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Operations linked with
bladder problems

Cystoscopy

This is an investigation of the bladder, while you are under anaesthetic; the doctor inserts a telescope in to the urethra. By looking into the telescope, he or she can see inside your bladder and detect any problems. It is done to help in the diagnosis of lower urinary tract (bladder and urethra) symptoms.

Biopsies can also be taken from any abnormal looking areas.

It is also used as a part treatment for bladder tumours and stones, and in gynaecology as part of operations such as TVT- (i.e. tension free vaginal tape) and collagen bladder neck injections

Types of cystoscopes:

Rigid cystoscope : this a straight solid metal tube with a high intensity light source and a separate channel to allow other instruments to be attached.

Flexible cystoscope: this is a fibre optic instrument, which bends easily and has a manoeuvrable tip.

The procedure

The cystoscopy may be done under local anaesthetic, but if it is a planned surgery it may be better to have a general anaesthetic.

A flexible cystoscope can be passed along the urethra with just a lubricating jelly and manoeuvring the tip helps to view all the corners of the bladder.

A rigid cystoscope is used with a general or local anaesthetic. A much wider range of instrument can be employed with this instrument.

Normal saline solution will be sent down the scope to fill the bladder and allow the surgeon to look all around inside the bladder.

An attached camera will allow a view of the bladder to be projected on to a TV monitor.

The information obtained:

As the instrument is passed inside the urethra it is carefully examined for a narrowing or obstruction.

Once inside the bladder the following are carefully looked at:
  • The lining (mucous membrane)- for any polyps (usually simple growths) diverticulea (bulges) tumours, calculi(stones), inflammation(irritation) and the capacity of the bladder and any deformities.
  •  The opening of the urinary passage from the kidneys to the bladder.
  • The link to the urethra (bladder neck).
Biopsies may be taken and bladder stones removed.

In procedures like pubovaginal sling to note whether the introducer needle has passed through the bladder.

Following the procedure:

After a short stay in the recovery room, you will return to the ward, your nurse will take your observations, and make sure that you are comfortable, if you have any discomfort you should be able to have some pain-killers.

2-4 hours after your return to the ward, and as long as you dont have any anaesthetic sickness, you can start eating and drinking.

When you first pass some urine after the procedure it may be slightly blood stained, this does not always happen, but if it does it is nothing to worry about.

Occasionally a patient may get a water infection after a cystoscopy.

If temperature, pain, or continuous burning is noted the doctor should be contacted.

What about driving?

We recommend that you have a few days off work to get over the anaesthetic, if you have a difficult job then see your GP and he/she will advise you.
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What is rigid cystoscopy ?

A rigid cystoscopy is a procedure to check for any problems with your bladder using a rigid telescope (cystoscope). Sometimes certain problems with your bladder and urinary tubes can be treated at the same time. Your doctor has recommended a rigid cystoscopy. However it is your decision to go ahead with the procedure or not.
This document will give you information about the benefits and risks to help you make an informed decision. If you have any questions that this document does not answer ask your doctor or healthcare team.

What are the benefits of a rigid cystoscopy?

Your doctor is concerned there may be a problem with your bladder. For example, you may be getting blood in your urine or repeated infections or you may have irritable bladder (a sudden and uncontrolled urge to pass urine). If your doctor does see a problem during the cystoscopy they perform a biopsy (removing a small piece of tissue) or they may be able to treat the problem using the cystoscope. If the cystoscopy is normal, your doctor may be able to tell you straightaway and they will reassure you.

Are there any alternatives to rigid cystoscopy?

A scan may give some information about the cause of the problems but a cystoscopy often leads to a diagnosis. Some problems with the lining of your bladder can be seen only with a cystoscope. It is possible to have a flexible cystoscopy that needs only an anaesthetic jelly. However, certain problems with your bladder and urinary tubes cannot be treated with a flexible cystoscopy.

What will happen if I decide not to have a cystoscopy?

Your doctor may not be able to confirm what the problem is. If you decide not to have a cystoscopy, you should discuss carefully with your doctor.

What does the procedure involve?

The healthcare team will carry out a number of checks to make sure you have the procedure you came in for. You can help by confirming to your doctor and healthcare team your name and the procedure you are having. The procedure is usually performed under a general anaesthetic or spinal anaesthetic. Your anaesthetist will discuss your options with you and recommend the best form of anaesthesia for you. The procedure including anesthetic usually takes less than 30 minutes. Your doctor will pass the cystoscope in to your bladder through your urethra (tube that carries urine from the bladder) they may place a finger in to your vagina while they place the cystoscope. Your doctor will use the cystoscope to look for any problems in the lining of your bladder and will be able to perform biopsies. 
Your doctor will pass fluid through the cystoscopy and in to your bladder to help them make the diagnosis. If your doctor finds a small growth. It may be possible to remove it using the cystoscope. Your doctor will remove the cystoscope.

What should I do about my medication?

Let your doctor know all about your medication you take and follow their advice. This includes all blood-thinning medications as well as herbal and complementary remedies, dietary supplements and medication that you buy over the counter.

What can I do to help make the procedure a success?

If you smoke stopping smoking several weeks or more before the procedure may reduce your risk of developing complications and will improve your long term health. Try to maintain a healthy weight. You have a higher risk of developing complications if you are overweight. Regular exercise should help to prepare you for the procedure, help you recover and improve your long-term health. Before you start exercising ask for advice.

What complication can happen?

The healthcare team will try to make the procedure as safe as possible but complications can happen. Some of these can be serious and can even cause death. The possible complications rigid cystoscopy are listed below. Any numbers which relate to risk are from studies of people who have had this procedure. Your doctor will be able to tell you if the risk of a complication is higher or lower for you.

  • Complications of anaesthesia – your anesthetist will be able to discuss this with you and the possible complications of having an anaesthetic.
  • Rigid cystoscopy complications
  • Bleeding during or after the procedure. You may notice a small amount of blood the first few times you pass urine risk 1:5. Most women who have a biopsy will notice blood in their urine. Any bleeding is usually little. The healthcare team can pass water through a catheter (tube) and in to your bladder to wash out any blood or to remove any blood clots (called bladder washout)
  • Infection risk 1:30 . If you need to pass urine often and pass only small amounts with a great deal of discomfort, you may have an infection. If your symptoms continue to get worse contact your GP. You may need treatment with antibiotics.
  • Narrowing of your urethra (stricture) caused by scars forming. This is unusual after a single cystoscopy. You may need further surgery risk less that 1:1000
  • Making a hole in your bladder. You may need a catheter in your bladder for a few days while the hole heals. If the hole does not heal you may need surgery. You should discuss these possible complications with your doctor if there is anything you do not understand.

How soon will I recover?

  • In Hospital – after the procedure you will be transferred to the recovery area where you can rest. You should be able to go home the same day after you have recovered from the anaesthetic and passed urine. However your doctor may recommend that you stay a little longer. If you do go home the same day a responsible adult should take you home in a car or taxi and stay with you for at least 24 hours be near a telephone in case of an emergency.
  • Returning to normal activities- do not drive, operate machinery (this includes cooking) or do any potentially dangerous activities for at least 24 hours and not until you have fully recovered feeling the movement and co-ordination. If you had a general anaesthetic or sedation, you should also not sign legal documents or drink alcohol for at least 24hours. You may get a little stinging the first few times you pass urine. Drink up to 3 liters (five pints) of water a day to help you to pass urine more easily. A rigid cystoscopy is not usually painful. If you have any discomfort take simple painkillers such as paracetamol. You should be able to return to work to work the day after the cystoscopy unless told otherwise. Regular exercise should help you to return to normal activities as soon as possible. Do not drive until you are confident about controlling your vehicle and always check your insurance policy.
  • The future- the healthcare team will tell you what was found during the cystoscopy and discuss with you any treatment or follow up you need. Results from biopsies will not be available for a few days so the

 Healthcare team may arrange for you to come back to clinic for your results.

Summary

A rigid cystoscopy is usually a safe and effective way of finding out if there is a problem with your bladder. However, complications can happen. You need to know about them to help you to make an informed choice about the procedure knowing about them will also help you to detect and treat problems early.

TOT

The Transobturator Tape (TOT)


A transobturator tape is a synthetic tape inserted through a small cut at the top of the groin area to support the urethra and helps improve stress incontinence. It s guided in to position by a small cut in the front wall of the vagina. The TOT is a surgical treatment option for stress incontinence.

What are the benefits of a TOT?

In supporting the urethra, when stress is put on the bladder (coughing, sneezing, lifting) the urethra squeezes against the tape to prevent leakage. 85 – 90% of women with a TOT are completely dry or their symptoms have significantly improved.

What are the risks of the operation?

Bleeding - 2 in 100 (2%) women will experience bleeding from the wound site.

Infection – there is a 2% risk of infection in the surgical wounds or bladder itself. These can be easily treated with antibiotics. You should not use tampons etc until the area is fully healed (4- 6 weeks).

Urinary Retention –
this means an inability to empty the bladder. It is usually temporary. A small number of women have to go home with a catheter in place and return 1 – 2 weeks later for its removal. This occurs about 15% of the time. We will perform a bladder scan before you go home to make sure you are emptying the bladder adequately. Very rarely the tape needs to be loosened or removed. Some women prefer to self catheterise rather than be incontinent again.

Bladder irritation –
5/100 (5%) of women will develop the sensation that the bladder is full and need to empty it often. This often settles spontaneously but sometimes needs physiotherapy and/or medication. If these symptoms are present prior to tape insertion the symptoms may worsen.

Pain/numbness in the groin –
5% will experience this where the cuts are made.

Damage to the bladder, urethra or vagina –
The risks are 1% for any of these and do not usually present a problem so long as they are recognised and repaired. Sometime a catheter is left in place for a few days afterwards.

Tape erosion –
this is where the tape wears through the tissue of the urethra (<1%) or vagina (4%). The latter is more common in older women.

The procedure

Two small cuts are made to the groin area and on the anterior wall of the vagina. The bladder is catheterised and the neck of the bladder identified. A small vaginal cut is made to guide the needle and tape in to position. A needle is inserted through the groin cut and mesh attached vaginally. It is then removed back out through the vaginal opening and back out through the groin cut. The second needle is passed through on the other side and the synthetic mesh is brought under the urethra and back out to the groin. The tape lies just in front of the urethra and under the opening of the bladder. Each cut is then closed with dissolvable stitches.

After the operation

You may have light vaginal bleeding. When you pass urine the nurse will measure how much you have passed and how much is in your bladder. When the volume left is under 150mls you will be allowed home. Some women will need a catheter for a few days so do not be unduly concerned if this happens to you. The stitches all dissolve.

Going Home

Most normal activities can be resumed within a few weeks of surgery. Avoid heavy lifting, exercise or sexual intercourse for four weeks after the operation.

Further Information

Bladder and Bowel Foundation – www. bladderand bowelfoundation .org

 

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