Flexible Cystoscopes Research Articles

MP22-09 FLEXIBLE PHOTODYNAMIC DIAGNOSIS OF THE BLADDER – READY FOR THE OUTPATIENT SETTING?

You have accessJournal of UrologyBladder Cancer: Detection & Screening1 Apr 2014MP22-09 FLEXIBLE PHOTODYNAMIC DIAGNOSIS OF THE BLADDER – READY FOR THE OUTPATIENT SETTING? Alexander Karl, Patrick Weidlich, Christoph Adam, Peter Stanislaus, Thomas Hoffmann, Stefan Tritschler, Christian Stief, and Dirk Zaak Alexander KarlAlexander Karl More articles by this author , Patrick WeidlichPatrick Weidlich More articles by this author , Christoph AdamChristoph Adam More articles by this author , Peter StanislausPeter Stanislaus More articles by this author , Thomas HoffmannThomas Hoffmann More articles by this author , Stefan TritschlerStefan Tritschler More articles by this author , Christian StiefChristian Stief More articles by this author , and Dirk ZaakDirk Zaak More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.857AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To evaluate the feasibilty and detection rate of flexible HAL-cystoscopy using a new chip-on-the-tip technology in patients with the suspicion of bladder cancer. In this study the performance of photodynamic diagnosis (PDD) and white light (WL) endoscopy using flexible and rigid cystoscopes were compared. METHODS In total 30 patients were included in this two-center study. The flexible chip on the tip endoscope (Storz) and the rigid system (Storz) were both used for diagnostic cystoscopy in the same patient. In preparation for PDD Hexylaminolevulinate (HAL) was used. Two experienced surgeons in each participating institution were involved. In every patient one of these surgeons performed the examination in white light and PDD using a rigid instrument first. Then another blinded surgeon performed a flexible cystoscopy using WL and PDD in the same patient again. All blinded findings were captured on a specially designed documentation sheet. RESULTS In all 30 patients flexible cystoscopy could be performed without any technical problems. In the WL setting the overall sensivitiy for flexible cystoscopy was 92% (22/24) vs. 83% (20/24) with the rigid endoscope. The specificity was 50% for flexible WL vs. 33% for rigid WL. The accuracy of flexible WLwas higher (83%) compared to rigid (73 %). There was an accordance of the two methods of 83% (25/30) with a Cohen's kappa of k=0.44 (p=0.007). Respecting only the results that were acquired in PDD mode, there was no difference in sensitiviy, specificity and accuracy between the two methods (p <0.001). The quality of fluorescence was judged by every examiner for flexible and rigid PDD. For quality assessment four different subjective levels for fluorescence (no, low, medium, high) were used. In 24 of 30 cases there was the same level documented in flexible and rigid. This represents an accuracy of 80% (p<0.001). During the whole study there were observed no side effects caused by the PDD or the flexible approach. Tangential views of the bladder resulting in false positive fluorescence could be avoided using the flexible endoscope. CONCLUSIONS Flexible PDD using the chip on the tip technology was feasible with an excellent picture quality. Sensitivity of flexible PDD was equivalent to the current gold standard – the rigid endoscopy. There was no loss in fluorescence intensity or diagnostic information using the flexible cystoscope. Therefore the outpatient use of flexible PDD seems reasonable in the diagnosis and follow up of bladder cancer patients. However larger clinical studies need to further verify the efficiency of this new equipment. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e237-e238 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Alexander Karl More articles by this author Patrick Weidlich More articles by this author Christoph Adam More articles by this author Peter Stanislaus More articles by this author Thomas Hoffmann More articles by this author Stefan Tritschler More articles by this author Christian Stief More articles by this author Dirk Zaak More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Technical aspects of botulinum toxin type A injection in the bladder to treat urinary incontinence: reviewing the procedure

Standardise the injection technique with botulinum toxin type A (BoNT A) in the bladder of patients with overactive bladder (OAB) [idiopathic overactive bladder (iOAB) or neurogenic overactive bladder (nOAB) with urinary incontinence], using a literature review and a survey of an International expert panel. PubMed literature searches of BoNT A in adults with iOAB/nOAB together with a survey of 13 experts from 10 countries. Data from 21 articles and completed questionnaires were collated. The procedure can be carried out in an out-/inpatient setting. Dose used in clinical studies vs. clinical practice was 300 and 200 U for nOAB and 200 and 100 U for iOAB. Recent studies have also demonstrated that there are no clinically relevant benefits between 100 and 150 U in iOAB or between 300 and 200 U in nOAB, though adverse effects are increased with higher doses. Usually, 30 sites for nOAB (range: 6.7-10 U/ml) and 20-30 sites for iOAB (range: 5-10 U/ml) are injected in clinical studies vs. 20-30 sites of 1 ml/injection for 200 U in nOAB and 10-20 sites of 0.5-1 ml/injection for 100 U in iOAB in clinical practice. BoNT A is usually injected directly into the detrusor, sparing the trigone. Flexible or rigid cystoscopes are used. The needle should be typically 22-27 gauge and 4 mm in length and should have a stopper to avoid any leakage or perforation of the bladder wall while ensuring a targeted injection. Based on the literature and survey analysis, recommendations are proposed for the standardisation of the injection procedure.

Risk of transmission of carbapenem-resistant Enterobacteriaceae and related "superbugs" during gastrointestinal endoscopy.

To evaluate the risk of transmission of carbapenem-resistant Enterobacteriaceae (CRE) and their related superbugs during gastrointestinal (GI) endoscopy. Reports of outbreaks linked to GI endoscopes contaminated with different types of infectious agents, including CRE and their related superbugs, were reviewed. Published during the past 30 years, both prior to and since CRE's emergence, these reports were obtained by searching the peer-reviewed medical literature (via the United States National Library of Medicine's "MEDLINE" database); the Food and Drug Administration's Manufacturer and User Facility Device Experience database, or "MAUDE"; and the Internet (via Google's search engine). This review focused on an outbreak of CRE in 2013 following the GI endoscopic procedure known as endoscopic retrograde cholangiopancreatography, or ERCP, performed at "Hospital X" located in the suburbs of Chicago (IL; United States). Part of the largest outbreak of CRE in United States history, the infection and colonization of 10 and 28 of this hospital's patients, respectively, received considerable media attention and was also investigated by the Centers for Disease Control and Prevention (CDC), which published a report about this outbreak in Morbidity and Mortality Weekly Report (MMWR), in 2014. This report, along with the results of an independent inspection of Hospital X's infection control practices following this CRE outbreak, were also reviewed. While this article focuses primarily on the prevention of transmissions of CRE and their related superbugs in the GI endoscopic setting, some of its discussion and recommendations may also apply to other healthcare settings, to other types of flexible endoscopes, and to other types of transmissible infectious agents. This review found that GI endoscopy is an important risk factor for the transmission of CRE and their related superbugs, having been recently associated with patient morbidity and mortality following ERCP. The CDC reported in MMWR that the type of GI endoscope, known as an ERCP endoscope, that Hospital X used to perform ERCP in 2013 on the 38 patients who became infected or colonized with CRE might be particularly challenging to clean and disinfect, because of the complexity of its physical design. If performed in strict accordance with the endoscope manufacturer's labeling, supplemented as needed with professional organizations' published guidelines, however, current practices for reprocessing GI endoscopes, which include high-level disinfection, are reportedly adequate for the prevention of transmission of CRE and their related superbugs. Several recommendations are provided to prevent CRE transmissions in the healthcare setting. CRE transmissions are not limited to contaminated GI endoscopes and also have been linked to other reusable flexible endoscopic instrumentation, including bronchoscopes and cystoscopes. In conclusion, contaminated GI endoscopes, particularly those used during ERCP, have been causally linked to outbreaks of CRE and their related superbugs, with associated patient morbidity and mortality. Thorough reprocessing of these complex reusable instruments is necessary to prevent disease transmission and ensure patient safety during GI endoscopy. Enhanced training and monitoring of reprocessing staffers to verify the proper cleaning and brushing of GI endoscopes, especially the area around, behind and near the forceps elevator located at the distal end of the ERCP endoscope, are recommended. If the ERCP endoscope features a narrow and exposed channel that houses a wire connecting the GI endoscope's control head to this forceps elevator, then this channel's complete reprocessing, including its flushing with a detergent using a procedure validated for effectiveness, is also emphasized.

A randomised single‐blind comparison of the effectiveness of Tristel Fuse (chlorine dioxide) as an office‐based fluid soak, with Cidex OPA (ortho‐phthaldehyde) using an automated endoscopic reprocessor (AER) as high‐level disinfection for flexible cystoscopes

To compare the effectiveness, safety and cost of Tristel Fuse (chlorine dioxide) with Cidex OPA (ortho-phthaldehyde; 1,2-benzenedicarboxaldehyde) in an automated endoscopic reprocessor (AER) for high-level disinfection of flexible cystoscopes. A randomised single-blind study comparing the high-level disinfectants Tristel Fuse as a simple office-based soak and Cidex OPA using an AER was performed. Participants were 'blinded' to the agent used for disinfection of the flexible cystoscopes. All patients had negative mid-stream urine at baseline, (MSU) no symptoms suggestive of urinary tract infection (UTI) on the day of investigation, no recent antibiotic use or current indwelling urinary catheter. Patients who underwent cystoscopic biopsy during the procedure were excluded. A urine analysis was done before and 3-5 days after cystoscopy and multiple equipment cultures were performed. The Urogenital Distress Inventory (UDI-6 + two questions from the 'long-form'), symptom and quality-of-life scores were assessed before and after cystoscopy as were ease-of-use assessments and a full cost analysis. In all, 180 of 465 screened participants were randomised 1:1 and the mean age was 72.1 years, 17% were females and 57% of procedures were performed for bladder tumour surveillance. The urine analysis was positive in 5.4% of patients in each group and 29% (Tristel) vs 20% (Cidex) of patients had urinary leukocyturia (p = ns) after cystoscopy. The turnover (minutes per cycle) was 7.5 (Tristel) vs 26.7 (Cidex). The per-procedure costs were $11.67 (American dollars) for Tristel Fuse and $21.82 for Cidex OPA with fixed costs of $4788 for Tristel Fuse and $60,514 for Cidex OPA. Tristel Fuse appears to be as effective and more cost-effective than Cidex OPA for high-level disinfection of flexible cystoscopes. This has significant cost implications for the office urologist.

A microbiological evaluation of level of disinfection for flexible cystoscopes protected by disposable endosheaths

BackgroundFlexible cystoscopy is used in urological outpatient departments for diagnostic cystoscopy of bladder cancer and requires a high-level disinfection between each patient. The purpose of this study was to make a microbiological post disinfection efficacy assessment of flexible cystoscopes (FC) using disposable sterile endosheaths.MethodsOne hundred endosheaths underwent a leak-test for barrier integrity after cystoscopy. Microbiological samples from these cystoscopies were obtained; after removal of the endosheath, and after cleaning the scope with a detergent cloth, rinsing with tap water followed by 70% ethanol disinfection and subsequent drying. The number of colony forming units (cfu) from the samples was counted after 72 hours and then divided in three categories, Clean FC (<5 cfu/sample), Critical FC (5–50 cfu/sample) and High-risk FC (>50 cfu/sample). The result was compared with data of 10 years continuous control sampling recorded in the Copenhagen Clean-Endoscope Quality Control Database (CCQCD) and analyzed with a Chi-square test for homogeneity.ResultsAll 100 endosheaths passed the leak-test. All samples showed a Clean FC and low means of cfu. A query to the CCQCD, showed that 99.8% (1264/1267) of all FC with a built-in work-channel reprocessed in a WD were clean before use.ConclusionThe reprocessing of FC using endosheaths, as preformed in this study, provides a patient-ready procedure. The results display a reprocessing procedure with low risk of pathogen transmission, high patient safety and a valid alternative to the recommended high-level disinfection procedure of FC. However, the general impression was that sheaths slightly reduced vision and resulted in some patient discomfort.

Durability of Flexible Cystoscopes in the Outpatient Setting

To ascertain cystoscope durability in relation to usage and cost in the outpatient setting. Six flexible cystoscopes were provided to our outpatient clinic by 2 vendors. Five Wolf 7305.006S02 cystoscopes (Richard Wolf Medical Instruments Corporation, Vernon Hills, IL) and 1 Olympus CYF-5 (Olympus America, Center Valley, PA) were used 2477 times over a 14-month study period. Prospective data were accumulated on each cystoscope including type of procedure, number of uses until mechanical failure, physician usage, and maintenance costs. All staff was trained in proper handling and maintenance of cystoscopes utilizing an Occupational Safety and Health Administration (OSHA) approved protocol. Retrospective comparison was performed of 1346 cystoscopic procedures during the previous 8 months before implementation of the processing protocol, with data including type and quantity of mechanical failures along with maintenance costs. Five total study period failures occurred in 4 cystoscopes, with a mean of 495.4 procedures/failure. In 3 separate cystoscopes, failure occurred after 70 (perforation of working channel), 194 (leak in bending rubber), and 236 uses (hole in bending rubber). One cystoscope had 2 failures after 168 (cut in bending rubber) and 255 uses (failed leak test). During the retrospective period, there were 10 failures, with a mean of 134.6 procedures/failure. Four failures were secondary to crushed insertion tubes. Comparison of retrospective and study period costs revealed a 43.9% decrease from $9.64 per procedure to $5.41 per procedure. Outpatient flexible cystoscope durability seems directly related to optimization of handling and storage of cystoscopes. Costs related to mechanical failure were reduced with a rigorous reprocessing protocol.

Cystoscopes souples : pratiques de désinfection et de surveillance microbiologique parmi les urologues français. Une enquête du comité d’infectiologie de l’AFU

According to the French regulatory authorities, the highest level of disinfection must be achieved for flexible cystoscopes, as they enter a sterile cavity, the current method being peracetic acid disinfection and sterile water terminal rinsing. The concordance between regulations and the routine was researched using a self-administered questionnaire sent to all French urologists. Responses from 78 urology units, totalling 317 urologists (26% response rate) were analysed. As a whole, 51.2% of centers followed all recommendations on disinfection. There was no microbiological surveillance in 16.6% of centers, although microbiological tests were performed in two out of three centers before using a new endoscope or when returning from maintenance. Improvements are needed, both in the disinfection process and the microbiological surveillance. Low temperature sterilization and the use of sterile disposable sheaths may represent an alternative.

Outpatient diagnostic of bladder tumours in flexible cystoscopes: Evaluation of fluorescence-guided flexible cystoscopy and bladder biopsies

The aim of this study was to evaluate photodynamic diagnosis (PDD) in flexible cystoscopes and the diagnostic quality of biopsies for diagnosis of non-muscle-invasive bladder cancer in the outpatients department (OPD). Seventy-three patients (aged 36-91 years) with recurrent non-muscle-invasive bladder cancer and a medium to high risk of recurrence had a flexible PDD cystoscopy performed in the OPD. The bladder was first examined in standard white light followed by PDD. PDD was superior to white light diagnosis; PDD was positive in 16 patients (22%) where white light showed a normal bladder mucosa. Four of these patients had bladder tumour [4/73, 6%; two carcinoma in situ (CIS), two Ta]. The diagnosis was verified by transurethral resection of the bladder tumour in the operating room. In 20 patients (20/73, 27%) PDD identified additional tumour lesions that were not identified in white light (five CIS, 15 Ta). The false-positive detection rate of PDD was 0.41. False positivity was significantly reduced by simultaneous flex biopsies disproving malignancy. Biopsies were obtained from 57 patients and diagnosis of stage and grade were possible in 55 of these (97%). In two patients (4%) the tissue material was too small for diagnostic evaluation. Biopsies from 47 patients (83%) included muscularis mucosa and from 20 patients (35%) muscularis propria. In 30 patients all but one diagnosis from the OPD was confirmed by biopsy in rigid scopes in the operating room. PDD-guided cystoscopy and bladder biopsy in flexible cystoscopes can be performed in an OPD setting and with reliable results for diagnosis of tumour stage Ta, CIS and T1a bladder cancer.

UP-01.113 A Randomized Single-Blind Comparison of the Cost-Effectiveness of the High-Level Disinfectants Tristel Fuse (Chlorine Dioxide) and Cidex Opa (Ortho-Phthaldehyde) for Use with Flexible Cystoscopes

The effectiveness of Tristel Fuse was compared with Cidex OPA for high-level disinfection of flexible cystoscopes. The clinical and microbiological efficacy, safety, cost-effectiveness and ease-of-use were compared.

Joint AUA/SUNA White Paper on Reprocessing of Flexible Cystoscopes

Numerous federal bodies and professional societies have produced guidelines and standards for the reprocessing of endoscopes, but few specifically address the reprocessing of cystoscopes. This document presents a summary of the current recommendations for reprocessing flexible cystoscopes, and highlights particular aspects of instrument reprocessing that are unique to cystoscopy. Cystoscopes are classified as "semi-critical" devices. Such devices require high-level disinfection or sterilization between patients. High-level disinfection differs from sterilization in that high-level disinfection does not kill large numbers of bacterial spores, while sterilization involves the complete destruction of all microbial life. In the office setting, high-level disinfection (using glutaraldehyde or another chemical disinfectant) is commonly employed for the reprocessing of flexible cystoscopes. During high-level disinfection, standard reprocessing steps should be followed to prevent contamination of the cystoscope between uses. These include precleaning, leak testing, cleaning, disinfection, rinsing, and drying. Recommended "soak times" for glutaraldehyde vary from 20 to 45 minutes, depending upon the degree to which these steps are followed. If no precleaning is performed, a 45-minute glutaraldehyde soak is required to achieve high-level disinfection. Conversely, a 20-minute soak is adequate to achieve high-level disinfection if recommended reprocessing steps are followed prior to immersion in the glutaraldehyde. One chemical disinfectant (ortho-phthalaldehyde) has been associated with anaphylaxis in bladder cancer patients, and should be avoided in these patients. This white paper provides a concise reference document for the reprocessing of flexible cystoscopes. In addition, references and links to more comprehensive resources are provided. This document may be useful for clinicians and others who are in search of guidance in this area.

Development of a Standardized Curriculum for Teaching Cystoscopic Skills Using a Computer-Based Endourologic Simulator

Educational opportunities with simulation are now available to teach endoscopic skills outside the clinical setting. The goal of this study is to assess the learning curve and subjective impressions of cystoscopic tasks performed by untrained subjects on a computer-based simulator using a standardized curriculum. We evaluated ten novice subjects on a computer-based cystoscopic simulator (URO Mentor, Simbionix, Lod, Israel) during a standardized cystoscopy skills course developed for the study. All trainees performed three basic cystoscopic tasks as part of the curriculum. Subjects were evaluated until a steady state of performance was observed. Subjectively, participants assessed their performance and opinions regarding the computer-based simulator. Among the ten novice subjects (five men, five women), a median of six training sessions were required to achieve a steady state of performance. Significant performance improvements were noted with additional simulator time (P<0.001), however, the rate of improvement declined with time. Regression analysis of completion times revealed significant gender effects for one cystoscopic task. At study end, gender performance differences for any task were not significant. Uniformly, novices felt that URO Mentor was easy to use and provided an overall realistic training experience. In this study a computer-based simulator was successfully incorporated into a training curriculum for cystoscopy education. For simulated tasks performed with rigid and flexible cystoscopes, a median of six training sessions was necessary. Objectively, performance on the testing scenarios significantly increased with experience. Subjectively based on nonvalidated criteria, comfort level, and perceived competency increased significantly from the pre- to postcourse evaluations.

Suburothelial Myofibroblasts in the Human Overactive Bladder and the Effect of Botulinum Neurotoxin Type A Treatment

BackgroundAn increasing body of evidence suggests a possible role of suburothelial myofibroblasts (MFs) in bladder mechanosensation and in the pathophysiology of detrusor overactivity (DO). ObjectiveTo determine whether markers of MFs, including gap junction protein connexin43 (Cx43) and c-kit have altered immunohistochemical expression in the suburothelium of patients with neurogenic DO (NDO) or idiopathic DO (IDO) and whether this is affected by successful treatment of DO with botulinum neurotoxin type A (BoNTA). Design, setting, and participantsPatients with NDO (n=10) or IDO (n=11) were treated in a single-centre, open-label study of intradetrusor BoNTA injections. Control tissue was obtained from 10 patients undergoing pelvic-floor repair procedures who had no overactive bladder (OAB) symptoms. This study is registered with ClinicalTrials.gov, number NCT00662064. InterventionsBladder biopsies performed with flexible cystoscopes were obtained from control subjects and from NDO and IDO patients before BoNTA treatment and at 4 wk and 16 wk after treatment. They were studied with quantitative immunofluorescence using antibodies to connexin 43 (Cx43), vimentin, and c-kit. MeasurementsDifferences in Cx43, vimentin, and c-kit immunoreactivity between control subjects and NDO or IDO patients (primary outcomes). Changes in NDO or IDO, Cx43 immunoreactivity, and c-kit immunoreactivity after BoNTA treatment (secondary outcomes). Results and limitationsCx43 immunoreactivity was increased in both IDO and NDO patients compared to controls, but remained unchanged after BoNTA treatment. C-kit immunoreactivity was similar in NDO/IDO patients and controls and remained unchanged after BoNTA treatment. ConclusionsIncreased gap junction formation in the suburothelium has been demonstrated in biopsies from humans with DO. It is hypothesised that this change could have a significant role in the pathogenesis of the detrusor abnormality. Successful treatment of NDO or IDO does not appear to be associated with changes in the expression of Cx43 or c-kit on suburothelial MFs.

Evaluation of Practice Efficiency with a Novel Sheathed Flexible Cystoscope: A Randomized Controlled Trial

The processing of standard flexible cystoscopes is time-consuming and potentially hazardous to healthcare staff. We evaluated a novel flexible cystoscope system containing a disposable sheath, which obviates the need for chemical processing. A total of 100 patients undergoing office cystoscopy were randomized into a "sheath" or a control group (n = 50 for each group). Disposable Slide-On sheaths and the CST-2000 Flexible Cystoscope System were used in the former group. A standard 16F flexible cystoscope, manually cleaned and disinfected with Cidex OPA or Rapicide, was used in the control group and the preparation times were recorded. Questionnaires to assess cystoscope setup, handling, optical quality, and patient comfort were completed by the physician, nursing staff, and patients. Data were available for 97 patients. The mean total time required for preparation of the cystoscopes was 10.7, 14.7, and 42.2 minutes for the sheath (n = 49), Rapicide (n = 21), and Cidex OPA (n = 27), respectively (P <0.01 for all comparisons). The control group scored better than the sheath group with regard to ease of cystoscope insertion (9.1 versus 7.7), cystoscope handling (8.8 versus 8.1), and irrigation setup (8.8 versus 8.2; all P < or = 0.01). No statistically significant difference was found between groups for procedure time, optical quality, or patient comfort, either during or after the procedure. The EndoSheath System can save 4 to 31 minutes of processing time while avoiding exposure to irritants found in conventional soaking methods. Although maneuvering of the sheathed cystoscope was slightly more difficult, the optical quality and patient comfort were similar to those of standard flexible cystoscopy.

Reprocessing rigid and flexible cystoscopes in urology

Reprocessing rigid and flexible cystoscopes in urology

An Independent Analysis of Flexible Cystoscope Repairs and Cost

To establish the repair patterns of flexible cystoscopes we performed a systematic review of repairs performed at an independent endoscope repair company. Repair and cost data for 2000 to 2004 were obtained from an independent endoscope repair company. All cystoscopes underwent a detailed inspection using a preset protocol and the frequency of individual repair descriptions was extracted from a computer database. A total of 1,150 repairs were performed on the Olympus CYF (3%), CYF-2 (21%), CYF-3 (56%) and CYF-4 (20%) flexible cystoscopes. Repairs to the distal tip (28% of all repairs) most commonly involved the bending rubber or outer polymer sheath. Repairs to the hand control segment (14% of all repairs) most commonly involved the ocular. Repairs for image (14% of all repairs) and deflection (9%) were most commonly performed on the fiberoptic bundle and wires, respectively. Repairs to the deflection apparatus comprised a significantly greater proportion of total repairs in the early CYF models than in the CYF-4 model (10% to 12% vs 3%, p <0.01, chi-square 10.73). Less than 1% of all cystoscopes needed more than 2 repairs. Olympus cystoscopes require repair every 2 to 3 years and they appear to be durable. The distal deflection tip, specifically the outer bending rubber, is the most common site of flexible cystoscope damage. Although it appears that significant improvements have been made to the deflection apparatus, the number of repairs to other areas has not changed significantly with time. Improvements in form and function of the distal tip, the hand control segment and the fiberoptic bundles may enhance the durability of flexible cystoscopes.

MP-12.07: Comparative study of bladder biopsies performed by using flexible and rigid cystoscopes

Cystoscopy is an important investigative tool in the diagnosis of lower urinary tract symptoms. Biopsy is necessary if there is any abnormality in the mucosa of the bladder to confirm the diagnosis. Biopsies can be performed using a flexible cystoscope under local anaesthesia or rigid cystoscope under regional or general anaesthesia. A good deep bladder biopsy can be obtained using a rigid cystoscope, but the advantage of using a flexible cystoscope is that it can be done under local (topical) anaesthesia and in the supine position.

Comparison of Flexible Grasping Forceps and Stone Basket for Removal of Retracted Ureteral Stents

Ureteral-stent dislocation can occur either during positioning or postoperatively. Grasping the distal end of the stent and removing it depends on the angulation between the extraction device and the stent, the size and length of the instrument, and the force of the branches and resistance of the dislocated stent. Six cases of challenging stent removal are presented, and details of the surgical technique are described. By in-vitro testing, we investigated the deflection of flexible cystoscopes and ureteroscopes using forceps or a four-wire stone basket, the ability to grasp a stent depending on the angle between the stent axis and the extraction device, and the force that can be applied on the stent with the different devices. In all cases, it was possible to extract the stent with a stone basket. In an in-vitro setting, maximum extraction forces, measured with a macro scale, were 1.3 kg (cystoscopic forceps) and 0.4 kg (ureteroscopic forceps) until the forceps slipped off the stent. In the same setting, a rupture of the wires of the 1.9F stone basket occurred at 0.8 kg, whereas with a 2.4F basket, a force of 1.9 kg led to rupture of the stent, leaving the basket intact. Using a stone basket instead of grasping forceps in difficult cases of dislocated stents opens new possibilities for their cystoscopic and ureteroscopic removal. Because the superiority of the basket is counterbalanced by its higher costs, we suggest the basket extraction method only in difficult cases.

Initial Experience of Laparoscopic Pyeloplasty: Retrograde Stenting Using Flexible Cystoscopes

Purpose: To describe our initial experience of laparoscopic pyeloplasty, with retrograde stenting, using flexible cystoscopes, in 9 cases of ureteropelvic junction obstruction (UPJO). Materials and Methods: Between September, 2004 and January, 2006, 9 cases of UPJO were treated by laparoscopic pyeloplasty. All of the medical records were reviewed retrospectively. The cases comprised of 5 males and 4 females, with a mean age of 37 years (13-58). All patients showed a preoperative grade 4 hydronephrosis. Results: Two laparoscopic pyeloplasty approaches were performed; a transperitoneal approach in 5 cases and a retroperitoneal approach in the other 4. All cases were treated with dismembered Anderson-Hynes pyeloplasty. The mean operating time was 249 minutes (170-324), including a mean of 7.1 minutes (6.5-8) for ureteral stenting. The patients were found to have aberrant vessels and renal stones in 1 and 3 cases, respectively. There were no intra-operative complications or open conversion. Of the 9 cases, 8 (89%) showed a decrease in their hydronephrosis grade on the excretory urographs taken 12 weeks postoperatively. The remaining case showed a marked improvement in the hydronephrosis, despite having no change in the hydronephrosis grade. No case experienced postoperative flank pain or recurrence of acute pyelonephritis. Therefore, symptomatic improvements were observed in all our cases (100%). Conclusions: Laparoscopic pyeloplasty, with retrograde stenting, using flexible cystoscopes, can be considered an effective and convenient method for the treatment of UPJO. (Korean J Urol 2006;47:1302-1308) ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ

Comparison of Resolution, Contrast, and Color Differentiation Among Fiberoptic and Digital Flexible Cystoscopes

Advances in electro-optics continue to improve the urologist's ability to perform minimally invasive procedures. While the development of flexible fiberoptic cystoscopes more than 20 years ago greatly impacted the practice of urology, distal-sensor digital technology may represent the next step in the evolution of endoscopy. We compared a new distal-sensor digital flexible cystoscope with two standard fiberoptic flexible cystoscopes. We evaluated the resolution, contrast, and color discrimination of a new ACMIICN distal-sensor digital cystoscope with >165,000 effective pixels in its clear aperture (viewing area), a new ACMI-ACN II fiberoptic cystoscope with <15,000 pixels in its clear aperture, and a Storz 1127 office fiberoptic cystoscope. Five subjects compared each cystoscope across 13 test parameters. There was no difference in the performance of the two fiberoptic cystoscopes. The ICN cystoscope was statistically superior to one or both fiberoptic cystoscopes across 12 of the 13 tests, including color differentiation between shades of dark red (P < 0.05), contrast discrimination along a 15-step grayscale gradient (P < 0.001 compared with the 1127 fiberoptic cystoscope only), resolution at 10 mm (7.52 line pairs/mm [lp/mm] (ICN) nu 3.58 lp/mm for both fiberoptic cystoscopes; (P < 0.001), and clear resolution of a 1-mm target at a distance of 6.1 cm (ICN) nu 3.3 cm (1127) and 3.8 cm (ACN II) (P < 0.001). The ICM distal-sensor all-digital cystoscope was clearly superior to two representative fiberoptic cystoscopes in vitro in terms of resolution, contrast discrimination, and red color differentiation. In-vivo performance remains to be assessed.

Comparison of optical resolution with digital and standard fiberoptic cystoscopes in an in vitro model

Objectives To compare two different distal sensor flexible endoscopes with standard fiberoptic cystoscopes for optical resolution. Distal video sensor flexible endoscopy may represent the cusp of a new endoscopic revolution. Methods Twenty-three participants evaluated the optical resolution capabilities of six flexible cystoscopes. The two presently available distal sensor flexible cystoscopes, ACMI DCN-2010 digital flexible cystoscope and Olympus CYF-V EndoEYE flexible video cystoscope, were compared with the four leading fiberoptic cystoscopes, ACMI ACN-2 fiberoptic cystoscope, Olympus CYF-4 Cystofiberscope, Karl Storz 11272CU1 Flexible Cystoscope, and Richard Wolf Flexible Fibre Urethro-Cystoscope, in an in vitro model. The participants recorded the numerical digits they were able to visualize through five solutions with progressively increasing concentrations of hematoxylin dye (C1 to C5). The cystoscopic images were viewed on a 13-in. medical grade Olympus monitor with an Olympus Visera camera system. Results No differences were detected among the cystoscopes at the lowest concentrations of hematoxylin dye (C1 and C2). At C3 to C5, the mean percentage of visualized numbers for the ACMI and Olympus distal sensor flexible cystoscopes was significantly greater than for all fiberoptic cystoscopes ( P <0.01). At the highest concentration (C5), the ACMI distal sensor cystoscope performed significantly better than did the Olympus distal sensor flexible cystoscopes ( P <0.01), although at all other concentrations, the two digital video cystoscopes performed equivalently. Conclusions The results of this in vitro study suggest that cystoscopes with distal sensor technology improve visibility in a simulated challenging working environment compared with fiberoptic cystoscopes.