Cystoscopy Scientific evidence does not support routine cystoscopy in women with stress urinary incontinence in the absence of other pathologies (136). Cystoscopy cannot be used to predict intrinsic sphincteric deficiency, stress incontinence, or detrusor overactivity. Cystoscopy can be considered in the following circumstances: (i) in women with urge incontinence to rule out other disorders, especially in women with microscopic hematuria, (ii) in the evaluation of vesicovaginal fistulae, and (iii) intraoperatively to evaluate possible ureteral or vesical injury.
Urologists often use ﬂexible cystoscopy in men; however, women tolerate a rigid cystoscope well, given their short urethras and absence of prostate glands. The view afforded by a rigid cystoscope is clearer than that obtained with a ﬂexible scope, and less technical skill is required to view the entire bladder using a rigid scope. However, with advancement in technology, the efficacy divide between rigid and ﬂexible cystoscopes continues to narrow. Cystoscopes are available with several viewing angles: 0 degree (straight), 30 degrees (forward-oblique), 70 degrees (lateral), and 120 degrees (retroview). The last scope is rarely used in women. Zero-degree lenses are essential for viewing the urethra, whereas a 30-degree lens provides the best view of the bladder base and posterior wall, and the 70-degree lens generally provides the best view of the anterior and lateral walls. For diagnostic cystoscopy, sterile water is an ideal medium because it is readily available and inexpensive.
To evaluate the urethra, the cystoscope, typically with a 0-degree or 30-degree lens, should be advanced with distension medium ﬂowing, keeping the center of the urethral lumen in the center of the visual field. The mucosa is normally pink and smooth and the urethral folds close.
After insertion of the cystoscope into the bladder with a 70-degree lens, an air bubble will be present at the bladder dome, which may assist in proper orientation. Then the remainder of the bladder is examined systematically by making a series of sweeps, slowly rotating the cystoscope between the dome and urethrovesical junction. To view the trigone, the light cord should be oriented toward the ceiling (keeping the camera in an upright position). The scope is pulled back until it is almost in the urethra and the base of the bladder is viewed. Because the trigone is a zone of metaplasia, it looks different from the rest of the urothelium (Fig. 26.15).
Vaginal and abdominal hysterectomies are associated with a 0.02% to 0.85% incidence of ureteral injury (137). The injury rate increases in reconstructive pelvic surgeries, reaching as high as 11% after uterosacral ligament suspension (138). In a study of 46 women who underwent proximal uterosacral ligament vaginal vault suspension, three of the five women with cystoscopic evidence of obstruction were treated successfully by removing and replacing the sutures. This finding emphasizes the importance of confirming ureteral integrity at surgery. The value of cystoscopy to evaluate ureteral injury after minimally invasive hysterectomy is unknown because this injury is often thought to occur in association with thermal injury, and it is unclear whether obstruction or decreased ﬂow will be apparent intraoperatively.