search yielded 234 articles and after going through titles and abstracts, four studies (399 patients, 199 in the music group and 200 in no music group) were included for the final review. There were three randomised controlled trials and one prospective study published between 2014 and 2017. These studies were done in China, the USA and Italy, with the study duration between 9 and 24 months. All patients had 2% topical lignocaine jelly given per-urethra before the procedure. The choice of music was classical in three studies and a mixture of different music types in one study. Three of the four studies showed significantly reduced pain and anxiety with the use of music for flexible cystoscopy procedures. Heart rate was noted to be higher for the no music group, reflecting a higher pain perceived by these patients.

Conclusion: The present review showed that listening to music was associated with reduced anxiety and pain during flexible cystoscopy. Listening to music is therefore likely to increase procedural satisfaction and willingness to undergo the procedure again, considering repeated flexible cystoscopy is often needed for surveillance. As music is simple, inexpensive and easily accessible, it should be routinely offered to patients for outpatient and office-based urological procedures.

Abbreviations: IQR: interquartile range; NRS: numerical rating scale; PTSD: post-traumatic stress disorder; RCT: randomised control trial; STAI: State–trait Anxiety Inventory; VAS: visual analogue scale

Pain reduction methods during transurethral cystoscopy

Transurethral cystoscopy (CS) is a common urological procedure, performed mostly for diagnostic but also for therapeutic purposes. Although CS is generally well tolerated, some patients describe the pain related to the procedure as high or even “unbearable”. As a result, many patients fear and avoid both primary and/or follow-up cystoscopies. This may lead to uncontrolled progression of neoplastic disease. Therefore, it is crucial to maximally increase the comfort of the patient and to implement safe and effective analgesia before the procedure. Providing the patients with appropriate care during CS can encourage them to comply with diagnostic schedules and improve their prognosis. The aim of this review is to analyze the available literature on various methods of pain reduction during transurethral CS. The PubMed electronic database limited to English articles published until January 2021 was used in the process. Meta-analyses, systematic reviews, randomized controlled trials, clinical trials, prospective randomized studies, multicenter comparisons, reviews and retrospective comparisons were used. As a result, 65 articles were included in this review.

Biopsy at flexible cystoscopy: is it worthwhile?

INTRODUCTION

Flexible cystoscopy is the gold standard for diagnosis and surveillance of bladder carcinoma. Most flexible cystoscopes feature a working channel allowing for bladder biopsy and diathermy if a suspicious lesion is observed. However, the working channel permits only small instruments which limit the volume of material retrieved for histological analysis. There are no published standards for quality control of biopsy specimens taken at flexible cystoscopy. We reviewed the diagnostic yield of biopsies taken at flexible cystoscopy at our institution.

METHODS

Theatre log books were retrospectively examined to identify cases of flexible cystoscopy where bladder biopsy was performed. Histopathology reports were reviewed. All biopsies were taken using single-use biopsy forceps, diameter 1.8 mm, open cup width 4.5 mm.

RESULTS

From January 2014 to December 2017, a total of 143 biopsies were performed. All biopsies were taken for suspicious lesions where the differential diagnosis included malignancy. Of the 143 samples taken, 27 biopsies showed evidence of malignancy, and 9 cases were high-grade urothelial cancer. A total of 16 samples were inadequate for any histological diagnosis. All remaining samples excluded malignancy within the sample provided. A histopathological diagnosis was provided for almost 89% of cases.

CONCLUSION

Approximately 18% of biopsies detected malignancy. While only small volumes of tissue are collected at flexible cystoscopy, these can help to distinguish malignancy from benign pathology. Our institution reports a non-diagnostic rate of approximately 11%, and in these cases, when there is still a suspicion of malignancy, a rigid cystoscopy and biopsy should be performed.

Efficacy of urination in alleviating man's urethral pain associated with flexible cystoscopy: a single-center randomized trial

BACKGROUND

This study aimed to assess whether urethral pain can be alleviated by urination in male patients undergoing flexible cystoscopy.

METHODS

Ninety-six male outpatients undergoing flexible cystoscopy were randomly divided into two groups. Patients in the test group urinated during flexible cystoscopy, whilst patients in the control group received no instructions to do so. All patients received 10 mL of 2% lidocaine gel prior to assessment. Using 0 (no-pain) to 10 (unbearable severe pain) pain scores (VAS), we assessed patient discomfort prior to anesthesia gel perfusion (baseline), during gel perfusion, during cystoscope insertion through the urethra, and 15 min post-examination analysis. The entire protocol was completed by a single doctor in our Department of Urology.

RESULTS

The groups showed no statistical differences regarding age or examination time. During cystoscope insertion, the test group recorded significantly lower pain scores 2 (IQR 1-3) - compared to the control group 3 (IQR 2-3), (P = 0.001). No significant differences between other evaluation points were observed between groups.

CONCLUSION

Urethral pain can be significantly alleviated by urination in male patients undergoing flexible cystoscopy through the urethra.

TRIAL REGISTRATION

Registry name: Clinical study of urination action to relieve urethral pain associated with flexible cystoscopy. Registration number: ChiCTR-INR-17013294 Date of Registration: 2017-11-08.

Pressure Makes Pleasure: A Preliminary Study of Increasing Irrigation Pressure of Flexible Cystoscopy Improves Male Patient Comfort by an Easy Way

OBJECTIVE

To evaluate the impact of increasing irrigation pressure when performing flexible cystoscopy for male patients on visual analog scale pain scores.

PATIENTS AND METHODS

A total of 168 male patients admitted to our clinic for flexile cystoscopy by the same urologist between March 2011 and December 2012 were randomized to three equal groups, each of which had 56 patients. Different irrigation pressures were easily achieved by adjusting the height of irrigation solution bag (1000 mL of 0.9% saline). The height difference between the bag and the bed (for cystoscopy) of group 1, 2, and 3 was 80, 100, and 150 cm, respectively. All patients received 10 mL lidocaine gel for 3 minutes for local anesthesia before flexible cystoscopy. Patients' pain feeling was recorded on a visual analog scale (VAS) ranging from 0 to 10 after the cystoscopy. The duration of the procedure for each patient was also recorded.

RESULTS

The mean pain score on VAS was 2.95±1.31, 2.48±1.26, and 1.66±1.00 in group 1, 2, and 3, respectively. Compared to group 1 and 2, the mean pain score was significantly lower in group 3 (p<0.001, Mann-Whitney U-test), and the mean pain score in group 2 was statistically significantly lower than that in group 1 (p=0.045, Mann-Whitney U-test). Patients who were with high irrigation pressure experienced less discomfort at cystoscopy. Patient age and duration of the procedure for each group were comparable.

CONCLUSION

Achieving higher irrigation pressure for flexible cystoscopy by adjusting the height of irrigation solution bag improves male patients' comfort. It is recommended for male patients.

Outpatient rigid cystoscopy: Is it acceptable to women?

Objective:

Flexible cystoscopy is commonly performed as an outpatient procedure whereas rigid cystoscopy is performed under general anaesthesia by urogynaecologists because of a perception that it is painful. The aim of this study is to assess women’s experience of outpatient cystoscopy (OC) with rigid cystoscope.

Materials and methods:

The first 56 women who attended our newly established OC service with rigid cystoscope were recruited prospectively for the study. They were requested to complete a questionnaire (with visual analogue scale) based on their expectations prior to the procedure. A post-procedure questionnaire was given to quantify their experience after the OC. Two patients were excluded from the study as they did not complete the questionnaire appropriately. Wilcoxon signed ranks test was used to compare the scores for comfort, pain and anxiety in the pre- and post-procedure questionnaires.

Results:

A total of 52/54 patients (96.3%) were fully satisfied at the end of the procedure as indicated in their visual analogue scale score of 10/10. Most patients found the procedure more comfortable and less painful than expected. There were no post-operative complications.

Conclusion:

OC with a rigid cystoscope is a well-tolerated, safe, cost-effective ambulatory service resulting in good patient experience.

Music reduces panic: an initial study of listening to preferred music improves male patient discomfort and anxiety during flexible cystoscopy

PURPOSE

To assess the impact of listening to preferred music on relieving male patients' pain and anxiety during flexible cystoscopy.

PATIENTS AND METHODS

A total of 124 male patients were admitted to our hospital for flexile cystoscopy by a single urologist between January 2013 and September 2013 and randomized to two equal groups. Group 2 included 62 patients who could select and listen to their preferred music during flexible cystoscopy. Group 1 included 62 patients who were unable to listen to the music. All patients were administered the same amount of lidocaine (10 mL) for 3 minutes for local anesthesia before flexible cystoscopy. A visual analog scale (VAS) ranging from 0 to 10 was used to assess patients' pain feeling after the cystoscopy procedure. Anxiety levels were calculated according to the State Instrument of State-Trait Anxiety Inventory (STAI-S), and the pulse rate were recorded 5 minutes before and immediately after the procedure. The duration of the procedure of each group were also analyzed.

RESULTS

Statistically significant differences were detected between group 1 and group 2 in the mean pain score on VAS (2.53 ± 1.34 vs 1.63 ± 1.09, P=0.002, Mann-Whitney U test), mean postprocedural State Anxiety Inventory pain score (39.4 ± 6.5 vs 34.5 ± 5.8), and postprocedural pulse rate (79.8 ± 5.5 vs 76.0 ± 7.3) (P<0.001 for both, t test). Patients who listened to their preferred music experienced less discomfort and lower anxiety at cystoscopy. Patient age, duration of the procedure, preprocedural STAI-S, and preprocedural pulse rate of each group were comparable.

CONCLUSION

Listening to preferred music during flexible cystoscopy is an easy way to improves male patients' comfort and reduce their anxiety. It could be recommended for male patients.