Discussion
A lot of studies have evaluated the adverse effects of cystoscopy in the literature. However, most of them have investigated the management of pain and discomfort in the patients who underwent cystoscopy(10-12). A few studies have compared between rigid and flexible cystoscopies but the diameters of the cystoscopes in these studies were not equal (5,6). Cicione et al also reported the lack of studies regarding comparison of these cystoscopies in literature (13). In a multi-center prospective study, Seklehner et al performed rigid cystoscopy for 150 patients and flexible cystoscopy for other 150 patients (5). They reported that the patients undergoing flexible cystoscopy were more frequently free of pain than the patients undergoing rigid cystoscopy. Consequently, they suggested that flexible instrument for diagnostic cystoscopy caused less pain than rigid instrument in male patients. However the most important limitations of their study were that the study was multi-institutional and the diameters of rigid cystoscopes (17.7 and 16 Fr) were bigger than flexible ones (16.5, 16 and 15.5 Fr). The two limitations might influence the results of the study regarding the negative effect of rigid cystoscopy on the pain of the patients. The present study was single-institutional and the cystoscopies were performed by the same surgeon. Also the diameters of rigid and flexible cystoscopes were equal. The result of our study showed that the mean VAS values of the patients undergoing the first rigid cystoscopies were statistically similar to the patients undergoing the first flexible ones. The second cystoscopies were performed using cross sectional design of the instruments. There was no statistically difference between the VAS values of the patients in the second cystoscopies (Table 2). There was also no difference between the mean VAS values of all patients in the first and second cystoscopies. Overall, the findings of our study showed that the pain levels of patients during cystoscopy were not affected by type of instrument or the cystoscopy experience of patient.
The other study compared between rigid (n=60) and flexible (n=60) cystoscopies in the male patients with bladder cancer(6). The results of this study indicated that flexible cystoscopy was less pain procedure and better tolerated than rigid cystoscopy by men with bladder cancer. However the different diameter instruments were used for cystoscopy in this study. Diameters of rigid and flexible cystoscopes were 20 and 15Fr, respectively. The most important limitations of previous two studies were that diameters of instruments were not equal and cystoscopies did not performed by the same surgeon. Our study was a prospective randomized cross-sectional single blind study and cystoscopy procedures were performed by the same urologist. LUTS, quality of life and erectile function as well as pain of male patients after rigid cystoscopy were compared with male patients undergoing flexible cystoscopy. After the second cystoscopies all of the patients were asked which instrument they preferred. While 22 patients preferred flexible instrument, the other 19 patients preferred rigid one (p=0.42). When the patients were divided into two groups according to the instrument using the first cystoscopy, there were no statistically differences between the choices of the patients.
Sexual functions of the patients in our study were evaluated by using IIEF form. The mean IIEF total and EF scores of the patients in the two groups before the both first and second cystoscopies were statistically similar to the scores after the cystoscopies (Table 3). These findings showed that cystoscopies using flexible or rigid instruments did not influence the erectile function of patients. LUTS of the patients were evaluated as two different groups including “voiding” and “incontinence” by using ICIQ-MLUTS form. The mean voiding and incontinence scores of the patients before and after the both first and second cystoscopies were statistically similar independently of cystoscope type (Table 3). The findings regarding quality of life were similar to the results associated with LUTS and erectile function. Overall, the results of our study indicated that flexsible or rigid cystoscopies did not effect adversely the LUTS, quality of life and erectile function of the patients.
Finally, when all parameters of the present study including age, quality of life scores, LUTS and sexual function scores of the groups, and type of cystoscopy were analyzed by using multivariate tests, no relationships between types of cystoscopy and other parameters were found. A limitation of our study was small sample size. Further large sample studies should confirm the finding of the present study.