Flexible Cystoscopy with Urethral Dilatation

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A diagnostic day procedure under local anesthetic, where a flexible cystoscope is placed in the bladder via the urethra

Why is it done?

To investigate:

  • Hematuria (blood in the urine)
  • Recurrent urinary tract infections
  • Space occupying lesions in the kidneys, ureters, bladder and urethra
  • Abnormal cells suggestive of urothelial carcinoma, on urine cytology
  • Possible urethral stricture

How is it done?

  • A cystoscopy is performed by placing a camera in the urethra with the help of a   lubricant jelly and saline
  • If a narrowing is found, a guidewire will be placed and urethra dilated
  • The bladder is then distended using the fluid
  • The inside of the bladder is viewed for pathology.
  • If any suspicious lesions are seen, a biopsy will be taken.
  • Urine would have been sent for cytology prior to the procedure, to rule out the existence of cancer.
  • Antibiotics may be given to prevent infection

 

What to expect after the procedure?

  • An indwelling catheter will be placed for 3 days
  • Bladder infection ranging from a burning sensation to, fever, to puss (rare)
  • Blood stained urine
  • Lower abdominal discomfort which will persist for a few days
  • NB! Each person is unique and for this reason symptoms vary.

 

What next?

  • This all depends on what is found during the procedure. All the options will be discussed in detail.
  • With the removal of stents, the ureters have been dilated and will regain function (peristalsis) as soon as the stents are out. Thus slight pain can be expected in the first 24-48hrs.
  • Urethral strictures with an IDC will require a trial of void 3 days later
  • There may be some blood in the urine. This can be remedied by drinking plenty of   fluids until it clears.

Urethral Dilatation

  • If you have a urethral stricture, a guidewire will be placed and the narrowing dilated
  • There may be some hemorrhaging and you may need a catheter for 3 days
  • This will be removed at the hospital in 3 days or alternatively arrange for your GP to remove.
  • I will review in 6 –8 weeks

 

Wes Flexible Cystoscopy and Urethral Dilatation IDC

Bladder Diverticulectomy – Robotic-assited

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Open excision of bladder diverticulum. Controversial procedure for the excision of a bladder diverticulum where there is bladder calculus and bladder function is compromised/

Why is it done?

  • This procedure is performed when all other treatment options are exhausted with recurrent symptoms.
  • Symptoms include: a weak stream, nightly urination, frequent urination, inability to urinate, sudden cut-off of stream, (LUTS), recurrent bladder infections, recurrent bladder calculi (stones).
  • Medication such as Flomaxtra, Urorec or Minipress etc. should always be given as a first resort.
  • Step-up therapy should have been used for prostates larger than 35-50cc with either Duodart, Avodart or Proscar and can be used as a first line in these huge prostates.
  • A TURP may have been performed to dis-obstruct a huge prostate.
  • Neurogenic causes of bladder dysfunction should be excluded by means of a Urodynamic study.
  • Patient informed decision is vital.
  • It provides a quicker solution with more marked side-effects and risks.

How is it done?

  • Patients will receive a general anaesthesia, unless contra-indicated.
  • Prophylactic anti-biotics is given.
  • An indwelling catheter is placed, and the bladder is filled with saline.
  • Robotic access with 6 port placements.
  • The retropubic space of Retzuis is entered.
  • The bladder is opened anteriorly in the midline.
  • A Foleys catheter is placed in the diverticulum.
  • The bladder incision is extended to the diverticulum. Diverticulum is excised.
  • Special care is required for diverticula close to the ureters. Placement of ureteric catheters are done to prevent ureteric injury.
  • Bladder is closed in 2 layers over a 3-way irrigation catheter.
  • A drain is left for a couple of days.
  • You may have continuous Antibiotics over the next few days.

What next?

  • You will spend 2-3 nights in hospital.
  • You will have a catheter for 14 days.
  • A drain for 1 -2 days.
  • You will be discharged as soon as you are drain free, temperature free and have opened your bowels.
  • You may initially suffer from urge symptoms caused by the catheter.
  • There may be some blood in your urine. You can remedy this by drinking plenty of fluids until it clears.
  • A ward prescription will be issued on your discharge, for your own collection at any pharmacy.
  • A follow-up appointment will be scheduled for 2 weeks for a cystogram.
  • Should the cystogram confirm to urine leaks, your catheter will be removed.
  • A review appointment is scheduled 6 weeks later.
  • Don’t hesitate to ask Jo if you have any queries.
  • DON’T SUFFER IN SILENCE, OR YOU WILL SUFFER ALONE!

Side–effects

  • Rarely blood loss requiring blood transfusion.
  • Infection.
  • Prolonged hospital stays.
  • Urine leak requiring prolonged catheterization.
  • NB! Each person is unique and for this reason symptoms vary!

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Wes Bladder Diverticulectomy

Bladder Fistulectomy

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Why is it done?

  • Bladder intestinal fistula is an abnormal communication between bladder and bowel.
  • Causes:
    • Previous surgery
    • Diverticular disease
    • Colonic cancers
    • Radiation
  • This procedure is performed when all other treatment options are exhausted with recurrent symptoms and persistent pneumaturia and fecal uria due to a colonic-vesical fistula
  • Symptoms include:
    • pneumaturia (air in urine),
    • fecal Uria (stool in Urine),
    • recurrent bladder infections.
  • This surgery is usually done with a colo-rectal surgeon and may involve a partial bowel resection, possibly a temporary loop ileo/colostomy (diversion of bowel with an external bag)

 

How is it done?

  • Patients will receive a general anaesthesia,  unless contra-indicated.
  • Prophylactic antibiotics are given.
  • An indwelling catheter is placed, and the bladder is filled with saline.
  • Open procedure or robotic assisted.
  • A lower midline incision is made, or robotic ports are placed
  • The retropubic space of Retzuis is entered
  • The bladder is resected away from the bowel.
  • The affected piece of bowel may be resected with either a temporary diversion of the bowel to a bag or a primary anastomosis depending on the colo-rectal surgeon’s findings
  • The affected part of the bladder may be resected. The bladder is closed in 2 layers over a 3-way irrigation catheter
  • Omentum will be placed between bladder and bowel where at all possible to limit recurrences
  • A drain is left for a couple of days
  • You may have continuous Antibiotics over the next few days.
  • You have a few days stay in ICU or high care facility

 

Complications

Side–effects

  • Rarely blood loss requiring a blood transfusion.
  • Infection/ sepsis
  • Prolonged hospital stays.
  • Urine leak requiring prolonged catheterization.
  • Bowel leak etc.
  • NB! Each person is unique and for this reason symptoms vary!

 

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Wes Bladder Fistulectomy

Copyright 2019 Dr. Jo Schoeman

Conduitoscopy, Retrograde Pyelogram, Stent Management

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A diagnostic procedure under general anesthetic where a rigid / flexible cystoscope is placed in your ileal conduit (stoma), ureteric catheters are placed to enable imaging of the upper tracts with/without insertion or removal of ureteric stents.

Why is it done?

To investigate:

  • Hematuria (blood in the urine)
  • Recurrent upper urinary tract infections
  • Space occupying lesions in the kidneys and ureters
  • Abnormal cells suggestive of urothelial carcinoma, on urine cytology
  • Surveillance of previous bladder cancer

Risk factors:

  • Previous bladder cancer
  • Upper tract urothelial carcinoma
  • Ureteric structuring
  • Stone disease

 

How is it done?

  • This is done under General anesthesia.
  • A cystoscopy is performed by placing a   camera in the conduit
  • The conduit is then distended with saline.
  • The inside of the conduit is viewed for pathology.
  • A retrograde pyelogram is done at the same time, (placement of small silicone catheters up the kidney pipes). Through this iodine contrast is injected up into the kidney collecting systems. This facilitates the viewing of kidney pipes and kidney collecting systems on X-ray to exclude any upper tract pathology.
  • If any abnormalities are found in the kidney/ ureters, a flexible ureteroscopy (which is the placement of a long thin camera up the ureter) will be performed.
  • If any suspicious lesions are seen, a biopsy will be taken.
  • A ureteric stent may be placed
  • Urine would have been sent for cytology, to rule out the existence of cancer.
  • Antibiotics may be given to prevent infection.

What to expect after the procedure?

  • Pain on initial passing of urine
  • Infection ranging from a burning sensation to, fever, to puss (rare)
  • Bloodstained urine
  • Lower abdominal discomfort which will persist for a few days
  • Pain radiating from bladder to renal angle associated with urinating.
  • An infection could present with a stent being present.

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Wes Conduitogram and stent

Copyright 2019 Dr Jo Schoeman

Cysto-Lithopaxy

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Endoscopic procedure used for breaking up a bladder stone. Either with a stone crusher or laser

Why is it done?

  • To break up a bladder calculus (stone).

 

Risk factors:

  • Bladder outflow obstruction.
  • BPH with chronic retention.
  • Urethral stricture.
  • Neurogenic bladder.
  • Renal calculi disease.
  • Metabolic disorders.
  • Malnutrition.
  • Chronic infections.
  • Foreign objects in bladder.

How is it done?

  • A cystoscopy is performed by placing a camera in the urethra with the help of a lubricant jelly and an irrigate (fluid).
  • The bladder is then distended with fluid (saline).
  • The inside of the bladder is viewed for pathology.
  • If any suspicious lesions are seen, a biopsy will be taken.
  • Stone crushing is attempted with a lithotrite (a crushing device).
  • If the calculus is too large, laser will be utilized to fragment the stone and the smaller stones evacuated.
  • Antibiotics may be given to prevent infection.

What to expect after the procedure?

  • Hematuria (blood in your urine)
  • You will have a n indwelling catheter (IDC), which will remain in your bladder until your urine is clear.
  • You may have a continuous bladder irrigation with Saline to help clear the bleeding.
  • Pain on initial passing of urine when the catheter is removed.
  • Bladder infection ranging from a burning sensation to, fever, to pus (rare).
  • Lower abdominal discomfort which will persist for a few days.
  • NB! Each person is unique and for this reason symptoms vary.

What next?

  • This all depends on what is found during the procedure. All the options will be discussed in detail.
  • You may require further attention to your prostate or bladder outlet to prevent further stone formation.
  • There may be some blood in the urine. This can be remedied by drinking plenty of fluids until it clears.
  • Patients should schedule a follow-up appointment within 1 month to discuss the etiology of the calculus as well as what other procedures may be involved to prevent this from occurring again.
  • Please don’t hesitate to direct all further queries to Dr Schoeman.

 

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Wes Cysto-Lithopaxy Laser

Flexible Cystoscopy

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An atraumatic endoscopic procedure to view the bladder. Under local or sedation

A diagnostic day procedure under local anaesthetic, where a flexible cystoscope is placed in the bladder via the urethra.

Why is it done?

To investigate:

  • Haematuria (blood in the urine).
  • Recurrent urinary tract infections.
  • Space occupying lesions in the kidneys, ureters and bladder.
  • Abnormal cells suggestive of urothelial carcinoma, on urine cytology.

Risk factors:

  • Strong family history of bladder cancer.
  • Smokers or passive smokers.
  • Factory workers: dyes, paints, etc.
  • Exposure to Schistosoma (Bilharzia).
  • Renal stone disease, bladder stones.

How is it done?

  • A cystoscopy is performed by placing a camera in the urethra with the help of a lubricant jelly and saline.
  • The bladder is then distended using the fluid.
  • The inside of the bladder is viewed for pathology.
  • If any suspicious lesions are seen, a biopsy will be taken.
  • Urine would have been sent for cytology prior to the procedure, to rule out the existence of cancer.
  • Antibiotics may be given to prevent infection.

What to expect after the procedure?

  • Pain on initial passing of urine.
  • Bladder infection ranging from a burning sensation to, fever, to puss (rare).
  • Blood stained urine.
  • Lower abdominal discomfort which will persist for a few days.
  • NB! Each person is unique and for this reason symptoms vary.

What next?

  • This all depends on what is found during the procedure. All the options will be discussed in detail.
  • With the removal of stents, the ureters have been dilated and will regain function (peristalsis) as soon as the stents are out. Thus slight pain can be expected in the first 24-48hrs.
  • There may be some blood in the urine. This can be remedied by drinking plenty of fluids until it clears.
  • A ward prescription will be issued to patients on discharge, for own collection at any pharmacy.
  • Patients should schedule a follow-up appointment within 7 days.
  • Please don’t hesitate to direct all further queries to Jo.
  • REMEMBER: THOSE WHO SUFFER IN SILENCE, SUFFER ALONE!

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Wes Flexible Cystoscopy

Wes Flexible Cystoscopy and Removal Stent

Flexible Cystoscopy

Flexible Cystoscopy & Removal Stent

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A day procedure under local anaesthetic, where a flexible cystoscope is placed in the bladder via the urethra to remove a stent placed with previous upper urinary tract work

Why is it done?

To investigate:

  • Removal of stent which was placed after a stone removal, recent ureteroscopy, ureteric re-implantation, precautionary placement prior to pelvic surgery (Colo-rectal, Gynae Oncology, Uro-Oncology)

 

Risk factors:

  • Strong family history of bladder cancer
  • Smokers or passive smokers
  • Factory workers: dyes, paints, etc
  • Renal stone disease, bladder stones with recent surgery resulting placement of a stent

 

How is it done?

  • A cystoscopy is performed by placing a camera in the urethra with the help of a lubricant jelly and saline
  • The bladder is then distended using the fluid
  • The inside of the bladder is viewed for pathology.
  • If any suspicious lesions are seen, a biopsy will be taken.
  • Urine would have been sent for cytology prior to the procedure, to rule out the existence of cancer.
  • Antibiotics may be given to prevent infection.
  • Stent removed

 

Complications

What to expect after the procedure?

  • Pain on initial passing of urine
  • Pain as the ureter contracts back to its usual size
  • Bladder infection ranging from a burning sensation to, fever, to puss (rare)
  • Bloodstained urine
  • Lower abdominal discomfort which will persist for a few days
  • NB! Each person is unique and for this reason, symptoms vary.

 

Indications for a Ureteric stent

  • Hematuria from upper tracts
  • Disobstruction of the ureter caused either calculus, blood clot or tumour
  • External compression of the ureter by   retro-peritoneal pathology ie: Fibrosis,  retroperitoneal lymph node compression
  • Reduced renal function associated with  hydronephrosis
  • Sepsis associated with hydronephrosis

 

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Wes Flexible Cystoscopy and Removal Stent

Copyright 2019 Dr Jo Schoeman

Indwelling Urethral Catheter – IDC

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Non-invasive placement of a silicone tube which is secured inside the bladder and attached to a drainage bag on the outside, in order to drain an obstructed bladder (urinary retention)

Why is it done?

  • This can be placed as an emergency for patients in acute urinary retention
    • Prostate obstruction
    • Urethral strictures
    • Blood clot obstruction caused by bleeding
    • Hematuria (bleeding)
    • Severe urinary tract infections
  • Commonly placed intra-operatively for long, non-urological surgical procedures to enable urine drainage and monitoring urine output.
  • Commonly placed at the end of a Urological procedure to enable urine drainage and to enable hemostasis (stopping bleeding)

 

How is it done?

  • This is done as a sterile procedure; therefore, the genital area will be cleaned with a non-abrasive disinfectant.
  • A sterile catheter will be used
  • A local anesthetic gel is placed in the urethra a few minutes prior to the placement of the catheter. This may initially sting for a few seconds until it numbs the mucosa.
  • An appropriate size catheter (14-18Fr) will be inserted
  • Urine should be aspirated with a syringe to confirm the correct position in the bladder.
  • An anchoring balloon will be inflated with 10cc of sterile water.
  • A drainage urine bag will be attached
  • The catheter will be secured to your leg. (check that this is always secured)

 

Complications

  • Urethra with resulting discomfort.
  • In the presence of urethral stricture, it may be impossible to pass the catheter, and a flexible cystoscopy with dilatation of the stricture may be required prior to placement.
  • If you had a large over-stretched bladder (urine retention) you may experience bleeding as the bladder empties, caused by the mucosal tears that have occurred.
  • Catheters that have been placed long term, may cause irritation and possibly attract infection. Permanent catheters are usually changed every 6-8 weeks.

 

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Wes Catheters Indwelling Catheter

Copyright 2019 Dr Jo Schoeman

Intravesical BCG-Therapy

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Why is it done?

  • Treatment for localized superficial Urothelial Carcinoma of Bladder and Ureter (T1G3)

 

How is it done?

  • A Local anaesthetic gel is administered as for a Urethral Catheterization procedure
  • This is done under a sterile procedure.
  • A 14-16 Fr Indwelling Catheter is placed into your bladder.
  • The BCG is installed using strict administering criteria
  • Usually, 1 vial of BCG is mixed with Saline to a 50cc volume
  • The catheter is then removed
  • The BCG is required to stay in your bladder for 2 hours.
  • Body rotation every 30 minutes allows optimal contact of urothelial Surfaces to the BCG.
  • WARNING: Any Fevers require urgent attention

 

 What next?

  • This will be done every week for 6 weeks
  • 6 weeks after this a check Flexible Cystoscopy will be scheduled as part of your surveillance protocol for your Urothelial carcinoma
  • A Further 2 Installations will be arranged in the following 3 months as part of a    Maintenance Protocol
  • This may be repeated.

 

Complications

Side–effects

  • Some local discomfort may be experienced.
  • Your voiding nature will change within the next week
  • You may experience some urinary frequency
  • You could develop a fever requiring urgent attention.
  • Systemic effects of BCG would be fever
  • Delayed effects would a urinary tract infection
  • The possibility of Miliary Tuberculosis
  • NB! Each person is unique and for this reason, symptoms may vary!

 

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Wes Intravesical BCG Therapy

Copyright 2019 Dr. Jo Schoeman