Abraham Leo Wolbarst Georges Luys.

A treatise of cystoscopy and urethroscopy online

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free from stricture, and stretched in advance by the passage of sounds
up to 28-29, if possible. If this precaution has been taken, the intro-
duction of the cystoscopic tube presents no difficulties. The instrument
is introduced into the bladder with the elbow^ed obturator. The screw
controlling the handle is released, thus straightening the obturator, and



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232 CYSTOSCOPY AND URETHROSCOPY

the latter is withdrawn from the tube. The operative technic is now
the same in both sexes.

The cystoscope having been inserted, the aspirator is connected,
so that the bladder will be kept dry throughout the examination. Oc-
casionally w^hen the bladder is not well dilated, the mucosa may pro-
trude into the interior of the tube. It is then necessary to interrupt
the aspiration until a little fluid has accumulated in the bladder. The
handle of the cystoscope is now fastened by a screw and the current
turned on.



Fig. 155. — Kxamination of the bladder. Exact position of the direct vision cystoscope in the female.

The bladder is seen splendidly illuminated, so that every detail
can be recognized. The vesical extremity of the cystoscopic tube moves
freely in the bladder and can be easily manipulated in all directions,
because of the distention brought about by the inclined position.

Examination of the bladder floor is quite simple. By raising the
handle of the instrument, the vesical end is depressed correspond-
ingly, thus bringing the trigone within view easily. The roof is ex-
amined by lowering the handle of the cystoscope and thus elevating
its vesical extremity. It is advisable to make gentle pressure on the
abdominal wall over the bladder; the entire bladder roof then comes
into view in the cystoscopic tube, and no portion of the vesical mucosa
can escape observation.



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technic of diiiect vision cystoscopy 23o

Abnormal Cases

In direct vision cystoscopy, petty difficulties may be encountered,
particularly by a novice, the two most important being tlie following:

1. The bladder does not dilate fidly under the influence of the in-
clined position. This may be due to several causes: (a) The patient



Fig. 156. — If the bladder does not dilate well in the inclined position, an assistant elevates the abdoni*
inal wall, thus facilitating the stretching of the bladder.

may be too stout, and the abdominal fat may prevent the bladder from
distending itself and thus becoming filled with air. It is then neces-
sary to still further elevate the pelvis. When the inclined position has
been pushed to its limit, and if the bladder still does not distend it-
self, the following expedient may be employed, especially when the
abdominal wall is flabby: An assistant grasps the abdominal wall as*



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234 CYSTOSCOPY AND URETHROSCOPY

near the pubis as possible, with both hands, raising up as much of the
wall as he can seize (Fig. 156). This maneuver will very often succeed
in causing distention of the bladder and a perfect view of the entire
vesical cavity is thus obtained. If, however, the result is still unsat-
isfactory, the genupectoral posture must be resorted to. (b) The pa-
tient may be thin, but resists and contracts the abdominal muscles
spasmodically. This is because the patient is nervous, and requires
a local anesthetic before relaxation is secured.

2. The vesical mucosa may bleed profusely. This renders a clear
view extremely difficult and nothing but blood can be seen. The ac-
tion of the aspirator is insufficient to take up a large quantity of blood,
and even if it took up all the fresh bleeding, it would still be unable to
remove the coat of blood which covers the fungosities in the bladder.
In such cases it is necessary to swab the mucosa with little tampons of
dry cotton. Occasionally however, the mere contact of these swabs
actually increases the bleeding of the mucosa. The only thing to do is
to use a 1:1000 solution of adrenalin. Tampons soaked with this solu-
tion are brought into contact with the bleeding points and the hemor-
rhage ceases.

ADVANTAGES OF DIRECT VISION CYSTOSCOPY
IN EXAMINATION OF THE BLADDER

The direct examination of the vesical mucosa by the simple cysto-
scopic tube offers many advantages over the indirect (prismatic)
method. In the normal bladder, the two principal advantages are the
following:

1. The Direct View. — With direct vision the various regions exam-
ined are seen just as they really are, in their normal position, form,
and situation, and are not deformed in any manner. The personal in-
terpretation does not enter into consideration and no matter how inex-
perienced in cystoscopy the observers may be, they all see the pictures
alike, because the image is not deformed or inverted. This is a de-
cided advantage, especially in determining the volume of a stone or of
a vesical tumor. In fact, in order to see well with the indirect cysto-
scope, it is necessary to keep the instrument at a certain distance from
the object. Inasmuch as it is difficult to say what this distance should
be, even a well-practiced eye may make serious errors in determining
the actual size of foreign bodies in the bladder.

In making a full view examination, the direct vision cystoscope
also has a decided advantage over the indirect. By inclining the tube
so that its long axis is almost parallel with the surface of the mucosa



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ADVANTAGES OF DIRECT VISION CYSTOSCOPY 235

to be examined, a series of changes of the mucosa can be seen in pro-
file which would escape unobserved when the same mucosa is looked
at in full view. I have thus been enabled to observe and make sketches
in numerous cases of chronic cystitis, of alterations consisting of little
elevations in the form of grains of sand which can not be seen well
with the indirect cystoscopy

2. Normal Coloring of the Mucosa. — The necessity of filling the
bladder with water or air, in order to obtain a good view in indirect
cystoscopy, causes a certain amount of distention which in turn, pro-
duces a condition of anemia. The real color of the mucosa is therefore
not seen. On the other hand, in direct vision cystoscopy, the bladder
is distended without force and the natural tints of the mucosa are seen
just as they are in reality.

3. Possibility of Examination in Contracted Bladder.—Tlie di-
rect vision cystoscope permits the examination of inflamed bladders
which have not a sufficiently large capacity to permit their distention
by the quantity of fluid required for indirect cystoscopy. It is well
known that prismatic (indirect) cystoscopy is well nigh impossible
when the vesical capacity is less than 60 c.c, and gives results which
are practically nil. Such instances are not at all rare; especially is
this true when the ureters are to be catheterized. I shall again con-
sider this later on.

4. Possibility of Examination in Hematuria and Pyuria.— rln hema-
turia and pyuria, when examination is almost impossible in spite of the
most copious irrigations, direct vision cystoscopy has a distinct ad-
vantage over the indirect method; only by this method, can we obtain
the necessary and precise information in cases of profuse hemorrhage
which would obstruct the field of vision in the indirect vision cysto-
scope. In this manner, errors which are as considerable as they are
to be regretted, can be avoided.

An especially interesting case observed by me, is that of a woman
aged forty years, whom I treated in 1907. She was a patient of Routier,
who had referred her to me because of hematuria, and he wanted my
cystoscopic opinion. Another specialist, who was previously consulted,
had declared after an indirect cystoscopy, that the patient did not have
a tumor of the bladder, but that she had a cyst in the lower extrem-
ity of the left ureter! When I examined her, she had well-marked
hematuria. As soon as the indirect cystoscope was inserted into the
bladder, whirlpools of blood prevented distinct vision and made the
examination impossible. I then used my direct cystoscope and was
enabled to make a positive diagnosis of a large tumor of the bladder



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236 CYSTOSCOPY AND URETHROSCOPY

situated in the left lateral portion of the fundus. In view of this diag-
nosis, Routier had his patient enter the sanitarium two days later.

On opening the bladder, a tumor the size of a pigeon's egg was
removed, and the histologic examination, made in the laboratory of
Necker by Herrenschmidt, showed that the growth was a fibroma.*

5. Possibility of Examination in Cases of Perforation or Vaginal
Fistula. — The direct vision cystoscope is the only instrument for the
examination of a bladder wath a fistula; such for example, as a vesico-
vaginal fistula. In these cases, it is manifestly impossible to distend
the bladder with a fluid which it can not hold, and the only method to
be employed is certainly direct vision cystoscopy.

It is superfluous to insist on the importance of the exact knowl-
edge of the seat of the vesical perforation in vesicovaginal fistula.
With the aid of my direct vision cystoscope, a probe can be introduced
into the fistula which penetrates the vagina and indicates the direction
of the fistula in the clearest manner. The services which this method
may render in such a case, are well shown by the two following ob-
servations by Ferron:^

'^Ferron examined a patient with a vesicovaginal fistula. A probe
was introduced into the fistula through the vagina; this was followed
by direct vision cystoscopy. It showed that the fistulous orifice was
very near tlie ureteral orifice. On operation, the fistula was sutured,
at the same time avoiding closure of the ureteral meatus.

^^In another case, a mistake in diagnosis was rectified by direct
vision cystoscopy. A woman having undergone total hysterectomy
was emitting urine through the vagina. The clinical diagnosis was
vesicovaginal fistula. Then Ferron employed direct vision cystoscopy;
the 'bladder seemed perfectly normal, and while catheterization of the
left ureter was easy and produced urine, it was impossible to pass even
a filiform into the right ureteral orifice. ' The diagnosis was therefore
changed to ureterovaginal fistula. '^

REFERENCE
iFerron: In These de Chardon, la Cystoscopie h vision diieete. Bordeaux, 1912, p. 47.

6. Possibility of Examination in Urethrovesicovaginal Fistula.* —

If vesicovaginal fistute are not relatively rare in Avomen, that can not
be said to be true of cases which are complicated with another com-
munication between the bladder and the urethra, in the form of an
abnormal channel passing outside of the vesical neck from the blad-

*The specimen is to be found in our private collection.



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ADVANTAGES OF DIRECT VISION CYSTOSCOPY 237

der to the posterior portion of the uretlira. In such a case, incon-
tinence of urine seems to proceed from tlie vesicovaginal fistula alone,
l)ut the other vesicoparaurethral canal is none the less an interesting



Fig. 157. — Vesicovaginal fistula. A catheter is introduced into the urethra; the opening of the fistula is

seen a little below and to the right.

anatomicopathologic complication which must be taken into consider-
ation.

These urethrovesicovaginal fistulje have been observed but rarely,
and the cases of this kind met with in literature do not reseml)le the
one about to be described, for the urethrocystoscopic investigations



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238 CYSTOSCOPY AND URETHROSCOPY

which could reveal them were not in current medical practice at that
time. My direct vision cystoscope gives a clear view of the neck of the
bladder quite as well on the vesical side as on the urethral, and thereby
facilitates the investigations considerably.^



/



Fig. 158. — Determining the exact position of the orifice of a vesicovaginal fistula by means of di-
rect vision cystoscopy. A grooved director inserted into the fistula marks the orifice of the fistula in the
bladder.

Verneuil has called attention to this subject/' and has reported sev-
eral cases of fistula joining the neck of the bladder with the urethra;
he termed them ^ * urethro vesicovaginal fistulas." He distinguished
several groups:



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ADVANTAGES OF DIRECT VISION CYSTOSCOPY 239

1. Very long fistulae, affecting the neck of the bladder and of the
urethra considerably, and showing one large opening bordered by the
bladder and the remnant of the urethra.

2. Fistulae situated low down, with a modification of the ure-
thral path or caliber:* Verneuil thought that many cases reported as
obliteration of the canal, are rather deviations, and that obliteration is
very rare. He cites two cases.

3. Fistulae situated low down, in which a continuous incontinence
simulated a complete destruction of the urethra and its sphincter:
Tavernier and Stephani have observed also a vesicovaginal fistula
which involved the neck of the bladder and the urethra; they suc-
ceeded in bringing about a perfect cure, with complete continence.^



Fig. 159. — Diagram showing the arrangement of the ureterovesicovaginal fistula.

A monograph has recently appeared on this subject, by Piontik,
of Pesia {Ueber Blasen-Cervixfisteln, Charlottenburg, 1909). The case
which is the basis of this report, is the following :

Mme. W. L., aged twenty-nine, was sent on February 3, 1911, to the Broca Hospital,
in the service of Pozzi, complaining of constant enuresis. Six months previously she had
been delivered of a child with forceps, at the Maternity ; half an hour later, incontinence set
in; the condition was unchanged whether she was lying in bed or up and about.

She went first to the Beau j on Hospital, where she was operated upon on October 12,
1910, but without any improvement whatever. On entering Broca Hospital, she presented a
marked erythema on the inner surface of the thighs, due to the constant involuntary flow
of urine.

On examination it was found that the vesical capacity was about 200 c.c. Above



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PLATE XV

Fig. 1. — Vesical leucoplalcia. This condition, observed during the course of
a very marked cystitis, is characterized by the pale plaques of cystitis
which contrast with the strikingly inflammatory red of the rest of the
bladder.

Fig. 2. — Chronic cystitis. Mosaic aspect.



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Fig. 2.

PLATE XV

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ADVANTAGES OF DIRECT VISION CYSTOSCOPY 241

this quantity the injected fluid escaped by the vagina. Urethral endoscopy showed that
the canal neck was distorted. A tube of my direct vision cystoscope was obstructed at the
bladder neck and could not penetrate further. It was impossible to introduce the instrument
into the bladder unless the extremity of the instrument was turned obliquely and directed
under control of the eye. The endoscopic examination showed that on the right side of the
bladder neck and external to it, there was a distinct orifice with edematous edges. A ureteral
catheter No. 6, was introduced into this orifice; it passed the right lateral portion of the
vesical neck, rounded it and entered the bladder after a passage of from two or three centi-
meters (Plate XIII, Fig. 6). This was therefore a real urethral fistula. Examination of
the ureteral orifices revealed that they were normal, normally located and could be easily
catheterized.

In Sims' position with the speculum, a vesicovaginal fistula about the size of a franc
[25 cent piece] was seen at the neck of the bladder and almost touching it. This fistula
took on the appearance of a cleft, the anterior edge of the orifice overlapping the posterior.
To sum up then, there existed in the vesicovaginal partition a fistulous passage, bi-
furcated from a single orifice: One passage, a large one, extended from the bladder to the
vagjna; a second passage, smaller, passed from the bladder to the urethra, and extended
around and outside of the bladder neck (see Fig. 159). The incontinence seemed to be
aue to the first of these passages, and was made the object of surgical interv^ention. The
radical cure of the vesicovaginal fistula was effected by operation, on March 4, 1911, by
Pozzi.

The edges of the fistula were transfixed by retention sutures of silver wire, the fistula
well exposed and the edges excised. Excision was difficult because of the proximity of the
neck of the bladder. To avoid traction on the upper edge, a large transverse incision was
made in front of the neck of the uterus, which allowed the union of the edge to the fistula
and thus gave a large raw surface. The fistula was first obliterated with chromic gut. The
closure of the fistula was then completed by some deep silver sutures which passed into the
uterine neck. Finally, perfect apposition of the wound was secured by superficial silver
sutures. A permanent catheter was passed into the bladder.

The postoperative history was without incident. On March 17 the sutures were re-
moved; on March 24 the catheter was withdrawn and patient sat up. The operative result
was perfect, for she regained complete urinary control, whether reclining or up and about.

On March 31, 1911, endoscopy showed that the above described anatomic conditions at
the bladder neck remained unchanged. The same orifice on the right side of the bladder
neck still permitted the introduction of a ureteral catheter which passed easily into the
bladder. But this did not at all interfere with the bladder function, the bladder remaining
quite water-tight, and urination being performed under normal conditions which required
no further therapeutic interference. The patient left the hospital, and when seen seven
months later (October, 1911) she was in excellent condition.
/■

7. Possibility of Examination with Pregnancy or Abdominal Tu-
mors. — ^It is a well-established fact that to obtain a distinct view with
the indirect vision cystoscope, it is necessary to keep the instrument at
a certain distance from the object to be examined. Now, when the
bladder is compressed through pregnancy or because of a tumor near
the bladder, this mass makes it impossible to maintain the cystoscopic
prism at a sufficient distance from the vesical mucosa. This disadvan-
tage does not exist in direct vision cystoscopy, because the instrument
can be brought to the very wall of the bladder, and allows the smallest
detail to be studied. Examination of the bladder in pregnancy with



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242 CYSTOSCOPY AND URETHROSCOPY

the direct vision eystoscope, has been studied in collaboration with
Bar; a report of this work is publishcKl further on (see page 248).

8. Extraction of Foreign Bodies. — Extraction of foreign bodies is
extremely easy with the direct vision eystoscope; this subject will also
be thoroughly discussed later on.

9. Treatment of Cystitis. — The treatment of cystitis with the di-
rect vision cystoscoi)e gives results that are absolutely remarkable,
and will be discussed at greater length.

10. Treatment of Bladder Tnmors. — The treatment of bladder tu-
mors with the direct vision cystoscoi)e produces radical cures. This
subject will likewise be discussed in subsequent pages.

REFERENCES

iLoys: Bcv. de gjiiec. et de chir. abd., March, 1912, No. 3.

-Luys: Exploration de I'appareil urinaire, Paris, Masson, 1909, ed. 2, p. 217.

zVemeuil; Chirurgie r^'paratrice, p. 932.

*VerneuiI: liull. et mem. 8oc. de chir. de Paris, 1875, p. 322.

i^Tavernier and Stophani: Lyon med., Dec., 1909, p. 1023.

OBJECTIONS TO DIRECT VISION CYSTOSCOPY

1. Diminution in the Visual Field. — ^It is undeniably true that the
visual field is much more restricted in direct vision cystoscopy than in
the indirect system. However, this reduction is more apparent than
real. It is quite true that when the extremity of the eystoscope is ap-
plied directly to a point of the vesical mucosa, the observer's eye can
not pass much beyond its limits. On the other hand, it is equally true
that when the cystoscopic tube is kept at a certain distance from the
surface to be examined, the visual field becomes much more extensive.
In fact, the ease and rapidity with which the cystoscopic tube can be
manipulated in the interior of the bladder, make possible a thorough
examination of the entire surface of the mucosa. Tuffier has well said
in this connection, '^What one sees, one sees very clearly."^

2. Caliber of the Instruments. — The instruments employed in di-
rect vision cystoscopy are necessarily larger in caliber than those used
in the indirect method. The size of the instruments used in the female
is of little moment, owing to the ease with which the female urethra
can be dilated; in the male, however, the question of size of the instru-
ment is of considerable importance. It may be well to remember how-
ever, in this connection, that the difference in caliber between the eysto-
scope for ureteral catheterization (25 Charriere) and my male eysto-
scope (27.5 Charriere) though appreciable, is nevertheless not very
considerable.



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OBJECTIONS TO DIRECT VISION CYSTOSCOPY 243

3. Unfolding of the Vesical Wall. — As has aheady been stated,
the unfolding of the vesical wall through the inclined position some-
times fails, in the obese, particularly the male, thus making the blad-
der examination difficult and sometimes even impossible.

This faulty retraction of the abdominal wall is usually due to ab-
dominal plethora, which prevents the bladder from filling up with air,
in the inclined position. However, there is a method of overcoming
this disadvantage, at least up to a certain point. It consists, as already
stated (see page 233, Fig. 156) in having an assistant seize the ab-
dominal wall above the pubis, with both hands, thus forming a large
transverse fold, and exerting an upward pull ; in this manner, the com-
plete unfolding of the vesical wall is often obtained, especially in very
stout women.

The inclined position is likewise accepted very poorly at times
by elderly patients, who are asthmatic or very stout. These conditions
are evidently entirely unfavorable for direct vision cystoscopy and
must be considered as a contraindication.

REFERENCE
iTuffier: Bull, et m^m. Soc. de chir. de Paris, March 7, 1905.

COMPARATIVE ROLE OF INDIRECT AND DIRECT
VISION CYSTOSCOPY

Having studied the comparative advantages and disadvantages of
direct and indirect vision cystoscopy, it is well now to examine in de-
tail the indications of each method, and the conditions under which
one or the other is to be preferred. Above all, however, it should be
stated that prismatic cystoscopy should not be set up in opposition to
direct vision cystoscopy. Both methods are useful and each has its
respective indications, and it were childish to attempt to establish a
rivalry between them.

When the condition of the bladder ensemble is to be determined
so that a diagnosis may be made, it is undeniably wise to begin with
the indirect cystoscope. This instrument gives an extensive visual
field, and a complete examination of the bladder can be made with it
in a short time; and when the patient happens to be large and stout,
in whom the inclined position would be particularly uncomfortable,
this instrument will be found preferable by far.

But on the other hand, when the presence of blood or pus in too
great a quantity renders it impossible to obtain a sufficiently trans-
parent medium even with the aid of the irrigating cystoscope, the di-



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244 CYSTOSCOPY AND URETHROSCOPY

rect vision cj^stoscope should be resorted to, and it will reveal every
portion of the bladder despite severe bleeding or intense pyuria. In
addition, doubtful points will be cleared up and the real size of a tu-
mor determined far better through the direct and immediate view than
through the prism.

If a vesical tumor or a foreign body is examined with both in-
struments, the same impression can not be obtained with the indirect
instrument as with the direct. It is a fact, that in order to see well
with the indirect cystoscope it is necessary to keep at a certain dis-
tance from the object to be observed; many bearings must be taken
in order to be able to examine all around the tumor, to determine the
distance and the volume of the tumor by this method. On the other
hand, with the direct vision cystoscope, the object is seen directly as
it really is, and its exact size can be determined in the most precise
manner.

Moreover, in numerous instances, the indirect cystoscope leaves



Online LibraryAbraham Leo Wolbarst Georges LuysA treatise of cystoscopy and urethroscopy → online text (page 19 of 33)