The Cystoscope consists of three parts the Telescope, the Bridge and the Sheath. The most expensive part is the Telescope. In addition to these we need the following for using the Cystoscope:
The Light source and the Cable
The camera unit
TV or Monitor
UPS or Generator for power back up.
All these are expensive and many of the rural surgeons would be wondering whether it is worthwhile making such an investment. It is a worthwhile investment if the Cystoscope could be used for the following in the rural areas.
A. FOR DIAGNOSIS WITH CYSTOMETROGRAM: Diagnostic cystoscopy is the original use for the cystoscope. We do about 100 low cost Cystometrogram in remote and rural areas during our diagnostic camps every year. This helps to diagnose conditions like urethral stones and strictures, prostate enlargement, bladder stones and tumours, rare conditions like ureterocele, bullous cystitis, etc., Cystometrogram or bladder pressure studies help to quantify bladder outflow obstruction and diagnose Nuerovesical dysfunction. In many places the rural surgeons have learnt to do these and do about half this number every year.
B. DOUBLE “J” STENTING AND STENT REMOVAL: The double “J” stent makes the ureter dilate to about two to three times the original size thus allowing the stones to come out [2]. They could be used as the sole treatment for renal stones up to 1 cm in diameter. Most of the stones less than 6 mm would pass by this method. When the stone is in the Ureter most of the time the stent can go along the side into the Kidney and facilitate passage of the stone when the ureter dilates. Even if the stent is not able to go above the stone when the ureter below it dilates it would help in relieving the block and facilitate the passage of the stones. If the stone is large or is unable to come down it could then be broken using the Ureterorenoscope and lithoclast when a Urologist is available. When there are no stones either in the Kidney or ureter the cystoscope could be used for stent removal. The Urologist would appreciate the work if the patient is referred with a DJ stent.
C. BLADDER WASH FOR CLOTS: Hemostasis in the bladder is achieved when the bladder is empty because the muscles collapse around the vessels, especially the veins. If bladder is filled with clots, they prevent the emptying of the bladder and the bleed continues. Bladder wash with catheters are not as effective as with cystoscope. Many lives could be saved using the cystoscope for bladder wash when there is bleed in the bladder.
D. BLADDER TUMOUR VAPORIZATION WITH BUGBEE ELECTRODE: The Transitional cell tumours of the bladder are multi - centric. Most of the time the first presentation is to Urologists and they resect / remove the tumour for biopsy. They are then advised to present themselves every month for check cystoscopy until the time when they have no tumour on three consecutive sessions. These recurrences are often very small and could be comfortably burnt with the bugbee electrode. Most of the rural patients do not go to Urologists for regular check - up and by the time they go the recurrences are much larger and difficult to treat. If the rural surgeons are able to do the check cystoscopies regularly and treat the small recurrences with bugbee electrode it would be of great benefit to the rural patients
E. PROSTATE VAPORIZATION WITH BUGBEE ELECTRODE: One of the distressing presentations of prostatic hypertrophy is acute painful retention of urine. Although this could be relieved by passing a Foley’s catheter often the trial void fails, and the patient is doomed to have the catheter till elective surgery is offered. However, in the rural setting having a catheter and maintaining it is difficult. The cystoscope and the bugbee electrode could be used to vaporize the prostate a little at a time and this gives sufficient time for the patient to go without catheter for a while.
F. EIU: Patients with stricture urethra need regular self - calibration with catheters and if they are not able to pass it would benefit from cystoscopy to dilate the stricture under vision. Even when they are diagnosed newly small feeding tubes or open-ended catheters could be passed under vision without causing trauma to the strictured area in the urethra.
G. CYSTOLITHOTOMY: Small bladder stones could be removed using the cystoscopy and grasper. The larger stones could be removed using the smallest possible incision using the cystoscope to locate and catch the stone and also to fill the bladder.
H. DIAGNOSTIC LAPAROSCOPY AND BIOPSY: The cystoscope is an excellent tool for diagnostic laparoscopy. With a small umbilical incision, the cystoscope could be introduced into the abdomen and a purse string suture prevents air leak. The BP cuff or a small motor that is used for fish tank pumps with a filter could be used for insufflation. The regular insufflators are also not expensive. The cystoscope has the facility for biopsies and another advantage is that cystoscope could be used with ascites too.
I. APPENDICECTOMY: One of the elective procedures that could be comfortably carried out is appendicectomies. The technique is similar and once the tip of the appendix is identified it could be pulled out of the wound to complete the surgery as an open procedure outside [5]
J. TUBECTOMIES: The technique of tubectomies are similar to that of appendicectomies. It would be helpful to have the patient in lithotomy position so that the uterus could be manipulated if necessary, to visualize the tubes.
K. OESOPHAGEAL FOREIGN BODIES: The cystoscope could be used for removing the foreign bodies in the oropharynx and the upper oesophagus
L. DETECTING AND BREAKING OF RENAL STONES AT OPEN SURGERIES: Nephrotomy or opening the Kidney for removing stones in rural areas is fraught with danger of bleeding either at the time of surgery or even later as secondary haemorrhage. Hence it is better as far as possible to remove the renal stones through the opening in the pelvis. The cystoscope is very useful during renal surgeries to look into the Kidney and remove the left-over stones.
M. CHOLECYSTOSCOPY: In rural areas some patients have had cholecystostomy as an emergency procedure. Many of them probably due to financial constraints refuse cholecystectomy. We have been able to do scopies for them to remove the stones and many of them have done well with a follow up of up to 6 years.
We have recently designed a new Laptop Cystoscope that uses the camera instead of the telescope. In addition, the Laptop computer could be used as the power and light source and monitor. This would reduce the investment of the rural surgeons to less than a tenth of what would be required for a traditional set up.
The drawback of the Laptop cystoscope is that it takes a few seconds to focus and hence the movements have to be slow and more time is required for clear vision. This however would not affect diagnostic cystoscopies or minor procedures like DJ stentings. There are few rural surgeons in Northeast India who are using this Laptop cystoscope.
J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is an urologist and laparoscopic surgeon trained at CMC Vellore. He is the Past President and Project Lead for the Project GILLS of the Association of Rural Surgeons of India, the Secretary of the International Federation of Rural Surgeons and board member of the G 4 Alliance. He is also an Adjunct Professor at Karunya University. He has over 400 publications in national and international Journals related to rural surgery and has won many innovations award like the EHA innovation award, Antia Finseth award, the Lockheed Martin award, the Millennium Alliance award, etc., He has few patents and the low cost equipment is listed in the WHO compendium of medical equipment for resource poor setting. He has helped many hospitals start Minimally Invasive Surgeries. The popular innovations that have made MIS possible in rural areas are the Gas Insufflation Less Laparoscopic Surgeries and the Laptop cystoscope.
indicates a Peer-Reviewed Article
LECTURE: The Laptop Cystoscope, Thursday, October 1, 2020
The Cystoscope consists of three parts the Telescope, the Bridge and the Sheath. The most expensive part is the Telescope. In addition to these we need the following for using the Cystoscope:
All these are expensive and many of the rural surgeons would be wondering whether it is worthwhile making such an investment. It is a worthwhile investment if the Cystoscope could be used for the following in the rural areas.
A. FOR DIAGNOSIS WITH CYSTOMETROGRAM: Diagnostic cystoscopy is the original use for the cystoscope. We do about 100 low cost Cystometrogram in remote and rural areas during our diagnostic camps every year. This helps to diagnose conditions like urethral stones and strictures, prostate enlargement, bladder stones and tumours, rare conditions like ureterocele, bullous cystitis, etc., Cystometrogram or bladder pressure studies help to quantify bladder outflow obstruction and diagnose Nuerovesical dysfunction. In many places the rural surgeons have learnt to do these and do about half this number every year.
B. DOUBLE “J” STENTING AND STENT REMOVAL: The double “J” stent makes the ureter dilate to about two to three times the original size thus allowing the stones to come out [2]. They could be used as the sole treatment for renal stones up to 1 cm in diameter. Most of the stones less than 6 mm would pass by this method. When the stone is in the Ureter most of the time the stent can go along the side into the Kidney and facilitate passage of the stone when the ureter dilates. Even if the stent is not able to go above the stone when the ureter below it dilates it would help in relieving the block and facilitate the passage of the stones. If the stone is large or is unable to come down it could then be broken using the Ureterorenoscope and lithoclast when a Urologist is available. When there are no stones either in the Kidney or ureter the cystoscope could be used for stent removal. The Urologist would appreciate the work if the patient is referred with a DJ stent.
C. BLADDER WASH FOR CLOTS: Hemostasis in the bladder is achieved when the bladder is empty because the muscles collapse around the vessels, especially the veins. If bladder is filled with clots, they prevent the emptying of the bladder and the bleed continues. Bladder wash with catheters are not as effective as with cystoscope. Many lives could be saved using the cystoscope for bladder wash when there is bleed in the bladder.
D. BLADDER TUMOUR VAPORIZATION WITH BUGBEE ELECTRODE: The Transitional cell tumours of the bladder are multi - centric. Most of the time the first presentation is to Urologists and they resect / remove the tumour for biopsy. They are then advised to present themselves every month for check cystoscopy until the time when they have no tumour on three consecutive sessions. These recurrences are often very small and could be comfortably burnt with the bugbee electrode. Most of the rural patients do not go to Urologists for regular check - up and by the time they go the recurrences are much larger and difficult to treat. If the rural surgeons are able to do the check cystoscopies regularly and treat the small recurrences with bugbee electrode it would be of great benefit to the rural patients
E. PROSTATE VAPORIZATION WITH BUGBEE ELECTRODE: One of the distressing presentations of prostatic hypertrophy is acute painful retention of urine. Although this could be relieved by passing a Foley’s catheter often the trial void fails, and the patient is doomed to have the catheter till elective surgery is offered. However, in the rural setting having a catheter and maintaining it is difficult. The cystoscope and the bugbee electrode could be used to vaporize the prostate a little at a time and this gives sufficient time for the patient to go without catheter for a while.
F. EIU: Patients with stricture urethra need regular self - calibration with catheters and if they are not able to pass it would benefit from cystoscopy to dilate the stricture under vision. Even when they are diagnosed newly small feeding tubes or open-ended catheters could be passed under vision without causing trauma to the strictured area in the urethra.
G. CYSTOLITHOTOMY: Small bladder stones could be removed using the cystoscopy and grasper. The larger stones could be removed using the smallest possible incision using the cystoscope to locate and catch the stone and also to fill the bladder.
H. DIAGNOSTIC LAPAROSCOPY AND BIOPSY: The cystoscope is an excellent tool for diagnostic laparoscopy. With a small umbilical incision, the cystoscope could be introduced into the abdomen and a purse string suture prevents air leak. The BP cuff or a small motor that is used for fish tank pumps with a filter could be used for insufflation. The regular insufflators are also not expensive. The cystoscope has the facility for biopsies and another advantage is that cystoscope could be used with ascites too.
I. APPENDICECTOMY: One of the elective procedures that could be comfortably carried out is appendicectomies. The technique is similar and once the tip of the appendix is identified it could be pulled out of the wound to complete the surgery as an open procedure outside [5]
J. TUBECTOMIES: The technique of tubectomies are similar to that of appendicectomies. It would be helpful to have the patient in lithotomy position so that the uterus could be manipulated if necessary, to visualize the tubes.
K. OESOPHAGEAL FOREIGN BODIES: The cystoscope could be used for removing the foreign bodies in the oropharynx and the upper oesophagus
L. DETECTING AND BREAKING OF RENAL STONES AT OPEN SURGERIES: Nephrotomy or opening the Kidney for removing stones in rural areas is fraught with danger of bleeding either at the time of surgery or even later as secondary haemorrhage. Hence it is better as far as possible to remove the renal stones through the opening in the pelvis. The cystoscope is very useful during renal surgeries to look into the Kidney and remove the left-over stones.
M. CHOLECYSTOSCOPY: In rural areas some patients have had cholecystostomy as an emergency procedure. Many of them probably due to financial constraints refuse cholecystectomy. We have been able to do scopies for them to remove the stones and many of them have done well with a follow up of up to 6 years.
We have recently designed a new Laptop Cystoscope that uses the camera instead of the telescope. In addition, the Laptop computer could be used as the power and light source and monitor. This would reduce the investment of the rural surgeons to less than a tenth of what would be required for a traditional set up.
The drawback of the Laptop cystoscope is that it takes a few seconds to focus and hence the movements have to be slow and more time is required for clear vision. This however would not affect diagnostic cystoscopies or minor procedures like DJ stentings. There are few rural surgeons in Northeast India who are using this Laptop cystoscope.
J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is an urologist and laparoscopic surgeon trained at CMC Vellore. He is the Past President and Project Lead for the Project GILLS of the Association of Rural Surgeons of India, the Secretary of the International Federation of Rural Surgeons and board member of the G 4 Alliance. He is also an Adjunct Professor at Karunya University. He has over 400 publications in national and international Journals related to rural surgery and has won many innovations award like the EHA innovation award, Antia Finseth award, the Lockheed Martin award, the Millennium Alliance award, etc., He has few patents and the low cost equipment is listed in the WHO compendium of medical equipment for resource poor setting. He has helped many hospitals start Minimally Invasive Surgeries. The popular innovations that have made MIS possible in rural areas are the Gas Insufflation Less Laparoscopic Surgeries and the Laptop cystoscope.
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