Endoscopy

Figure 21.2. Flexible cystoscope.

Figure 21.1. rigid cystoscope.

with >165,000 effective pixels, were compared to

two brand-new standard fiber optic cystoscopes

level of distension. Continuous flow prevents

for resolution, contrast, and color discrimina-

tion in vitro. The group found no difference

the bladder from collapsing or overdistending.

between the standard fiber optic flexible cysto-

Overdistension results in thinning the overlying

scopes; however, the distal-sensor all-digital

bladder musculature, which can predispose to

cystoscope was superior to the fiber optic scopes

bladder perforation in

the area of resection.

in terms of resolution, contrast discrimination,

Continuous flow allows a bladder lesion to

and red color differentiation.2

remain at a fixed level of distension to facilitate

Video-cystourethroscopy, -ureteroscopy, and

resection. Additionally, some authors feel that it

-ureteropyeloscopy (discussed below) allow the

improves visualization

in settings of heavy

image in both the rigid and flexible endoscopes

bleeding, particularly

during a transurethral

to be projected onto a monitor and are currently

resection of the prostate (TURP).

available in high definition. This obviates the

The main advantages of the flexible cystoscope

need to look through the eyepiece on the lens.

are greater patient tolerability, the ability to per-

Benefits of the video include avoiding contact

form the procedure supine in the office, the ease

with body fluids,improvement in ability to main-

of passing the scope over an elevated bladder

tain a sterile field, ease in documentation of the

neck, and the deflection at the end of scope

procedure, providing patient education during

allowing visualization of the entire bladder and

the procedure, aiding in teaching, and improved

retroflexion to visualize the bladder neck. The

surgeon ergonomics with potential prevention

flexible scope utilizes fiber optic bundles within

of cervical injuries, which were common in

a flexible shaft to provide illumination and visu-

previous generations of urologists.

alization (Fig. 21.2). The tip of the scope can be

deflected 180–220°. The irrigation connection

and working port are on the instrument’s shaft

and typically connect to a single common rub-

Ureteroscopy and Ureteropyeloscopy

ber-lined working channel within the scope

which can be damaged if instrumentation is

Retrograde endoscopic evaluation of the upper

passed with the scope in the deflected position.

urinary tract typically has a much lower mor-

The newest technology for flexible endoscopy

bidity profile than a percutaneous or open renal

is the distal-sensor digital chip system, which

procedure. Ureteroscopy with laser lithotripsy is

eliminates the need for fiber bundles and the

the gold standard for the treatment of distal ure-

resultant “honeycomb” honeycomb pattern of

teral stones and is commonly utilized for stones

the image. In a study from University of

throughout the collecting system. AUA guide-

California at Irvine, three flexible systems,

lines state that the majority of renal calculi can

including a new distal-sensor digital cystoscope

be effectively treated by laser lithotripsy using a

Nephroscopy, which consists of antegrade endo-

scopic visualization of the renal pelvis and caly-

ces, is generally performed in the setting of

percutaneous procedures via a dilated tract.

Applications include percutaneous management

of renal calculi, tumors, ureteropelvic junction

obstruction, and calyceal diverticuli. The neph-

roscope consists of an inner and outer sheath

with a working port, a lens, and an apparatus

for continuous flow through irrigation ports

(Fig. 21.3). The large bore of the rigid nephro-

scope provides optimal visualization and a

generously sized working channel for graspers

Figure 21.3. Percutaneous nephroscope.

or a variety of lithotrite. The rigidity and size,