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Endoscopic Photography of the Urinary Bladder
THE JoLR~_..._L OF UROLOGY
Vol. U6, Nov. Printed 1'.J1 .8 . .lL
Copyright. (JZ:, HHifi hy The Williams & Wilkim, Co.
E?\DOSCOPIC PHOTOGRAPHY OF THE URINARY BLADDER RALPH J. VEENEMA, H. H. TARA AND HERRICK C. RIDLON Prom the Departmenl of Urology, Columbia University, Institule of Cancer Francis Delafield Hospital and Squier Urological Clinic, New New York
Photographic documrntation of intravesical and urethral pathology and anatomy would sePm to offer a valuable teaching and research tool. Despite these prospects, endoscopic photography has not bPen widrl.\· u~ed. Our interest was dPveloped in this field by our attempts to thoroughly document the effects of topical thioTEP/1. on bladder turnoff. It soon became evident that many problems were involved in
Fie;.
by McCarthy and Ritter in 1957. These pro· ceduresl. 2 and instrurnenb were useful but with limitations. \Ve will describe some of these uses and limitations. The basic faetors of photography such as cl tS· tancc, lens diaphragm OJJ8ning, film ,:;peed and light intensity are eminently important for endoscopic photography. The diameter of the cystoscope limits the fidcl that can be recorded
l. Exakta :35 mm. reflex cmnera with clear prism and adaptor for cystoscope
obtaining cy~toscopic pictures, both motion picture and still, which were not generally appreciated. "With the co-operation of American toscopc l\Takers, Inc. many of these probfoms in endoscopic photography are gradually being resolved. Endoscopic photography was firnt tried in 1887 l\fax Nitze but with little success. Color endoscopic photography was done in 1942 using a quartz rod light by JVIcCrea, which was also used Accepted for publication .January 19, 1966" 829
by the camera; also the light source will vmv greatly, depending upon the nature of the liquid medium within the bladder. The presence flocculent debris or blood greatly reduces ligh;; intensity. \Ve most conunonly use sterile distilled 1 :McCrea, L. E.: Recent advances in cystoscopi1: photography: Presentation of new equipmentc J. Urol., 78: 669-673, 1957. 2 McCarthy, J. F. and Hitter, J. Sc. Colored rnotion picture photography and black-a11cl-whiLe television of the human urinary bladder and other interior body organs. J. Urol., 78: (174-680, ]\)57.
830
VEENEMA, TARA AND RIDLON
water as the irrigating solution during our endoscopic photography to avoid light dispersion. The constant development of improved light sources and more sensitive photographic film indicates the possibility of further improving endoscopic photography. ENDOSCOPIC STILL PHOTOGRAPHY
Our first endoscopic 35 mm. photographs were done with the 27F Brown-Buerger cystoscope with a specially constructed ACMI adapter fitted to an Exakta camera (fig. 1). The Exakta is a suitable reflex camera, but its frosted prism must be replaced by a clear prism. We have used model VX II A 35 mm. with an f:2 Biotar lens, but any
other similar reflex camera would be suitable. The No. 27 Brown-Buerger scope with light supplied from a transformer using regular AC 110volt current and a graduated output to 10 volt has approximately a maximum of 300 foot-candle light power. The telescope is right angle and the light bulb specially constructed in a metallic jacket as a hooded lamp (ACMI No. 42). Using Ektachrome ERB indoor type film with ASA of 135, we found that the best pictures were obtained at a lens setting of f: 4-f: 5.6 and distance of 1.8 feet to infinity, with an exposure time of 3-4 seconds. No special tripod was used. However, the endoscopist with his elbows firmly placed on the tray of the cystoscopic table could usually
FIG. 2. Enlargements of endoscopic photograph taken with Exakta camera (35 mm.) through No. 27 Brown-Buerger cystoscope. A, ureteral orifice, bladder mucosa and blood clot. B, bladder tumor, heavy trabeculations and cellules. C, bladder tumor.
ENDOSCOPIC PHOTOGRAPHY
Fw. :3. lVIcCarthy urethroscope with quartz rod light source and 8 mm. Camex camera. Light. source can be used alRo with 35 mm. reflex camera.
Fm. 4. Enlargements of :35 mm. endoscopic photographs taken with Exakta camera, throscope and quartz rod light. source. A, urethral tumor. B, bladder neck and lateral prosta.tic
832
VEENEMA, 'FARA AND RIDLON
maintain a fixed position during the exposure. At this exposure of 3-4 seconds, motions by the cystoscopist, patient, bladder wall, etc., are disturbing factors. These 35 mm. still pictures gave satisfactory slides and reproductions but enlargements accentuate the blurring and lack clarity (fig. 2). To reduce the exposure time we used the instrument described by McCarthy and Ritter2 in November 1957. The instrument is a No. 28F
McCarthy urethroscope with direct vision (fig. 3). The light supplied by this transformer is transferred to a quartz rod which has approximately a 400-foot candle power. One problem with the quartz rod is that light is high centrally but fades· in the periphery. A special built-in blower keeps the bulb and instrument cool. The direct vision urethroscope limits the view within the bladder and particularly limits the photography of lesions at the dome of the bladder. The light cord and
Fm. 5. Fiberoptic light carrier power supply and light bundle. (Top) direct vision fiberoptic telescope. (Bottom) sheath and obturator for right angle fiberoptic telescope.
E>TDOSCOPIC PHOTOGRAPHY
blower tube necessary for proper use of the quartz rod :.\lcCarthy instrument is heavy and not easily handlecL However, the exposure time was reduced to one second, using similar film and setting
(fig. 4). The only advantage the quartz rod instrument had over previous equipment was the greater
light intensity, but the disadvantages, as were many, and we did not continue the use of this instnunent when the fiberoptic system became available. Development of the fiberoptic 5) has given improved light for photography. At a J !1 to 2 inch working distance
FIG. G. Enlargements of :35 mm. e11doscopic photographs taken with Camex camera, Ektachrome !ilm and fiberoptic light. A, bladder neck- direct vision fiberoptic cystoscope. n, bladder tumor·-right a.ngk• fiberopti c cystoscope.
:F'!G. , . Camex 8 mm. motion picture camcrn, and adapter and bracket for endoscopic photography
VEENEMA, TARA AND RIDLOC'J
with a 36 inch fiberoptic bundle and using conventional fiberoptic transfonncr as a light sonn:e, 950-1200 foot candle is available. This i1nprovement in delivering higher intensity light has reduced the exposure time to ½ second. The direct vision fiberoptic telescope delivers higher light intensity than the right angle telescope. The 35 mm. photographs obtained through the fiberoptic system are sharper and have greater potentiality for processing and enlargement. Since the fiberoptic cystoscope became available we have used it exclusively for endoscopic photography. The cystoscope we have used is size 28F, but a smaller caliber cy,;toscope is available, and photographs are essentially the same (fig. 6). To produce a satisfactory motion picture require8 nrnch higher light intensity because of shorter exposure time. The ::\IcCarthy quartz rod instrument was used initially. The Camex 8 mm. single lens (fig. 7) reflex camera with special ACMI adaptor for the instnm1cnt and a lens 12.5 mm. with f: 1.9 was used. We have taken photographs with fully open lens diaphrag1n, distance set at infinity and 16 frames per second. The film used was Kodachrome II indoor type, with an ASA of 40. The quality of the photographs produced was good, and enlargement can be made (fig. 8).
When the fibcroptic system becarne available we discontinued the quartz rod instrurnent. The Camex camera with the AC:\11 adaptor and high 8peed Ektad1rome film with an ASA of 125 is now being used. The speed of 16 frames per second through the clirect vision telescope and 8 frames per second through a right angle telescope proved most satisfactory. The pictures produced are clear and can be enlarged for demonstration; however the granularity of the high speed film is present and cannot be elim:nated. The Kodachrome II indoor type may be used and good photographs can be obtained from the prostatic urethra and bladder neck, but the photographs from a distance, namely, bladder wall, are usually dark. As mentioned, whenever a right angle telescope is used 8 fran1es per second is recommended. At this speed it is extremely important to move the instrument much slower since the conventional projectors show 16 frames per second. The direct vision telesrnpe admits greater light intensity for photography, and pictures can thus be taken 16 frames per second. When photographing the posterior urethra and bladder neck, light power can be reduced to ~even or eight setting on the power pack to avoid overexposure and glare with both cameras.
FIG. 8. Enlargements from frames of 8 mm. motion picture endoscopic photographs. A, bladder carcinoma at anterior and left vesical neck. B, prostatic urethra following transurethral resection.
ENDOSCOPIC PHO'rOGRAPHY COM}!ENT
The full potential of endoscopic photography has as yet not been realized. It gives promise of a valuable research and teaching tool and with i1nproved fibcroptic light sources now becoming available, we may ultimatdy be able to have adaptorn which fit. the routine urological instruments and permit less cumbersome photographic techniques. This is presently being studied. Our experiences with the 35 mm.. films, and 8 mm. motion picture films have emphasized the importance of dear medium, adequate light source and suitable film sensitivity. vVe use the 8 mm. motion picture camera becau,;e of its flexibility, ease of handling, and economy. The motion pictures produced can be enlarged to 16 mm. for demonstration in a large auditorium, or a single frame can be enlarged to ;3.5 mm. for projection as a slide. Another factor in endoscopic ;)hotography which appears to improve the depth perception of bladder lesions is to avoid direct
pictures and attempt to obtain the picture al smncwhat of an angle. The 1G mm. rnrner:1s available today are bulky and not as adapted to the cystoscope. vVith improved 16 mrn . reflex movie cameras, this may prove to be more satisfactory than 8 mm. When taking motion pictures within the bladder it is essential that IJ.H, endoscopist move slowly and that the field be carefully oriented within the bladder. For exam ple, in endoscopic photographs of neopla.,ms ii, ii important to demonstrate the bladder neck nnd floor of the bladder and move towards the tumor, from. the norm.al urothelium. All of these movements must be clone considerably slower than a1 the usual cysto~copy rate. The greatest cbrity of the lesion is obtained at a distance of about, 2 cm. SUMMARY
Our experiences with endoscopic photography have been presented and its present limitations as well as future encouraging prospects have been outlined.
Vol. U6, Nov. Printed 1'.J1 .8 . .lL
Copyright. (JZ:, HHifi hy The Williams & Wilkim, Co.
E?\DOSCOPIC PHOTOGRAPHY OF THE URINARY BLADDER RALPH J. VEENEMA, H. H. TARA AND HERRICK C. RIDLON Prom the Departmenl of Urology, Columbia University, Institule of Cancer Francis Delafield Hospital and Squier Urological Clinic, New New York
Photographic documrntation of intravesical and urethral pathology and anatomy would sePm to offer a valuable teaching and research tool. Despite these prospects, endoscopic photography has not bPen widrl.\· u~ed. Our interest was dPveloped in this field by our attempts to thoroughly document the effects of topical thioTEP/1. on bladder turnoff. It soon became evident that many problems were involved in
Fie;.
by McCarthy and Ritter in 1957. These pro· ceduresl. 2 and instrurnenb were useful but with limitations. \Ve will describe some of these uses and limitations. The basic faetors of photography such as cl tS· tancc, lens diaphragm OJJ8ning, film ,:;peed and light intensity are eminently important for endoscopic photography. The diameter of the cystoscope limits the fidcl that can be recorded
l. Exakta :35 mm. reflex cmnera with clear prism and adaptor for cystoscope
obtaining cy~toscopic pictures, both motion picture and still, which were not generally appreciated. "With the co-operation of American toscopc l\Takers, Inc. many of these probfoms in endoscopic photography are gradually being resolved. Endoscopic photography was firnt tried in 1887 l\fax Nitze but with little success. Color endoscopic photography was done in 1942 using a quartz rod light by JVIcCrea, which was also used Accepted for publication .January 19, 1966" 829
by the camera; also the light source will vmv greatly, depending upon the nature of the liquid medium within the bladder. The presence flocculent debris or blood greatly reduces ligh;; intensity. \Ve most conunonly use sterile distilled 1 :McCrea, L. E.: Recent advances in cystoscopi1: photography: Presentation of new equipmentc J. Urol., 78: 669-673, 1957. 2 McCarthy, J. F. and Hitter, J. Sc. Colored rnotion picture photography and black-a11cl-whiLe television of the human urinary bladder and other interior body organs. J. Urol., 78: (174-680, ]\)57.
830
VEENEMA, TARA AND RIDLON
water as the irrigating solution during our endoscopic photography to avoid light dispersion. The constant development of improved light sources and more sensitive photographic film indicates the possibility of further improving endoscopic photography. ENDOSCOPIC STILL PHOTOGRAPHY
Our first endoscopic 35 mm. photographs were done with the 27F Brown-Buerger cystoscope with a specially constructed ACMI adapter fitted to an Exakta camera (fig. 1). The Exakta is a suitable reflex camera, but its frosted prism must be replaced by a clear prism. We have used model VX II A 35 mm. with an f:2 Biotar lens, but any
other similar reflex camera would be suitable. The No. 27 Brown-Buerger scope with light supplied from a transformer using regular AC 110volt current and a graduated output to 10 volt has approximately a maximum of 300 foot-candle light power. The telescope is right angle and the light bulb specially constructed in a metallic jacket as a hooded lamp (ACMI No. 42). Using Ektachrome ERB indoor type film with ASA of 135, we found that the best pictures were obtained at a lens setting of f: 4-f: 5.6 and distance of 1.8 feet to infinity, with an exposure time of 3-4 seconds. No special tripod was used. However, the endoscopist with his elbows firmly placed on the tray of the cystoscopic table could usually
FIG. 2. Enlargements of endoscopic photograph taken with Exakta camera (35 mm.) through No. 27 Brown-Buerger cystoscope. A, ureteral orifice, bladder mucosa and blood clot. B, bladder tumor, heavy trabeculations and cellules. C, bladder tumor.
ENDOSCOPIC PHOTOGRAPHY
Fw. :3. lVIcCarthy urethroscope with quartz rod light source and 8 mm. Camex camera. Light. source can be used alRo with 35 mm. reflex camera.
Fm. 4. Enlargements of :35 mm. endoscopic photographs taken with Exakta camera, throscope and quartz rod light. source. A, urethral tumor. B, bladder neck and lateral prosta.tic
832
VEENEMA, 'FARA AND RIDLON
maintain a fixed position during the exposure. At this exposure of 3-4 seconds, motions by the cystoscopist, patient, bladder wall, etc., are disturbing factors. These 35 mm. still pictures gave satisfactory slides and reproductions but enlargements accentuate the blurring and lack clarity (fig. 2). To reduce the exposure time we used the instrument described by McCarthy and Ritter2 in November 1957. The instrument is a No. 28F
McCarthy urethroscope with direct vision (fig. 3). The light supplied by this transformer is transferred to a quartz rod which has approximately a 400-foot candle power. One problem with the quartz rod is that light is high centrally but fades· in the periphery. A special built-in blower keeps the bulb and instrument cool. The direct vision urethroscope limits the view within the bladder and particularly limits the photography of lesions at the dome of the bladder. The light cord and
Fm. 5. Fiberoptic light carrier power supply and light bundle. (Top) direct vision fiberoptic telescope. (Bottom) sheath and obturator for right angle fiberoptic telescope.
E>TDOSCOPIC PHOTOGRAPHY
blower tube necessary for proper use of the quartz rod :.\lcCarthy instrument is heavy and not easily handlecL However, the exposure time was reduced to one second, using similar film and setting
(fig. 4). The only advantage the quartz rod instrument had over previous equipment was the greater
light intensity, but the disadvantages, as were many, and we did not continue the use of this instnunent when the fiberoptic system became available. Development of the fiberoptic 5) has given improved light for photography. At a J !1 to 2 inch working distance
FIG. G. Enlargements of :35 mm. e11doscopic photographs taken with Camex camera, Ektachrome !ilm and fiberoptic light. A, bladder neck- direct vision fiberoptic cystoscope. n, bladder tumor·-right a.ngk• fiberopti c cystoscope.
:F'!G. , . Camex 8 mm. motion picture camcrn, and adapter and bracket for endoscopic photography
VEENEMA, TARA AND RIDLOC'J
with a 36 inch fiberoptic bundle and using conventional fiberoptic transfonncr as a light sonn:e, 950-1200 foot candle is available. This i1nprovement in delivering higher intensity light has reduced the exposure time to ½ second. The direct vision fiberoptic telescope delivers higher light intensity than the right angle telescope. The 35 mm. photographs obtained through the fiberoptic system are sharper and have greater potentiality for processing and enlargement. Since the fiberoptic cystoscope became available we have used it exclusively for endoscopic photography. The cystoscope we have used is size 28F, but a smaller caliber cy,;toscope is available, and photographs are essentially the same (fig. 6). To produce a satisfactory motion picture require8 nrnch higher light intensity because of shorter exposure time. The ::\IcCarthy quartz rod instrument was used initially. The Camex 8 mm. single lens (fig. 7) reflex camera with special ACMI adaptor for the instnm1cnt and a lens 12.5 mm. with f: 1.9 was used. We have taken photographs with fully open lens diaphrag1n, distance set at infinity and 16 frames per second. The film used was Kodachrome II indoor type, with an ASA of 40. The quality of the photographs produced was good, and enlargement can be made (fig. 8).
When the fibcroptic system becarne available we discontinued the quartz rod instrurnent. The Camex camera with the AC:\11 adaptor and high 8peed Ektad1rome film with an ASA of 125 is now being used. The speed of 16 frames per second through the clirect vision telescope and 8 frames per second through a right angle telescope proved most satisfactory. The pictures produced are clear and can be enlarged for demonstration; however the granularity of the high speed film is present and cannot be elim:nated. The Kodachrome II indoor type may be used and good photographs can be obtained from the prostatic urethra and bladder neck, but the photographs from a distance, namely, bladder wall, are usually dark. As mentioned, whenever a right angle telescope is used 8 fran1es per second is recommended. At this speed it is extremely important to move the instrument much slower since the conventional projectors show 16 frames per second. The direct vision telesrnpe admits greater light intensity for photography, and pictures can thus be taken 16 frames per second. When photographing the posterior urethra and bladder neck, light power can be reduced to ~even or eight setting on the power pack to avoid overexposure and glare with both cameras.
FIG. 8. Enlargements from frames of 8 mm. motion picture endoscopic photographs. A, bladder carcinoma at anterior and left vesical neck. B, prostatic urethra following transurethral resection.
ENDOSCOPIC PHO'rOGRAPHY COM}!ENT
The full potential of endoscopic photography has as yet not been realized. It gives promise of a valuable research and teaching tool and with i1nproved fibcroptic light sources now becoming available, we may ultimatdy be able to have adaptorn which fit. the routine urological instruments and permit less cumbersome photographic techniques. This is presently being studied. Our experiences with the 35 mm.. films, and 8 mm. motion picture films have emphasized the importance of dear medium, adequate light source and suitable film sensitivity. vVe use the 8 mm. motion picture camera becau,;e of its flexibility, ease of handling, and economy. The motion pictures produced can be enlarged to 16 mm. for demonstration in a large auditorium, or a single frame can be enlarged to ;3.5 mm. for projection as a slide. Another factor in endoscopic ;)hotography which appears to improve the depth perception of bladder lesions is to avoid direct
pictures and attempt to obtain the picture al smncwhat of an angle. The 1G mm. rnrner:1s available today are bulky and not as adapted to the cystoscope. vVith improved 16 mrn . reflex movie cameras, this may prove to be more satisfactory than 8 mm. When taking motion pictures within the bladder it is essential that IJ.H, endoscopist move slowly and that the field be carefully oriented within the bladder. For exam ple, in endoscopic photographs of neopla.,ms ii, ii important to demonstrate the bladder neck nnd floor of the bladder and move towards the tumor, from. the norm.al urothelium. All of these movements must be clone considerably slower than a1 the usual cysto~copy rate. The greatest cbrity of the lesion is obtained at a distance of about, 2 cm. SUMMARY
Our experiences with endoscopic photography have been presented and its present limitations as well as future encouraging prospects have been outlined.