Ambulatory Uretrocystoscopy in the Urology Andrology Department of Grand Mbour Hospital ()
1. Introduction
Uretrocystoscopy is an intracavitary exploration under visual control of the lower urinary tract [1] . It allows direct visualization of the urethra, the prostate, the bladder neck, the bladder trigone, the ureteral orifices and the different walls of the bladder. It is one of the common procedures performed by urological surgeons. It can be performed on an outpatient basis under local anesthesia. It can be performed using a flexible or rigid cystoscope in the operating room or outpatient, in an office. There are several indications for urethrocystoscopy which are mainly hematuria and lower urinary tract symptoms (LUTS) [1] [2] [3] . Urethrocystoscopy plays an important role in the diagnosis of bladder tumors often revealed by hematuria but also in the monitoring of non-infiltrating bladder tumors. It is also an initial step in endoscopic resection of the prostate or bladder. The use of these endoscopes has transformed the diagnosis and treatment of urological diseases. In sub-Saharan Africa, particularly in Senegal, very few urological services have endoscopic equipment despite the burden of urological diseases [3] [4] [5] [6] .
The use of this endoscopy in urology can cause complications which may include pain, infections and bleeding [1] .
We undertook a retrospective study with the aim of evaluating the indications for urethrocystoscopy and presenting the results and complications of outpatient urethrocystoscopy in department of urology of Grand Mbour Hospital.
2. Patients and Method
This was a retrospective and descriptive study carried out in the Urology department of the Mbour hospital including all patients who underwent urethrocystoscopy from January 1st, 2018 to December 31st 2021. The data were collected from patient files kept in the archives and care registers from the endoscopy practice. All patients who underwent outpatient urethrocystoscopy and whose medical report was available during the study period were included. Patients whose procedure were incomplete and those with incomplete records were excluded.
The rigid cystoscope components used include: a monitor, a camera and a light source, a 12 and 30 degree telescope, a 22G sheath (for adults), a bridge connector. And for flexible cystoscopy, include the flexible cystoscope with camera; light source and monitor. Two towers of this equipment were available, the second serving as a backup in the event of a breakdown of one of the equipment.
The patients were all prepared to undergo an outpatient urethrocystoscopy. They received information regarding the performance of the endoscopic procedure. All patients in the study had a sterile urine culture before performing the procedure. All patients underwent a quinolone-based antibioprophylaxy and then a prescription for painkillers and/or non-steroidal anti-inflammatory drugs was prescribed at the end of the examination. After installation, patients were prepared with antiseptic scrup and draped and local anesthesia was performed with intra urethral instillation of lidocain gel. A waiting period of 15 to 30 minutes between the anesthesia and the start of the examination was observed. For patients with a permanent transurethral urinary catheter, this was removed before placing the patient on the examination table.
The examination consisted of carrying out a careful and systematic exploration of the bladder in the different areas: the trigone, the lateral walls, the dome and finally the anterior wall. This examination ended with the exploration of the bladder neck, the prostate in men and the urethra as the endoscope exits. Post-examination monitoring was systematically carried out in all our patients.
The parameters studied were age, sex, indications, type of endoscopic equipment used, results of urethrocystoscopy, additional procedures and complications.
The generated data was entered into excel sheets and analyzed using statistical package Origin Pro system and results presented text figures and tables.
3. Results
3.1. Epidemiological Result
3.1.1. Annual Frequency of Urethrocystoscopy
In total, we reported 216 cases of urethrocystoscopy performed on an outpatient basis over a period of 4 years (54 cases per year). The greatest number of cases was noted in 2019 (n = 68). Figure 1 illustrates the distribution of patients according to the year of procedures.
3.1.2. Gender and Type of Urethrocystoscope Used
The mean age was 53.71 ± 18.76 years (age range: 17 to 91 years). The age group of 60 to 75 was the most represented (32.98%).
We noted a male predominance (82.87%) and the sex ratio was 4.84. The mean age of women was 53.69 ± 17.18 years and that of men was 53.71 ± 19.12 years.
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Figure 1. Distribution of patients according to year.
All urethrocystoscopy procedures under local anesthesia by intraurethral instillation of 2% (100%) lidocaine gel. The majority of procedures were performed with a rigid urethrocystoscopy (84.72%) while the remaining 12.96% had a flexible urethrocystoscopy. Both procedures were used at 2.32% of patients.
Table 1 shows the epidemiological characteristics and the number of patients according to type of equipment used.
3.2. Indications for Urethrocystoscopy
Lower urinary tract symptoms (LUTS) and hematuria were the main indications accounting respectively for 60.18% (n = 130) and 28.70% (n = 68) of patients. Table 2 describes the distribution of patients according to the indications for urethrocystoscopy.
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Table 1. Distribution of patients according the gender and type of urethrocystoscope used.
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Table 2. Clinical indications for urethrocystoscopy according to age.
In men the primary indication was LUTS with 118 cases (65.92%). The association of dysuria and pollakiuria dominated in 56 patients (47.46%) followed by 48 cases of dysuria alone (40.68%). In women, hematuria was the most frequent indication with 17 patients (45.95%) followed by LUTS in 12 patients (32.43%) and assessment of extension of a uterine tumor (8.11%).
3.3. Distribution of Urethrocystoscopy by Findings
The examination revealed prostatic hypertrophy in 31.9% (n = 59) of cases, a bladder tumor in 13.4% (n = 29) of cases, a urethral stenosis in 13.4% (n = 29) of cases and bilharzal cystitis in 8.8% (n = 19) of cases. Urethrocystoscopy was normal for 32 patients (14.8%). Table 2 shows the distribution of urethrocystoscopy results according to male and female gender. In men, the lesions found were prostatic hypertrophy in 69 patients (38.55%), urethral strictures in 29 patients (16.2%), bilharzal cystitis in 16 patients (8.9%). and bladder tumors in 14 patients (7.9%), while in women bladder tumors were diagnosed in 15 patients (40.54%) followed by schistosomiasis lesions in 3 patients (8.11%) and struggle bladder (8.11%). Table 3 describes the distribution of patients by uretrocystoscopy findings and gender.
Among the 130 indications for LUTS, the diagnosis established at urethrocystoscopy was a prostate tumor in 58 patients, urethral stenosis in 22 patients and bilharzial cystitis in 8 patients (Figure 2).
Out of 62 cases indicating hematuria, the diagnosis established at urethrocystoscopy was bladder tumor in 27 cases (43.5%), prostate tumors in 10 cases (16.12%), cystopathy lesions (in 10 cases (16.12%), bilharzal cystitis in 8 cases
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Table 3. Distribution by uretrocystoscopy findings and gender.
(12.90%), bladder lithiasis in 1 case (1.6%) and urethral tumor in 1 case (1.6%). Figure 3 distribution of diagnoses obtained at urethrocystoscopy according to the indication of hematuria.
Three patients (1.38%) underwent biopsy of the bladder tumor and we performed 3 JJ catheter ablations. Three patients (1.38%) had hematuria that resolved spontaneously before 24 hours after performing urethrocystoscopy.
4. Discussion
4.1. Epidemiology
During the study period, we reported 216 cases of urethrocystoscopy performed in our department of urology. This number was smaller than that of Takure et al. [2] who reported 599 patients over a period of 5 years and Jalloh et al. [3] who
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Figure 2. Distribution of diagnoses obtained at urethrocystoscopy according to the indication of LUTS.
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Figure 3. Distribution of diagnoses obtained at urethrocystoscopy according to the indication of hematuria.
reported 655 cases over a period of 5 years. On the other hand, it was greater than that of Ouattara et al. [4] who performed 165 uretrocystoscopies over a period of 4 years. This difference is explained by the fact that our urology department is the only one in the Mbour department and the third in the Thiès region, in Senegal. Urethrocystoscopy is also performed in these hospitals.
The highest number of cases was reported during the years 2018 and 2019 with 27.31% and 29.17% respectively compared to 17.59% for the year 2021. This drop in activity is partly due to the Covid-19 pandemic.
In our series the average age was 53.71 ± 18.76 years. This average age is similar to that of Takure et al. [2] who reported an average age of 52.1 years. In the studies of Ouattara et al. [4] , in Benin and Jalloh et al. [3] in Senegal, the mean age was 47.29 ± 16.80 years and 47.44 years respectively. This variability in average ages would be linked to the indication for urethrocystoscopy due to the fact that subjects over 50 years of age often present with LUTS. In fact, patients aged 60 to 75 were more numerous and were predominantly men.
We noted a male predominance with a sex ratio (M/F) of 4.84. This predominance is clearer for Popoola et al. [7] who reported a ratio of 36 men for 3 women. It is less accentuated for Jalloh et al. [3] with a sex ratio of 1.60 and for Sow et al. [5] the sex ratio was 1.49.
4.2. The Indications
Lower urinary tract symptoms (LUTS) and hematuria were the main indications constituting 60.8% and 28.70% of our cohort, respectively. This trend was observed by the majority of African and European series where urethrocystoscopy is systematically performed as a first-line examination for hematuria [3] [5] [6] [8] .
In men, the main indications were lower urinary tract symptoms (LUTS) with 65.92% unlike in women where the main indications included haematuria (45.94%). These results are in agreement with those of Takure et al. [2] who reported hematuria as an indication in the group of women where it accounted for 47.8% of cases (n = 57). In the series of Jalloh et al. [3] , carried out in Senegal, haematuria was the most frequent indication 28.13%, followed by lower urinary tract urinary disorders 23.61%. For Jalloh et al. [3] the diagnosis of extension of cervical tumors represented the first indication in women with 59 patients (29.9%). In men, urinary disorders linked to prostate pathology were the first indication. The findings are similar to the reports from other studies across West Africa [3] [5] [6] [8] .
4.3. Urethrocystoscopy Findings
Urethrocystoscopy is an examination which contributes to the initial diagnosis of tumor, inflammation and other stenosing urethro-cervico-prostatic conditions by allowing a direct vision of urethra, the prostate and endocavitary lesions. It also contributes to the diagnosis of extension of pelvic tumors to the bladder and/or urethra. In our series, prostatic hypertrophy was the most common lesion (31.9%) followed by urethral strictures (13.4%) and bladder tumors (13.4%).
In men, we noted 14 cases (7.9%) of bladder tumor while in women, bladder tumors came first with 15 patients (40.54%) followed by bilharzal lesions with 3 patients (8.3%) and the features of bladder outlet obstruction in the same proportions. On the other hand, in the study by Jalloh et al. [3] bladder tumors were the most frequent lesions, observed in 135 cases (18.2%), followed by prostatic hypertrophy in 92 cases (12.4%). The high rate of bladder tumors in our regions could be explained by the prevalence of urogenital bilharziasis and smoking explaining the high frequency of hematuria.
We reported schistosomiasis associated cystitis lesions. For Ndour et al. [9] , schistosomiasis lesions were reported in 47.3% cases. This confirms the high prevalence of urogenital bilharziasis in our regions.
Cystoscopy contributes to the monitoring of tumor recurrence after transurethral bladder resections of bladder tumors (TURBT) [3] [8] . During our study period, we did not have any patients to monitor because none of them had benefited from TURBT.
4.4. Associated Procedures
Three patients (1.39%) with bladder tumors underwent tumor biopsy. In cases of invasive tumor occupying almost the entire bladder, tumor biopsy remains indicated. Sow et al. [5] reported bladder biopsy indicated for 2.6% of bladder tumors. During cystoscopies, double JJ stent can be removed.
4.5. Complications
In the literature, some authors [5] [9] [10] [11] have reported complications and incidents after performing an urethrocystoscopy. Ouatara et al. [4] reported 4% of complications while Ndour et al. [9] noted a single infectious complication; hence the need to train urologists in the practice of endoscopy and to prepare patients before the procedure [10] .
Sow et al. [5] reported a higher proportion of pain in men (63%) compared to women (41%). Flexible cystoscopy considerably reduces pain compared to rigid cystoscopy [5] [7] . Some authors prescribe a urine culture before performing urethrocystoscopy in order to avoid the spread of a possible infection [3] [5] .
Our work, as preliminary as it may be, has some limitations because it should be able to:
- assess pain tolerance using a simple binary questionnaire or other,
- and even carry out a cost-effectiveness analysis for the possible performance of single-use urethrocystoscopy.
5. Conclusion
Urethrocystoscopy is an endoscopic examination that allows the diagnosis of urethro-cervico-prostatic pathologies. It must be carried out as first intention, on an outpatient basis, for any hematuria and obstructive urinary disorders of the lower urinary tract.
Financial Support
None declared.
Contributions of the Authors
Each of the co-authors read the text beforehand and their orientations and amendments were taken into account in this work.
Declaration of Interests
The authors declare that they have no conflict interest for this article.
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