Detecting Bladder Cancer with a Cystoscopy

Cystoscopy enables the inside of the urethra and bladder to be examined and sampled. Alongside urine testing and diagnostic imaging procedures, cystoscopy is used in both the initial diagnosis of bladder cancer and in ongoing surveillance for recurrence. In addition, cystoscopy-based procedures are commonly used to remove or treat small bladder tumors.

What is a cystoscopy?

A cystoscope is a thin tube with a light and camera attached to the end. During a cystoscopy, the cystoscope is passed through the urethra (the tube through which urine leaves the bladder) into the bladder. The two main types of cystoscopy are termed flexible and rigid:

  • Flexible cystoscopy uses a flexible cystoscope tube that is able to bend easily as it passes through the urethra. This procedure can be carried out under local anesthetic while the patient is awake and is commonly used for simple visual examination of the inside of the bladder, although the collection of bladder washings (for cytology testing) or small tissue samples may be undertaken.
  • Rigid cystoscopy uses a hard, straight cystoscope. For this type of cystoscopy, patients are usually under general anesthesia; in some patients, spinal anesthesia that numbs the lower half of the body may be used instead. Rigid cystoscopy is performed when tissue samples (biopsies) and/or removal of small bladder tumors are required. Long, small-diameter instruments can be passed down the cystoscope to take biopsies from the bladder lining, and a tool called a resectoscope that has a cutting wire loop at the end may be used to remove abnormal tissue or small tumors. This procedure is referred to as ‘transurethral resection of a bladder tumor’ or ‘TURBT’.

A white light source or blue light source may be used for flexible and rigid cystoscopy procedures. White light cystoscopy is traditionally the most commonly used technique for the detection of bladder cancer. Blue light cystoscopy (sometimes referred to as ‘photodynamic diagnosis’) has been developed more recently, and while not as common, its use in clinical settings is increasing. For this procedure, a fluorescent dye is injected into the bladder through a catheter in the urethra. The dye is absorbed by cancer cells, which then appear red or pink when examined under the blue light of the cystoscope.

Diagram of a cystoscopy for a man
Diagram of a cystoscopy for a man

Diagram of a cystoscopy for a woman
Diagram of a cystoscopy for a woman

Preparing for a cystoscopy

The process of preparing for a cystoscopy depends on which type of cystoscopy and anesthetic a patient is undergoing. For example:

  • If a general anesthetic is required, a pre-assessment is carried out several days before the procedure; this may involve routine pre-anesthetic checks such as blood tests and x-rays. Instructions will also be given regarding how long before the procedure to stop eating and drinking.
  • If a local anesthetic is being used the patient can eat and drink normally beforehand.

What happens during a cystoscopy?

During flexible cystoscopy, the patient lies on their back and an anesthetic gel is passed into the urethra to make the area numb. Once the local anesthetic is working, the doctor inserts the cystoscope through the urethra and then into the bladder. Sterile water may be injected through the cystoscope into the bladder to help make the inner surface of the bladder easier to see. The cystoscope is moved around inside the bladder so that the entire inner surface can be examined.

During rigid cystoscopy, the procedure is similar to flexible cystoscopy but as the patient is usually under general anesthesia they will not be aware of any associated physical sensations. If the doctor sees an abnormal area, biopsies will be taken or a transurethral resection of bladder tumor (TURBT) may be carried out to remove the suspected tumor. The extracted tissues are then sent to a laboratory to be tested for cancer.

How long does a cystoscopy take?

The cystoscopy procedure itself generally takes 10 to 20 minutes. In some instances it may take longer, for example if multiple biopsies or tumor removal are undertaken.

Is a cystoscopy painful?

Some discomfort may be felt when the local anesthetic gel is applied to the urethra, and when the cystoscope is passed through the urethra into the bladder. At this stage the patient may also feel a need to pass urine. In contrast, if a cystoscopy is carried out under general anesthesia there will be complete unawareness of the procedure taking place. If a spinal anesthetic is used the patient will not feel any discomfort, though a sensation of movement or pressure may be noticed.

What to expect after a cystoscopy

Patients usually leave the hospital on the same day of a cystoscopy. Depending on the type of anesthesia used, it may be necessary to arrange a ride home with a friend or family member.

For 1 or 2 days after a cystoscopy, patients may notice blood in the urine and/or a burning sensation when passing urine. Drinking plenty of fluids usually helps to minimize these symptoms. Returning to work, physical, and sexual activities is usually quick, for example later the same day after a flexible cystoscopy and 1 to 2 days after a rigid cystoscopy. If discomfort is severe or symptoms do not improve as expected, it is important to promptly seek medical help.

Are there any risks associated with cystoscopy?

Cystoscopy is usually a safe procedure and serious complications are uncommon. The most frequent complication is urinary tract infection (UTI). UTIs may require antibiotic treatment, so it is important to seek medical help if urinary symptoms persist for longer than expected following a cystoscopy (for instance, longer than 2 to 3 days) or if other UTI symptoms develop (e.g., cloudy, odorous urine; high body temperature). Less commonly, patients may be temporarily unable to pass urine after a cystoscopy and it may be necessary for a catheter to be inserted into the bladder to enable emptying. There is also a small risk that the urethra or bladder may be damaged by the cystoscope and subsequently require remedial surgery.

In patients who undergo rigid cystoscopy, side effects associated with anesthesia may be experienced. Common side effects of general anesthesia include nausea, vomiting, sore throat, muscle aches, itching, shivering, and sleepiness; side effects most frequently associated with spinal anesthesia include itchiness, a drop in blood pressure, and temporary difficulty passing urine (particularly in men).

Cystoscopy results

Depending on the type of cystoscopy procedure undertaken, results may be communicated to the patient immediately or at a follow-up appointment. These may include images taken during the procedure and the results of laboratory tests carried out on any tissue samples collected.

The figure below shows images of bladder cancers taken by standard white light cystoscopy (at left) and blue light cystoscopy (at right). In the blue light cystoscopy a fluorescent dye has been used that turns bladder cancer cells pink when they are exposed to blue light.

Cystoscopy - white and blue light
Source: Wikimedia Commons

Can a cystoscopy miss bladder cancer?

While cystoscopy is a key tool for detecting bladder cancers, like other diagnostic tests it is not 100% accurate. For instance, traditional white light cystoscopy has a limited ability to detect certain types of bladder cancer such as small papillary tumors (a type of cancer that grows out towards the hollow center of the bladder in small finger-like projections) and carcinoma in situ (a flat, high-grade type of non-muscle-invasive bladder cancer that carries a risk of metastasis). The skill and experience of the urologist carrying out the cystoscopy are also factors contributing to the accuracy of the procedure. Recently developed blue light cystoscopy techniques have shown improved detection rates for some tumor types and, depending on cost, may play an increasing role in the future management of bladder cancer.

Taking these limitations into account, cystoscopy is predominantly used in combination with other diagnostic procedures such as urine testing (e.g., non-invasive genomic urine tests like Cxbladder) and imaging. Ultimately, an integrated approach maximizes the likelihood that any cancer present will be detected.
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General Sources

  • American Cancer Society. Cystoscopy
  • American Cancer Society. Tests for Bladder Cancer
  • Bladder Cancer Advocacy Network. Transurethral Resection of a Bladder Tumor (TURBT)
  • Cancer Research UK. Cystoscopy
  • Daneshmand S, Bazargani ST, Bivalacqua TJ, et al. Blue light cystoscopy for the diagnosis of bladder cancer: Results from the US prospective multicenter registry. Urol Oncol. 2018;36:361.e1-361
  • Daneshmand S, Patel S, Lotan Y, et al. Efficacy and Safety of Blue Light Flexible Cystoscopy with Hexaminolevulinate in the Surveillance of Bladder Cancer: A Phase III, Comparative, Multicenter Study. J Urol. 2018;199:1158-1164
  • Jocham D, Stepp H, Waidelich R. Photodynamic diagnosis in urology: state-of-the-art. Eur Urol. 2008;53:1138-1148
  • Mayo Clinic. General anesthesia
  • National Comprehensive Cancer Network. (2021). Bladder Cancer NCCN Evidence Blocks (version 1.2021)
  • NHS. Cystoscopy
  • NHS Ayrshire & Arran. Having a flexible cystoscopy
  • Patient. Spinal Anaesthetic
  • Stenzl A. Editorial comment. J Urol. 2018;199:1165

Last Updated: 15 Dec 2023 01:39 pm

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