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Reduction of pain during flexible cystoscopy: a systematic review and meta-analysis

  • Dima Raskolnikov,
  • Benjamin Brown,
  • Sarah K. Holt,
  • Andrea L. Ball,
  • Yair Lotan,
  • Seth Strope,
  • Florian Schroeck,
  • Ralph Ullman,
  • Robert Lipman,
  • Angela B. Smith,
  • John L. Gore

Publication: Journal of Urology, June 2019





Purpose

The Bladder Cancer Advocacy Network (BCAN) Patient Survey Network identified pain during intravesical procedures as a research priority for patients. Although intraurethral lidocaine is standard of care in this setting, evidence for its use is equivocal. We performed a systematic review of studies evaluating interventions to reduce discomfort during cystoscopy and intravesical therapies for bladder cancer. We performed a meta-analysis for interventions with available randomized-controlled trials.

Materials and Methods
Search terms derived from the Key Questions were incorporated into the literature search constructed by a research librarian and accessed English medical literature from 1990-2017. Initial search yielded 626 potential studies. Final review incorporated 62 studies. We combined 12 trials into a meta-analysis with a random-effects model of the efficacy of intraurethral lidocaine versus plain lubricant for reducing pain during flexible cystoscopy as measured by a 10-point Visual Analog Scale (VAS).

Results
Data from 12 randomized-controlled trials on 1,549 patients were included in the final intraurethral lidocaine meta-analysis. The standardized mean difference between VAS pain scores in patients undergoing flexible cystoscopy with intraurethral lidocaine and plain lubricant was -0.22 (95% CI -0.39 to -0.05). The evidence was insufficient to evaluate other interventions for mitigating discomfort from invasive bladder procedures.

Conclusions
Intraurethral lidocaine provides a statistically significant reduction in pain among men undergoing flexible cystoscopy, particularly with longer dwell times. The evidence was insufficient for other tested interventions. A prospective study is needed to further clarify interventions to decrease patient discomfort during cystoscopy and other intravesical procedures in a diverse population.


Editorial comment from Dr. Benjamin Pradere

Cystoscopy is one of the most common invasive urological procedure performed without general anesthesia. In the era of numerous studies on biomarkers in the diagnosis and surveillance of bladder cancer allowing to potentially reduce the numbers of cystoscopy during the follow-up of NMIBC, it remains a priority to decrease patients discomfort and pain during flexible cystoscopy.

Actually, the most common way to reduce pain during cystoscopy is local anesthesia with intraurethral lidocaine. Nevertheless, the evidence to support its use is still weak, and previous meta-analyses found controversies results.

Beyond the strong methodology of this meta-analysis, one of the original points of this study is the collaboration with the Bladder Cancer Advocacy Network Patient Centered Outcomes and Policy Working Group from who six urology informants were recruited to elaborate the Key Questions of the PICOTS. This is the first systematic review addressing a series of questions identified by patients with bladder cancer.

The primary objective of this meta-analysis was to evaluate the efficacy of intraurethral lidocaine. For the assessment, the control group was patients who only received plain lubricant.

The final analysis included 12 trials with 1,549 patients over 20 years. They found a benefit for intraurethral lidocaine compared to plain lubricant on mean VAS pain score during flexible cystoscopy: -0.22 (95% CI -0.39 to -0.05). in the same way, there was a benefit for intraurethral lidocaine when the dwell time was >10 minutes and a benefit when the volume instilled was of 20 mL.

Other interesting factors were assessed to reduce discomfort and some of them were suggested to have a benefit as: watching cystoscopy or listening music during the procedure.

This study is important as it reach patients priorities questions. The benefit of local anesthesia with lidocaine during flexible cystoscopy is demonstrated despite the lack of standardization among cystoscopy protocols across centers and shown the importance of dwell time.

The anxiety and discomfort impact of cystoscopy is absolutely not negligible and have to be considered by all the urologist. Future development of new technology as virtual reality could have an impact to optimize the patient comfort during the procedure.