The goal of this clinical trial is to learn if certain comfort-enhancing interventions can reduce pain and anxiety during flexible cystoscopy and bladder instillation in patients with bladder cancer. The main questions it aims to answer are:

• Do these interventions reduce patient-reported anxiety during the procedure?
• Do these interventions reduce patient-reported pain or discomfort during the procedure?

Researchers will compare patients receiving comfort interventions (such as timing of anesthetic gel, calming music, or visual distraction) to those receiving standard care to see if these changes improve patient experience.

Participants will:

• Undergo a flexible cystoscopy or bladder instillation as part of their usual care
• Be randomly assigned to receive one or more comfort interventions, or standard care
• Complete short questionnaires about their pain, comfort, and anxiety

Bladder cancer is one of the most common malignancies of the urinary tract, and many patients require frequent endoscopic procedures as part of diagnosis, treatment, and surveillance. Flexible cystoscopy and intravesical instillation are standard procedures but are often associated with patient discomfort, anxiety, and negative procedural experiences. Improving comfort during these procedures has the potential to increase patient satisfaction, reduce procedural avoidance, and improve adherence to follow-up care.

Rationale Although flexible cystoscopy is minimally invasive, it can cause pain, embarrassment, and significant anxiety. Standard strategies to improve patient comfort, such as intravesical anesthetic gel, are variably effective. Previous work suggests that environmental modifications (e.g., calming music, ambient lighting), behavioral strategies (e.g., distraction), and optimization of local anesthetic use may enhance the patient experience. However, rigorous randomized controlled data in the cystoscopy and bladder instillation setting are lacking.

This study will address this gap by systematically evaluating comfort-enhancing interventions during flexible cystoscopy and bladder instillation for bladder cancer patients.

Study Objectives The primary objective is to determine whether comfort interventions reduce patient-reported anxiety and pain during flexible cystoscopy and bladder instillation procedures.

Secondary objectives include:

• To assess whether these interventions improve overall patient satisfaction.
• To determine whether these interventions influence willingness to undergo repeat procedures.
• To explore procedural efficiency, clinician satisfaction, and feasibility of implementing these interventions in routine care.

Study Design This study includes both a randomized controlled trial (RCT) and an observational component.

Randomized Controlled Trial (Interventional Arm):

Participants will be randomly assigned to receive standard care or a comfort interventions, such as:

• Optimized timing of intravesical anesthetic gel
• Calming background music
• Visual distraction or environmental modifications
• Ambient lighting changes

Outcomes will be assessed using validated questionnaires (e.g., visual analogue scales for pain and anxiety, standardized patient-reported outcome measures).

Observational Arm:

Parallel to the RCT, observational data will be collected from a cohort undergoing flexible cystoscopy or intravesical instillation under standard care conditions. This will allow comparison with historical and real-world data, provide additional context for generalizability, and help inform the feasibility of widespread adoption of interventions.

Participant Population Participants will include adults undergoing flexible cystoscopy or bladder instillation for bladder cancer. Eligibility is broad to maximize generalizability, with minimal exclusion criteria. Translation services and literacy supports will be offered to ensure equitable participation.

Study Procedures

• All participants will undergo flexible cystoscopy or intravesical instillation as clinically indicated.
• RCT participants will be randomized to intervention vs. standard care groups.
• Participants will complete short questionnaires before, during, and after the procedure assessing comfort, pain, and anxiety.
• Follow-up will include willingness to undergo repeat procedures and satisfaction ratings.

Outcomes

• Primary outcomes: Patient-reported pain and anxiety scores.
• Secondary outcomes: Overall satisfaction, willingness to repeat procedure, efficiency measures, and clinician feedback.

Significance This study will generate high-quality evidence on practical, low-cost, and easily implementable interventions to improve the patient experience during routine urological procedures. Findings may inform best practice guidelines, enhance patient-centered care, and support broader adoption of comfort-enhancing strategies in cystoscopy services.

Inclusion Criteria:

• Age ≥ 18 years
• Diagnosis of bladder cancer undergoing diagnostic/surveillance flexible cystoscopy or intravesical bladder instillation in the outpatient urology clinic
• Able to provide informed consent

Exclusion Criteria:

Individuals <18 years of age.

• Individuals unable to provide informed consent (e.g., diminished or fluctuating capacity).
• Individuals unable to communicate verbally with study staff (e.g., severe speech/hearing impairment without assistive support available).
• Individuals with severe cognitive impairment or acute distress at the time of approach that prevents informed consent.
• Individuals with known hypersensitivity or allergy to lidocaine, topical anesthetic gel, or any components used in the procedure.
• Individuals for whom, in the opinion of the treating urologist, participation would pose undue clinical risk or interfere with urgent clinical care.

De-identified individual participant data (IPD) underlying the primary results will be made available to researchers upon reasonable request, beginning 12 months after publication. Requests will require a methodologically sound proposal and approval by the study steering committee. Data will be shared via secure transfer after execution of a data use agreement.

IPD and supporting documents will be available beginning 12 months after publication of the primary results, for a period of 5 years.

De-identified individual participant data (IPD) underlying published results will be made available to qualified researchers upon reasonable request. Access will be limited to investigators with a methodologically sound proposal addressing a scientifically valid research question. Requests must be reviewed and approved by the study steering committee. A data use agreement will be required prior to release. Data and supporting documents (protocol, SAP) will be shared via secure electronic transfer.