Executive Summary

Standardized Office Cystoscopy Training for Advanced Practice Providers in Urology

Michelle J. Lajiness, FNP-BC; Heather Schultz, FNP-C; Susanne A. Quallich, PhD, ANP-BC, NPC, CUNP, FAANP


Urol Nurs. 2020;40(1):31-33. 

In This Article


The expansion of APPs into office-based procedures within urology clinical environments is occurring out of necessity and with the prevalence of on-the-job training. This creates a lack of standardization among training, which also makes it difficult to compare outcomes. This is influenced by the fact that the U.S. population is aging, as is the population of practicing urologists (McKibben et al., 2016). Advances in technology relative to flexible office cystoscopy allowed for less complicated training for a wider range of providers. This is limited only by the ability of those performing cystoscopy to recognize relevant abnormalities; however, images saved directly into the electronic medical record (EMR), improvements in image quality, and the ability to capture or print images allow for providers of all disciplines to seek input into potential abnormalities, especially if the collaborating physician is not available at the time of the procedure.

Advanced practice providers in real-world settings are becoming more adept at providing urologic care in environments that have limited access to urologists and urology residents, or who run independent urology clinics with the collaborating urologist off-site in another facility. This also warrants the increasing need for flexible cystoscopy. As the population ages, APPs with a skill set that includes office cystoscopy will become increasingly valuable in providing access for urology patients and helping facilities maintain the surveillance cystoscopy schedule for patients who have low-grade bladder cancer. This further speaks to the need for a standardized program of training and evaluation for APPs that will ensure high quality care with office cystoscopy.

For NPs, individual state scope of practice laws may limit their ability to offer this service to their urology patients. Even in states that have full practice authority for NPs, the lack of a standardized training program and curricula makes it difficult for NPs to seek credentialing and privileging for office cystoscopy. This is compounded by the fact that urology residents have office procedures such as cystoscopy built into their training program and that urology content can be limited in both NP and PA curricula alike. As a result, APPs preparing for office cystoscopy should provide a working knowledge of the pathophysiology, diagnosis, management of urologic conditions, and indications for office cystoscopy, as well as a working knowledge of facilities' consent procedures and plan for adverse events, especially if a urologist is not onsite.

Despite this lack of training prior to graduation, both NPs and PAs in urology environments have been performing increasing numbers of cystoscopies (Ikenberry et al., 2009; Langston et al., 2016; Langston et al., 2017). Mentorship and training are vitally important and can take the form of training with a urologist, experienced APP cystoscopist, or through a structured process at an individual facility, as proposed by Quallich and colleagues (2019) (Arunachalam & Wallach, 2015; Mitchell & Spitz, 2015). Facilities that offer training and the opportunity for APPs to perform cystoscopy will not only decrease wait times, but may potentially improve APP job retention and satisfaction, while enhancing the APP's skills and confidence. APPs will develop plans for complex management, in part as required by the state practice act and scope of practice, and in consultation with the urologist when needed.

Increasing clinical skills and ability to effectively utilize APPs in urology clinics at the highest scope of their training and education will be vital within the context of the decrease in the urologist workforce over the coming decades (Gonzalez et al., 2015). NPs and PAs are well-positioned to move into urology clinical practice and alleviate much of the need for the episodic and chronic management for many non-surgical urology patients, such as those needing stent removal or surveillance cystoscopy.

This cystoscopy training curriculum, when adopted as proposed, ensures that APP training, utilization, and outcomes can be evaluated in a standardized manner regardless of facility or geographic location. However, Quallich and colleagues (2019) do not offer a specific number of procedures that should be performed by an APP when being trained to do office cystoscopy; the authors felt that a supervised assessment of proficiency and skill were more important than a set number of procedures. BAUN and BAUS (2017) suggest 50 supervised procedures, and facilities may wish to adopt this or another number of procedures as they see fit.

Advanced practice providers and NPs in particular will need to confirm that adding office cystoscopy to their privileges is acceptable under their individual state law and scope of practice. Furthermore, specific cystoscopy-based office procedures performed by the APP will be determined by individual facility need, ability to maintain skills, competencies, and outcomes assessment.