OFFICE & SURGICAL TECHNOLOGIES Single-Use Flexible Cystoscopes: What's Available and Where Can They Be Used?
By: Jonathan Modai, MD and Kymora Scotland, MD, PhD | Posted on: 01 Sep 2022
The cystoscope has been part of the urologist toolkit for many decades. In recent years, single-use cystoscopes have hit the market, promising to improve on some of the shortcomings of reusable cystoscopes. What began as a rigid instrument evolved, with the invention of fiberoptics, into a reusable flexible tool capable of both diagnostic and therapeutic procedures in an office-based setting. Continued innovation led to the development of digital flexible cystoscopes. These instruments swapped the camera-fiberoptic apparatus for the charged coupled device or the complementary metal-oxide-semiconductor chip.1 These chips are common in many household items such as digital cameras and cellular phones, and can convert an image to a digital signal without relying on delicate fiberoptics or an expensive and heavy external camera. Single-use cystoscopes have harnessed this technology while tackling some of the limitations of reusable cystoscopes. In this article, we will survey currently available single-use cystoscopes and discuss the various uses for which they have been developed.
But why use disposable cystoscopes? Buying and maintaining reusable cystoscopes is expensive due to their high initial cost and the expensive sterilization required between uses.2 Moreover, the sterilization process needed can be time-consuming and requires specific equipment and dedicated staff. Despite this heavy resource requirement, reusable flexible endoscopes have been associated with infection.3 Single-use cystoscopes were devised to address these concerns, assuming the cystoscope itself is cheap enough. Several studies evaluating the economics of single-use cystoscopes have found them cost-effective in low-volume centers, but less so in high-volume centers.4–7 It should be noted that the studies done to date have evaluated the cost-effectiveness of single-use cystoscopy for Double-J® stent removal, and thus its economic benefits for other procedures, such as diagnostic cystoscopy, are unknown. Most studies done to date also did not report on infectious complications; those that did actually found single-use cystoscopes to be superior, although the evidence is of low quality and further trials need to be done to investigate this issue.5,8 Thus, while there are still some questions about the benefit of single-use cystoscopes versus their reusable counterparts, there has been enthusiasm for their use as evidenced by the rapidly increasing number of commercially available options.
So what single-use cystoscopes are available and how can they be used? There are several already on the market (see Figure). Most include a working channel, as is common in reusable cystoscopes. The Isiris® α, one of the earliest single-use cystoscopes, is dedicated to Double-J stent removal, and has an integrated grasper without a working channel (part B of Figure); similarly, the Uro-N™ cystoscope was developed strictly for the injection of material into the bladder wall (part C of Figure). The single-use cystoscope with integrated grasper may have a unique advantage over other products when it comes to stent removal, as it negates the need for an assisting nurse to operate the grasper and was found in different studies to shorten the process of ureteral stent retrieval by 10 to 20 minutes.6 There are currently no published studies on the efficiency of the cystoscope with an integrated needle for injection. The Table lists the different single-use cystoscopes available and their technical specifications as noted on the manufacturer’s website and in benchtop testing.
Table. Available single-use cystoscopes and their specifications
|NeoFlex (NeoScope)||aScope 4 Cysto (Ambu)||WiScope
|Working channel||None||3.6Fr/5Fr/8Fr||6.6Fr||6.6Fr||6.6Fr/3 Fr/None||7.2Fr|
|Resolution||800/600 pixels||400/400 pixels||400/400 pixels||800/480 pixels||800/800 pixels|
|Deflection||Up 80°/down 90°||Up 270°/down 270°||Up 210°/down 120°||Up 180°/down 1 80°||Up 210°/down 130°||Up 210°/down 180°|
|Field of view||85°*||120°||120°||100°||140°||110°±10%|
|Depth of view||3–100 mm||2–50 mm||3–50 mm||5–100 mm|
|Needle injector||No||No||No||No||Yes (Uro-N)||No|
|Signal output||Dedicated portable screen||HDMI/USB||Dedicated portable screen||USB/CVBS/HDMI||Dedicated portable screen||2 DVI/1 SDI/1 VGA|
|Utility||Diagnostic, stent removal||Diagnostic, operative||Diagnostic, operative||Diagnostic, operative||Diagnostic, injections, operative||Diagnostic, operative|
|Special features||Direct laptop connection||Cordless, portable handle|
|*From Seyam et al.10 LED, light-emitting diode.|
As companies continue to introduce new commercially available cystoscopes, there has been increasing customization of scopes for every indication (see Table). While all allow for diagnostic cystoscopy, 1 cystoscope (Uro-G™) was specifically designed for diagnostic urogynecologic procedures with a narrow diameter sheath (part C of Figure). This manufacturer (UroViu) has an array of cystoscopes including the Uro-N for needle injection and an additional full-service cystoscope (part C of Figure). Two companies (UroViu and Neoscope) have developed entirely portable cystoscopes (parts C and D of Figure), with 1 cystoscope (NeoFlex™) having a dongle allowing for direct connection to either a video processing unit or a laptop, which then would provide power, light, and visualization. Since no other equipment such as a control box or video tower is required, this facilitates patient care in a wide variety of clinical settings.2
An issue that needs to be addressed when discussing single-use cystoscopes is the environmental implication of replacing reusable cystoscopes with disposable ones. Interestingly, studies comparing the carbon footprint of a single-use cystoscope (aScope™ 4 Cysto™) to reusable cystoscopes found the single-use cystoscope to have a smaller carbon footprint.7,9
Studies evaluating the performance of all the different single-use cystoscopes are lacking, but the limited data published thus far on 2 of the available cystoscopes (Isiris α, NeoFlex) suggest that there are no major performance issues regarding ureteral stent removal2,5 or diagnostic cystoscopy for urothelial carcinoma.10 Given the array of single-use cystoscopes currently on the market with several more in development, studies are required to rigorously evaluate their performance, cost-effectiveness, and environmental impact.
- Okhunov Z, Hruby GW, Mirabile G, et al. Prospective comparison of flexible fiberoptic and digital cystoscopes. Urology. 2009;74(2):427-430.
- Scotland K, Wong VKF, Chan JYH, et al. Evaluation of a single-use flexible cystoscope: a multi-institutional international study. J Endourol. 2020;34(9):981-986.
- Kenters N, Huijskens EG, Meier C, Voss A. Infectious diseases linked to cross-contamination of flexible endoscopes. Endosc Int Open. 2015;3(4):E259-E265.
- Su ZT, Huang MM, Matlaga BR, et al. A micro-costing analysis of outpatient flexible cystoscopy: implications for adoption of single-use flexible cystoscopes. World J Urol. 2021;39(11):4275-4281.
- Adam A, Lawrentschuk N, Bhattu AS, et al. Efficacy of the novel, innovative, single-use grasper integrated flexible cystoscope for ureteral stent removal: a systematic review. ANZ J Surg. 2021;91(12):2599-2605.
- Hughes T, Pietropaolo A, Jones P, et al. Outcomes and cost evaluation related to a single-use, disposable ureteric stent removal system: a systematic review of the literature. Curr Urol Rep. 2021;22(8):41.
- Boucheron T, Lechavallier E, Gondran-Tellier B, et al. Cost and environmental impact of disposable flexible cystoscopes compared to reusable devices. J Endourol. 2022; doi: 10.1089/end.2022.0201.
- Baston EL, Wellum S, Bredow Z, et al. Office-based ureteric stent removal is achievable, improves clinical flexibility and quality of care, whilst also keeping surgeons close to their patients. Cent European J Urol. 2018;71(2):196-201.
- Hogan D, Rauf H, Kinnear N, et al. The carbon footprint of single-use flexible cystoscopes compared with reusable cystoscopes. J Endourol. 2022; doi: 10.1089/end.2021.0891.
- Seyam RM, Zeitouni OM, Alsibai TM, et al. The grasper-integrated disposable flexible cystoscope is comparable to the reusable, flexible cystoscope for the detection of bladder cancer. Sci Rep. 2020;10(1):13495.