4 DISCUSSION
Rigid cystoscopy is still widely used compared with flexible cystoscopy
in outpatient operations or an office setting in most countries due to
the low cost. The current prospective randomized study has shown that
levobupivacaine is significantly more effective than lidocaine alone as
a local anesthetic in rigid cystoscopy. The VAS scores during the
procedure in this study were determined to be meaningfully high only in
the lidocaine and 4-mL levobupivacaine groups compared with other
higher-dose levobupivacaine groups. After the procedure, VAS scores were
significantly higher only with the lidocaine, 4-mL levobupivacaine, and
6-mL levobupivacaine groups compared with other higher-dose
levobupivacaine groups. The highest patient satisfaction rates were
found in the 10-mL levobupivacaine group. Thus, it is believed that this
is the first randomized study on the use of levobupivacaine urethrally
in local cystoscopy procedures.
The mean age of the subjects in this study was 62.37 years old, and no
statistical difference exists among the groups. In a previously reported
study, older patients were reported to significantly tolerate cystoscopy
better than younger patients.6 Therefore, the absence
of a significant age difference among the groups in this study did not
cause this error.
Goldfischer et al., in 1997, compared the use of intraurethral lidocaine
gel 20 min before rigid cystoscopy with the lubricant only for local
anesthesia in rigid cystoscopy.7 In that study,
although no difference was reported in pain control in female patients,
significantly less pain level was documented among men in the group in
which the lidocaine gel was used. In another published study,
intravesical lidocaine gel application in rigid cystoscopy 5 and 10 min
before the operation was reported to not be overall beneficial. It was
also reported that reducing anxiety among women on pain sensation was
positive while it did not make a difference in men.8Thus, this study did not include female patients and studied only male
patients. This study is a randomized prospective study similar to both
studies. The study of Goldfischer et al. reported that different
cystoscopes were used and that no difference between size and pain
exist. However, the current study preferred to standardized using a
single-size cystoscope.7
The detailed information given to the patients by the healthcare team
before the procedure reduced anxiety and positively affects the level of
pain.9 The patient group of this study had undergone
cystoscopy at least six times before, and they were included in the
study as a group who knew what they would encounter during the
procedure. Consequently, it did not affect the state of anxiety and
anxiety-related pain of the patients because no statistical difference
exists between the groups compared to the previous cystoscopy numbers.
Although some studies in the literature preferred the way of measuring
pain status at different stages of cystoscopy, this study decided to
assess pain both during and 30 min after the procedure because it would
be more practical and reliable.10
Some studies suggest that the intraurethral administration of lidocaine
is ineffective and that its administration does not provide sufficient
absorption.8,11-13 Most of the specified studies were
done with a flexible cystoscope, and it is observed that evaluations
were made only 5 and 10 min after the procedure in rigid cystoscopy
studies.8 However, some studies have reported that
lidocaine has an onset of action from 15 to
60 min.14,15 In addition, levobupivacaine has a longer
effect than lidocaine.3 Therefore, cystoscopy was
started 30 min after the applications in both the lidocaine gel and
levobupivacaine groups in this study. A second VAS assessment was made
30 min after the cystoscopy.
The additional cost of levobupivacaine used in this study currently
ranges from 33 to 66 Turkish lira. This does not bring a huge cost in
countries with strong social security institutions such as Turkey. A
South Korean study for ureteral stenting similarly reported that
sedation with propofol brings about a tolerable cost. However, almost
twice the cost stands out as the difference in detailed local and
sedation applications.16 The cost of performing rigid
cystoscopy is lower in Turkey than the use of flexible cystoscopes.
Many methods have been tried to reduce pain in cystoscopy procedures.
Müntener et al. compared the transrectal periprostatic lidocaine
blockade with the standard approach but found no significant difference
in VAS and concluded that periprostatic blockade for transurethral
procedures was ineffective.17 Al-Hunayan et al.
investigated the effect of transperineal urethrosphincteric lidocaine
blockade and found that the discomfort/pain rates of the study group
were significantly lower than the other control groups. In addition, no
significant side-effects were reported.10 However, in
this study, infiltration from the perineum to the prostate apex requires
experience and does not seem practical for the patient and the
healthcare team. Thus, the practice of the current study is
significantly more practical and easier to apply.
In another study, as a different approach, oral zaltoprofen administered
with intraurethral lidocaine before cystoscopy was reported to decrease
pain compared with only intraurethral lidocaine.18Karthikeyan et al. compared 75 mg diclofenac sodium administered orally
and intraurethral lidocaine 1 h before cystoscopic ureter stent
extraction with only placebo and intraurethral
lidocaine.19 Consequently, the diclofenac group
reported significantly less pain levels. In both studies, effective oral
nonsteroidal anti-inflammatory drugs were similarly used. During the
SARS-CoV-19 pandemic, drugs such as diclofenac were reported to increase
renal involvement in patients infected with SARS-CoV-19, increasing the
TMPRSS2 gene expression.20 The use of such drugs
should be avoided as much as possible due to their potential
nephrotoxicity, especially with the SARS-CoV-19 pandemic.
Several pieces of the literature have reported that local anesthesia is
used especially in the treatment of bladder tumor laser ablation,
fulguration, and diathermy in the level that the patients can
tolerate.21-25 However, these studies are case series
and have not yet become the standard approach. In addition, Stravodimos
et al. have published that local levobupivacaine intravesical
infiltration in resection of superficial bladder tumors is an
appropriate method for pain control and can be an alternative to general
anesthesia.26 This was a pilot study reporting that
levobupivacaine was first administered as intraurethral infiltration. It
is one of the most reliable local anesthetics in terms of side-effects
because levobupivacaine passes into the systemic circulation on a
limited amount.3 No drug-related side-effects were
observed in this study. Therefore, it is suggested that intraurethral
instillation of levobupivacaine can be used for local anesthesia for
outpatient cystoscopy procedures in light of the results of this study.
This study has some limitations. First, this is a randomized,
prospective, but not a double-blinded study. Second, the study involved
a relatively small number of patients. In addition, pain levels were
measured during and after 30 min, but the cystoscopy stages were not
separately considered. Evaluating the individual cystoscopy stages could
create inconsistency in the patient group of this study.