BAUS Flexi Logbook

THE BRITISH ASSOCIATION
UROLOGICAL SURGEONS
OF
Flexible Cystoscopy
Performance Criteria, Training
and Assessment Logbook
November 2012
1
Tristel has provided an unrestricted educational grant for this independent publication
Flexible Cystoscopy
Performance Criteria, Training and Assessment Record
Trainee Name
Title of Trainee
NMC Number
Supervisor Name
Title of Supervisor
Name of Assessor
Title of Assessor
NHS Trust/Employing Organisation
Date Training Commenced
Date Assessment Completed
Contents
Reflective Diary
Contents Contents
Skills for Health Standards for Flexible Cystoscopy
3
ReflectiveReflective
Diary
Diary
Performance Criteria for Undertaking Flexible Contents
Cystoscopy
5
Skills
for
Health
Standards
for
Flexible
Cystoscopy
Skills
for
Health
Standards
for
Flexible
Cystoscopy
Contents
Reflective
Diary
Observation
of Cystoscopy
Aims and Objectives
7
Performance
Criteria
forCriteria
Undertaking
Flexible Cystoscopy
Performance
for Undertaking
Flexible Cystoscopy
Reflective
Diary
Skills forofHealth
Standards
for Flexible
Observation
Cystoscopy
Training
Record Cystoscopy
Observation
of
Cystoscopy
Aims
and Aims
Objectives
9
Observation
ofUndertaking
Cystoscopy
andCystoscopy
Objectives
Skills
for Health
Standards
for
Flexible
Cystoscopy
Performance
Criteria
for
Flexible
Withdrawal
of Flexible
Cystoscope
Aims and
Objectives
Observation
of
Cystoscopy
Training
11
Observation
ofUndertaking
Cystoscopy
Training
Record
Performance
Criteria
for
Flexible Cystoscopy
Observation
of
Cystoscopy
Aims
andRecord
Objectives
Withdrawal
of Cystoscope
Training
Record
Withdrawal
of
Aims
and Aims
Objectives
12
Withdrawal
ofCystoscope
Flexible
Cystoscope
and Objectives
Observation
of Flexible
Cystoscopy
Aims and
Objectives
Observation
of
Cystoscopy
Training
Examination
of Bladder
Urothelium
UsingRecord
a Flexible Cystoscope Aims And Objectives
Withdrawal
of
Training
Record
13
Withdrawal
ofCystoscope
Cystoscope
Training
Record
Observation
of Cystoscope
Cystoscopy
TrainingAims
Record
Withdrawal
of
Flexible
and Objectives
Examination
of Bladder
Urothelium
Training Record
Examination
Bladderof
Urothelium
Usingand
a Flexible
Aims AndAims
Objectives
Examination
Bladder Urothelium
Using aCystoscope
Flexible Cystoscope
And Objectives
14
Withdrawal
ofofCystoscope
Flexible
Cystoscope
Aims
Objectives
Withdrawal
of
Record
Insertion
of Flexible
CystoscopeTraining
Aims and
Objectives
Examination
Bladder
Training
Record
Examination
ofUrothelium
Bladder
Training
Record Aims And Objectives
15
Withdrawal
ofof
TrainingUrothelium
Record
Examination
ofCystoscope
Bladder
Urothelium
Using a Flexible
Cystoscope
Insertion
of Flexible
Cystosope
Training Record
Insertion
of
Flexible
Aims
and aAims
Objectives
Insertion
ofCystoscope
Flexible
Cystoscope
and Objectives
16
Examination
of
Urothelium
Using
Flexible
Cystoscope Aims And Objectives
Examination
of Bladder
Bladder
Urothelium
Record
Flexible
Cystoscopy
Full Procedure
AimsTraining
and Objective
Insertion
of
Flexible
Training
Record
Insertion
ofCystosope
Flexible
Cystosope
Training
Record
17
Examination
of Bladder
Urothelium
Training
Record
Insertion
Flexible
Cystoscope
Aims
and
Objectives
Performance
ofofFull
Procedure
Training
Record
Flexible
Cystoscopy
Full Procedure
Aims
and
Objective
Flexible
Cystoscopy
Full
Procedure
Aims
and Objective
18
Insertion
of
Flexible
Cystoscope
Aims
and
Objectives
Insertion
of
Flexible
Cystosope
Training
Record
Summary
of Training
Record
Performance
of Full Procedure
Training
Performance
ofProcedure
Full Procedure
Training Record
19
Insertion
of
Flexible
Cystosope
TrainingRecord
Record
FlexibleofCystoscopy
Full
Assessment
Flexible Cystoscopy
SkillsAims and Objective
Summary
of Training
Record
Summary
Training
Record
20
Flexible
Cystoscopy
Full
Procedure
Aims and Objective
Performance
of Full of
Procedure
Statement
of Competence
to PerformTraining
FlexibleRecord
Cystoscopy
Assessment
of
Flexible
Cystoscopy
Skills
of Flexible
Cystoscopy
Skills
of Assessment
21 Record
Performance
of Full Procedure
Training
Record
ofStandards
Training
Record
SkillsSummary
for Health
for Removal of Ureteric Stent Using a Flexible Cystoscope
Statement
ofof
Competence
to PerformSkills
ofRecord
Competence
toFlexible
PerformCystoscopy
Flexible Cystoscopy
23
Summary Statement
of
Training
Assessment
Flexible
Cystoscopy
Performance
Criteria
for Undertaking
Removal of Ureteric Stent
Skills for Health
Standards
for
Removal
UretericofStent
Using
a Flexible
Skills
for
Health
forof
Removal
Ureteric
Stent
Using aCystoscope
Flexible Cystoscope
24
Assessment
Flexible
Cystoscopy
Skills
Statement
ofofCompetence
toStandards
Perform
Flexible
Assessment
of Ureteric
Stent Removal
Skills
UsingCystoscopy
a Flexible Cystoscope
Performance
Criteria
forCriteria
Undertaking
Removal
of
Ureteric
Performance
for Undertaking
Removal
ofStent
Ureteric
Stent Cystoscope
Statement
of Competence
tofor
Perform
Flexible
Cystoscopy
25
Skills
forCompetence
Health
Standards
Removal
Ureteric
Stent
Using
a Cystoscope
Flexible
Statement
of
to Remove
UretericofStents
Using
a Flexible
Assessment
ofCriteria
Ureteric
Skills
Using
aStent
Flexible
Assessment
ofStent
Ureteric
StentRemoval
Removal
Using
aCystoscope
Flexible
Cystoscope
Skills
for Health
Standards
forRemoval
Removal
of Ureteric
Using
a Flexible
Cystoscope
26
for
ofSkills
Ureteric
Stent
SkillsPerformance
for Health Standards
to Undertaking
Use Cystodiathermy
Via
a Flexible
Cystoscope
Statement
ofof
Competence
to Remove
Stents
a Flexible
of
toUreteric
Remove
Ureteric
Using
aCystoscope
Flexible Cystoscope
Performance
Criteria
forCompetence
Undertaking
Removal
of
Ureteric
Stent
Statement Statement
of
Competence
Remove
Ureteric
Stents
Using
aStents
Flexible
Cystoscope
27
Assessment
Ureteric
Stent
Removal
Using
a Using
Flexible
Cystoscope
Assessment
of Cystodiathermy
Skills
UsingSkills
a Flexible
Cystoscope
Skillsfor
forHealth
Health
Standards
to
Use
Cystodiathermy
a Flexible
Skills
for
Health
to
Use Cystodiathermy
aCystoscope
Flexible
Cystoscope
Assessment
Ureteric
Stent
Removal
Skills
Using
a Using
Flexible
Cystoscope
Skills
Standards
-Standards
Use
cystodiathermy
viaVia
flexible
cystoscope
28
Statement
ofofCompetence
to
Remove
Ureteric
Stents
a Via
Flexible
Cystoscope
Statement
of Competence
to Perform
Cystodiathermy
Using
a Flexible
Cystoscope
Assessment
Cystodiathermy
Skills
Using
a Flexible
Cystoscope
Assessment
of Undertaking
Cystodiathermy
Skills
UsingUsing
ausing
Cystoscope
Statement
ofofCompetence
totoRemove
Ureteric
Stents
aaFlexible
Cystoscope
Performance
Criteria
for
Cystodiathermy
Flexible
Cystoscope
for Health
Standards
Use
Cystodiathermy
aFlexible
Flexible
Cystoscope
SkillsSkills
for Health
Standards
to Undertake
Biopsy
Using aVia
Flexible
Cystoscopy
Statement
ofofCompetence
totoPerform
a Flexible
Statement
of Competence
toCystodiathermy
Perform
Cystodiathermy
Using
aCystoscope
Flexible Cystoscope
Skills
for Health
Standards
Use Cystodiathermy
ViaUsing
a Flexible
Cystoscope
31
Assessment
Cystodiathermy
Using
a Flexible
Cystoscope
Assessment
of Biopsy
Skills Using aSkills
Flexible
Cystoscope
Skills
for Health
Standards
toPerform
Undertake
Biopsy
Using
a Flexible
Skills
for
HealthtoStandards
to
Undertake
Biopsy
Using
aCystoscopy
Flexible
Cystoscopy
Assessment
Cystodiathermy
Skills Cystodiathermy
Using
a Flexible
Cystoscope
33Statement
Statement
ofofCompetence
Using
aCystoscope
Flexible
Cystoscope
of Competence
to Undertake
Biopsies Using a Flexible
Assessment
Biopsy
Skills
Using
a Flexible
Assessment
of
Biopsy
Skills
Using
aCystoscope
Flexible
Statement
ofofCompetence
totoPerform
Cystodiathermy
a Flexible
Cystoscope
35Background
Skills forReading
Health
Standards
Undertake
Biopsy
UsingUsing
aCystoscope
Flexible
Cystoscopy
Cystoscope
and
References
Statement
ofof
Competence
totoUndertake
Biopsies
Using
Flexible
Statement
of
Competence
Undertake
Biopsies
UsingCystoscope
aCystoscope
Flexible Cystoscope
Skills
for Health
Standards
Undertake
Biopsy
Using
Flexible
Cystoscopy
37
Performance
Criteria
for
Undertaking
Biospsies
Using
a aaFlexible
Assessment
Biopsy
Skills
Using
atoFlexible
Cystoscope
Background
Reading
References
Background
Reading
and aReferences
Assessment
Biopsyand
Skills
Using
Flexible
Cystoscope
39
37
Statement
ofof
Competence
to Undertake
Biopsies
Using a Flexible Cystoscope
29
41
39
Statement
of Reading
Competence
to Undertake Biopsies Using a Flexible Cystoscope
Background
and References
42
41
Background Reading and References
42
2
2
2
2
Prompts to structure reflection:
Reflective Diary
Reflective Diary
to
Write
a description
of a significant cystoscopy procedure.
Prompts
structure
reflection:
What issues
seemedofsignificant?
Write
a description
a significant cystoscopy procedure.
How was
I feeling
what made me feel that way?
What
issues
seemedand
significant?
What was
was II feeling
trying to
achieve?
How
and
what made me feel that way?
Did I respond
effectively
and in tune with my values?
What
was I trying
to achieve?
WhatI respond
were theeffectively
consequences
onvalues?
the patient, others and me?
Did
and of
in my
tuneactions
with my
How were
feeling and what
them
that way?
What
were others
the consequences
of mymade
actions
on feel
the patient,
others and me?
What were
factors
influenced
I was
feeling,
thinking
or responding?
How
others
feelingthe
andway
what
made
them feel
that way?
To what
extent
did I act for
What
factors
influenced
the the
waybest?
I was feeling, thinking or responding?
How
doesextent
this situation
with previous experiences?
To
what
did I act connect
for the best?
How does
mightthis
I respond
more
effectively
given this
situation again?
How
situation
connect
with previous
experiences?
What might
wouldI the
consequences
be of alternative
How
respond
more effectively
given thisactions?
situation again?
How do
I now
about this experience?
What
would
thefeel
consequences
be of alternative actions?
Am I do
now
able feel
to better
myself and others better as a consequence?
How
I now
aboutsupport
this experience?
Am II now
now able
moretoable
to work
with
patients
the better
team toashelp
them meet their needs?
Am
better
support
myself
andand
others
a consequence?
(Johns 2006)
Am I now more able to work with patients and the team to help them meet their needs?
(Johns 2006)
3
3
3
Reflective Learning Log (cont.)
4
4
B
CYST1 - Undertake diagnostic and surveillance
CYST1 - Undertake diagnostic and surveillance
cystoscopy using a exible cystoscope.
cystoscopy using a flexible cystoscope

OVERVIEW
This standard covers the use of a flexible cystoscope to examine the interior of the
bladder and urethra and the identification and recording of normal and abnormal
findings.
This standard covers the use of flexible cystoscopy for adults only. Paediatric services
are excluded.
Users of this competence will need to ensure that practice reflects up to date
information and policies.
Version No 1
KNOWLEDGE AND UNDERSTANDING

You will need to know and understand:
1. National and local cystoscopy policies and guidelines
2. National and local infection control policies and guidelines
3. National and local policies and guidelines for used equipment and waste handling
and disposal
4. National and local policies and guidelines for consent to cystoscopy
5. National and local policies and guidelines for patient identification
6. National and local policies and guidelines for patients records, their storage and
confidentiality of information
7. The range of information which should be made available to the patient
8. National and local policies and guidelines appertaining to the examination report
9. The normal anatomy and physiology, normal variants and anatomical relationships
of the lower urinary tract
10. The abnormal anatomy, pathology and physiology visible through cystoscopy and
the significance of such abnormalities
11. The cystoscopy blind areas and techniques for visualising these
5
5
12. The clinical conditions appropriate for cystoscopy

13. The indications and contra-indications for cystoscopy
14. The medical terminology relevant to the procedure
15. The common pathologies of the lower urinary tract
16. The signs and symptoms of the patient's physical and emotional status
17. The complications of cystoscopy and remedial strategies
18. The range of local anaesthetics for use in cystoscopy, their specifications and
possible side effects
19. The function, specification and performance characteristics of the equipment to be
used in cystoscopy
20. The impact of equipment controls on the visual image
21. The safe operation of cystoscopy equipment
22. The importance of timely equipment fault recognition and local procedures for
dealing with these
23. Equipment capabilities, limitations and routine maintenance
24. The preparation of environment and equipment for cystoscopy
25. The roles and responsibilities of other team members
26. The limits of ones own knowledge and experience and the importance of not
operating beyond these
27. Audit data to reflect on own practice and maintenance of competence in
accordance with national and local policies and guidelines
ADDITIONAL INFORMATION
This National Occupational Standard was developed by Skills for Health.
This standard links with the following dimension within the NHS Knowledge and Skills
Framework (October 2004):
Dimension: HWB6 Assessment and treatment planning
Reproduced with kind permission of Skills for Health
6
6
Performance Criteria for Undertaking Flexible Cystoscopy
Action
Rationale
Verify correct patient with correct notes for correct

procedure
To ensure that the correct patient has the

correct procedure performed
Check that the patient has no relevant allergies
To avoid adverse reaction to medication/latex

used prior to or during procedure.
Explain procedure including risks and benefits to

patient and obtain informed written consent
To comply with DH (2009) recommendations

on consent and to ensure patient is prepared for
procedure
Prepare patient for procedure:
To ensure clear view of bladder urothelium
empty bladder
Flexible cystoscopy should be avoided in

patients with a UTI
urine dipstick recorded
To avoid spillage of irrigation fluid on to

patient clothing
Patient to undress from below the waist ,,ensure

ensure
patient dignity is maintained
If patient has an artificial urinary sphincter
implanted, ensure that it is deactivated
To avoid adverse incident
Communicate with patient throughout the

procedure
To confirm understanding of procedure,

provide patient with reassurance and answer
patient questions or concerns
Cover patient from waist down with sterile drapes
To reduce the risk of patient developing a

healthcare acquired infection
Clean penis/vulva and urethral meatus with sterile

sodium chloride 0.9%
To reduce the risk of patient developing a

healthcare acquired infection
Instil local anaesthetic lubricant gel into urethra

with minimum discomfort to patient
To allow smooth passage of cystoscope into

bladder and cause minimum discomfort to the
patient
Check cystoscope and processor in working order
To avoid harming the patient and to ensure that

the procedure is performed safely.
Introduce flexible cystoscope into the urethra

Urethra
under direct vision using deflection and inflection
of the tip to maintain urethral lumen within the
centre of vision ,with minimum discomfort to the
patient, ensuring irrigation fluid is continuously
running
To reduce the risk of trauma to the urethra and

minimise patient discomfort
7
7
Performance Criteria for Undertaking Flexible Cystoscopy
Action
Rationale
Fill bladder with irrigation fluid with minimum

discomfort to the patient
To allow complete examination of bladder

urothelium
Aspirate fluid from the bladder/washout the bladder via

the cystoscope if view is poor due to debris or bleeding
To improve vision
Using rotation, deflection and inflection (including J/U

manoeuvre) of the flexible cystoscope tip,
systematically examine the bladder urothelium, trigone,
ureteric orifices and bladder neck
To ensure thorough examination of bladder

urothelium
Withdraw flexible cystoscope under direct vision using

deflection and inflection of the tip to maintain urethral
lumen within the centre of vision with minimum
discomfort to the patient, ensuring irrigation fluid is
continuously running
To examine the urethra whilst minimising the risk

of trauma and causing minimum patient discomfort
Clean any surplus lubricant from patient and ensure

that they are dry before dressing
To maintain patient comfort and dignity
Ask patient to empty their bladder before leaving the

department
To ensure patients are able to void
Explain findings and management plan to patient and

confirm understanding
To ensure patient remains informed
Reminds
patientof
ofexpected
expectedurinary
urinarydiscomfort/
Remindpatient
patient
of
expected
urinary
Remind
discomfort/bleeding
risk
of
urinary
tract
infection
and
bleeding risk of urinary tract infection
and
to ensure
to
ensure
good
fluid
intake
following
procedure.
good fluid intake following procedure.
Ensures
patientisisisaware
awareof
actionto
takenin
the of
Ensure patient
patient
aware
ofofaction
action
totobe
bebetaken
taken
ininevent
Ensure
event of complications arising.
complications arising
To avoid unnecessary patient anxiety, reduce the

risk of urinary tract infection and to ensure patient is
aware of when and who to contact in the event of
complications arising.
Discard rubbish in accordance with local health and

safety at work waste management policies and
procedures
Safe disposal of waste
Ensure used flexible cystoscope is reprocessed in

accordance with Infection Control Services Ltd (2007)
decontamination policy, manufacturers instructions
and local health and safety at work policies and
procedures
To avoid cross infection and prevent avoidable

damage to cystoscope
Document
Documentsprocedure
procedurein
incase
casenotes
notesand
andcommunicates
communicates
result to the patients General Practitioner
To ensure everyone involved in the patient pathway

is informed that the procedure has been performed
and of the result to maintain continuity of care
Arrange any necessary follow up appointments
To maintain continuity of care
8
8
Aims and Objectives

Aims and Objectives
ctives
Observation of Flexible Cystoscopy
Aims and Objectives

Aims and Objectives
Aims and Objectives
Observation of Flexible
Observation
Cystoscopy
of Flexible Cystoscopy
Flexible Cystoscopy
Minimum 10 (five male and five female)

Observation of Flexible Cystoscopy
10 (five
Minimum
male and10five
(five
female)
male and five female)
five male andMinimum
five female)
The
aim of10
a period
of observation
is to allow the trainee to become familiar with the
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and five female)
The
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erforming
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and
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erve the
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asthe
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pearances
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as seen
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erforming
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To
observe
the
handling
of
cystoscopy
Handling
deflection
Handling
and
theinflection
deflection
controls
and
of
the
endoscope
controls ofwhile
in the bladder
the endoscope
while in the bladder
To
observethe
technique
of
the
withdrawal
of
theinflection
cystoscope
ng the deflection
and
inflection
controls
of the
endoscope
while
in
the
bladder
physiology
of
the
lower
urinary
tract
and
identified
pathologies
equisite
and
knowledge.
ols
theskills
endoscope
while
in the
bladder
To
observe
ofand
the
withdrawalcontrols
the
cystoscope
deflection
Tocystoscope
observe
technique
ofofthe
withdrawal
of the
cystoscope
listen
and
observe
the
post-examination
explanations
and
advice
to patients
erveoftechnique
of the
withdrawal
of
the
Handling
thetechnique
inflection
of the endoscope
while
in the bladder
he and
cystoscope
To observe
listen and
the
post-examination
explanations
advice to patients
observe
To listen
andwithdrawal
observe
and advice to patients
en
observe the post-examination
explanations
and
advicethe
to
patients
To
technique
of the
ofpost-examination
the
cystoscopeandexplanations
explanations and advice

to patients
To listen
to and observe the post-examination explanationsand
andadvice
advicetotopatients
patients
listen and of
observe
thecystoscopy
post-examination
explanations
en to and observetheTo
explanation
flexible
to the patient
and
of informed consent
To observe towelling and sterile precaution techniques
erve the technique of inertion of the into the urethra
erve the anatomy and endoscopic appearances of the lower urinary as seen
h closed circuit television
ication of bladder landmarks, verification of knowledge of anatomy and
logy of the lower urinary tract and identified pathologies
9
9
9
9 in the bladder
ng the deflection and inflection controls
of the endoscope while
9
Learning Outcomes
The trainee will be able to: 1. Describe the internal anatomy of the lower urinary tract.
pathologies:
2. Recognise the following common Pathologies:
Paphimosis
I. Paraphimosis
Paraphimosis
Phimosis/Paraphimosis
II. Urethral stricture
III. Debris
IV. Haematuria
V. Diverticulae
VI. Inflammatory changes
VII. Stones
VIII. Cystitis cystica
IX. Squamous metaplasia
X. Prostatic enlargement
XI. Abnormalities that may be suggestive of cancer (papillary, solid or CIS)
3. Gain an understanding of the techniques used in the performance of flexible

cystoscopy:
I.
II.
Patient counselling and consent

Positioning of the patient
III.
Handling the cystoscope including retroflexion of tip to perform J/U manoeuvre
IV.
Communication of results to patient and post procedure patient advice
V.
VI.
VII.
Documentation of procedure
Formulation of follow up/management plan
Communication of results to patients General Practitioner
Observation of Cystoscopy Training Record
10
10
VII.
Communication of results to patients General Practitioner

Observation of Cystoscopy Training Record
Observation No.
10
Date
Anatomy identified
Reason for cystoscopy
Male Patient
Female Patient
Haematuria
Dome of bladder
Dome of bladder
UTI
Body of bladder
Body of bladder
LUTs Irritative
Right Ureteric orifice
LUTs Obstructive
Left Ureteric orifice
TCC Surveillance
Trigone
Trigone
Bladder neck
Bladder neck
Prostatic urethra
Urethra
Verumontanum
Membranous urethra
Penile urethra
Pathology Seen
Outcome of Procedure
NAD
Calculi
Discharge
Cystitis cystica
Inflamed bladder
urothelium
Further investigation
Debris
Papillary lesion
Review in OPD
Diverticula
Solid lesion
Biopsy GA
Enlarged prostate
Urethral stricture
Biopsy LA
Squamous metaplasia
Cystodiathermy
Trabeculation
Litholopaxy
Introduction, explanation and consent
Rigid cystoscopy
Patient results and post procedure information
TURBT
Communication to GP
Urethrotomy
Signature
11
11
Aims and Objectives

Withdrawal of Flexible Cystoscope
Minimum number to achieve 10 (5 male and 5 female)
Aim
For the trainee to gain experience in the handling of the cystoscope, in particular the use of
the control lever to locate urethral landmarks and inspect the urethra.
Learning Outcomes
The trainee will be able to:
1. Understand the importance of keeping the lumen of the urethra in view all times.
2. Demonstrate the use of the control lever to facilitate keeping the lumen of the urethra
in view at all times.
3. Comment on the anatomy and physiology of the lower urinary tract viewed through
the cystoscope
procedures,
4. At
Atthe
theend
end of
of10
theprocedures,
10 withdrawals,
withdraw
the flexible
cystoscope
withdraw
the cystoscope
smoothly
and smoothly
safely withand
safely with
minimal to
discomfort
to the patient.
minimal
discomfort
the patient.
12
12
Withdrawal No.
Withdrawal No.
Withdrawal of Cystoscope Training Record

M of CystoscopeFTraining Record Date
Withdrawal
M
F
Date
Anatomy identified
Male Patient
Male Patient
Anatomy identified
Female Patient
Female Patient
Haematuria
Dome of bladder
Dome of bladder
Haematuria
UTI
Dome of bladder
Body of bladder
Dome of bladder
Body of bladder
UTI
LUTs Irritative
Body of bladder
Body of bladder
LUTs Irritative
LUTs Obstructive


LUTs Obstructive
TCC Surveillance

Trigone

Trigone
TCC Surveillance
Trigone
Bladder neck
Trigone
Bladder neck
Bladder neck
Prostatic urethra
Bladder neck
Urethra
Prostatic urethra
Verumontanum
Urethra
Verumontanum
Membranous urethra
Membranous urethra
Penile urethra
Penile urethra
Pathology Seen
NAD
Pathology Seen
NAD
Cystitis cystica
Cystitis cystica
Debris
Discharge
Calculi
Calculi
Inflamed bladder
urothelium
Inflamed
bladder
Discharge
urothelium
Papillary lesion
Review in OPD
Debris
Diverticula
Papillary lesion
Solid lesion
Review in OPD
Biopsy GA
Diverticula
Enlarged prostate
Solid lesion
Urethral stricture
Biopsy GA
Biopsy LA
Enlarged prostate
Squamous metaplasia
Urethral stricture
Biopsy LA
Cystodiathermy
Squamous metaplasia
Trabeculation
Cystodiathermy
Litholopaxy
Trabeculation
Litholopaxy
Rigid cystoscopy

Rigid cystoscopy
TURBT

Communication to GP
TURBT
Urethrotomy
Communication to GP
Urethrotomy
Signature
Signature
13
13
13
Aims
Aims
and
and
Objectives
Objectives
Examination
Examination
of of
Bladder
Bladder
Urothelium
Urothelium
Using
Using
a Flexible
a Flexible
Cystoscope
Cystoscope
Minimum
Minimum
number
number
to to
achieve
achieve
10
10
(Five
(Five
male
male
andand
five
five
female)
female)
Aim
Aim
ForFor
thethe
trainee
trainee
to to
gain
gain
further
further
experience
experience
in in
thethe
handling
handling
of of
thethe
cystoscope,
cystoscope,
in in
particular
particular
thethe
useuse
of of
thethe
control
control
lever,
lever,
byby
systematically
systematically
inspecting
inspecting
thethe
bladder
bladder
urothelium
urothelium
andand
locating
locating
bladder
bladder
landmarks.
landmarks.
. .
Learning
Learning
Outcomes
Outcomes
1. 1.
Demonstrate
Demonstrate
thethe
safe
safe
useuse
of of
thethe
control
control
lever
lever
(including,
(including,
deflection
deflection
andand
inflection
inflection
of of
tiptip
to to
perform
perform
JJ/U
manoeuvre)
J manoeuvre)
andand
rotation
rotation
of of
thethe
cystoscope
to to
systematically
examine
cystoscope
systematically
examine
manoeuvre
bladder
urothelium
andand
identify
bladder
landmarks
with
minimal
discomfort
to to
thethe
bladder
urothelium
identify
bladder
landmarks
with
minimal
discomfort
patient.
patient.
2. 2.
Comment
onon
thethe
anatomy
andand
physiology
of of
thethe
lower
urinary
tract
viewed
through
Comment
anatomy
physiology
lower
urinary
tract
viewed
through
thethe
cystoscope
cystoscope
1414
14
Examination of Bladder Urothelium Training Record

Examination No.
Date
Anatomy identified
Male Patient
Female Patient
Haematuria
Dome of bladder
Dome of bladder
UTI
Body of bladder
Body of bladder
LUTs Irritative
LUTs Obstructive
TCC Surveillance
Trigone
Trigone
Bladder neck
Bladder neck
Prostatic urethra
Urethra
Verumontanum
Membranous urethra
Penile urethra
Pathology Seen
NAD
Calculi
Discharge
Cystitis cystica
Inflamed bladder
urothelium
Debris
Papillary lesion
Review in OPD
Diverticula
Solid lesion
Biopsy GA
Enlarged prostate
Urethral stricture
Biopsy LA
Squamous metaplasia
Cystodiathermy
Trabeculation
Litholopaxy
Rigid cystoscopy
TURBT
Communication to GP
Urethrotomy
Signature
15
15
Aims and Objectives

Insertion of Flexible Cystoscope
Minimum number to achieve 10 (Five male and five female)
Aim
For the trainee to gain further experience in the handling of the cystoscope, in particular the
use of the control lever to safely insert the flexible cystoscope through the urethra into the
bladder.
Learning Outcomes
1.
Safely prepare the aseptic field
2.
Correctly clean the patient
3.
Safely instil local anaesthetic lubricant into the urethra with minimal discomfort to the
patient
4.
Safely insert the cystoscope into the bladder, using aseptic technique with minimal
discomfort to the patient, whilst observing the lumen of the urethra.
5.
Demonstrate the use of the control lever to facilitate keeping the lumen of the urethra in
view at all times
6.
Comment on the anatomy and physiology of the lower urinary tract viewed through the
cystoscope
proceduresofdemonstrate
insertion ofdemonstrate
the cystoscope
7. At
At the
the end of the 10 insertions
the flexible cystoscope
insertion of the
smoothly
safely with
minimal
discomfort
to the patient
keeping
lumenthe
cystoscopeand
smoothly
and safely
with
minimal discomfort
to the
patientthe
keeping
of
the urethra
in viewinatview
all times.
lumen
of the urethra
at all times.
16
16
Insertion of Flexible Cystosope Training Record

Insertion No.
Date
Anatomy identified
Male Patient
Female Patient
Haematuria
Dome of bladder
Dome of bladder
UTI
Body of bladder
Body of bladder
LUTs Irritative
LUTs Obstructive
TCC Surveillance
Trigone
Trigone
Bladder neck
Bladder neck
Prostatic urethra
Urethra
Verumontanum
Membranous urethra
Penile urethra
Pathology Seen
NAD
Calculi
Discharge
Cystitis cystica
Inflamed bladder
urothelium
Debris
Papillary lesion
Review in OPD
Diverticula
Solid lesion
Biopsy GA
Enlarged prostate
Urethral stricture
Biopsy LA
Squamous metaplasia
Cystodiathermy
Trabeculation
Litholopaxy
Rigid cystoscopy
TURBT
Communication to GP
Urethrotomy
Signature
17
17
Aims and Objectives

Aims and Objectives
Flexible Cystoscopy Full Procedure

Minimum
number to achieve:
- 50 (25 male patients and 25 female patients)
Flexible Cystoscopy
Full Procedure
Minimum number to achieve: - 50 (25 male patients and 25 female patients)
Aim
By
Aimthe end of 50 flexible cystoscopies the trainee will be able to perform a flexible
cystoscopy
safely,
identifycystoscopies
any
and
develop
aa flexible
treatment
follow
up
By the
50
thepathology
traineethe
willpresent
be ablewill
to perform
safely,
By
the end
end of
of
50 procedures
flexible
trainee
be able to
performcystoscopy
a and
flexible
identify any pathology present and develop a treatment and follow up plan.
plan.
cystoscopy safely, identify any pathology present and develop a treatment and follow up
plan.
Learning outcomes
The
traineeoutcomes
will be able to:
Learning
The trainee will be able to:
1. Gain informed consent from the patient
2.
1.
3.
2.

Gain informed consent from the patient
Safely instil local anaesthetic lubricant into the urethra with minimal discomfort to the
patient
3. Safely instil local anaesthetic lubricant into the urethra with minimal discomfort to the
4. Safely pass a flexible cystoscope using aseptic technique with minimal discomfort to the
patient
patient
4. Safely pass a flexible cystoscope using aseptic technique with minimal discomfort to the
5. Correctly identify bladder landmarks and make a complete examination of the bladder
patient
urothelium
5. Correctly identify bladder landmarks and make a complete examination of the bladder
6. Withdraw the flexible cystoscope smoothly and safely with minimal discomfort to the
urothelium
patient
6. Withdraw the flexible cystoscope smoothly and safely with minimal discomfort to the
7. Recognise situations, which require the trainee to stop and if necessary abandon the
patient
procedure
7. Recognise situations, which require the trainee to stop and if necessary abandon the
8. Provide a report of the procedure and the findings
procedure
9. Explain the findings to the patient and provide an action plan for follow up
8. Provide a report of the procedure and the findings
10. Communicate the findings and action plan to the patients General Practitioner
9. Explain the findings to the patient and provide an action plan for follow up
10. Communicate the findings and action plan to the patients General Practitioner
18
18
18
Performance of Full Procedure Training Record

Observation No.
Date
Anatomy identified
Male Patient
Female Patient
Haematuria
Dome of bladder
Dome of bladder
UTI
Body of bladder
Body of bladder
LUTs Irritative
LUTs Obstructive
TCC Surveillance
Trigone
Trigone
Bladder neck
Bladder neck
Prostatic urethra
Urethra
Verumontanum
Membranous urethra
Penile urethra
Pathology Seen
NAD
Calculi
Discharge
Cystitis cystica
Inflamed bladder
urothelium
Debris
Papillary lesion
Review in OPD
Diverticula
Solid lesion
Biopsy GA
Enlarged prostate
Urethral stricture
Biopsy LA
Squamous metaplasia
Cystodiathermy
Trabeculation
Litholopaxy
Gains informed consent
Rigid cystoscopy
Gives Patient results and post procedure information
TURBT
Communicates results and management plan to GP
Urethrotomy
Signature
19
19
Summary of Training Record

Observations of Flexible
Cystoscopy
Start Date
Completion Date
Number Achieved
Comments: - ..
.
Withdrawal of Flexible
Cystoscope
Start Date
Completion Date
Number Achieved
Comments: - ..
............
Insertion of Flexible
Cystoscope
Start Date
Completion Date
Number Achieved
Comments: - ..
............
Examination of Bladder
Urothelium
Start Date
Completion Date
Number Achieved
Comments: - ..
.
Full Procedure of
Flexible Cystoscopy
Start Date
Completion Date
Number Achieved
Male
Female
Surveillance
Total
Comments:
20
20
Record of Assessment of Flexible Cystoscopy Skills

Date
Name
NMC Number
Assessment Number
Minimum Five Assessments
Reason for Cystoscopy
Difficulty of Procedure
Easier than usual
Patient Gender
Average difficulty
More difficult than usual
Time to complete procedure
mins
Standard: The trainee should be judged against the standard expected of a competent urologist
Not
Performed
accuratelyand
andcorrect
correctpatient
patient
Ensuresmedical
medicalnotes
notes are
are checked
checked accurately
1. Ensure
identified for
indentified
forprocedure
procedure
2. Takes informed consent,
3.
Ensures equipment is in working order
4.
Ensures that pre-procedure checks have been carried out e.g.

urine sample checked for UTI and acts upon them accordingly
Administers pre-procedure antibiotics in accordance with local
policy
Ensures safe positioning of patient on examination couch
5.
6.
7.
8.
9.
Maintains good communication with patient and observes and

responds to their needs throughout the procedure
Prepares sterile field and maintains aseptic technique throughout
procedure
Cleans, identifies and examines the urethral orifice and
surrounding area
21
21
Performed
1.
10.
Instils local anaesthetic into urethra and allows time for it to work
in accordance with manufacturers recommendations
Not
Performed
Performed
11. Introduces
Introducesscope
scopeinto
intothe
theurethra
urethraunder
underdirect
directvision
vision
using
using
thethe
deflection
and
inflection
of
the
tip,
ensuring
irrigation
fluid
is on
deflection and inflection of the tip, ensures irrigation fluid
is
12. Fills
bladder
to enable examination
running
with sufficiently
minimum discomfort
to the patientof bladder
urothelium
13. Identifies
Identifies anatomical
anatomicallandmarks
landmarks
using
a systematic
of
using
a systemic
system system
of
deflection
deflection and
and infection
inflectionofofthe
thetip
tip(J/U
(J/Umanoeuvre)
manoeuvre)
14. Recognises
Recognisesabnormalities
abnormalitieswithin
within
anatomical
structure
thethe
anatomical
structure
and and
records
as
appropriate
records as appropriate
15. Withdraws
Withdrawsscope
scope
maintaining
irrigation
whilst
observing
urethral
maintaining
irrigation
whilst
observing
urethral
lumen
lumen
16. Maintains
Maintainsgood
good
communication
assistant
throughout
the
communication
with with
assistant
throughout
the
procedure
procedure
17. Recognises
Recognises
deals
any complications
and
andand
deals
with with
any complications
and seeks
helpseeks help
when
whenappropriate
appropriate
18. Makes appropriate management/follow up plan
19. Communicates findings and management plan with patient and
assistant and arranges appropriate follow up
20. Gives clear post procedure instructions to patient in a professional
manner.
21. Disposes of rubbish as per local health and safety policy
22. Documents
Documentsclearly
clearlythe
thefindings
findingsand
andfollow
followupupplan
plan
ininthethe patients
record record
and communicates
results
to tothe
patients General
patients
and communicates
results
the patients
Practitioner
General
Practitioner
23. Ensure
Ensure used
used flexible
flexiblecystoscope
cystoscopeisisreprocessed
reprocessedininaccordance
accordancewith
with
Infection
Control
Services
Ltd
(2007)
decontamination
policy
Services
Ltd
(2007)
decontamination
policy,
Infection Control
ControlServices
Infection
Ltd
(2007)
decontamination
policy
manufacturers
andand
safety
at work
manufacturers instructions
instructions and
andlocal
localhealth
health
safety
at work
policies
policiesand
andprocedures
procedures
Signature of Trainee
Signature of Assessor
Adapted from Intercollegiate Surgical Programme Curriculum (ISCP) (2012)
22
22
Statement
Statement
of Competence
of Competence
to Perform
to Perform
FlexibleFlexible
Cystoscopy
Cystoscopy
Name ofName
Trainee
of Trainee
NMC Number
NMC Number
The aboveThe
named
above
person
named
hasperson
achieved
has the
achieved
learning
theoutcomes
learning outcomes
and assessed
andas
assessed
competent
as competent
to
to
perform flexible
performcystoscopy.
flexible cystoscopy.
Name ofName
Assessor
of Assessor
GMC Number
GMC Number
Signature
Signature
of Assessor
of Assessor
23
23
23
B
CYST3 - Remove ureteric stent using a flexible cystoscope
OVERVIEW
This standard covers the use of a flexible cystoscope to visualise and remove ureteric
stents.
This standard covers ureteric stent removal using a flexible cystoscope for adults only.
Paediatric services are excluded.
Users of this standard will need to ensure that practice reflects up to date information
and policies
Version No 1

1. the types of ureteric stents, reasons for ureteric stent insertion, and when not to
remove
2. the complications of undertaking ureteric stent removal using flexible cystoscopy
and the appropriate remedial strategies
3. sensations associated with ureteric stent removal
4. the safe operation of grasping forceps
5. the limits of ones own knowledge and experience and the importance of not
Dimension: HWB7 Interventions and treatments
24
24
Performance Criteria for Undertaking Removal of Ureteric Stent

Action
Action
Action
Rationale
Rationale
Rationale
Verify
correct
patient
with
correct
notes
for removal
of stent
that
the
correct
patient
has
Verify
correct
patient
with
notes
ofofureteric
To
ensure
has
the
Verify
correct
patient
withcorrect
correct
notesfor
forremoval
removal
ureteric
stent To
Toensure
ensurethat
thatthe
thecorrect
correctpatient
patient
has
the
ureteric
stent at correct time
the
correct
procedure
performed
atatcorrect
correct
procedure
performed
correcttime
time
correct
procedure
performed
To
Toavoid
avoidadverse
adverseincident
incidentby
byremoving
removingthe
the
To avoid adverse incident by removing

wrong
wrongureteric
uretericstent
stentififbilateral
bilateralureteric
ureteric
the wrong ureteric stent if bilateral
stents
stentsare
areininplace
place
ureteric stents are in place
Confirm
Confirmwhich
whichureteric
uretericstent
stentisistotobe
beremoved
removed
Confirm which ureteric stent is to be removed
To
Tocomply
complywith
withDH
DH(2009)
(2009)
Explain
Explainprocedure
procedureincluding
includingrisks
risksand
andbenefits
benefitstotopatient
patientand
andobtains
obtains
To
comply
with
DH
(2009)
recommendations
on
consent
recommendations
on
consentand
andtoto
Explain
procedure
including risks and benefits to patient
informed
written
consent
informed
written
consent
recommendations
on consent
and to
ensure
for
ensurepatient
patientisisprepared
prepared
forprocedure
procedure
and obtains informed written consent
ensure patient is prepared for procedure

To
Toavoid
avoidadverse
adverseincident
incidentduring
during
Select
Selectgrasper
grasperand
andensure
ensurethat
thatititisisininworking
workingorder
order
Select grasper and ensure that it is in working order
To
avoid adverse incident during
procedure
procedure
procedure
To
Toavoid
avoidadverse
adverseincident
incidentby
byremoving
removingthe
the
Locate
Locatethe
thecorrect
correctureteric
uretericstent
stent
Locate the correct ureteric stent
Insert
Insertthe
thegrasper
grasperthrough
throughthe
thecorrect
correctchannel
channelofofthe
thecystoscope,
cystoscope,
ensuring
ensuringthe
thecystoscope
cystoscopetip
tipisismaintained
maintainedininstraight
straightposition.
position.
Insertthe
thegrasping
grasperforceps
through
correct
channel
of the
Identify
asasthe
they
enter
bladder.
Identify
the
grasping
forceps
they
enterthe
the
bladder.
cystoscope, ensuring the cystoscope tip is maintained in
Position
Positionthe
thegrasping
graspingforceps
forcepsover
overthe
theureteric
uretericstent
stenttotobe
beremoved,
removed,
straight position. Identify the grasping forceps as they enter
ensuring
ensuringthe
thehinges
hingesofofthe
theforceps
forcepsare
arenot
notwithin
withinthe
thechannel
channelofofthe
the
the bladder.
cystoscope.
cystoscope.
Position
the grasping
forceps
over
ureterichandles,
stent
toor
be
Open
the
ofofthe
using
the
instrument
Open
theforceps
forceps
thegrasper
grasper
using
thethe
instrument
handles,
or
instruct
assistant
totodo
instruct
assistant
doso.
so. hinges of the forceps are not within
removed,
ensuring
the
the channel of the cystoscope.
Grasp
Graspthe
theureteric
uretericstent
stentfirmly
firmlybetween
betweenthe
thejaws
jawsofofthe
theforceps
forceps
taking
care
tototake
hold
any
urothelium.
taking
care
not
takeof
hold
anyofofthe
thebladder
bladder
urothelium.
Open
thenot
forceps
theofof
grasper
using
the instrument
handles, or instruct assistant to do so.
Keeping
Keepinghold
holdofofthe
theureteric
uretericstent
stentwith
withthe
thetightly
tightlyclosed
closedforceps,
forceps,
withdraw
the
ureteric
stent
and
together
withdraw
thecystoscope,
cystoscope,
ureteric
stent
andgraspers
graspers
together
from
Grasp the
ureteric
stent
firmly
between
the jaws
of thefrom
the
bladder
and
the
urethra,
maintaining
direct
vision
throughout.
the
bladder
and
the
urethra,
maintaining
direct
vision
throughout.
forceps taking care not to take hold of any of the bladder
urothelium.
IfIfresistance
resistanceisisencountered,
encountered,abandon
abandonthe
theprocedure
procedureand
andseek
seek
appropriate
appropriateadvice.
advice.
Keeping hold of the ureteric stent with the tightly closed

forceps, withdraw the cystoscope, ureteric stent and
Inspect
the
stent
totoensure
ititisiscomplete.
Inspect
theureteric
ureteric
stent
ensure
complete.
graspers
together
from
the
bladder
and the urethra,
maintaining direct vision throughout.
Recognise
complications
and
takes
appropriate
action
Recognises
complications
and
appropriate
action
Recognises
complications
andtakes
takes
appropriate
action
If resistance
is encountered,
abandon
the procedure
and
seek appropriate advice.

Reminds
Remindspatient
patientofofexpected
expectedurinary
urinarydiscomfort/bleeding
discomfort/bleedingrisk
riskofof
urinary
urinarytract
tractinfection
infectionand
andtotoensure
ensuregood
goodfluid
fluidintake
intakefollowing
following
procedure.
patient
isisaware
aware
ofofaction
action
totobe
be
taken
ininthe
the
event
procedure.Ensures
Ensurespatient
patientis
awareof
actionto
betaken
takenin
theevent
event
procedure.
Ensure
ofofcomplications
complicationsarising.
arising.
Document procedure in case notes and communicate
communicatesresult
resulttotothe
the
patients General Practitioner
25
25
To
avoid
adverse
incident
by removing
wrong
ureteric
stent
ififbilateral
ureteric
wrong
ureteric
stent
bilateral
ureteric
stents
ininplace
stents
place
the
wrong
ureteric stent if bilateral
ureteric stents in place
To
Toavoid
avoiddamaging
damagingcystoscope
cystoscope
To avoid damaging cystoscope
To
Toavoid
avoiddamaging
damagingcystoscope
cystoscopeand
and
grasping
graspingforceps
forceps
To avoid damaging cystoscope and

grasping forceps
To
Toallow
allowremoval
removalofofthe
theureteric
uretericstent
stent
without
withoutdamaging
damagingbladder
bladderurothelium
urothelium
To
Toremove
removethe
theureteric
uretericstent
stentwith
withminimal
minimal
discomfort
to
the
patient
discomfort
to
the
patient
To allow removal of the ureteric stent
without damaging bladder urothelium

To
Toavoid
avoidtraumatic
traumaticremoval
removalofofureteric
ureteric
stent
stent
To remove the ureteric stent with

To
Toensure
ensureureteric
uretericstent
stentisiscompletely
completely
minimal
removed
removeddiscomfort to the patient
To
reduce
the
adverse
Toavoid
reduce
therisk
riskofofremoval
adverseincident
incident
To
traumatic
of
ureteric
stent
To
Toavoid
avoidunnecessary
unnecessarypatient
patientanxiety,
anxiety,
reduce
reducethe
therisk
riskofofurinary
urinarytract
tractinfection
infection
and
andtotoensure
ensurepatient
patientisisaware
awareofofwhen
when
and
andwho
whototocontact
contactininthe
theevent
eventofof
complications
complicationsarising.
arising.
To ensure everyone involved in the patient

pathway is informed that the procedure
has been performed and of the result to
maintain continuity of care
Assessment of Removal of Ureteric Stent Skills Using a Flexible Cystoscope

Date
Date
Name Name
NMC Number
NMC Number
Assessment Number
Minimum five Assessments

Assessment Number
Reason for Removal of Ureteric stent
Reason for Removal of Ureteric stent
Difficulty
Easier than
usual of Procedure
Easier than usual
Side of Ureteric Stent
Average difficulty
Average difficulty
R
mins
Side of ureteric
L
to complete
Standard: The assessment
should beR
judges againstTime
the standard
expectedprocedure
of a competent urologist
stent
mins
Standard: The assessment should be judged against the standard expected of Not
a competent urologist
Ensure medical
Ensures
medicalnotes
notesare
arechecked
checked accurately
accurately and
and correct
correct patient
patient
indentified
1
2
Performed
Not
Performed
Ensure medical notes are checked accurately and correct patient
Describes
indication for ureteric stent and reason removal
indentified
2 Correctly
Describes
indication
for ureteric
reason removal
verifies
which ureteric
stent is stent
to be and
removed
informedverifies
consent,which
after explaining
procedure
andremoved
risks and
3 Takes
Correctly
ureteric stent
is to be
5
6
7
8
9
10
4
5
benefits of removing the ureteric stent
Takes informed consent, after explaining procedure and risks
Selects
for procedure
andappropriate
benefits ofequipment
removingrequired
the ureteric
stent and checks that
it is in working order
Selects appropriate equipment required for procedure and
checksaseptic
that ittechnique
is in working
orderprocedure
Maintains
throughout
bladder sufficiently
to enable examination
bladder wall
6 FillsMaintains
aseptic technique
throughoutofprocedure
Identifies correctly ureteric stent for removal
Fills bladder sufficiently to enable examination of bladder wall
Removes ureteric stent with minimal discomfort to the patient
8 Maintains
Identifies
ureteric
stent
for removal
goodcorrectly
communication
with
patient
and observes and
9
Removes ureteric stent with minimal discomfort to the patient
11
Recognises and deals with any complications and seeks help when
10appropriate
12
Correctly recognises abnormalities within the anatomical structure

Recognises and deals with any complications and seeks help
11and records as appropriate
13
Maintains
assistant
throughout
procedure
Maintains good
goodcommunication
communicationwith
assistant
throughout
thethe
procedure

when appropriate
14
Correctly recognises abnormalities within the anatomical

12Documents ureteric stent removal and management plan in the
structure and records as appropriate
16
Maintains good communication assistant throughout the

13Gives clear post procedure instructions to patient in a professional
procedure
16
patients records and informs patients General Practitioner

manner.
Arranges appropriate follow up

27
26
Performed
Performed
Statement of Competence Remove Ureteric Stents Using a Flexible Cystoscope
Name of Trainee
Registration Number
The above named person has achieved the learning outcomes and assessed as competent to
remove ureteric stents using a flexible cystoscopy.
Name of Assessor
GMC Number
29
27
B
CYST4 - Use cystodiathermy via flexible cystoscope
OVERVIEW
OVERVIEW
This
standard covers the use of a exible cystoscope and diathermy equipment to control small
bleeding points, to facilitate the detachment of tissue or to destroy small areas of tissue within the
This standard
covers
the use
a flexible cystoscope and diathermy equipment to
bladder
through the
application
of of
heat.
control small bleeding points, to facilitate the detachment of tissue or to destroy small
This standard covers cystodiathermy procedures using a exible cystoscope for adults only.
areas of services
tissue within
the bladder through the application of heat.
Paediatric
are excluded.
This standard covers cystodiathermy procedures using a flexible cystoscope for adults
only. Paediatric services are excluded.
Users of this standard will need to ensure that practice reects up to date information and policies
Version No 1
Users of this standard will need to ensure that practice reflects up to date information
and policies
Version No 1
KNOWLEDGE
AND UNDERSTANDING
1.
the types and use of irrigation uids
2.
the indications and contra-indications for cystodiathermy
3.
the complications of undertaking cystodiathermy using exible cystoscopy and the

appropriate remedial strategies

4.
the sensations resulting from use of heat cauterisation
1. the types and use of irrigation fluids
5. the
theindications
function, speci
and performance
characteristics of diathermy equipment
2.
and cation
contra-indications
for cystodiathermy
6. the
thecomplications
safe operationof
of undertaking
diathermy equipment
in accordance
national
and localand
policies
3.
cystodiathermy
usingwith
flexible
cystoscopy
the
and
guidelines
appropriate remedial strategies
7. the
thesensations
importanceresulting
of timely equipment
fault
recognition
and local procedures for dealing
4.
from use of
heat
cauterisation
with these
5. the function, specification and performance characteristics of diathermy equipment

8.
equipment capabilities, limitations and routine maintenance
6. the safe operation of diathermy equipment in accordance with national and local
9. policies
the manufacturers
guidelines for preparation, checking and use of diathermy equipment
and guidelines
10. the
theimportance
limits of ones
own knowledge
andfault
experience
and the
of not operating
7.
of timely
equipment
recognition
andimportance
local procedures
for
beyond
these
dealing with these
8. equipment capabilities, limitations and routine maintenance

9. the manufacturers guidelines for preparation, checking and use of diathermy
equipment INFORMATION
ADDITIONAL
10.National
the limits
of ones own
knowledge
and experience
the importance of not
This
Occupational
Standard
was developed
by Skillsand
for Health.
Dimension: HWB7 Interventions and treatments
30
28
Performance Criteria for Undertaking Cystodiathermy using a Flexible Cystoscope
Rationale
Action
Verify that patient does not have a cardiac
pacemaker/defibrillator fitted
To identify contraindications to undertaking

cystodiathermy
Check patients past medical history for metal prosthetic

implants and ask patient to remove jewellery. (Apply
non conductive tape to jewellery that cant be removed)
To perform procedure with care and safely
Inform patient of risks and benefits of cystodiathermy

using a flexible cystoscope and obtain informed consent
To comply with DH (2009) recommendations on

consent and to ensure patient is prepared for
procedure
Position patient on couch ensuring that they are not in

contact with any metal surface
To perform procedure safely
Verify that cystoscope is diathermy compatible
To avoid adverse incident during cystodiathermy
Verify that irrigation fluid is diathermy compatible, i.e.

sterile water or 1.5% Glycine
Ensure cystodiathermy generator is available, in

working order and set at required power level
Identify abnormality or bleeding area within the bladder

that is appropriate for cystodiathermy using a flexible
cystoscope
Ensure assistant correctly applies Patient Return
Electrode (diathermy plate) to clean dry skin, preferably
on patients thigh, avoiding bony prominences, scar
tissue, tattoos, over an implanted metal prosthesis, or
hairy surfaces (if necessary shave skin before applying).
Ask assistant
assistanttotoplace
placefoot
foot
pedals foot controls
Ask
pedals/controls
so they so
arethey
easily
and
comfortably
accessible. accessible.
are easily
and comfortably
Inspect the diathermy wire to ensure that the insulation
coating is intact. Ask assistant to connect wire to
diathermy lead
Insert the diathermy wire through the correct channel of
the cystoscope, ensuring the cystoscope tip is maintained
in straight position. Identify the diathermy wire as it
enters the bladder, advance the diathermy wire so that it
is not touching the tip of the cystoscope
Position tip of the diathermy wire so that it is gently
touching the area to be diathermied
To avoid causing burns to the patient
To avoid damaging cystoscope
To confine diathermy current to the area to be

diathermised
32
29
Action
Rationale
Maintain good communication with patient throughout

the procedure, ensuring patient is aware when diathermy
is about to take
be taken
place
To keep patient informed of what is happening and to

prepare them for when discomfort/pain may be felt
Press foot pedals in short bursts until the abnormality is

destroyed or bleeding stopped, whilst observing patient
and responding to their needs throughout the procedure
To achieve the desired effect whilst causing

minimum discomfort to the patient
Withdraw the diathermy wire and hand it over to

assistant maintaining aseptic technique
To allow checking of bladder urothelium for

additional lesions or bleeding requiring further
cystodiathermy
Examine bladder urothelium to ensure treatment

complete before fully withdrawing the cystoscope.
To confirm successful procedure
Check skin under diathermy plate for evidence of burns.
Poor application of diathermy plate can cause burns

to skin which will need documented and or treatment
Ensure diathermy generator switched off and foot pedals

and diathermy lead put away.

Remind patient of expected urinary discomfort/bleeding

risk of urinary tract infection and to ensure good fluid
Ensure patient
intake following procedure. Ensures
patientisisaware
awareofof
action to be taken in the event of complications arising.
To avoid unnecessary patient anxiety, reduce the risk

of urinary tract infection and to ensure patient is
Inform patient of follow up arrangements and make

appropriate arrangements
33
30
Assessment of Cystodiathermy Skills Using a Flexible Cystoscope

Date
Name
NMC Number
Assessment Number
Reason for Cystodiathermy

Easier than usual
Average difficulty

mins
Standard: The assessment should be judged against the standard expected of a competent urologist
Not
Performed
1
2
3
4
5
6
7
8
Ensure medical notes are checked accurately and correct patient

indentified
Describes indication for undertaking a cystodiathermy
Performs pre procedure checks to ensure there are no
contraindications for cystodiathermy
Takes informed consent, after explaining procedure and risks and
benefits of performing cystodiathermy
Ensures cystodiathermy equipment available and in working order
Selects appropriate equipment required for procedure, ensuring
that the cystoscope is diathermy compatible and checks that it is
in working order
Ensures irrigation fluid is diathermy compatible
Fills bladder sufficiently with diathermy compatible irrigation

fluid to enable examination of bladder urothelium
10 Identifies correctly abnormality suitable for cystodiathermy
11 Performs cystodiathermy with minimal discomfort to the patient
12 Maintains aseptic technique throughout procedure
13
Visually checks bladder and diathermy site for additional lesion

or bleeding and performs further cystodiathermy if appropriate
34
31
Performed
Not
Performed
14

when appropriate
15
Maintains good communication with assistant throughout the

procedure
16
Documents cystodiathermy performed and management plan in

the patients records and informs patients General Practitioner
17
Gives clear post procedure instructions to patient in a professional

manner.
Performed
18 Arranges appropriate follow up
Adapted from ISCP (2012)
35
32
Statement
Statement
of Competence
of Competence
to Perform
to Perform
Cystodiathermy
Cystodiathermy
Using
Using
a Flexible
a Flexible
Cystoscope
Cystoscope
Name
Name
of of
Trainee
Trainee
NMC
NMC
Number
Number
TheThe
above
above
named
named
person
person
hashas
achieved
achieved
thethe
learning
learning
outcomes
outcomes
andand
assessed
assessed
as competent
as competent
to to
perform
perform
cystodiathermy
cystodiathermy
using
using
a flexible
a flexible
cystoscope.
cystoscope.
Name
Name
of of
Assessor
Assessor
GMC
GMC
Number
Number
Signature
Signature
of of
Assessor
Assessor
36 36
33
34
B
CYST2 - Undertake biopsy using a flexible cystoscope
OVERVIEW
OVERVIEW
This standard covers the use of a exible cystoscope to take tissue samples from the inside of
the bladder.
It also
covers the
requests
for ahistopathology
investigations
and the
initialsamples
handling of the
This
standard
covers
use of
flexible cystoscope
to take
tissue
tissue the
samples.
from
inside of the bladder. It also covers requests for histopathology
investigations
andbiopsy
the initial
handling
ofathe
tissue
samples.
This standard covers
procedures
using
exible
cystoscope
for adults only. Paediatric
services
are excluded.
This
standard
covers biopsy procedures using a flexible cystoscope for adults
only.
Paediatric
services
are excluded.
Users of
this competence
will need
to ensure that practice reects up to date information and
policies.of this competence will need to ensure that practice reflects up to date
Users
information
Version No 1 and policies.
Version No 1

1. The clinical conditions appropriate for bladder biopsy
2. The
and contra-indications
for bladder biopsy
You
will indications
need to know
and understand:
Tissue
specimen
criteria for
histopathology
1.3. The
clinical
conditions
appropriate
forexaminations
bladder biopsy
2.4. The
indications
and contra-indications
for bladder biopsy
Emergency
indications
of use of cystodiathermy
3.5. Tissue
specimenofcriteria
for histopathology
examinations
The complications
undertaking
a biopsy using exible
cystoscopy and the appropriate
remedial
strategies
4. Emergency indications of use of cystodiathermy
Sensations
resulting from
use of biopsyaforceps
5.6. The
complications
of undertaking
biopsy using flexible cystoscopy and
the
appropriate
remedial
strategies
7. The safe operation of biopsy forceps
6.8. Sensations
resulting
use offault
biopsy
forceps
The importance
of timelyfrom
equipment
recognition
and local procedures for dealing with
these
7. The
safe operation of biopsy forceps
The importance
limits of onesof
own
knowledge
and experience
and the importance
of not
operating
8.9. The
timely
equipment
fault recognition
and local
procedures
beyond
these
for
dealing
with these
9. The limits of ones own knowledge and experience and the importance of
not operating beyond these
This standard links with the following dimension within the NHS Knowledge and
Skill Framework (October 2004):
Dimension: HWB6 Assessment and treatment planning
37
35
36
Performance Criteria
Criteria for
Via a Flexible
Cystoscope
Performance
for Undertaking
Undertaking Biopsies
Biopsies Using
a Flexible
Cystoscope
Action
Rationale
Verifythat
thatpatient
patient
taking
anticoagulant
therapy
Verify
is is
notnot
taking
anticoagulant
therapy
or or
has a cardiac pacemaker/defibrilator fitted
To identify contraindications to undertaking biopsies
Verify that cystoscope is diathermy compatible
To avoid adverse incident if cystodiathermy

necessary
Ensure cystodiathermy equipment available and in

working order
In case needed for prevention of bleeding following

taking biopsies
Inform patient of risks and benefits of cystodiathermy

biopsy
using a flexible cystoscope and obtain informed consent
To comply with DH (2009) recommendations on

consent and to ensure patient is prepared for
procedure
Identify abnormality within the bladder that is

appropriate for biopsy using a flexible cystoscope
Select biopsy forceps and ensure that they are in
working order
To avoid adverse incident during procedure
Insert the biopsy forceps through the correct channel of

the cystoscope, ensuring the cystoscope tip is maintained
in straight position. Identify the jaws of the forceps as
they enter the bladder.
To avoid damaging the flexible cystoscope
Position the biopsy forceps over the area to be biopsied,

ensuring the hinges of the forceps are not within the
channel of the cystoscope.
To avoid damaging the flexible cystoscope and allow

forceps to open fully
Maintain good communication with patient throughout

the procedure, ensuring patient is aware when biopsy is
about to be taken
To keep patient informed of what is happening and to

prepare them for when discomfort/pain may be felt
Open the biopsy forceps using the instrument handles, or

instruct assistant to do so.
Grasp the area to be biopsied firmly between the jaws of
the forceps ensuring sufficient tissue for
histopathological examination is within the forceps.
Keeping the jaws of the forceps closed, pull sharply but
carefully away from the bladder urothelium
39
37
To allow removal of the tissue to be biopsied with

minimum discomfort to the patient
Performance Criteria for Undertaking Biopsies using a Flexible Cystoscope
Action
Rationale
Keeping hold of the biopsy with the tightly closed

forceps, withdraw the biopsy forceps from the
cystoscope channel, or instruct assistant to do so
To ensure biopsy is not lost during removal from the

bladder
Drop specimen into fixative or instruct assistant to do so

ensuring all tissue is removed from biopsy forceps.
Inspect biopsy, before repeating procedure if necessary
To ensure that sufficient tissue is taken and is

suitable for histopathological examination
Observe for bleeding and perform cystodiathermy if

necessary
To reduce the risk of haemorrhage and clot retention

of urine
Complete histopathology request form in accordance

with national and local policies and guidance.
To ensure specimen labelled with correct patient

identification details and facilitate histopathological
examination
Ensure biopsy is packaged within a leak proof container

in accordance with local and national policies and
guidelines for transport to pathology
To comply with Health and Safety at work

regulations


Remind patient of expected urinary discomfort/bleeding

risk of urinary tract infection and to ensure good fluid
Ensure patient
intake following procedure. Ensures
patient is aware of
action to be taken in the event of complications arising.
To avoid unnecessary patient anxiety, reduce the risk

of urinary tract infection and to ensure patient is
Inform patient of follow up to receive biopsy results and

arrange appropriate arrangements
40
38
Assessment of Biopsy Skills Using a Flexible Cystoscope

Date
Name
NMC Number
Assessment Number
Reason for Biopsy

Easier than usual
Average difficulty

mins
Not
Performed
1
2
3
4
5
6
7
8
9
Ensures medical notes are checked accurately and correct patient

indentified
Describes indication for undertaking a biopsy
contraindications for bladder biopsy
benefits of performing a bladder biopsy
in working order
Identifies correctly abnormality suitable for biopsy
10 Takes biopsy with minimal discomfort to the patient

11 Visually checks biopsy is sufficient for histopathological
examination and repeats biopsy if necessary
13 Visually checks biopsy site for obvious bleeding and performs
cystodiathermy if appropriate
41
39
Performed
Not
Performed
14
Performed

when appropriate
15 Ensures biopsy sample container correctly labelled.

16
Ensures histopathology request card completed in accordance

with national and local policies and guidance
17

procedure
18
Documents biopsy taken and management plan in the patients

records and informs patients General Practitioner
19

manner.
42
40
Statement of Competence to Undertake Biopsies Using a Flexible Cystoscope
Name of Trainee
Registration Number
undertake biopsies using a flexible cystoscopy.
Name of Assessor
GMC Number
43
41

Department of Health (2004) The NHS Knowledge and Skills Framework (NHS KSF) and
the Development Review Process. London. Department of Health Publications.
Department of Health (2009) Reference Guide to Consent for Examination or Treatment. 2nd
Edition. [Online] Available at:
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_1
03653.pdf (Accessed 10th October 2010).
Hinchcliff S & Rogers R (Eds.) Competencies for Advanced Nursing Practice. London.
Edward Anurseold Publications Ltd.
Infection Control Services Ltd (2007) Cystoscopes [Online] Available at:
http://www.infectioncontrolservices.co.uk/endoscopes_cystoscopes.htm (Accessed April 29th
2011).
Intercollegiate Surgical Curriculum Programme (2012) Direct Observation of Procedural
Skills (Surgical DOPS).
Johns C. (2006) Guided Reflection Advancing Practice. Aylesbury Blackwell Publishing.
Skills for Health (2010a) CYST1 Undertake diagnostic and surveillance cystoscopy using a
flexible cystoscope. Version 1. [Online] Available at:
https://tools.skillsforhealth.org.uk/competence/show/html/id/2005/ (Accessed 20th March
2011)
Skills for Health (2010b) CYST2 Undertake biopsy using a flexible cystoscope. Version 1.
[Online] Available at: https://tools.skillsforhealth.org.uk/competence/show/html/id/2005/
(Accessed 20th March 2011)
Skills for Health (2010c) CYST3 Remove ureteric stent using a flexible cystoscope Version 1.
Skills for Health (2010d) CYST4 Use cystodiathermy via flexible cystoscope. Version 1.
[Online] Available at:
https://tools.skillsforhealth.org.uk/competence_search/?search=&advanced=1&suite[]=43
44
42
Assessment of Biopsy Skills Using a Flexible Cystoscope

Date
Name
NMC Number
Assessment Number
Reason for Biopsy

Easier than usual
Average difficulty

mins
Not
Performed
1
2
3
4
5
6
7
8
9
Ensures medical notes are checked accurately and correct patient

indentified
Describes indication for undertaking a biopsy
contraindications for bladder biopsy
benefits of performing a bladder biopsy
in working order
Identifies correctly abnormality suitable for biopsy
10 Takes biopsy with minimal discomfort to the patient

11 Visually checks biopsy is sufficient for histopathological
examination and repeats biopsy if necessary
13 Visually checks biopsy site for obvious bleeding and performs
cystodiathermy if appropriate
41
39
Performed
Not
Performed
14
Performed

when appropriate
15 Ensures biopsy sample container correctly labelled.

16
Ensures histopathology request card completed in accordance

with national and local policies and guidance
17

procedure
18
Documents biopsy taken and management plan in the patients

records and informs patients General Practitioner
19

manner.
42
40
Statement of Competence to Undertake Biopsies Using a Flexible Cystoscope
Name of Trainee
Registration Number
undertake biopsies using a flexible cystoscopy.
Name of Assessor
GMC Number
43
41

Department of Health (2004) The NHS Knowledge and Skills Framework (NHS KSF) and
the Development Review Process. London. Department of Health Publications.
Department of Health (2009) Reference Guide to Consent for Examination or Treatment. 2nd
Edition. [Online] Available at:
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_1
03653.pdf (Accessed 10th October 2010).
Hinchcliff S & Rogers R (Eds.) Competencies for Advanced Nursing Practice. London.
Edward Anurseold Publications Ltd.
Infection Control Services Ltd (2007) Cystoscopes [Online] Available at:
http://www.infectioncontrolservices.co.uk/endoscopes_cystoscopes.htm (Accessed April 29th
2011).
Intercollegiate Surgical Curriculum Programme (2012) Direct Observation of Procedural
Skills (Surgical DOPS).
Johns C. (2006) Guided Reflection Advancing Practice. Aylesbury Blackwell Publishing.
Skills for Health (2010a) CYST1 Undertake diagnostic and surveillance cystoscopy using a
flexible cystoscope. Version 1. [Online] Available at:
https://tools.skillsforhealth.org.uk/competence/show/html/id/2005/ (Accessed 20th March
2011)
Skills for Health (2010b) CYST2 Undertake biopsy using a flexible cystoscope. Version 1.
Skills for Health (2010c) CYST3 Remove ureteric stent using a flexible cystoscope Version 1.
Skills for Health (2010d) CYST4 Use cystodiathermy via flexible cystoscope. Version 1.
[Online] Available at:
https://tools.skillsforhealth.org.uk/competence_search/?search=&advanced=1&suite[]=43
44
42

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BAUS Flexi Logbook

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THE BRITISH ASSOCIATION

Background Reading and References

Prompts to structure reflection:

Reflective Learning Log (cont.)

cystoscopy using a flexible cystoscope

KNOWLEDGE AND UNDERSTANDING

12. The clinical conditions appropriate for cystoscopy

Performance Criteria for Undertaking Flexible Cystoscopy

Verify correct patient with correct notes for correct

To ensure that the correct patient has the

Check that the patient has no relevant allergies

To avoid adverse reaction to medication/latex

Explain procedure including risks and benefits to

To comply with DH (2009) recommendations

Prepare patient for procedure:

To ensure clear view of bladder urothelium

Flexible cystoscopy should be avoided in

urine dipstick recorded

To avoid spillage of irrigation fluid on to

Patient to undress from below the waist ,,ensure

To avoid adverse incident

Communicate with patient throughout the

To confirm understanding of procedure,

Cover patient from waist down with sterile drapes

To reduce the risk of patient developing a

Clean penis/vulva and urethral meatus with sterile

To reduce the risk of patient developing a

Instil local anaesthetic lubricant gel into urethra

To allow smooth passage of cystoscope into

Check cystoscope and processor in working order

To avoid harming the patient and to ensure that

Introduce flexible cystoscope into the urethra

To reduce the risk of trauma to the urethra and

Performance Criteria for Undertaking Flexible Cystoscopy

Fill bladder with irrigation fluid with minimum

To allow complete examination of bladder

Aspirate fluid from the bladder/washout the bladder via

Using rotation, deflection and inflection (including J/U

To ensure thorough examination of bladder

Withdraw flexible cystoscope under direct vision using

To examine the urethra whilst minimising the risk

Clean any surplus lubricant from patient and ensure

To maintain patient comfort and dignity

Ask patient to empty their bladder before leaving the

To ensure patients are able to void

Explain findings and management plan to patient and

To ensure patient remains informed

To avoid unnecessary patient anxiety, reduce the

Discard rubbish in accordance with local health and

Safe disposal of waste

Ensure used flexible cystoscope is reprocessed in

To avoid cross infection and prevent avoidable

To ensure everyone involved in the patient pathway

Arrange any necessary follow up appointments

To maintain continuity of care

Aims and Objectives

Observation of Flexible Cystoscopy

Aims and Objectives

Minimum 10 (five male and five female)

explanations and advice

To observe towelling and sterile precaution techniques

erve the technique of inertion of the into the urethra

h closed circuit television

ication of bladder landmarks, verification of knowledge of anatomy and