Comprehensive Study Notes on Urological Endoscopic Procedures

Classification and Scope of Endoscopical Procedures

Endoscopic procedures in urology are performed exclusively through natural orifices. These procedures are categorized into two primary types: diagnostic and therapeutic. A common diagnostic procedure is urethrocystofibroscopy, also known as cystoscopy. Therapeutic procedures include the Transurethral Resection of the Prostate (TURP) and the Transurethral Resection of the Bladder (TURB).

Urethrocystoscopy (Cystoscopy)

Urethrocystofibroscopy is a diagnostic procedure often performed on an ambulatory (outpatient) basis. It allows for the sequential visualization of the urethra, prostate, bladder, and the ureters.

The surgical technique involves several precise steps. First, the patient is placed in the lithotomy position using stirrups and leg supports. Second, antisepsis is performed, and surgical drapes are applied. This includes large drapes to cover the legs and stirrups, two lateral drapes, and a large cephalic drape. A specific drape is placed beneath the sacrum to ensure only the perineum is exposed. Third, local anesthesia is administered using lidocaine jelly delivered via a $20\,mL$ syringe. Fourth, the cystoscope is introduced. Fifth, the surgical team performs an evaluation of the urethra, prostate, and bladder, which may include a biopsy if indicated.

Specialized Instrumentation for Cystoscopy

The instrumentation for cystoscopy includes several specific components. The tubular sheath, sized between $19\,FR$ and $22\,FR$, is the first instrument placed after the administration of lidocaine; it is a rigid component that passes through the urethra. Inside the sheath, a mandrel is always present during insertion. The mandrel has a blunt tip designed to prevent lesions or trauma to the urethral walls.

The visualization system consists of an endo-camera and an optic lens, typically with a $30^{\circ}$ angle. A fiber optic light source provides illumination. A "bridge" is used to connect the sheath to the optic lens, ensuring the assembly remains secure and does not slip. For tissue sampling, flexible biopsy forceps are used. Flexibility is required to navigate the internal curvatures of the patient's anatomy; a rigid forceps would likely become stuck or "trap" itself. The procedure is monitored via a specialized video tower, though an insufflator is not required for this type of urological endoscopy.

Irrigation and Disposable Materials in Diagnostic Endoscopy

To create sufficient internal space and a clear visual field, the bladder must be distended. This is achieved by filling the organ with an irrigation solution, which is typically physiological saline ($0.9\%\,NaCl$) or distilled water ($H_2O_{distilled}$).

Disposable materials required for the procedure include syringes in $20\,mL$ and $50\,mL$ sizes, lidocaine jelly, and a V-14 irrigation guide or tubing. Additional supplies include gauze, a vesical probe (catheter), and the flexible biopsy forceps.

Transurethral Resection (TUR)

Transurethral Resection (TUR) is a therapeutic surgical intervention. There are two main variations. Transurethral Resection of the Prostate (TURP) involves the extirpation of the prostate in small fragments through the urethra. This is primarily used to treat Benign Prostatic Hyperplasia (BPH). Transurethral Resection of the Bladder (TURB) involves the removal of bladder tissue via the urethra. During a TURB, the surgeon aims to resect the mucosa, submucosa, and the muscularis layers. The serosa, which is the outermost layer of the bladder, cannot be resected using a transurethral approach.

Specialized Instrumentation for TUR

Specific equipment is required for resection procedures. The optic lens used is typically $0^{\circ}$ or $30^{\circ}$, which is placed into the resectoscope after the mandrel has been removed. The sheath used for TUR is typically $26\,FR$ and is accompanied by a mandrel.

The resectoscope is the primary operative housing where the optic lens and the active working elements are encased. These working elements include the cutting loops, such as the "hook" for resection and the "ball" for coagulation. These loops are connected to a monopolar or bipolar electrosurgical cable. The loops are introduced through the sheath after the mandrel is removed and typically have a measurement of approximately $7\,mm$. A Toomey syringe is essential for the extraction of the small tissue fragments created during the resection.

Surgical Technique and Fragment Extraction in TUR

The surgical technique for TUR begins with the patient in the lithotomy position using stirrups. Following antisepsis and draping, lidocaine jelly is introduced into the urethra. A $26\,FR$ sheath is inserted, followed by the resectoscope, which is then connected to a continuous irrigation system via a V-109 guide. As the bladder fills with the irrigation solution, the resected tissue fragments naturally sink to the lower portion of the bladder.

The surgeon performs the resection of the prostatic adenoma or the vesical lesion. To remove the debris, a Toomey syringe—a large-volume glass syringe with a metal tip—is connected to the sheath. The surgeon injects fluid and allows it to return; the resulting pressure causes the fragments to swirl and rise, allowing the surgeon to aspirate them into the transparent barrel of the syringe.

The fragments are then emptied into a specialized apron worn by the surgeon, which features a funnel-like shape and a filter at the bottom to catch the tissue. If an official apron is unavailable, a container with gauze placed in the center can act as a manual filter. The procedure concludes with a thorough check for hemostasis (bleeding control) and a verification that all residual tissue has been removed. Finally, a $22-24\,FR$ hematuric Foley catheter is placed, and continuous bladder irrigation is established using a V-14 irrigation guide and a collection bag.

Disposable Materials for Resection Procedures

Therapeutic resection requires a specific set of disposable materials. These include lidocaine jelly and a V-109 irrigation guide for the main procedure. Post-operative care requires a hematuric vesical probe sized between $22\,FR$ and $24\,FR$, along with a drainage collection bag. Syringes in $10\,mL$ and $20\,mL$ sizes are used, and a V-14 irrigation guide is required for the final continuous wash setup.