How to care for the cystoscopy patient
In the final post in our endoscopy series, we’re talking all about cystoscopy. This is performed less commonly than GI, nasal and airway endoscopy but is becoming much more widely available in practice, as smaller endoscopes are manufactured. The procedure requires special preparation and nursing support, so the veterinary nurse plays a key role in caring for cystoscopy patients. If you haven’t already, be sure to check out the rest of our endoscopy series, too! Ready to learn more? Let’s dive in.
What is cystoscopy?
Cystoscopy is the endoscopic examination of the lower urinary tract; specifically, the examination of the vagina, urethral opening, urethra, urinary bladder and ureteral openings. This is performed with a narrow rigid endoscope in female dogs, and a very small flexible endoscope called a cystoscope in male dogs.
Cystoscopy is typically not performed in cats, due to their size and the need for an incredibly narrow endoscope! However, most feline lower urinary tract disorders do not require cystoscopy for their diagnosis.
In addition to visualising the lower urinary tract, cystoscopy guides the collection of biopsies from specific lesions or areas, as well as basket urolith retrieval. Certain minimally-invasive procedures, such as laser lithotripsy of uroliths and the placement of urethral stents, are also performed under endoscopic guidance.
How is cystoscopy performed?
As we are examining the lower urinary tract, we have the potential to introduce contamination into a sterile tract when performing cystoscopy. Aseptic technique is therefore very important in these patients - cystoscopy should be performed in theatre, or as the first procedure of the day in a dedicated endoscopy suite which has been pre-cleaned and prepared. The endoscopes, and any instruments used, should be sterile (autoclaved or ethylene oxide sterilised, depending on the endoscope manufacturer’s recommendations), and all staff handling the endoscope (endoscopist and nurse assistant) should wear sterile gloves and gowns. Special camera cover drapes can be used to cover the camera and light cables, or they can be EO sterilised.
Following anaesthetic induction and patient preparation, the cystoscope is inserted into the vagina (female dog) and/or urethra (male dog) and the area is inspected for any abnormalities (lesions, evidence of inflammation, masses or strictures). The cystoscope is advanced through the urethra and into the urinary bladder. When in the bladder, the endoscopy assistant removes the urine with a 60ml syringe and 3-way tap, through the instrument channel (if using a flexible endoscope) or the working sheath of a rigid scope. After the urine is removed, a bag of sterile 0.9% saline, flushed through a fluid line, is attached to the endoscope and the line is opened, to fill the bladder with saline - this improves visualisation for the endoscopist.
Once the bladder is full of saline, the endoscopist can examine the bladder more thoroughly. They will observe the left and right ureters entering the bladder (at the level of the trigone, a triangular region just above the bladder neck) and confirm they can see jets of urine entering the bladder through both ureters. Biopsies are then taken from the bladder +/- urethra and vagina as required and submitted for histopathology and culture.
The bladder mucosa is delicate and some bleeding can occur during endoscopy, particularly if biopsies are collected. Having a bag of cold 0.9% saline on-hand can be really helpful if this occurs - the cold saline can be drawn into a syringe and manually flushed into the bladder, to help stem any haemorrhage.
How is the patient prepared?
The patient should be prepared for anaesthesia as per standard practice protocols. They should have a standard pre-anaesthetic fast, and a full clinical examination should be performed prior to anaesthesia, in order to formulate an individualised anaesthesia plan. Following anaesthetic induction, the patient is positioned according to the endoscopist’s preference - this is usually in VD, though some clinicians prefer to place the patient in right lateral recumbency, and others prefer to place them in DV with a wedge placed under the pelvis, and the hindlimbs positioned downwards, off of the end of the table. They should be positioned with their head facing the anaesthetic machine, as the endoscopist will work off of the opposite edge of the table.
Following positioning, the veterinary nurse should prepare the site. The fur around the vulva/prepuce should be carefully clipped and the site cleaned using diluted chlorhexidine solution and sterile swabs. The tail should be wrapped with a bandage, to prevent the fur becoming wet or soiled, and tucked out of the way during the procedure.
What about sampling?
Biopsies are commonly collected during cystoscopy. Generally, multiple biopsies are collected for histopathology, with one biopsy being stored in sterile saline for bacterial culture. Impression smears of biopsies may also be prepared for cytology if necessary.
The veterinary nurse is heavily involved in biopsy collection, whether that be guided biopsies through the endoscope channel, or handling blind biopsies. Here are my tips for handling instruments and collecting tissue samples:
Advance any forceps gradually (1cm at a time) and stop if you feel increased resistance when trying to advance them.
Ensure that you keep all instruments in the ‘closed’ position until you can see the end fully exit the instrument channel/sheath.
After exiting the endoscope, open your forceps and advance them as directed by the clinician, whilst held in the ‘open’ position.
When directed, purposely but carefully push the forceps against the area to be biopsied, and firmly close the forceps.
Holding the forceps in the closed position, withdraw them fully from the instrument channel.
When removing samples from the forceps, this can be done either by carefully ‘hooking’ them out of the forceps using a 25g needle, or by ‘shaking’ the end of the forceps in a sterile pot of saline, to free the biopsies from the forceps.
Transfer the biopsies into an endoscopic biopsy cassette, using one cassette per anatomical region (e.g. vagina, urethra and bladder).
Gently close each cassette and place each in a labelled formalin pot for submission to the laboratory.
Place one fresh biopsy in a 1ml plain blood tube filled with sterile saline, for culture and sensitivity.
How is the patient nursed in recovery?
Following the procedure, the patient is monitored closely until they recover fully from anaesthesia. Interference with the site is common, so an Elizabethan collar must be placed to prevent self-trauma, inflammation and infection. Post-operative nursing considerations include monitoring urination, regular pain assessment and the administration of analgesia at appropriate intervals, in addition to general nursing care.
So that’s the end of our endoscopy series. I hope you found it useful and are feeling ready to tackle any scopes that come your way. I would love to know - what have you learned from the series that you’ll take back to practice with you? Let me know below!
Don’t forget that you can download a full booklet of endoscopy equipment lists to complement this blog series - simply enter your email address below, and the link to our resource library will be sent straight to your inbox, alongside the password to access it!
References and further reading:
Cox, S. 2016. Endoscopy for the Veterinary Technician. Iowa: Wiley-Blackwell.
Merrill, L. 2012. Small Animal Internal Medicine for Veterinary Technicians and Nurses. Iowa: Wiley-Blackwell.
Disclaimer: Individual endoscope use and maintenance protocols may vary depending on your practice, the endoscopes you use, and clinician preference. The above information is intended as a guide only. Veterinary Internal Medicine Nursing is not responsible for any issues which may arise as a result of their use. Any products mentioned or images included within this post are for reference only and are not product endorsements or recommendations.
