British Journalof Urology (1992),69.5 18-520 01992 British Journal of Urology
Cystodiathermy under Local Anaesthesia using the Flexible Cystoscope K. GERMAN, S. T. HASAN and C. DERRY Department of Urology, Buckland Hospital, Dover
Summary-The use of the flexible cystoscope in the follow-up of patients with bladder carcinoma is becoming more widespread. In a series of 17 patients, cystodiathermy of small recurrent tumours using the flexible cystoscope and topical urethral anaesthesia proved to be a safe, effective and well tolerated procedure.
Out-patient flexible cystourethroscopy, as a method for surveying bladder carcinoma, has now become routine in most centres (Kahn, 1987). Approximately 5 to 10% of patients undergoing cystoscopy will have recurrences that are small in size and few in number. This study was designed to investigate the possibility of treating these recurrences by cystodiathermy using the flexible cystoscope and topical urethral anaesthesia. Over a period of 6 months, 17 patients were recruited into this pilot study from a total of just over 200 patients undergoing flexible cystoscopy. Patients and Methods Patients were assessed by preliminary cystourethroscopy to determine the size, number and location of recurrent bladder tumours. Recurrences > 1 cm in diameter (or approximately 5 times the width of the diathermy electrode) were considered unsuitable for treatment under local anaesthesia and were treated under general anaesthesia using the rigid cystoscope. The technique of flexible cystoscopy was similar to that described by Fowler (1984). We used the Olympus CHF P 10 choledochofiberscope, which incorporates a 2 mm irrigation/instrument channel, a range of tip-bending of 160" upwards and 130"
Accepted for publication 31 May 1991
downwards and a working length of 330 mm. The coagulating electrode was 4 F (Order number 27023 T ; Storz) and was used with a high frequency cord (Order number 27170). The Eschmann TD311 Series 2(GB), a solid state electrosurgical unit, was set for monopolar coagulation at 3.5 (i.e. half maximum power output rated at 7 or 125 W). An earthing plate electrode was strapped to the patient's thigh and glycine was used as the irrigating fluid. A mid-stream specimen of urine (MSU) was obtained from all patients pre-operatively, and 4 days after the cystoscopy. Tolerance was graded subjectively on a scale of 1 to 4 (Table 1). Postoperative symptoms and the patient's general impression of the procedure were obtained by means of a telephone conversation with the patient 1 week after cystodiathermy. The follow-up period after initial cystodiathermy was 12 months. An initial follow-up cystoscopy was performed at 3 months and thereafter as necessary. Results Seventeen patients (13 male, 4 female) were studied. Their ages ranged from 39 to 93 years (median 69). A total of 58 recurrent tumours (range 1-8, average 3.4) were treated by diathermy at initial cystoscopy and the average duration of the procedure was 25 min (range 10-45). Cystodiathermy was performed using topical urethral anaesthesia alone and no additional analgesia.
518
CYSTODIATHERMY UNDER LOCAL ANAESTHESIA USING THE FLEXIBLE CYSTOSCOPE
519
Table 1 Summary of Patients Treated by Flexible Cystoscopy No. of patienis
Sex
1
M
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
F
M F
M M M F
M M M M M M M M F
No. of lesions treuted
I I I 3 6 1 3 5 3 8 7 6 2 3 I 6 1
*Grading for patient tolerance I Painful Comfortable Uncomfortable 2 Unbearable
Duration (min)
Put ieni tolerunce'
20 20 15 20 35
2
10
35 25 15 45 30 35 25 30 20 40 15
Initial follow-up cysioscopy (Anuesihesiu)
Clear Clear Clear 1 recurrence (Local) Recurrences (General) Clear Clear Clear 2 recurrences (Local) Recurrences (General) Recurrences (General) Recurrences (General) 2 recurrences (Local) 5 recurrences (Local) 3 recurrences (Local) 5 recurrences (Local) Clear
1
1 1 I 1 3 1 1 3 2 2 2 1 1
2 1
3 4
Tolerance of the procedure was graded subjectively on a scale of 1 to 4 (Table 1); 10 patients described it as comfortable, 5 as uncomfortable and 2 as painful. Of the 2 patients who found the procedure painful, the first had required preliminary urethral dilatation and the other had received cystodiathermy to a recurrence situated at the bladder neck. Poor tolerance scores were not related to the age of the patient, but seemed to correlate well with the longer duration of the procedure (average 33 min) and with the diathermy of a larger number of recurrences (average 4.7). All 4 women described the procedure as comfortable, indicating perhaps a better tolerance by women than men. No urinary tract infection resulted de nouo from this procedure. The post-operative symptoms ranged from mild dysuria of 24 hours' duration to the passage of blood clots and marked urinary frequency for 4 days. With one exception, patients felt that the post-operative symptoms following flexible cystoscopy were less severe than those following rigid cystoscopy. We feel that the larger calibre of the rigid cystoscope may be more traumatic to the urethra and so account for this observation. Seven patients were clear at their first follow-up cystoscopy, 6 had recurrent disease which was suitable for further treatment under local anaesthesia, but 4 patients required general anaesthesia
for the treatment of recurrences that were either greater than 1 cm in diameter or more than 8 in number. The longer period of follow-up showed that patients with more than 5 recurrences at their initial cystoscopy would usually go on to develop recurrences that were unsuitable for treatment by local anaesthetic procedures alone. In contrast, the 12 patients with up to 5 recurrences at presentation required a total of 33 follow-up cystoscopies over 12 months, of which 15 were clear and only 6 required procedures under general anaesthesia (Table 2).
Discussion Day-case flexible cystoscopy under local anaesthesia has been shown to be a safe, fast and cost-effective means of surveillance of bladder carcinoma (Fowler et al., 1984; Webb et al., 1984; Kahn, 1987). The procedure avoids the risk of repeated general anaesthesia in a population of patients at risk from age-related cardiac and respiratory disorders. Patients have also expressed a preference for this form of out-patient surveillance of their bladder carcinoma. This pilot study has demonstrated the technique of flexible cystodiathermy to be successful and acceptable in the treatment of recurrent superficial bladder tumours. Although the largest number of
520
BRITISH JOURNAL OF UROLOGY
Table 2 Follow-up Cystoscopies over a 12-month Period Recurrences treated under No. of recurrences at presentation
No. of cystoscopies
Clear
Local anaesthesia General anaesthesia
5 (n=5)
33
15
12
6
19
I
8
10
recurrences treated in 1 session in this study was 8, References there is no absolute limit, and there is no reason Engberg, A., Spangberg, A. and Urnes,T. (1983). Transurethral why multiple small recurrences should not be resection of bladder tumours under local anaesthesia. Urology, treated in 2 or more sessions. Cystodiathermy to 22,385-387. most areas of the bladder was well tolerated; Fowler, C. G . (1984). Fibrescope urethrocystoscopy. Br. J . Urol., 56,304-307. treatment of recurrences in the trigone or bladder Fowler,C. G. (1987). Removal of ureteric stents with the flexible neck was painful, but may be better tolerated if a cystoscope. Br. J. Urol., 60,280. local anaesthetic were to be injected directly into Fowler, C. G., Badenoch, D. F. and Thakar, D. R. (1984). Practical experience with flexible fibrescope cystoscopy in the site. A limitation of flexible cystodiathermy is out-patients. Br. J . Urol., 56,618421. the size of the diathermy electrode, which precludes R. I. (1987). Outpatient endourologic procedures. Urol. the treatment of larger recurrences. However, larger Kahn, Clin. North Am., 14,877-894. bladder tumours have been successfully resected Krikler, S. J. (1989). Flexible urethroscopy: use in difficult male under local anaesthesia using a rigid cystoscope catheterisation. Ann. R.C.S.of Engl., 71, 3. and prior injection of lignocaine into the planned Reddy, P. K. and Hulbert, J. C. (1986). Retrograde pyelogram using the flexible cystoscope. J. Urol., 136, 1283-1284. site for resection (Engberg et al., 1983). Webb, D. R., Butler, M. R. and Fitzpatrick, J. M. (1984). Flexible We have co-ordinated the timing of the flexible cystourethroscopy :advantages and limitations. Eur. Urol., 10, cystoscopy list with the urology out-patient clinic 336337. and are therefore able to offer diagnostic cystoscopy to some patients at the time of their original clinic visit. This has resulted in a reduction in the time The Authors interval between presentation and diagnosis. K. German, FRCS, FRCSE, Research Fellow in Urology, Royal Infirmary, Cardiff. Practical applications for the flexible cystoscope such as biopsy, retrograde pyelography (Reddy and S. T. Hasan, FRCS, Senior House Officer in Urology, Freeman Newcastle upon Tyne. Hulbert, 1986), retrieval of ureteric stents (Fowler, C.Hospital, D. Derry, FRCS, Consultant Surgeon, Buckland Hospital, 1987) and aiding the difficult male catheterisation Dover, and William Harvey Hospital, Ashford. (Krikler, 1989) have been described. We have found cystodiathermy to be a further useful appli- Requests for reprints to: K. German, c/o Department of cation when dealing with small recurrences of Urology, Cardiff Royal Infirmary, Newport Road, Cardiff CF2 1sz. bladder carcinoma.
Cystodiathermy under Local Anaesthesia using the Flexible Cystoscope K. GERMAN, S. T. HASAN and C. DERRY Department of Urology, Buckland Hospital, Dover
Summary-The use of the flexible cystoscope in the follow-up of patients with bladder carcinoma is becoming more widespread. In a series of 17 patients, cystodiathermy of small recurrent tumours using the flexible cystoscope and topical urethral anaesthesia proved to be a safe, effective and well tolerated procedure.
Out-patient flexible cystourethroscopy, as a method for surveying bladder carcinoma, has now become routine in most centres (Kahn, 1987). Approximately 5 to 10% of patients undergoing cystoscopy will have recurrences that are small in size and few in number. This study was designed to investigate the possibility of treating these recurrences by cystodiathermy using the flexible cystoscope and topical urethral anaesthesia. Over a period of 6 months, 17 patients were recruited into this pilot study from a total of just over 200 patients undergoing flexible cystoscopy. Patients and Methods Patients were assessed by preliminary cystourethroscopy to determine the size, number and location of recurrent bladder tumours. Recurrences > 1 cm in diameter (or approximately 5 times the width of the diathermy electrode) were considered unsuitable for treatment under local anaesthesia and were treated under general anaesthesia using the rigid cystoscope. The technique of flexible cystoscopy was similar to that described by Fowler (1984). We used the Olympus CHF P 10 choledochofiberscope, which incorporates a 2 mm irrigation/instrument channel, a range of tip-bending of 160" upwards and 130"
Accepted for publication 31 May 1991
downwards and a working length of 330 mm. The coagulating electrode was 4 F (Order number 27023 T ; Storz) and was used with a high frequency cord (Order number 27170). The Eschmann TD311 Series 2(GB), a solid state electrosurgical unit, was set for monopolar coagulation at 3.5 (i.e. half maximum power output rated at 7 or 125 W). An earthing plate electrode was strapped to the patient's thigh and glycine was used as the irrigating fluid. A mid-stream specimen of urine (MSU) was obtained from all patients pre-operatively, and 4 days after the cystoscopy. Tolerance was graded subjectively on a scale of 1 to 4 (Table 1). Postoperative symptoms and the patient's general impression of the procedure were obtained by means of a telephone conversation with the patient 1 week after cystodiathermy. The follow-up period after initial cystodiathermy was 12 months. An initial follow-up cystoscopy was performed at 3 months and thereafter as necessary. Results Seventeen patients (13 male, 4 female) were studied. Their ages ranged from 39 to 93 years (median 69). A total of 58 recurrent tumours (range 1-8, average 3.4) were treated by diathermy at initial cystoscopy and the average duration of the procedure was 25 min (range 10-45). Cystodiathermy was performed using topical urethral anaesthesia alone and no additional analgesia.
518
CYSTODIATHERMY UNDER LOCAL ANAESTHESIA USING THE FLEXIBLE CYSTOSCOPE
519
Table 1 Summary of Patients Treated by Flexible Cystoscopy No. of patienis
Sex
1
M
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
F
M F
M M M F
M M M M M M M M F
No. of lesions treuted
I I I 3 6 1 3 5 3 8 7 6 2 3 I 6 1
*Grading for patient tolerance I Painful Comfortable Uncomfortable 2 Unbearable
Duration (min)
Put ieni tolerunce'
20 20 15 20 35
2
10
35 25 15 45 30 35 25 30 20 40 15
Initial follow-up cysioscopy (Anuesihesiu)
Clear Clear Clear 1 recurrence (Local) Recurrences (General) Clear Clear Clear 2 recurrences (Local) Recurrences (General) Recurrences (General) Recurrences (General) 2 recurrences (Local) 5 recurrences (Local) 3 recurrences (Local) 5 recurrences (Local) Clear
1
1 1 I 1 3 1 1 3 2 2 2 1 1
2 1
3 4
Tolerance of the procedure was graded subjectively on a scale of 1 to 4 (Table 1); 10 patients described it as comfortable, 5 as uncomfortable and 2 as painful. Of the 2 patients who found the procedure painful, the first had required preliminary urethral dilatation and the other had received cystodiathermy to a recurrence situated at the bladder neck. Poor tolerance scores were not related to the age of the patient, but seemed to correlate well with the longer duration of the procedure (average 33 min) and with the diathermy of a larger number of recurrences (average 4.7). All 4 women described the procedure as comfortable, indicating perhaps a better tolerance by women than men. No urinary tract infection resulted de nouo from this procedure. The post-operative symptoms ranged from mild dysuria of 24 hours' duration to the passage of blood clots and marked urinary frequency for 4 days. With one exception, patients felt that the post-operative symptoms following flexible cystoscopy were less severe than those following rigid cystoscopy. We feel that the larger calibre of the rigid cystoscope may be more traumatic to the urethra and so account for this observation. Seven patients were clear at their first follow-up cystoscopy, 6 had recurrent disease which was suitable for further treatment under local anaesthesia, but 4 patients required general anaesthesia
for the treatment of recurrences that were either greater than 1 cm in diameter or more than 8 in number. The longer period of follow-up showed that patients with more than 5 recurrences at their initial cystoscopy would usually go on to develop recurrences that were unsuitable for treatment by local anaesthetic procedures alone. In contrast, the 12 patients with up to 5 recurrences at presentation required a total of 33 follow-up cystoscopies over 12 months, of which 15 were clear and only 6 required procedures under general anaesthesia (Table 2).
Discussion Day-case flexible cystoscopy under local anaesthesia has been shown to be a safe, fast and cost-effective means of surveillance of bladder carcinoma (Fowler et al., 1984; Webb et al., 1984; Kahn, 1987). The procedure avoids the risk of repeated general anaesthesia in a population of patients at risk from age-related cardiac and respiratory disorders. Patients have also expressed a preference for this form of out-patient surveillance of their bladder carcinoma. This pilot study has demonstrated the technique of flexible cystodiathermy to be successful and acceptable in the treatment of recurrent superficial bladder tumours. Although the largest number of
520
BRITISH JOURNAL OF UROLOGY
Table 2 Follow-up Cystoscopies over a 12-month Period Recurrences treated under No. of recurrences at presentation
No. of cystoscopies
Clear
Local anaesthesia General anaesthesia
5 (n=5)
33
15
12
6
19
I
8
10
recurrences treated in 1 session in this study was 8, References there is no absolute limit, and there is no reason Engberg, A., Spangberg, A. and Urnes,T. (1983). Transurethral why multiple small recurrences should not be resection of bladder tumours under local anaesthesia. Urology, treated in 2 or more sessions. Cystodiathermy to 22,385-387. most areas of the bladder was well tolerated; Fowler, C. G . (1984). Fibrescope urethrocystoscopy. Br. J . Urol., 56,304-307. treatment of recurrences in the trigone or bladder Fowler,C. G. (1987). Removal of ureteric stents with the flexible neck was painful, but may be better tolerated if a cystoscope. Br. J. Urol., 60,280. local anaesthetic were to be injected directly into Fowler, C. G., Badenoch, D. F. and Thakar, D. R. (1984). Practical experience with flexible fibrescope cystoscopy in the site. A limitation of flexible cystodiathermy is out-patients. Br. J . Urol., 56,618421. the size of the diathermy electrode, which precludes R. I. (1987). Outpatient endourologic procedures. Urol. the treatment of larger recurrences. However, larger Kahn, Clin. North Am., 14,877-894. bladder tumours have been successfully resected Krikler, S. J. (1989). Flexible urethroscopy: use in difficult male under local anaesthesia using a rigid cystoscope catheterisation. Ann. R.C.S.of Engl., 71, 3. and prior injection of lignocaine into the planned Reddy, P. K. and Hulbert, J. C. (1986). Retrograde pyelogram using the flexible cystoscope. J. Urol., 136, 1283-1284. site for resection (Engberg et al., 1983). Webb, D. R., Butler, M. R. and Fitzpatrick, J. M. (1984). Flexible We have co-ordinated the timing of the flexible cystourethroscopy :advantages and limitations. Eur. Urol., 10, cystoscopy list with the urology out-patient clinic 336337. and are therefore able to offer diagnostic cystoscopy to some patients at the time of their original clinic visit. This has resulted in a reduction in the time The Authors interval between presentation and diagnosis. K. German, FRCS, FRCSE, Research Fellow in Urology, Royal Infirmary, Cardiff. Practical applications for the flexible cystoscope such as biopsy, retrograde pyelography (Reddy and S. T. Hasan, FRCS, Senior House Officer in Urology, Freeman Newcastle upon Tyne. Hulbert, 1986), retrieval of ureteric stents (Fowler, C.Hospital, D. Derry, FRCS, Consultant Surgeon, Buckland Hospital, 1987) and aiding the difficult male catheterisation Dover, and William Harvey Hospital, Ashford. (Krikler, 1989) have been described. We have found cystodiathermy to be a further useful appli- Requests for reprints to: K. German, c/o Department of cation when dealing with small recurrences of Urology, Cardiff Royal Infirmary, Newport Road, Cardiff CF2 1sz. bladder carcinoma.
