TsISTOSKOPYYa (Greek kystis a bladder - f-skopeo to consider, investigate) — a method of a research of a bladder by survey of its inner surface by means of the special device — the cystoscope. C. is one of the most informative and often applied methods of inspection at a beater. patients; C. serves also for carrying out nek-ry medical manipulations in a cavity of a bladder under control of sight.
The idea of survey of uric ways by means of an external light source belongs to Bozzini (Ph. Bozzini, 1805). In the subsequent various researchers, including Dezormo (A. J. Desormeaux, 1853), Grün-feld (J. Griinfeld, 1874), offered for survey of an urethra and a bladder various devices which did not gain, however, distribution as the light source located out of the studied body did not provide sufficient illumination of an object of a research. To M. Nittsa (1877, 1879) connected a bright light source and optical system in one device. This device was entered into the bladder filled with liquid. The cavity of a bladder was lit with the electric bulb located on the internal end of a tube. I. Lljbarran in 1897 entered into system of the cystoscope the special managed elevator for introduction of a catheter in the mouth of an ureter.
Indications to C. are very diverse since the method allows to reveal defeat not only a bladder, but also upper uric ways, and also kidneys. Diagnostic C. apply at a gross hematuria (see the Hamaturia) to identification of a bleeding point; at the long and often repeating dysuria (see) for an exception of a nephrolithiasis (see), tumors of a bladder (see the Bladder, tumors) or tuberculosis of uric system (see Tuberculosis extra pulmonary, tuberculosis of uric ways). By means of C. it is possible to establish the reasons of a resistant pyuria and an erythrocyturia. These C. are most informative at diagnosis of anomalies of kidneys and uric ways (an aplasia of a kidney, doubling of an ureter, an ectopia of the mouth of an ureter, etc.), and also in the presence of a foreign body in a bladder. C. the C can be used not only for diagnosis, but also for development of the plan and scoping of alleged operation at a tumor of a bladder, puzyrnovlagalishchny and vesical pryamokishechnykh fistulas, a diverticulum of a bladder, etc. Besides. is an integral part of other diagnostic procedures, e.g. hromotsistoskopiya (see), ureteropi-elografiya (see Piyelografiya).
Not less the C is important surgical., providing capture of a piece of fabric for gistol. researches, a cystolithotripsy (see. To am a subsoil obleniv), electrothermic coagulation of benign tumors, a section, etc.
Tsistoskopiya is contraindicated to an ureterotsela at acute inflammatory diseases of an urethra, prostate, small egg and its appendage, a bladder, injuries of an urethra. Acute pyelonephritis with high temperature of a body is not a contraindication to a tsistoskopiya and catheterization of ureters.
For performance of C. certain conditions are necessary: the urethra shall be passable for the cystoscope, a bladder — rather extensible, with a capacity not less than 75 — 100 ml. During the research the liquid filling a bladder shall be transparent. Therefore the bladder is washed out before a research and during a procedure. According to special indications at impassability of an urethra of C. it can be carried out through the functioning suprapubic vesical fistula.
C. make by means of the special device — the cystoscope supplied with lighting and optical systems, to-ry enter into a bladder on an urethra. Basic elements of the cystoscope are the thin-walled metal trunk (tube) and the tube entered into it with optical system. The last consists of a lens, system of lenses and an eyepiece. On the distal end of the cystoscope the lighter accommodates. Between an optical tube and a trunk there is a gap used for introduction to a bladder of liquid and its removal, and also for carrying out catheters or flexible tools. In the cystoscope there can be a valve or conical system of sealing of connection of a trunk with an optical tube.
To destination distinguish observation cystoscopes, kateterizatsion-ny, operational, a special purpose and universal.
The observation cystoscope provides survey and washing of a bladder. Kateterizatdionny tsisto-
ospreys are intended for catheterization of ureters. By quantity of at the same time carried out catheters distinguish unilateral and two-sided kateterizatsionny cystoscopes. The operating cystoscope (fig. 1) serves for carrying out medical or diagnostic manipulations by means of flexible tools. The device of a trunk of kateterizatsion-ny and operating cystoscopes allows to carry out through it catheters and flexible tools of different diameter, using branch pipes on an optical tube or on a node of the mechanism of Albarran. Cystoscopes of a special purpose are adapted for implementation of a certain procedure or a research. The cystolithotriptor is intended for mechanical crushing of stones in a cavity of a bladder under control of sight. Lithotripsy is carried out by squeezing of a stone gear sponges of the device. Cis-torezektoskop (the resectoscope, fig. 2) serves for a transurethral electroresection of a neck of a bladder at its sclerosis, a prostatectomy at its adenoma and cancer, a resection under control of sight of papillomas and tumors of a bladder current of high frequency. Fo-totsistoskop provides a possibility of photography of an inner surface of a bladder. The special optical tube and the camera are included in its package. The universal cystoscope is intended for survey of a bladder, catheterization of ureters, interventions by flexible tools under control of sight, and also for electrohydraulic crushing of stones in a cavity of a bladder by means of «Urate» devices (see Lithotripsy).
In system of lighting of modern cystoscopes use the fiber light guides more often located in optical tubes and transferring light from a stationary source (a light projector) to a cavity of a bladder. The flexible endoscope with a fiber optics entered through an ostium ureteris can be used for a research of an inner surface of an ureter.
Cystoscopes will sterilize by a cold method (liquid sterilization of 6% solution of hydrogen peroxide or ethylene oxide in special cameras).
Special training of the patient for a research is not required. In need of performance of C. at the patient with hron. carry out by inflammatory process in an urethra, a prostate gland, a small egg and its appendage before a research within several days antiinflammatory treatment in order to avoid
Fig. 1. Operating cystoscope with a fiber light guide of TsiO-VS-2: a vver
hu — a tube with optical system; in the middle — a trunk of the cystoscope with the entered obturator; below — the flexible tool; sideways — a kra of N tee, applied to intensive washing of a bladder; 1 — an ocular part of an optical tube; 2 — the obturator (the proximal end) in a trunk of the cystoscope; 3 — cranes for giving and removal of wash liquid; 4 — a trunk of the cystoscope; 5 — the distal end of the obturator; in — the elevator of the mechanism of Albarran; 7 — a trunk part of an optical tube; 8 — the drafts managing the elevator; 9 — makhovichka for management of drafts of the elevator; 10 — branch pipes for introduction of catheters and flexible tools.
aggravations of process. The patient is stacked in ginekol. a chair or on rentgenol. table. Legs, cover pubic area and a crotch with sterile linen, leaving opened only a penis at the man or a sexual crack at the woman.
Introduction of the cystoscope to a bladder at women, as a rule, comes easy and does not demand anesthesia. Difficulties can arise only during the narrowing of an outside opening of an urethra. In this case before introduction of the cystoscope make expansion of an urethra direct buzha to number 22 on Sharryer's scale (see. Urological tools). In most cases C. carry out under local anesthesia. Enter 10 ml of warm 5% of solution of novocaine into an urethra and on a penis under a head impose for 5 — 10 min. a unit clamp — a penisklemma (see. Urological tools). After this time remove a clip and enter the cystoscope into a bladder by the technique used at introduction of a metal catheter or buzh (see Catheterization). For introduction of the cystoscope by the patient with adenoma of a prostate, with lengthening and a curvature of a back urethra the penis is lowered down and carefully
advance the tool, holding his beak in such situation that it was turned strictly to a front wall of an urethra. C. it is complicated also at women in the second half of pregnancy because of the shift of a wall of a bladder by the head of a fruit which is located usually in the right half of a basin; in these cases the cystoscope is carefully advanced in the left half of a bladder.
After introduction of the cystoscope remove optical system from a tube and fill a bladder with warm solution of oxymercurous cyanide 1:5000 or 2 of % solution boric to - you (200 ml). If in contents of a cavity of a bladder there is an impurity of blood or pus, the bladder is washed out, and then enter optical system and start systematic survey, to-ry carry out according to a certain scheme.
In the beginning examine a front wall and a top of a bladder where the air traps serving as a reference point are defined (tsvetn. tab., Art. 112, fig. 12, b). Then the cystoscope is turned on 90 ° to the right and examine the left sidewall, further — right and, at last, a back wall of a bladder and its bottom. Considering that patol. processes are localized often in the field of a lyetodiyev (vesical, T.) triangle,
Fig. ‘2. Tsistorezektoskop Tsir-VS-1 with a fiber light guide and a set of flexible tools: above — a tube with optical system (a working part of a trunk in assembled form); in the middle — a trunk of a tsistorezektoskop with the entered obturator; below — a set of flexible tools with tips for fixing, coagulation and removal of various educations in a gleam of a bladder; 1 — an optical tube with a fiber light guide; 2 — an ocular part of an optical tube;
3 — the obturator with the unbent end; 4 — cranes for giving and removal of wash liquid; 5 — a trunk of a tsistorezektoskop; 6 — the end of the obturator; 7 — the end of the trunk of the tool inserted into a working part; 8 — the mechanism managing movement of tools;.9 — a block for fastening of tools; Yu — the electric probe for connection to the generator of current of high frequency.
formed by mouths of ureters and an internal opening of an urethra, this area is explored with special attention. For survey the front wall of a top of a bladder is hardly accessible. For its best visualization release a part of liquid from a bladder and press on a stomach of the patient in suprapubic area; at the same time the wall of a bladder is displaced in sight of the cystoscope.
The normal mucous membrane of a bladder has light pink coloring, slightly brilliant, with the gentle vascular drawing (tsvetn. tab., Art. 112, fig. 12, a); only in the field of a lyetodiyev of a triangle and a neck of a bladder larger vessels are traced. Mouths of ureters are symmetrized on small eminences on the ends of the interureteric roller differing on color from a surrounding mucous membrane. In relation to the imagined dial of hours, on Krom the arrangement of an air bubble corresponds to 12 hours, the right ureter is on 7, and left — at 5 o'clock. Mouths of ureters have the funneled form with pinholes in the center more often, but they can have the form of a comma or a crack. It is the most convenient to examine sites of a bladder from distance apprx.
25 mm from a lens to the explored area. At approach of optical system an object becomes larger, but the field of vision at the same time decreases.
A cystoscopic picture at various patol. changes has idiosyncrasies. At an aplasia of a kidney the respective mouth of an ureter is absent. In some cases it is possible to find doubling of mouths of ureters or even trebling. Ureterotsele (a cystic megaloureter in the field of the mouth) is defined in the form of the spherical protrusion covered with a normal mucous membrane, places penetrated by small vessels. At a diverticulum of a bladder it is possible to see its inlet opening, oval or roundish with a ra-diarny skladchatost of a mucous membrane, usually in close proximity to the mouth of an ureter. Information, necessary for a successful diverticulectomy, on interposition of the mouth of an ureter and khod in a diverticulum can be received only by means of C.
Valuable data receive by means of C. at inflammatory diseases of a bladder. As it was already noted, acute cystitis is a contraindication to tool methods of inspection. However at the long course of cystitis with a persistent dysuria sometimes only C.
allows to define the prime cause of a disease and degree of manifestation of changes in a mucous membrane of a bladder. The picture of a polimorfn observed at a tsistoskopiya in connection with various etiology and a fa-zovost of a course of a disease (see Cystitis).
By means of C. ulcer changes of a mucous membrane of a bladder can be revealed. Ulcers can be single and multiple, various form and the sizes. The ulcer of a bladder at intersticial cystitis usually happens single and is located on a front wall while tubercular ulcers are localized in the field of the mouth of an ureter, a cut at the same time happens involved, edematous and surrounded with tubercular hillocks.
At a leukoplakia (see) bladder on his mucous membrane sharply outlined ochroleucous spots with a little raised edges are visible. The centers of a leukoplakia can have various form and size, are sometimes inlaid with salts and are surrounded with a narrow zone of a hyperemia.
At inflammatory changes of paravesical cellulose (see Para-cystitis]), napr, owing to a purulent salpingitis, appendicular abscess, etc., and formation of purulent fistula at C. define a prolapse of a wall on the respective site of a bladder and existence of a perforation opening, from to-rogo pus is emitted.
C. allows to find urinary stones (see) and foreign bodys (see) a bladder, and also a stone in the mouth of an ureter. By the form and coloring of a stone it is possible to establish its chemical structure conditionally. For at military stones bright yellow coloring, a smooth surface, a flat or ovoid form are characteristic (tsvetn. tab.,
Art. 112, fig. 13). Oxalic stones dark brown (sometimes black) colors, on their surface are quite often visible thorns. Phosphatic and calcium stones smooth, white or white-bluish color. As in most cases formation of stones of a bladder — secondary process, at C. carefully examine a mucous membrane throughout for the purpose of identification patol. changes — a diverticulum, a tumor, increase in a prostate, etc. Pristenochny (alloyed) stones form around silk threads at accidental underrunning of a wall of a bladder during operations on bodies of a small pelvis. Most often it is fosfatnokaltsiyevy stones. Their characteristic feature is the immovability at change of position of a body of the patient during C.
The patient with adenoma of a prostate of C. make only in the presence of a hamaturia or at suspicion of a tumor of a bladder. At C. the hilly bright red education pressing in a gleam of a bladder is found, the trabekulyarnost of a wall of a bubble, false diverticulums come to light (tsvetn. tab., Art. 112, fig. 22). At the big sizes of adenoma of the mouth of ureters and a bottom of a bladder it is not possible to see. At a prostate cancer during C. find the hilly tumor of light pink or bluish color pressing in a bubble (see tsvetn. tab., Art. 112, fig. 20). The bottom of a bladder is raised, mouths of ureters are well distinguishable.
Sometimes at C. it is possible to observe violent hypostasis of the mouth of an ureter, to-ry it is caused by infringement of a stone in an intramural part of an ureter, tubercular or tumoral defeat of area of a lyetodiyev of a triangle. At a hamaturia release of blood from the mouth of an ureter, sometimes in the form of a clot of a worm-shaped form usually accurately is defined. It is characteristic cystoscopic picturesand at a pyonephrosis (see) when from the mouth of an ureter pus as «paste from a tube» is emitted.
During C. it is possible to carry out and lay down. manipulations: endovesical electrothermic coagulation of a simple ulcer or papilloma, a section of the mouth of an ureter at the ureterotsel, an injetsirovaniye under a mucous membrane of a bubble of various pharmaceuticals, napr, at tuberculosis, a simple ulcer; bougieurage of an ureter at its stricture, catheterization of an ureter for recovery of its passability at obturation a stone, bringing down of a stone from an ureter by means of extractors, a section and extraction of a pristenochny ligature, a mechanical or electrohydraulic cystolithotripsy (tsvetn. tab., Art. 112, fig. 14,15,16), transurethral electroresection of adenoma or prostate cancer, etc. With the differential and diagnostic purpose carry out a biopsy, the type of a tumor and degree of its zlokachestvennost allows to establish edges. For carrying out a biopsy by means of an operating cystoscope enter nippers into a bladder, the opened spoons to-rykh bring to a tumor, using Albarran's screw, and occupy its site. Holding the cystoscope one hand, another is taken by nippers with a piece of a tumor, to-ry place in 10% solution of formalin and direct on gistol. research.
Endovesical electrothermic coagulation of papillomas of a bladder (tsvetn. tab., Art. 112, fig. 21) carry out by means of the device for a diathermy to one or several sessions with breaks in 2 — 6 and more days. The inactive electrode (a lead plate) is enclosed under sacral area of the patient, and active — brought on the special channel of an operating cystoscope to the basis of a leg of a tumor and include current. After separation of papilloma from a wall of a bladder coagulate a stump of a leg, and also the small site of a mucous membrane and a submucosal layer on its periphery. Electrothermic coagulations, as a rule, are not subject malignant tumors since it does not provide their radical removal. On the nature of coagulation to a certain extent it is possible to make representation about patol. process. So, papilloma of a bladder is easily coagulated and quickly disappears, malignant tumors hardly give in to coagulation. Predictively more favorable results are observed at a transurethral electroresection of papilloma.
The transurethral electroresection is used at adenoma of a prostate of the small sizes, a sclerosis of a neck of a bladder and its inborn valves, and also as a palliative measure at an occlusive prostate cancer, cancer of a neck of a bladder. In nek-ry cases, napr, at elderly people or with serious associated diseases when other operative measures are contraindicated, only the electroresection saves patients from constant suprapubic fistula (see Vesicotomy). Operation is performed under spinal anesthesia or under anesthetic. Special elektrore-zektoskop enter on an urethra into a bladder, pieces of fabric cut off coagulating current by means of a metal loop. The cut-off pieces of fabric periodically delete together with the liquid produced on a tube of the cystoscope. Operation is performed at constant washing of a bladder, e.g. 4% solution of glucose. Upon completion of an electroresection carry out a hemostasis by electrothermic coagulation of the bleeding vessels.
To complications of C. carry bleeding, damage of a wall of an urethra, napr, at the forced introduction of the tool at the patient with the bent and narrowed urethra; an aggravation of inflammatory process in an urethra, a prostate gland, appendages, testicles. At the strict accounting of contraindications, careful observance of a technique of C. and rules of an asepsis in most cases it is possible to avoid complications.
Tsistoskopiya at children has no fundamental differences from that at adults and is carried out according to the same indications. The device of children's cystoscopes similar to those, to-rye is used at adult patients; they differ only by the sizes. Feature of C. at children the fact that it is carried out under anesthetic is.
Bibliogra of l and p and G. Ya. N and In and y N the Dr. at x A. A. Organization of work in cystoscopic and a short technique of urological researches, Kharkiv, 1959; And y-sinskiyb. E., Gudynskiyya, V. and Khokhlov H. M. Urological endoscopy, M., 1978; Dunayevsky JI. And. and Nyankovskiya. M. A transvesical electroresection of adenoma and the stenosing necking of a bladder, Urol. and nefrol., No. 4, page 38, 1968; Lopatkinn. And. and Sabbath of A. JI. Tsistoskopiya and her value in urology (To the 100 anniversary of the first tsistoskopiya), in the same place, No. 4, page 53, 1979; The Guide to clinical urology, under the editorship of A. Ya. Py-tel, M., 1969 — 1970; Special methods of a research in surgery of children's age and bordering limits, under the editorship of
S. Ya. Doletsky, M., 1970; Frumkin
A. P. Cystoscopic atlas, M., 1954; Khokhlova N. M., the Pier in A. I. and Glebovaz. C. The new unified urological endoscopes, Medical tekhn., No. 5, page 13, 1979; H at the h e l about in N. I. Max Nittse (To the 125 anniversary since birth), Urol. and nefrol., No. 5, page 42, 1973; I TT of e r g u t M., Gulp D. Flocks R. H. The urethral caliber in normal female children, J. Urol. (Baltimore), v. 97, p. 693, 1967; KneiseO. u. Stol zeM. Hand-atlas der Cystoskopie und Urethrocysto-skopie, Lpz., 1955; ReuterH. J. Atlas der urologischen Endoskopie, Stuttgart, 1980; R o u s S. N. Urology in primary care, St Louis, 1976.
Yu. G. Alyaev; H. M. Khokhlova (tekhn.),
B. A. Romanov, O. A. Troitsky (tsvetn.