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.