Bladder instillations vs onabotulinumtoxinA injection for interstitial cystitis/bladder pain syndrome: a randomized clinical trial

BACKGROUND

Interstitial cystitis (IC)/bladder pain syndrome (BPS) is an unpleasant sensation related to the bladder with lower urinary tract symptoms lasting more than 6 weeks, unrelated to an otherwise identifiable cause. The etiology is likely multifactorial including urothelial abnormalities, neurogenic pain upregulation, and potentially bladder and vaginal microbiome alterations. Despite treatment effectiveness of both bladder instillations and intradetrusor onabotulinumtoxinA injection for this condition, a head-to-head comparison has not been performed.

OBJECTIVE

To compare the efficacy of bladder instillations and intradetrusor onabotulinumtoxinA injection for treatment of IC/BPS.

STUDY DESIGN

Patients with O'Leary-Sant (OLS) questionnaire scores of ≥6, meeting clinical criteria for IC/BPS, and desiring procedural management were randomized to bladder instillations or intradetrusor onabotulinumtoxinA injection. The primary outcome was the difference in OLS scores at 2 months posttreatment between groups. Secondary outcomes included evaluation of sexual function, physical/mental health status, pain, patient satisfaction, treatment perception, retreatment, and adverse event rates.

RESULTS

Forty-seven patients were analyzed with 22 randomized to bladder instillations and 25 to onabotulinumtoxinA injection. There were no differences in demographic and clinical characteristics between groups. From baseline to 2 months posttreatment, there was a decrease in OLS subscales in all patients (Interstitial Cystitis Symptom Index [ICSI] -6.3 (confidence interval [CI] -8.54, -3.95), P<.0001; Interstitial Cystitis Problem Index [ICPI] -5.9 (CI -8.18, -3.57), P<.0001). At 2 months posttreatment, patients in the onabotulinumtoxinA group had significantly lower OLS scores compared to those in the bladder instillation group (ICSI 6.3±4.5 [onabotulinumtoxinA] vs 9.6±4.2 [instillation], P=.008; ICPI 5.9±5.1 [onabotulinumtoxinA] vs 8.3±4.0 [instillation], P=.048). The difference in OLS scores between groups did not persist at 6 to 9 months posttreatment. There were no statistically significant differences between baseline and posttreatment time points for the remaining questionnaires. Eight percent of patients who received onabotulinumtoxinA injection experienced urinary retention requiring self-catheterization. Patients who underwent onabotulinumtoxinA injection were significantly less likely to receive retreatment within 6 to 9 months compared to patients who received bladder instillations (relative risk 13.6; 95% CI, 1.92-96.6; P=.0002). There were no differences between groups regarding patient satisfaction, perception of treatment convenience, or willingness to undergo retreatment.

CONCLUSION

Both onabotulinumtoxinA injection and bladder instillations are safe, effective treatments for patients with IC/BPS, with significant clinical improvement demonstrated at 2 months posttreatment. Our findings suggest that intradetrusor onabotulinumtoxinA injection is a more effective procedural treatment for this condition than bladder instillation therapy and associated with decreased rates of retreatment.

Reviving the poppy seed test for the diagnosis of colovesical fistula: A case report from a single rural center experience

Key Clinical Message

The poppy seed test is a valuable, cost-effective, and sensitive initial diagnostic investigation to identify the presence of colovesical fistula, particularly for clinicians in remote or rural areas with lack of access to specialist radiologic, endoscopic, surgical, or urological support. The poppy seed test therefore may act as a bridge toward the commencement of appropriate referral pathways for the management of colovesical fistula.

Abstract

The diagnosis of colovesical fistula is resource intensive, often requiring a combination of radiological investigation and endoscopy. The poppy seed test is a non-invasive and cost-effective alternative that has been demonstrated to identify presence of colovesical fistula with high sensitivity. There is however a noticeable paucity of recommendations for the poppy seed test in the diagnostic approach to colovesical fistula due to significant advancements in alternative radiologic and endoscopic technologies. Despite this, in resource-challenged areas with lack of specialist support, the poppy seed test is a cost-effective, accessible and safe test that can be performed to confirm the presence of colovesical fistula. We report a case of a 79-year-old man with a past history of colorectal cancer managed surgically with adjuvant chemoradiotherapy who develops noisy micturition, pneumaturia, and fecaluria 22 years after treatment. Given the suspicion of colovesical fistula, computed tomography imaging and cystoscopy were performed which was unable to demonstrate an overt fistula. The poppy seed test was utilized and demonstrated presence of poppy seeds in the urine, confirming the presence of a fistula. The patient was referred to a specialist surgical center for consideration of further management. The poppy seed test is a valuable initial diagnostic investigation for clinicians in remote or rural areas with lack of access to specialist radiologic, endoscopic, surgical, or urological support in confirming the presence of a colovesical fistula and initiating referral pathways for the management of this condition.

Selection of Convolutional Neural Network Model for Bladder Tumor Classification of Cystoscopy Images and Comparison with Humans

Purpose: An investigation of various convolutional neural network (CNN)-based deep learning algorithms was conducted to select the appropriate artificial intelligence (AI) model for calculating the diagnostic performance of bladder tumor classification on cystoscopy images, with the performance of the selected model to be compared against that of medical students and urologists. Methods: A total of 3,731 cystoscopic images that contained 2,191 tumor images were obtained from 543 bladder tumor cases and 219 normal cases were evaluated. A total of 17 CNN models were trained for tumor classification with various hyperparameters. The diagnostic performance of the selected AI model was compared with the results obtained from urologists and medical students by using the receiver operating characteristic (ROC) curve graph and metrics. Results: EfficientNetB0 was selected as the appropriate AI model. In the test results, EfficientNetB0 achieved a balanced accuracy of 81%, sensitivity of 88%, specificity of 74%, and an area under the curve (AUC) of 92%. In contrast, human-derived diagnostic statistics for the test data showed an average balanced accuracy of 75%, sensitivity of 94%, and specificity of 55%. Specifically, urologists had an average balanced accuracy of 91%, sensitivity of 95%, and specificity of 88%, while medical students had an average balanced accuracy of 69%, sensitivity of 94%, and specificity of 44%. Conclusions: Among the various AI models, we suggest that EfficientNetB0 is an appropriate AI classification model for determining the presence of bladder tumors in cystoscopic images. EfficientNetB0 showed the highest performance among several models and showed high accuracy and specificity compared to medical students. This AI technology will be helpful for less experienced urologists or nonurologists in making diagnoses. Image-based deep learning classifies bladder cancer using cystoscopy images and shows promise for generalized applications in biomedical image analysis and clinical decision making.

Implementing Change Through an Outpatient Antibiotic Stewardship Program

INTRODUCTION

We sought to implement a multipronged behavioral intervention to reduce and tailor antibiotic use for 2 common urologic outpatient procedures.

METHODS

This study was a nonblinded intervention study that consisted of a preintervention phase (November 2018-January 2019), an intervention phase (January 2020-December 2020) in which a multipronged behavioral intervention was implemented, and a postintervention phase (January 2021-March 2021). We examined antibiotic use for cystoscopy and transrectal prostate biopsy at 3 separate urologic outpatient clinics. A multipronged behavioral intervention consisted of formal physician education, modification of the electronic health order sets, clinic staff education, literature review, development and introduction of patient questionnaires, and individual audit feedback. The primary outcome was 30-day infections. Secondary outcomes were adherence to the recommended antibiotic protocols, questionnaire completion, and Escherichia coli outpatient antibiograms.

RESULTS

A total of 2374 patients underwent 3047 cystoscopies, and 547 patients underwent 559 prostate biopsies. The proportions of cystoscopy patients receiving antibiotic prophylaxis and prostate biopsy patients receiving augmented antibiotic prophylaxis decreased 33% and 35%, respectively. The odds of postcystoscopy infection were not different between the preintervention and intervention phases and were lower in the postintervention phase. The odds of postbiopsy infection were not changed between the preintervention and intervention phases or between the preintervention and postintervention phases.

CONCLUSIONS

Implementing a multipronged behavioral intervention reduced and tailored antibiotic use without an increase in 30-day infections. These findings suggest that outpatient antibiotic stewardship and facilitating rapid adoption of guidelines can be accomplished via this approach.

Unusual Presentation of Bladder Cancer in a Young Male With Significant Tattoo Exposure: A Case Report

Recent studies have shown that polycyclic aromatic hydrocarbons (PAHs) can be found in commercial black tattoo inks raising suspicion of tattoo-related PAHs exposure to cancer risk. We present a case of a 27-year-old Hispanic nonsmoker male with bladder cancer (BC) following extensive tattoo sessions totaling over 100 hours. The patient was treated with transurethral resection of the bladder tumor (TURBT) and adjuvant intravesical Bacillus Calmette-Guerin (BCG) therapy. Although the oncogenesis of urothelial tumors in young patients is unclear, multiple environmental and genetic factors may contribute to the etiology. This case report underscores the importance of conducting toxicological and epidemiological studies on PAHs and emphasizes the need for increased documentation of tattoos in patients diagnosed with BC.

MAGnetic REtriaval Device for Minimally Invasive Ureter Stent Removal

Purpose: To assess the effectiveness and pain intensity associated with magnetic ureteral stent removal using a retriever, without the aid of ultrasound guidance. Methods: We prospectively enrolled 100 patients who underwent retrograde rigid and flexible ureterorenoscopy with or without laser lithotripsy for ureteronephrolithiasis treatment from September 2021 to June 2023. These patients were assigned in two groups. Group 1 underwent the traditional ureteral stent insertion, while Group 2 underwent magnetic ureteral stent insertion. Both insertion and removal times were documented. The indwelling time for ureteral stents was 14 days. One group underwent stent removal via flexible cystoscopy using grasping forceps and the other group using just a magnetic retriever, without the aid of ultrasound guidance. The numeric pain rating scale, recommendation rate, and a standardized self-answered ureter stent symptoms questionnaire (USSQ) were obtained directly after stent removal. Results: Both groups presented comparable characteristics in factors such as age, body mass index, history of stone treatments, procedure type, and complication rates during and post-surgery. Time taken for ureteral stent insertion did not differ significantly between the groups (131.2 seconds for Group 1 vs 159.1 seconds for Group 2). However, the stent removal time (152.1 seconds for Group 1 vs 35.4 seconds for Group 2) and pain intensity (6 for Group 1 vs 2 for Group 2) were significantly lower for Group 2. Furthermore, five out of the six sections of the USSQ showed significantly better results for Group 2. Conclusions: The use of magnetic ureteral stents, as a safe and efficient alternative to conventional ureteral stents, not only eliminates the need for cystoscopy but also conserves resources and reduces patient discomfort.

Varying the intensity of cystoscopic surveillance for high-risk non-muscle-invasive bladder cancer

OBJECTIVES

To compare the clinical, economic, and health utility outcomes associated with alternative cystoscopic surveillance regimens for high-risk non-muscle-invasive bladder cancer (HRNMIBC).

PATIENTS AND METHODS

We performed real-world clinical data-driven microsimulations of a hypothetical cohort of 100 000 patients diagnosed with HRNMIBC at age 70 years. The cohort was simulated to undergo alternative surveillance regimens recommended by five guidelines, and two hypothetical regimens-surveillance intensity escalation and de-escalation-which had a surveillance intensity moderately higher and lower, respectively, than the guideline-recommended regimens. We evaluated the 10-year cumulative incidence of muscle-invasive bladder cancer (MIBC), cancer-specific survival (CSS), overall survival (OS), and cost-effectiveness from a United States healthcare payer perspective.

RESULTS

The guideline-recommended surveillance regimens led to an estimated 10-year cumulative incidence of MIBC ranging from 11.0% to 11.6%, CSS 95.0% to 95.2%, and OS 69.7% to 69.8%. Surveillance intensity escalation resulted in a 10-year cumulative incidence of MIBC of 10.5% (95% confidence interval [CI] 10.3-10.7%), CSS of 95.4% (95% CI 95.2-95.5%), and OS of 69.9% (95% CI 69.6-70.1%), vs 11.9% (95% CI 11.7-12.1%), 94.9% (95% CI 94.8-95.1%), and 69.6% (95% CI 69.3-69.9%), respectively, from surveillance intensity de-escalation. By increasing surveillance intensity, the number-needed-to-treat to prevent one additional MIBC progression over 10 years was ≥80, and ≥257 to avoid one additional cancer-related mortality. Compared to surveillance intensity de-escalation, higher-intensity regimens incurred an incremental cost of ≥$336 000 per incremental quality-adjusted life year gained, which well exceeded conventional willingness-to-pay thresholds, ≥$686 000 per additional MIBC progression prevented, and ≥$2.2 million per additional cancer-related mortality avoided.

CONCLUSION

In microsimulations testing a wide range of cystoscopic surveillance intensity for patients newly diagnosed with HRNMIBC, moderate surveillance de-escalation appears associated with an insignificant change in 10-year OS and furthermore is cost-effective vs higher-intensity surveillance regimens. These results suggest that moderate surveillance de-escalation can reduce costs of care without compromising life expectancy for many patients.

Patient Satisfaction with a Novel Tele-Cystoscopy Model: Expanding Access to Bladder Cancer Surveillance for Rural Patients

Background

Tele-cystoscopy involves trained advanced practice providers performing cystoscopy with real-time interpretation by an urologist. The goal of this externally validated care model is to expand the availability of cystoscopy to underserved rural areas. Herein we report on population demographics and describe the socioeconomic benefits of tele-cystoscopy for bladder cancer surveillance.

Methods

Using an IRB-approved protocol, patients were consented for dual, sequential cystoscopy wherein they experienced a standard-of-care cystoscopy along with tele-cystoscopy. Patients completed a questionnaire that contained both subjective and objective health and socioeconomic-related questions as well as a satisfaction survey. Patients were also probed about factors associated with transportation to their cystoscopy appointments including gasoline costs, travel time, and time off work. Using the Distressed Community Index, patients were ascribed an economic resource category ranging from prosperous to distressed.

Results

In total, 48 patients with a mean age of 55 completed surveys after completing dual cystoscopies. Thirteen patients (27%) were uninsured and 10 patients (20%) had Medicaid as primary insurance. The tele-cystoscopy clinic saved patients an average of 235 miles and 434 min of travel time. In total, 82% of patients resided in a distressed community indicating fewer economic resources. Satisfaction results showed a mean score of 31.38 (out of 32).

Conclusions

Patients were satisfied with tele-cystoscopy, noting increased access to health care and fewer disruptions impacting bladder cancer surveillance. Tele-cystoscopy may be a viable option to expand access and improve adherence to guidelines for bladder cancer surveillance, particularly benefiting patients in rural areas and those of lower socioeconomic status.

An unexpected complication after removing bladder foreign body: a case report

Background

Bladder foreign bodies commonly arise as urgent issues in urology. These foreign bodies are typically extracted through cystoscopy or cystotomy. In general, these surgical approaches rarely lead to serious complications.

Methods

A 34-year-old woman presented with a one-year history of frequent urination, urgency, and urodynia. Abdominal computed tomography (CT) scan revealed the presence of an intrauterine device (IUD) [a medium-sized (20 mm × 22 mm) circular IUD] near the posterior bladder wall. The object was successfully removed via cystoscopy. Two months later, the patient exhibited food residues in her urine. Enterography demonstrated a large amount of contrast agent had entered the bladder from the small intestine. We repaired the bladder with catheter for 2 weeks, removed the segment of small intestine with fistula, and anastomosed the intestine canal.

Results

Post-operation urine tests yielded negative results, and the patient resumed a normal diet.

Conclusions

Evaluating the location between foreign body and bladder wall, which is based on medical history, CT scan, and cystoscopy examination, is essential for doctors before they remove the foreign body by cystoscopy or laparoscopy. It is necessary to check for leakage by applying radiopaque fluids under fluoroscopy after removing the foreign body, which migrates from other abdominal organs. If there is damage in the bladder or other organs, laparoscopic surgery or open surgery should be performed immediately.

Objective Evaluation of Gaze Location Patterns Using Eye Tracking During Cystoscopy and Artificial Intelligence-Assisted Lesion Detection

Background: The diagnostic accuracy of cystoscopy varies according to the knowledge and experience of the performing physician. In this study, we evaluated the difference in cystoscopic gaze location patterns between medical students and urologists and assessed the differences in their eye movements when simultaneously observing conventional cystoscopic images and images with lesions detected by artificial intelligence (AI). Methodology: Eye-tracking measurements were performed, and observation patterns of participants (24 medical students and 10 urologists) viewing images from routine cystoscopic videos were analyzed. The cystoscopic video was captured preoperatively in a case of initial-onset noninvasive bladder cancer with three low-lying papillary tumors in the posterior, anterior, and neck areas (urothelial carcinoma, high grade, and pTa). The viewpoint coordinates and stop times during observation were obtained using a noncontact type of gaze tracking and gaze measurement system for screen-based gaze tracking. In addition, observation patterns of medical students and urologists during parallel observation of conventional cystoscopic videos and AI-assisted lesion detection videos were compared. Results: Compared with medical students, urologists exhibited a significantly higher degree of stationary gaze entropy when viewing cystoscopic images (p < 0.05), suggesting that urologists with expertise in identifying lesions efficiently observed a broader range of bladder mucosal surfaces on the screen, presumably with the conscious intent of identifying pathologic changes. When the participants observed conventional and AI-assisted lesion detection images side by side, contrary to urologists, medical students showed a higher proportion of attention directed toward AI-detected lesion images. Conclusion: Eye-tracking measurements during cystoscopic image assessment revealed that experienced specialists efficiently observed a wide range of video screens during cystoscopy. In addition, this study revealed how lesion images detected by AI are viewed. Observation patterns of observers' gaze may have implications for assessing and improving proficiency and serving educational purposes. To the best of our knowledge, this is the first study to utilize eye tracking in cystoscopy. University of Tsukuba Hospital, clinical research reference number R02-122.

Methotrexate‑associated B‑cell lymphoproliferative disease that exhibits hematuria due to urinary bladder lesions: A case report

Methotrexate (MTX)-related lymphoproliferative disease (LPD) is one of the most prominent late complications associated with MTX treatment. Although MTX-related LPD exhibits a relatively high incidence of extranodal disease, the incidence of disease in a urinary bladder is very low. The present study reports the case of a patient with MTX-related LPD involving a urinary bladder mass. A 75-year-old female patient, who had been receiving MTX for ~15 years, was referred to the hospital due to fever and hematuria. A computed tomography scan revealed the thickening of the urinary bladder wall, hydronephrosis and lymph node swelling. The histopathological findings of the urinary bladder mass resulted in a diagnosis of MTX-related LPD. Although MTX withdrawal did not have any effect, the subsequent chemotherapy resulted in complete remission. Although MTX-related LPD in the bladder is rare, it is pertinent to consider MTX-related LPD when hematuria is observed during MTX therapy.

Intra/inter-observer reliability of cystoscopic sphincter evaluation in men undergoing sling surgery

OBJECTIVES

To assess the intra/inter-observer reliability of cystoscopic sphincter evaluation (CSE) in men undergoing sling surgery for urinary incontinence and if possible to evaluate its correlation with the final clinical decision.

PATIENTS AND METHODS

Two expert urologists prospectively filmed and recorded, incontinent patient's cystoscopies according to a standard scenario. Anonymised recordings where randomly offered to the same observer twice. The observers (medical students, urology residents and full urologist with 0-5, 5-10, >10 years of practice, respectively) were asked to assess and score the recordings without knowing any of the patients' characteristics.

RESULTS

In total, 37 recordings were scored twice by the 26 observers. The intraclass correlation coefficient (ICC) for intra-observer reliability of the CSE was 0.54 (moderate), 0.58 (moderate) and 0.60 (substantial) for medical students, residents, and urologists, respectively. However, when stratifying observers according to their experience, the lowest agreement values were found between experts with >10 years of experience. The inter-observer reliability for the CSE ICCs ranged between 0.31and 0.53, with the lowest ICC value observed between urologists (0.31).

CONCLUSIONS

The study demonstrates poor intra- and inter-observer reliability of the CSE. According to these results, a CSE does not add valuable information to the clinical evaluation. In this scenario, it should not be considered in isolation from the patient's characteristics.

Intrauterine device (IUD) embedded in bladder wall with calculus formation treated with cystoscopy: a case report

In the realm of unusual gynecological complications, the displacement of an intrauterine device (IUD) into the bladder, resulting in stone formation, stands out as an exceptionally rare and perplexing condition. Such occurrences challenge diagnostic and therapeutic protocols, often leading to unique case studies that expand our understanding of IUD-related complications. We present an interesting case of a 50-year-old woman with a stone-forming ectopic IUD in the bladder diagnosed with imaging modalities and treated with cystoscopy, with a subsequent resolution of symptoms. This case underscores the importance of considering ectopic IUD placement in the differential diagnosis of patients presenting with urinary symptoms and a history of IUD use. Moreover, it emphasizes the role of imaging in the accurate diagnosis of such cases and highlights cystoscopy as an effective treatment modality for the removal of IUD and stones.

Exploring the Histopathological Landscape of Urinary Bladder Diseases: A Tertiary Care Center Study

Introduction Urinary bladder lesions encompass a wide spectrum, from benign inflammatory conditions to malignant neoplasms, presenting diagnostic and therapeutic challenges. Urothelial carcinoma predominates among bladder malignancies, exhibiting diverse clinical presentations and prognoses. Objective This study aimed to delineate the histopathological spectrum of urinary bladder lesions and correlate demographic profiles, clinical features, and cystoscopic findings with various bladder lesions. Methods This prospective descriptive observational study spanned 24 months at a tertiary care center, involving 65 cases of urinary bladder biopsies, including transurethral resection of bladder tumors, cystoscopic biopsies, and cystectomy specimens. The histopathological examination followed the WHO 2022 classification of urinary bladder tumors and the American Joint Committee on Cancer eighth edition staging. Clinical data, including age, gender, cystoscopic findings, and presenting symptoms, were correlated with histopathological diagnoses to explore the spectrum of bladder lesions. Results Neoplastic lesions predominated, constituting 92.3% of cases, with urothelial carcinoma comprising 83.33% of these cases. Among neoplastic lesions, invasive high-grade urothelial carcinoma (36.7%) and non-invasive low-grade papillary urothelial neoplasm (20.0%) were the most frequently observed subtypes. Non-neoplastic lesions accounted for 7.7%, including various forms of cystitis. Hematuria was the predominant presenting symptom (81.5%), while cystoscopic examinations revealed that most lesions were situated in the lateral bladder wall. High-grade urothelial carcinomas were mostly associated with muscularis propria invasion. Conclusion This study underscores the critical role of histopathological examination in diagnosing and managing urinary bladder diseases and distinguishing between non-neoplastic and neoplastic lesions. Urothelial carcinoma, prevalent among older age groups, often demonstrated muscle invasion indicative of high-grade tumors. Including the muscle layer in cystoscopic biopsies is crucial for an accurate diagnosis. Conversely, though less common, non-neoplastic conditions encompass various forms of cystitis. These findings highlight the importance of precise diagnostic tools such as cystoscopy and histopathological examination for the early detection and management of bladder neoplasms. Histopathological assessment offers essential prognostic guidance, aids in precise staging and grading, and directs tailored treatment strategies.

Non-Muscle Invasive Bladder Cancer: Many More Patients Die With It Than Of It

BACKGROUND

The National Cancer Institute SEER Program regularly publishes bladder-cancer specific survival statistics. However, this data is for all bladder cancers, and information for non-muscle invasive bladder cancer (NMIBC) is difficult to obtain.

OBJECTIVE

To quantify 5-year overall and bladder cancer-specific survival in a cohort of Department of Veterans Affairs (VA) patients diagnosed with NMIBC.

METHODS

We identified VA patients diagnosed with NMIBC who underwent a transurethral resection from 2003-2013. The patient demographics and Charlson Comorbidity Index were categorized. We acquired the patients' date of death from the Veterans Health Administration's Death Ascertainment File and their cause of death from the Mortality Data Repository. We calculated Kaplan Meier estimates of survival.

RESULTS

A total of 27,008 patients were included; median age was 69 and almost all were male (99%). The median comorbidity score was 4. The most prevalent comorbidity indicators included Chronic Pulmonary Disease (48%), cancer other than Bladder (41%), and diabetes (40%). This cohort was found to have a 5-year overall survival of 68% (99% CI 67% -69%) and a 5-year bladder cancer-specific survival of 93% (99% CI 92% -94%).

CONCLUSIONS

The 5-year bladder cancer-specific survival in patients diagnosed with non-muscle invasive bladder cancer is substantially higher than the 5-year overall survival. This difference may be related to the severity and number of comorbidities that patients in this population must manage. This warrants further research into the necessity of currently recommended high-intensity cancer surveillance for individuals with NMIBC.

A Self-Induced Foreign Body in the Urinary Bladder of an Adolescent Female

In the pediatric population, foreign bodies within the urinary bladder are uncommon, typically resulting from urethral insertion out of curiosity. Other etiologies include sexual assault, iatrogenic factors, or migration from adjacent sites. Symptoms such as urinary retention, dysuria, increased frequency, decreased volume, nocturia, hematuria, painful erections, and pelvic pain are common. Radiographic imaging in the form of pelvic X-rays, ultrasound and CT scans often aids in diagnosis and making an action plan. Management depends on the object type, size, location and available expertise, often starting with a transurethral approach and resorting to open surgery if necessary. This case report describes a 13-year-old female presenting with severe dysuria and visible hematuria. Initially reporting the accidental insertion of a scarf pin into her vagina, she later admitted to intentionally inserting it. A pelvic radiograph revealed a needle-like object in the pelvis but its location and position were more convincing of its presence in the urinary bladder. A diagnostic cystoscopy was performed which confirmed a scarf pin in the urinary bladder, embedded in its wall. The pin was successfully removed transurethrally using endoscopic forceps.

Intravesical misplacement of vaginal contraceptive ring: a video report and review of the literature

Background

The NuvaRing®, a hormonal vaginal contraceptive device, has gained widespread usage due to its favourable efficacy and safety profiles. Exceedingly rare instances of unintended misplacement in the bladder have been reported. This study presents a review of the literature and the first video report illustrating the extraction of an intravesical NuvaRing®, discussing diagnostic and therapeutic approaches.

Objective

To illustrate an effective method for intravesical NuvaRing® retrieval and raise awareness about this unusual complication.

Materials and Methods

A 27-year-old patient with low urinary tract symptoms related to NuvaRing® misplacement underwent diagnostic procedures, including ultrasound and diagnostic cystoscopy. A cystoscopic extraction under general anaesthesia was performed.

Main outcome measures

The effectiveness of pelvic ultrasound for diagnosing an intravesical foreign body, successful cystoscopic removal of NuvaRing® from the bladder, and symptom resolution were assessed.

Results

The intravesical NuvaRing® was identified through pelvic ultrasound. During cystoscopy, the ring was detected inside the bladder. Multiple attempts with cystoscopic alligator graspers were made; the NuvaRing® was eventually extracted using transurethral Heiss forceps. The patient experienced minimal blood loss and was discharged the following day, reporting relief from symptoms.

Conclusions

Unintentional NuvaRing® placement in the bladder is an extremely rare event that healthcare providers should consider when patients present with urinary symptoms and pelvic pain. Pelvic ultrasound is an efficient diagnostic tool, possibly averting the need for further imaging techniques. Cystoscopy remains the preferred method for diagnosis and treatment. This video report illustrates an effective technique for NuvaRing ® extraction, especially when appropriate graspers are unavailable. Adequate instruction on NuvaRing® insertion should always be emphasised.

Unexpected Metastasis of Primary Colonic Adenocarcinoma: A Case Report and Literature Review

Colorectal cancer is a common cancer worldwide. The major sites of colorectal cancer metastasis are the liver, lungs, peritoneum, lymph nodes, and bones. However, secondary localization in the bladder is extremely rare. Herein, we present the case of a 36-year-old patient who underwent surgery for colonic adenocarcinoma. Subsequently, the patient presented total hematuria during adjuvant chemotherapy. Cystoscopy and biopsy identified a bladder metastasis. In our discussion, we aim to delve into the distinct characteristics of bladder metastases originating from digestive neoplasms.

Enhancing bladder cancer diagnosis through transitional cell carcinoma polyp detection and segmentation: an artificial intelligence powered deep learning solution

Background

Bladder cancer, specifically transitional cell carcinoma (TCC) polyps, presents a significant healthcare challenge worldwide. Accurate segmentation of TCC polyps in cystoscopy images is crucial for early diagnosis and urgent treatment. Deep learning models have shown promise in addressing this challenge.

Methods

We evaluated deep learning architectures, including Unetplusplus_vgg19, Unet_vgg11, and FPN_resnet34, trained on a dataset of annotated cystoscopy images of low quality.

Results

The models showed promise, with Unetplusplus_vgg19 and FPN_resnet34 exhibiting precision of 55.40 and 57.41%, respectively, suitable for clinical application without modifying existing treatment workflows.

Conclusion

Deep learning models demonstrate potential in TCC polyp segmentation, even when trained on lower-quality images, suggesting their viability in improving timely bladder cancer diagnosis without impacting the current clinical processes.

Fiberscopic pattern removal for optimal coverage in 3D bladder reconstructions of fiberscope cystoscopy videos

Purpose

In the current clinical standard of care, cystoscopic video is not routinely saved because it is cumbersome to review. Instead, clinicians rely on brief procedure notes and still frames to manage bladder pathology. Preserving discarded data via 3D reconstructions, which are convenient to review, has the potential to improve patient care. However, many clinical videos are collected by fiberscopes, which are lower cost but induce a pattern on frames that inhibit 3D reconstruction. The aim of our study is to remove the honeycomb-like pattern present in fiberscope-based cystoscopy videos to improve the quality of 3D bladder reconstructions.

Approach

Our study introduces an algorithm that applies a notch filtering mask in the Fourier domain to remove the honeycomb-like pattern from clinical cystoscopy videos collected by fiberscope as a preprocessing step to 3D reconstruction. We produce 3D reconstructions with the video before and after removing the pattern, which we compare with a metric termed the area of reconstruction coverage (A RC ), defined as the surface area (in pixels) of the reconstructed bladder. All statistical analyses use paired t -tests.

Results

Preprocessing using our method for pattern removal enabled reconstruction for all (n = 5 ) cystoscopy videos included in the study and produced a statistically significant increase in bladder coverage (p = 0.018 ).

Conclusions

This algorithm for pattern removal increases bladder coverage in 3D reconstructions and automates mask generation and application, which could aid implementation in time-starved clinical environments. The creation and use of 3D reconstructions can improve documentation of cystoscopic findings for future surgical navigation, thus improving patient treatment and outcomes.

Evaluation of a New Cystoscopic Cryocatheter and Method for the In Situ Destruction of Bladder Cancer: Preliminary In Vivo Study

Purpose: To assess the ability to deliver full-thickness bladder wall cryoablation through a cystoscopic approach using a new closed-loop 6F cryocatheter and thermal dose-controlled protocol. Materials and Methods: Evaluations were conducted using a chronic porcine model wherein 10 lesions/animal were created throughout the bladder (bladder wall, trigone region, ureteral orifice, and distal ureter). A 6F cryocatheter was passed through the working channel of a flexible cystoscope. Single 1- and 1.5-minute freeze protocols in a saline environment were evaluated and resultant lesion size was determined. A laparoscopic approach was utilized to observe the transmural extension of the ice propagation. Results: Studies demonstrated the generation of transmural lesions characterized by full-thickness histologic necrosis after freezing for 1.5 minutes regardless of tissue thickness (range 2-12 mm). All animals were found to have good overall health (maintained weight, appetite, mobility, and energy levels) throughout the recovery period. No significant deviations were noted in complete blood count and serum chemistry bloodwork except for elevated creatine kinase levels. Importantly, no fistulas or perforations were noted. Conclusions: The cryocatheter was able to rapidly and effectively freeze the bladder wall through a cystoscopic approach. The results showed the ability to consistently ablate an ∼1 cm diameter and up to 1.2 cm deep using a single 1.5-minute freeze protocol. Analysis of the ablation efficacy revealed ∼80% destruction within the frozen mass. Although further testing and refinement are needed, these studies demonstrate the potential of this new approach to provide a next-generation strategy for the treatment of bladder cancer.

Active Surveillance in Non-Muscle Invasive Bladder Cancer, the Potential Role of Biomarkers: A Systematic Review

Bladder cancer (BC) is the tenth most common cause of cancer worldwide and is the thirteenth leading cause of cancer mortality. The non-muscle invasive (NMI) variant represents 75% of cases and has a mortality rate of less than 1%; however, it has a high recurrence rate. The gold standard of management is transurethral resection in the case of new lesions. However, this is associated with significant morbidity and costs, so the reduction of these procedures would contribute to reducing complications, morbidity, and the burden to the health system associated with therapy. In this clinical scenario, strategies such as active surveillance have emerged that propose to manage low-risk BC with follow-up; however, due to the low evidence available, this is a strategy that is underutilized by clinicians. On the other hand, in the era of biomarkers, it is increasingly known how to use them as a tool in BC. Therefore, the aim of this review is to provide to clinical practitioners the evidence available to date on AS and the potential role of biomarkers in this therapeutic strategy in patients with low-grade/risk NMIBC. This is the first review linking use of biomarkers and active surveillance, including 29 articles.

Outcomes of Bladder Washout for the Treatment of Recurrent Urinary Tract Infections After Renal Transplantation

Background Current literature suggests that anywhere from 2.9-27% of renal transplant recipients (RTR) will develop recurrent urinary tract infections (UTIs) (≥2 UTIs over six months or ≥3 UTIs over 12 months). Recurrent UTIs are of particular importance to RTR given its increased risk for allograft fibrosis and overall patient survival. Alternative solutions are needed for the management of recurrent UTIs, especially given the vulnerability of RTR to UTIs. We hypothesize that bladder washout (BW) reduces the incidence and recurrence of UTIs in RTR. Methods This is a retrospective study evaluating the utility of BW procedures on RTR diagnosed with recurrent UTIs between December 2013 and July 2021 at a single center. Results A total of 106 patients were included in the study with a total of 118 BW performed. 69% of patients were successfully treated with BW, meaning they no longer met the criteria for recurrent UTIs (<1 UTI) in the six-month post-BW period. The mean number of UTIs was 2.76 (range 2-7) before the BW and 1.16 (range 0-5) after the BW. On average, there were 1.60 fewer UTIs in the post-BW period compared to the pre-BW period (p<0.0001). There is no statistically significant difference in success rates stratified by bacterial class (p=1) or antimicrobial resistance class (p=0.6937). Conclusion BW decreased the incidence of UTIs in the six-month post-operative period as nearly 70% of patients did not have UTI recurrence. This data provides evidence that BW may have utility in transplant recipients with recurrent UTIs. We hope this will stimulate further prospective randomized studies in this area.

Optimizing practices to prevent urinary tract infection after cystoscopy and urodynamics in women: A quality improvement study

OBJECTIVE

The objective of this study was to reduce the incidence of urinary tract infection (UTI) in women undergoing outpatient cystoscopy and/or urodynamic studies (UDS) at our centre by identifying and then altering modifiable risk factors through an analysis of incidence variability among physicians.

METHODS

This was a quality improvement study involving adult women undergoing outpatient cystoscopy and/or UDS at an academic tertiary urogynecology practice. Prophylactic practices for cystoscopy/UDS were surveyed and division and physician-specific UTI rates following cystoscopy/UDS were established. In consultation with key stakeholders, this delineated change concepts based on associations between prophylactic practices and UTI incidence, which were then implemented while monitoring counterbalance measures.

RESULTS

Two "Plan-Do-Study-Act-Cycles" were conducted whereby 212 and 210 women were recruited, respectively. Change concepts developed and implemented were: (1) to perform routine urine cultures at the time of these outpatient procedures, and (2) to withhold routine prophylactic antibiotics for outpatient cystoscopy/UDS, except in patients with signs of cystitis. There was no change in the incidence of early presenting UTI (9.0% vs. 9.2%, p = 0.680), but there were significantly fewer antibiotic-related adverse events reported (8.5% vs. 1.5%, p = 0.001). There was no significant change in the total incidence of UTI rates between cycles (7.8% vs. 5.6%, p = 0.649).

CONCLUSIONS

No specific strategies to decrease the incidence of UTI following outpatient cystoscopy/UDS were identified, however, risk factor-specific antibiotic prophylaxis, as opposed to universal antibiotic prophylaxis, did not increase UTI incidence.

Diagnostic value of repeated comprehensive investigation with CT urography and cystoscopy for recurrent macroscopic haematuria

Objectives

To perform a descriptive analysis of a series of patients with recurrent macroscopic haematuria after a primary standard evaluation including computed tomography urography (CTU) and cystoscopy negative for urinary bladder cancer (UBC) and upper tract urothelial cancer (UTUC) and to identify potential factors associated with occurrence of recurrent macroscopic haematuria.

Methods

All patients older than 50 years who underwent urological investigation for macroscopic haematuria with both cystoscopy and CTU 2015-2017 were retrospectively reviewed. A descriptive analysis of the primary and later investigations for recurrent macroscopic haematuria was performed. To investigate the association between explanatory variables and the occurrence of recurrent macroscopic haematuria, a Poisson regression analysis was performed.

Results

A total of 1395 eligible individuals with primary standard investigation negative for UBC and UTUC were included. During a median follow-up of 6.2 (IQR 5.3-7) years, 248 (18%) patients had recurrent macroscopic haematuria, of whom six patients were diagnosed with UBC, two with prostate cancer, one with renal cell carcinoma and one had a suspected UTUC at the repeated investigation. Within 3 years, 148 patients (11%) experienced recurrent macroscopic haematuria, of whom two patients were diagnosed with low-grade UBC (TaG1-2), one with T2G3 UBC and one with low-risk prostate cancer. The presence of an indwelling catheter, use of antithrombotic medication, pathological findings at CTU or cystoscopy or history of pelvic radiotherapy were all statistically significant independent predictors for increased risk for recurrent macroscopic haematuria.

Conclusion

In the case of recurrent macroscopic haematuria within 3 years of primary standard evaluation for urinary tract cancer, there was a low risk of later urological malignancies in patients initially negative for UBC and UTUC. Therefore, waiting 3 years before conducting another complete investigation in cases of recurrent macroscopic haematuria might be appropriate.