OUTPATIENT FLEXIBLE URETHROCYSTOSCOPY - INITIAL EXPERIENCE AT UNIVERSITY OF ILORIN TEACHING HOSPITAL

Abstract

Background:

Endourology has revolutionized urological practices worldwide. This is not so in many urological centers in the West African sub-region. Although, some centers have made progress in the level of urological services that they offer; many of such centers provide rigid urethrocystoscopy services and only a few centers provide flexible urethrocystoscopy services. Flexible urethrocystoscopy has the advantage of being convenient as daycare procedure with no requirement for invasive forms of anaesthesia or the need for lithotomy position. In addition, skill transfer and acquisition is good.

Aim & Objectives:

We present our 2 year experience with outpatient flexible cystoscopy at the University of Ilorin Teaching Hospital, Ilorin.

Patients & Methods:

A review of the records of patients who had flexible cystoscopy at our outpatient endoscopy unit over a 2 year period was carried out.

Results:

There were 39 patients (36 males and 3 females) with the age range of 25 -84 years and a mean of 58.5 years. The indications were both diagnostic and therapeutic. All the procedures were done under topical anesthesia. There were no complications noted. Consultants performed 80% of the cases while the remaining was performed by a senior registrar. The year 2 registrars from surgery and Obstetrics & Gyneacology assisted in most cases.

Conclusion:

Outpatient flexible urethrocystoscopy has positively improved endourological services in this centre with less invasive anesthesia, less morbidity and improved patient satisfaction. It has also enhanced training of residents doctors in lower urinary tract endoscopy.

Introduction

Endourology is an essential part of urological practice worldwide and it has revolutionized urological practices. Lower urinary tract endoscopy involves the use of urethrocystoscopes which can be in rigid or flexible for diagnostic or therapeutic and monitoring purposes.

Prior to the seventies, most urethrocystoscopes were rigid. This requires the patient to be in lithotomy position and may require the application of invasive form of anaesthesia. However, with the introduction of flexible fibercystoscope in 19731and further introduction of purpose built cystoscope in 19842, the practice of cystoscopy became revolutionized; most procedures were done under local anaesthesia3 with patient in supine position4.

Several studies have compared the use of rigid and flexible urethrocystoscopy; the later was found to be cost efficient, time saving5, better tolerated by patients4, often painless, atraumatic6and with less complication7. With these advantages of flexible over rigid urethrocystoscopy in terms of less time spent in patient positioning and preparation, with the use of less invasive anaesthesia, improved patients’ satisfaction and less morbidity and complication, it is often preferred for outpatient or office practice urethrocystoscopy.

In Nigeria, urological services have improved with the introduction endo-urological services in many centres. However, many of such centres provide rigid urethrocystoscopy services8,9,10.

We report our initial experience of outpatient flexible urethrocystoscopy at University of Ilorin Teaching Hospital (UITH), Nigeria.

Reports

METHODS

This was a retrospective study of patients who had had urethrocystoscopy at the endoscopy suites of University of Ilorin Teaching Hospital, Ilorin, Nigeria on out-patient basis using flexible urethrocystocope over a period of two years (from July, 2012 to June, 2014).

Data were collected on the patients’ demographics, the indications for the procedure, the positioning of patients during the procedure, the type of anesthesia, the use of prophylactic antibiotics, complication after the procedure and cadre of the endoscopist and his assistant.

The data obtained were analyzed for sex distribution, mean age, percentage of each indication for the procedure and percentage of procedures done by each cadre of endoscopist and assistant endoscopist using Microsoft 2007 excel statistical software.

RESULTS

A total of 39 patients; 36 males and 3 females (Figure 1) had flexible urethrocystoscopy during the period under review. The age range was 25 -84 years with a mean of 58.5 years. The indications were: bladder outflow obstruction in 13 patients (33.3%), heamaturia in 12 patients (30.8%), irritative lower urinary tract symptoms in 5 patients (12.8%), ureteric stents removal in 3 patients(7.7%), surveillance cystoscopy post- transurethral resection of bladder tumor in 2 patients (5.1%), anaejaculation / retrograde ejaculation in 2 patients (5.1%), genital wart in 1 patient (2.6%) and neurogenic bladder in 1 patient (2.6%) as shown in Table 1. All the procedures were done in supine position except in females who were placed in supine frog-leg position. Topical anesthesia with 2% Lidocaine jelly urethral instillation was used in all patients. All the patients had prophylactic antibiotics (Intravenous Gentamycin 160mg).

Figure 1 .

Sex distribution

Table 1: Indications for urethrocystoscopy

Indications	Frequency	Percentage
Bladder outflow obstruction	13	33.3%
Heamaturia	12	30.8%
Irritative symptoms	5	12.8%
Stent removal	3	7.7%
Surveillance cystoscopy	2	5.1%
Neurogenic bladder	2	5.1%
Genital wart	1	2.6%
Anaejaculation/retrograde ejaculation	1	2.6%

No complication was recorded following the procedure and there was no complication noted during follow up clinic visit in all the patients.

Consultants performed 31 (80%) of the cases while 8(20%) was done by a senior registrar (Figure 2). The year 2 registrars from surgery and Obstetrics & Gyneacology assisted in most cases (Figure 3).

Figure 2 .

Cadre of endoscopist

Figure 3 .

Carde of Assistant endoscopist

Discussion

Prior to the introduction of flexible urethrocystoscope in this centre, lower urinary tract endoscopy was done with rigid urethrocystoscope in operating theatre as there was no separate endoscopy suite for rigid cystoscopy. This is so because of the need for anesthetist support as most of the rigid urethrocystoscopy were done with invasive aneasthesia either in form of caudal block, subarachnoid block or general aneasthesia; as most patients do not tolerate topical anaesthesia for rigid cystoscopy. Thus, the procedure is shared with other procedures on the operating list. This often leads to long waiting time for patients who require cystoscopy due to inadequate theatre space and anesthetist support. However, with the introduction of flexible urethrocystocope, the procedures were done on outpatient basis or office practice with less invasive form of anaesthesia. This has significantly reduced our waiting list for endourological procedures.

Flexible urethrocystoscopes could be used for diagnostic, therapeutic and monitoring purposes11. In our review, we had varied indications, majority of which were diagnostic in the evaluation of patients with bladder out flow obstruction, heamaturia, irritative lower urinary tract symptoms, anaejaculation /retrograde ejaculation, genital wart to exclude intra-urethral extension and neurogenic bladder. The therapeutic indication was removal of ureteric stents while monitoring indication was surveillance cystoscopy post- transurethral resection of bladder tumor. These procedures were done on scheduled without the challenges of competing for space in the main operating room with open procedures which used to be the norm before the introduction of flexible urethrocystoscope.

Flexible urethrocystoscope have the advantages of being less traumatic, with no dead zones6compared with rigid type due to its flexible nature and reduced diameter of about 6mm allowing for easy navigation through the urethra. However, it does have some disadvantages because of its smaller field of view and difficulty of orientation12, lower visual acuity and sometimes inadequate irrigant flow4which may be a problem when there is significant heamaturia and reduced working channel diameter which does not allow for introduction of many instrument for therapeutic procedures. Thus, its use for therapeutic purpose is limited compared to the rigid type2.

Despite some of these drawbacks, it is of essence in patients who required endourological procedures to be done in supine position either because of an ankylosed joint or pain with reduced movement across the joint from severe joint arthritis. It is mostly used in office practice or outpatient procedures2 with the use of 2% lidocaine gel urethral instillation for anaesthesia with good tolerability by patients13. In our study, all the procedures were done with urethral instillation of 2% lidocaine; all the patients tolerated the procedure as none of the procedures were abandoned due to pain or discomfort to the patients

The use of prophylactic antibiotics during flexible urethrocystoscopy is often controversial14,15,16. In this study, all the patients had intravenous Gentamycin 160mg as prophylactic antibiotics. Following the procedure, none of the patients had a febrile episodes or symptoms of bacteriuria. The appropriateness of the use of prophylactic antibiotics could not be ascertained from this study. In order to determine the appropriateness of its usage, a randomized controlled study with large number of patients will be required.

Flexible urethrocystoscopy has been reported to be more tolerable by the patients with less pain and complication5. It is difficult to ascertain the tolerability of the patients to the use of flexible urethrocystoscopy in our study though none of the procedure was abandoned due to pain. An objective assessment of its tolerability will be desirable with a prospective study comparing the tolerance of patients with rigid and flexible urethrocystoscope using a visual analog scale for pain assessment.

Flexible urethrocystoscopy is different from rigid procedure though because of its flexibility; some dexterity is needed in its handling and operation. Overtime this can be learned. In advanced countries, learning is done outside the clinical setting using UroMentor visual reality simulators which have been found to be effective12. Due to non availability of this simulator in our institution, training is by hands on in a clinical setting bearing in mind ethical consideration. About 80% of the procedures were done by the consultants trained and experience in its usage. The consultants were assisted by a senior registrar, year 2 surgical residents and obstetrics and gyneacological residents on urology posting. Over time, the senior registrar was able to perform the procedures successfully assisted by the consultant in keeping with skills acquisition required in residency training. To improve training with its use, a visual reality simulator will be desirable to allow for more training outside the clinical settings because of legal and ethical consideration.

The limitation of this study was the small sample size which was a reflection of the number of urologist in the country and those in training.

Conclusions

Outpatient flexible urethrocystoscopy has positively improved endourological services in this centre with less invasive anesthesia, less morbidity and improved patient satisfaction. It has also enhanced training of residents doctors in lower urinary tract endoscopy.