Rigid cystoscopy, cold-cup biopsy and fulguration

Operative visualisation

UrOops3D · UroRef · © Nity G

Operative steps

1. Before the sheath The indication: a tissue diagnosis that a flexible scope cannot make, a red patch or a flat lesion to biopsy, a positive cytology with nothing seen, a bleeding point to burn, or an examination the patient cannot tolerate awake. General or spinal anaesthetic, lithotomy in supports with the legs padded at the peroneal nerve and the buttocks at the end of the table. Antibiotics at induction where the urine or the history asks for them. The consent names infection, bleeding, urethral injury and the small chance of a perforation.
2. The stack A 21 French sheath with its obturator, a bridge with a working channel, a 30 degree telescope for the survey and a 70 degree for the dome and anterior wall, the camera and light lead, irrigation of saline by gravity from a bag no higher than sixty centimetres. On the trolley: cold-cup biopsy forceps, the button or Bugbee electrode with the generator on coagulation, a ureteric catheter, specimen pots already labelled by site, and formalin. The plate goes on the thigh if monopolar diathermy is used.
3. The sheath in under vision The sheath goes in on the visual obturator with the 30 degree lens looking through it, following the lumen: never blind, never forced. The bulbar urethra turns upward and the sheath is dropped between the legs to follow the curve. The sphincter is a closed ring that the anaesthetic relaxes; the sheath passes it without push. The veru, the prostatic urethra with its lobes, and the bladder neck are noted on the way through, and the obturator comes out for the bridge and the telescope.
   where it bites: a rigid sheath forced through a stricture or a closed sphincter makes a false passage; the fix is to withdraw and find the lumen with the lens.
4. The survey The bladder is emptied and refilled to half. The air bubble at twelve o'clock orients the view; the trigone is on the floor with an orifice at each corner, each watched for a jet. The survey is in a fixed order: dome, anterior wall, right wall, posterior wall, left wall, floor. The 70 degree lens looks round the corner at the dome and the anterior wall that the 30 cannot reach, and suprapubic pressure from the assistant brings the dome down into view. A red velvety patch, a flat lesion, a diverticulum or a papillary tumour is described by wall, clock position and size before it is touched.
5. The cold-cup biopsy The cold-cup forceps go through the bridge and are opened and pressed against the lesion so that the mucosa domes into the cup, then closed and pulled sharply away. The bite is mucosa with some lamina propria, taken without current so the histology is not burnt; a second bite from the same site if the first was small. Each bite goes straight into the pot labelled with its site. The site bleeds a little, which is expected and is dealt with once the specimen is safe.
   where it bites: a cold-cup bite at the thin dome of a distended bladder can go through the wall; the dome is biopsied with the bladder half full and the cup pressed, not driven.
6. Fulguration The button or Bugbee electrode on coagulation is touched to the bleeding point, not painted across the wall, and a short burst is given until the point blanches. The current goes to where the electrode touches, and a distended bladder makes the wall thinner under it, so the bladder is kept half full. A small flat lesion can be fulgurated in full once its biopsy is taken; a papillary tumour is resected, not burnt, because burning destroys the stage. Fulguration near the lateral wall can stimulate the obturator nerve and jerk the leg: shorter bursts and lower power.
7. Mapping biopsies When the cytology is positive and the bladder looks normal, or when carcinoma in situ is suspected, cold-cup bites are taken from named sites: the trigone, both lateral walls, the posterior wall and the dome, each in its own labelled pot, and the prostatic urethra with a loop or a cup. Nothing is biopsied at the orifice itself. The sites are drawn on a bladder map in the note so that a positive result can be placed. Random biopsies of a normal-looking bladder without a reason are not taken.
8. Haemostasis and the check The irrigation is slowed and every biopsy site inspected; a spurting point is fulgurated, an ooze is left. Both orifices are seen again with their jets, because a bite or a burn near one can obstruct it. The bladder is emptied through the sheath and the sheath is withdrawn under vision with a last look at the prostatic urethra and the sphincter. A catheter is left only if the bleeding or the number of biopsies asks for it.
9. The note and the specimens The note draws the bladder and marks every site with what was done there: biopsy, fulguration, both. The pots and the request forms match the map, site by site, and the number of pots is counted against the number of sites before the patient leaves theatre. The patient is warned about pink urine and burning for a few days and told when and how the histology will be given. The team that requested the biopsies chases the result.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

FRCS viva questions

The examiner stems this scene prepares you for. Try to answer out loud first, then reveal, and learn the discriminator, the detail that turns a pass into a strong pass.

Evidence and guidance