Environmental Impact of Flexible Cystoscopy: A Comparative Analysis Between Carbon Footprint of Isiris® Single-Use Cystoscope and Reusable Flexible Cystoscope and a Systematic Review of Literature

Introduction: There is an absence of data on the environmental impact of single-use flexible cystoscopes. We wanted to review the existing literature about carbon footprint of flexible cystoscopy and analyze the environmental impact of the Isiris® (Coloplast©) single-use flexible cystoscope compared to reusable flexible cystoscopes. Methods: First, a systematic review on single-use and reusable cystoscope carbon footprint was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Second, carbon footprints of Isiris single-use flexible cystoscope and reusable cystoscope were analyzed and compared. Life cycle of the single-use flexible cystoscope was divided in three steps: manufacturing, sterilization, and disposal. For the reusable cystoscope, several steps were considered to estimate the carbon footprint over the life cycle: manufacturing, washing/sterilization, repackaging, repair, and disposal. For each step, the carbon footprint values were collected and adapted from previous comparable published data on flexible ureteroscope. Results: The systematic literature review evidenced total carbon emissions within a range of 2.06 to 2.41 kg carbon dioxide (CO2) per each use of single-use flexible cystoscope compared to a wide range of 0.53 to 4.23 kg CO2 per each case of reusable flexible cystoscope. The carbon footprint comparative analysis between Isiris single-use flexible cystoscope and reusable cystoscope concluded in favor of the single-use cystoscope. Based on our calculation, the total carbon emissions for a reusable flexible cystoscope could be refined to an estimated range of 2.40 to 3.99 kg CO2 per case, depending on the endoscopic activity of the unit, and to 1.76 kg CO2 per case for Isiris single-use cystoscope. Conclusion: The results and our systematic literature review demonstrated disparate results depending on the calculation method used for carbon footprint analysis. However, the results tend rather toward a lower environmental impact of single-use devices. In comparison to a reusable flexible cystoscope, Isiris compared favorably in terms of carbon footprint.

Workflow efficiencies for flexible cystoscopy: comparing single-use vs reusable cystoscopes

BACKGROUND

Flexible cystoscopy is a common procedure to diagnose and treat lower urinary tract conditions. Single-use cystoscopes have been introduced to eliminate time-consuming reprocessing and costly repairs. We compared the hands-on labor time differences between flexible reusable cystoscopes versus Ambu's aScope™ 4 Cysto (aS4C) at a large urology Ambulatory Surgery Center (ASC).

METHODS

Reusable and single-use cystoscopy procedures were shadowed for timestamp collection for setup and breakdown. A subset of reusable cystoscopes were followed through the reprocessing cycle. T-tests were calculated to measure the significance between groups.

RESULTS

The average hands-on time necessary for reusable cystoscope preparation, breakdown, and pre-cleaning was 4'53″. Of this, 2'53″ were required for preparation, while 2'0″ were required for breakdown and pre-cleaning. The average hands-on time for reprocessing for reusable was 7'1" per cycle. The total time for single-use scopes was 2'22″. Of this, 1'36″ was needed for single-use preparation, and 45 s for breakdown. Compared to reusable cystoscopes, single-use cystoscopes significantly reduced pre and post-procedure hands-on labor time by 2'31", or 48%. When including reprocessing, total hands-on time was 80% greater for reusable than single-use cystoscopes.

CONCLUSION

Single-use cystoscopes significantly reduced hands-on labor time compared to reusable cystoscopes. On average, the facility saw a reduction of 2'31″ per cystoscope for each procedure. This translates to 20 additional minutes gained per day, based on an 8 procedures per day. Utilizing single-use cystoscopes enabled the facility to reduce patient wait times, decrease turnaround times, and free up staff time.

Forgotten ureteral stents: a systematic review of literature

BACKGROUND

The forgotten ureteral stents (FUS) is one of the late complications of stent placement. This systematic review summarized different aspects of FUS and focused on the problems and solutions related to FUS.

METHODS

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. PubMed® and Embase® were searched from inception until October 1st, 2022. Eligible studies were those defining FUS as a stent unintentionally left in situ longer than at least 2 months.

RESULTS

Total 147 studies with 1292 patients were finally included. The mean indwelling time of FUS was 33.5 months (range from 3 months to 32 years). The most common initial cause for stent placement was adjunct treatment to urolithiasis (79.2%). The major forgetting reasons were patient-related (83.9%), which included poor compliance, lapse in memory, and misconceptions about the necessity of timely removal. Primary presenting complaints were flank pain (37.3%), lower urinary tract symptoms (33.3%), and hematuria (22.8%). Encrustation (80.8%) and urinary tract infections (40.2%) were the most common complications detected in patients with FUS. Computed tomography evolving as a preferred imaging test (76.1%) was indispensable for evaluating encrustation, migration, fracture and other complicated situations in patients with FUS. Besides, evaluation of kidney function and infection status was also of great importance. Multiple and multimodal procedures (59.0%) were often necessitated to achieve the stent-free status, and were mostly endoscopic procedures. Cystoscope was most commonly used (64.8%). Retrograde ureteroscopy (43.4%) and antegrade stent removal (31.6%) were often used when dealing with more complicated situations. Extracorporeal shockwave lithotripsy (30.4%) was often used as adjunctive to other endoscopic procedures, but it sometimes failed. The decision regarding the choice of treatment is based on the volume and site of encrustation, the direction of migration, the site of fracture, kidney function and other urinary comorbidities.

CONCLUSIONS

FUS not only pose hazard to patients' health, but also impose a huge economic burden on medical care. Thorough preoperative evaluation is fundamental to developing the treatment strategy. The management of FUS should be individualized using different treatment modalities with their advantages to minimize patients' morbidities. Prevention is better than cure. Strengthening health education and setting a tracking program are of great importance to the prevention of FUS.

Time Efficiency and Performance of Single-Use vs Reusable Cystoscopes: A Randomized Benchtop and Simulated Clinical Assessment

Introduction: A flexible cystoscope is an indispensable tool for urologists, facilitating a variety of procedures in both the operating room and at bedside. Single-use cystoscopes offer benefits including accessibility and decreased burden for reprocessing. The aims of this study were to compare time efficiency and performance of single-use and reusable cystoscopes. Methods: Ten new Ambu® aScope™ 4 Cysto single-use and two Olympus CYF-5 reusable cystoscopes were compared in simulated bedside cystoscopy and benchtop testing. Ten urologists performed simulated cystoscopy using both cystoscopes in a randomized order. Times for supply-gathering, setup, cystoscopy, cleanup, and cumulative time were recorded, followed by a Likert feedback survey. For benchtop assessment, physical, optical, and functional specifications were assessed and compared between cystoscopes. Results: The single-use cystoscope demonstrated shorter supply-gathering, setup, cleanup, and cumulative times (824 vs 1231 seconds; p < 0.05) but a comparable cystoscopy time to the reusable cystoscope (202 vs 212 seconds; p = 0.32). The single-use cystoscope had a higher image resolution, but a narrower field of view. Upward deflection was greater for the single-use cystoscope (214.50° vs 199.45°; p < 0.01) but required greater force (2.5 × ). The working channel diameter and irrigation rate were greater in the reusable cystoscope. While the single-use cystoscope lacked tumor enhancing optical features, it had higher Likert scale scores for Time Efficiency and Overall Satisfaction. Conclusion: The single-use cystoscope demonstrates comparable benchtop performance and superior time efficiency compared to reusable cystoscopes. However, the reusable cystoscope has superior optical versatility and flow rate. Knowledge of these differences allows for optimal cystoscope selection based on procedure indication.

The impact of single-use digital flexible cystoscope for double J removal on hospital costs and work organization: A multicentric evaluation

BACKGROUND

Isiris-α® is a single-use digital flexible cystoscope with an integrated grasper designed for double J (DJ) stent removal. Aim of this study was to conduct a multicentric evaluation of the costs and criticalities of stent removals performed with Isiris®-α in different hospitals and health systems, as compared to other DJ removal procedures.

METHODS

After gathering 10 institutions worldwide with experience on Isiris-α®, we performed an analysis of the reported costs of DJ removal with Isiris-α®, as compared to the traditional reusable equipment used in each institution. The cost evaluation included instrument purchase, Endoscopic Room (EnR)/ Operatory Room (OR) occupancy, medical staff, instrument disposal, maintenance, repairs, decontamination or sterilization of reusable devices.

RESULTS

The main factor affecting the costs of the procedure was OR/EnR occupancy. Decontamination and sterilization accounted for a less important part of total costs. Isiris-α® was more profitable in institutions where DJ removal is usually performed in the EnR/OR, allowing to transfer the procedure to outpatient clinic, with a significant cost saving and EnR/OR time saving to be allocated to other activities. In the only institution where DJ removal was already performed in outpatient clinics, there is a slight cost difference in favor of reusable instruments in high-volume institutions, given a sufficient number to guarantee the turnover.

CONCLUSION

Isiris-α® leads to significant cost benefit in the institutions where DJ removal is routinely performed in EnR/OR, and brings significant improvement in organization, cost impact and turnover.

Single-use digital flexible cystoscope for double J removal versus reusable instruments: a prospective, comparative study of functionality, risk of infection, and costs

BACKGROUND

The removal of ureteral stent can be performed with disposable or reusable flexible cystoscopes, but limited comparative data are available on functionality, risk of infections, and costs.

METHODS

We performed a multicentric, prospective, observational study on patients undergoing in-office ureteral stent removal with Isiris-α® or a reusable Storz™ flexible cystoscope. Study endpoints were the functionality and effectiveness of the devices, the rate of postoperative bacteriuria and UTIs, and the costs of the procedure.

RESULTS

A total of 135 patients were included, 80 (59.2%) treated with reusable cystoscopes and 55 (40.8%) with Isiris-α®. No significant baseline differences between groups were detected. Isiris-α® outperformed the reusable device in terms of quality of vision (p 0.001), manoeuvrability (p 0.001), grasper functionality (p < 0.001), and quality of the procedure (p 0.01). Mean procedure time was shorter with Isiris-α® (p < 0.001) due to a shorter instrument preparation time (p < 0.001). No differences were found in terms of perceived patient pain (p 0.34), nor postoperative bacteriuria or symptomatic UTIs. According to our cost analysis, the in-office procedure performed with Isiris-α® was more expensive (+ 137.8€) but was independent from instrument turnover or disinfection. Among limitations of study we acknowledge the lack of randomization, the use of antibiotic prophylaxis in several patients, and the high rate of missing preoperative urine cultures.

CONCLUSIONS

Isiris-α® outperforms reusable cystoscopes for in-office ureteral stent removal in terms of total operative time and quality of the procedure, at the cost of being more expensive. No significant differences in postoperative bacteriuria or symptomatic UTIs were found.

Wireless Cystoscope the Future of Cystoscopy (With Video)

Background: The first modern cystoscope was developed with the invention of rod lens and optical fibers in the 1960s. Since then, many advances have been made in functionality and camera image analysis. The cost of purchasing equipment and volume of the endoscopic tower remains a challenge and a barrier to the spread of cystoscopy. Urinary tract injury is a significant complication in women undergoing gynecologic surgery. Selective intraoperative cystoscopy at laparoscopic hysterectomy or complex pelvic surgery is valuable for recognizing lower urinary tract injuries. We have developed a novel wireless cystoscope for performing diagnostic and operative cystoscopy. Methods: The new wireless cystoscopic setup consists of a rigid cystoscope 4 mm, 30° that joins a modified action camera to a c-mount adapter f 18-35 mm and a portable led light source. Results: The new setup has so far been effectively used in more than 50 diagnostic cystoscopies and pigtail catheter replacements without complications. Two cases performed with the new setup are presented in the video. Conclusions: The new cystoscopic setup has the advantage of a wireless video camera, 4K ultraHD, and is easy setup. Due to its low cost and portability, the wireless cystoscope is easy to obtain and use. Also, it is invaluable and ergonomic in managing the integrity or pathology of the bladder, urethra, and ureters.

Utilising alternative cystoscopic schedules to minimise cost and patient burden after trimodality therapy for muscle-invasive bladder cancer

BACKGROUND

To assess urinary symptoms and urine cytology as screening tools for cystoscopic detection of local recurrence after bladder-preserving trimodality treatment (TMT).

METHODS

Patients with muscle-invasive bladder cancer receiving definitive TMT follow-up three monthly for 2 years, six monthly for the next 3 years and then yearly, with a clinical review, urine cytology and cystoscopy at each visit (triple assessment, TA). Grade 2+ cystitis/haematuria absent/present was scored 0/1, and urine cytology reported negative/suspicious or positive was scored 0/1, respectively. The performance of these two parameters for predicting local recurrence in cystoscopic biopsy was tested. Other hypothetical surveillance schedules included cystoscopy on alternate visits (COAV), or suspected recurrence (COSR), six-monthly COSR and six-monthly TA.

RESULTS

A total of 630 follow-up visits in 112 patients with 19 recurrences (7 muscle invasive, 12 non-muscle invasive) at a median follow-up of 19 months were analysed. The sensitivity and specificity of clinical symptoms were 47.4% and 92%, and for urine cytology 58% and 85%, respectively. The combination of clinical symptoms and cytology (COSR) was 95% sensitive and 78% specific for local recurrence but 100% sensitive for muscle-invasive recurrence. Both COAV and COSV schedules showed a high area under the curve (AUC) for detecting local recurrence (COAV = 0.84, COSR = 0.83), muscle-invasive recurrence (AUC = 0.848 each) and non-muscle-invasive recurrence (COAV = 0.82, COSR = 0.81); reducing the need for TAs by 64% and 67% respectively, and overall cost by 18% and 33%, respectively.

CONCLUSION

Cystoscopy at suspected recurrence during follow-up is safe and the most cost-effective for detecting muscle-invasive local recurrences, while cystoscopy at alternate visits may be more optimal for detecting any local recurrence.

Prospective Analysis of Versatility and User Satisfaction with a Novel Single-Use Cystoscope with Working Channel

INTRODUCTION

In the present study, a prospective systematic assessment of the clinical utility of the Ambu® aScopeTM 4 Cysto Reverse Deflection with regard to image quality, maneuverability, and navigation in an outpatient and inpatient setting was performed.

MATERIALS AND METHODS

A prospective multicenter study was performed for evaluation of the instrument during routine cystoscopy. We evaluated the clinical performance of the instruments using a standardized user questionnaire in different categories including image quality, treatment success, imaging of all areas of the urinary bladder, quality of navigation, flexibility of the endoscope, and satisfaction with the device. Statistical analyses were performed by SPSS using the Kruskal-Wallis and Wilcoxon-Mann-Whitney tests. A p value of p ≤ 0.05 was defined as statistically significant.

RESULTS

A total of 200 cystoscopies were performed, and the questionnaire response rate was 100%. The image quality was rated as very good in 65.5% (n = 131), good in 30.5% (n = 61), and neutral in 4% (n = 8) of cases. The criteria for poor or very poor were not mentioned. The characteristic "treatment success based on image quality" was also evaluated as very good in 49% (n = 98) and good in 50.5% (n = 101). The analysis revealed a very good or good overall impression of the examiners in all cases. Replacement of the cystoscope was not necessary during any of the examinations. However, in 3 cases, technical difficulties were documented. Further analysis of the data showed that physicians with less professional experience rated the visualization of the urinary bladder (p = 0.007) and the treatment success with regard to image quality significantly worse (p = 0.007).

CONCLUSION

The Ambu® aScope™ 4 Cysto Reverse Deflection shows high satisfaction values among users in clinical routine. In analogy to other studies with flexible endoscopes, urologists with more professional experience show higher satisfaction values than examiners with less training in flexible endoscopy.

Reusable vs. single-use cystoscope for removal of double-j stent: a prospective randomized comparison and cost analysis

OBJECTIVE

Two main types of cystoscopes, reusable cystoscope (RC) and disposable cystoscope, (DC) are used for the removal of ureteric stents. This study aimed to prospectively compare the effectiveness of disposable and reusable cystoscopes for the removal of ureteric stents.

PATIENTS AND METHODS

Patients who recently underwent double-J stent insertion were recruited and randomly assigned to the disposable and reusable cystoscope groups. Data were collected prospectively, which included pain scores (10-point visual analog scale), operation time, complications, and a 5-point Likert scale satisfaction assessment for surgeons, nurses, and patients. A cost analysis was also performed. The association between categorical data was assessed using the Chi-square/Fisher's exact test. The t-test was used to assess the mean difference in surgery time.

RESULTS

Overall, 128 patients (mean age, 46.8 years) were included in the study; 64 procedures were completed using each cystoscope type. Stent removal satisfaction among surgeons and patients was equivalent in both groups, while nurses favored the disposable cystoscope. A significant reduction of 23% in the procedural time and 27% in the total operative time was observed in the disposable cystoscope group. Pain score was the same for both groups. Two patients in the reusable cystoscope group had UTI. No complications were reported in the disposable cystoscope group.

CONCLUSIONS

Both disposable and reusable cystoscopes are comparable in terms of pain score and surgeons' and patients' satisfaction. Disposable cystoscope is more cost effective than reusable cystoscope.

A Flexible Cystoscope Based on Hydrodynamic Cavitation for Tumor Tissue Ablation

OBJECTIVE

Hydrodynamic cavitation is characterized by the formation of bubbles inside a flow due to local reduction of pressure below the saturation vapor pressure. The resulting growth and violent collapse of bubbles lead to a huge amount of released energy. This energy can be implemented in different fields such as heat transfer enhancement, wastewater treatment and chemical reactions. In this study, a cystoscope based on small scale hydrodynamic cavitation was designed and fabricated to exploit the destructive energy of cavitation bubbles for treatment of tumor tissues. The developed device is equipped with a control system, which regulates the movement of the cystoscope in different directions. According to our experiments, the fabricated cystoscope was able to locate the target and expose cavitating flow to the target continuously and accurately. The designed cavitation probe embedded into the cystoscope caused a significant damage to prostate cancer and bladder cancer tissues within less than 15 minutes. The results of our experiments showed that the cavitation probe could be easily coupled with endoscopic devices because of its small diameter. We successfully integrated a biomedical camera, a suction tube, tendon cables, and the cavitation probe into a 6.7 mm diameter cystoscope, which could be controlled smoothly and accurately via a control system. The developed device is considered as a mechanical ablation therapy, can be a solid alternative for minimally invasive tissue ablation methods such as radiofrequency (RF) and laser ablation, and could have lower side effects compared to ultrasound therapy and cryoablation.

Preclinical and Clinical Evaluation of a Novel, Variable-View, Rigid Endoscope for Female Cystoscopy

OBJECTIVE

To evaluate the preclinical and clinical performance of the pivoting lens rigid Endocameleon (ECAM) endoscope in white light cystoscopy (WLC).

MATERIALS AND METHODS

Preclinical evaluation was performed ex vivo in CT-based, anatomically accurate and validated bladder phantoms. Six defined tasks with objective endpoints were compared between ECAM-WLC and rigid WLC (30° view angle, rWLC) in 30 interventions. Subsequently, the comparison was transferred to in vivo n = 21 interventions. A validated usability score (System Usability Scale, SUS) as well as physician and patient-related outcomes were assessed using Likert-scale-based questionnaires. Intra- and postinterventional complications were recorded according to the Clavien-Dindo classification.

RESULTS

The ex vivo evaluation showed a significant superiority of ECAM-WLC in 4 of 6 endoscopic tasks. Noteworthy is the lower pressure on the bladder neck due to the endoscopesalteration of the endoscope (4/60 vs 17/60, P <.0001) and a more precise imaging of all bladder regions (22/30 vs 30/30, P = .046), including the anterior wall (0/30 vs 28/30, P <.0001). In vivo, surgeons rated the ECAM-WLC with an "excellent" SUS of 86.79%, also expressing that ECAM-WLC would enhance bladder surface visualization (4.52/5.0 ± 0.51), with a preferred use for ECAM-WLC during their next cystoscopy (4.62 ± 0.50). Patients reported ECAM-WLC to be less painful (4.5/5.0 ± 0.84) compared to rWLC. No intervention-related complications were observed.

CONCLUSION

ECAM-WLC is a safe and accessible procedure that could improve conventional diagnostic WLC by combination of the advantages of fWLC and rWLC.

Urethral Stricture Disease: Evaluation of the Male Urethra

The diagnosis of urethral stricture disease is often made when a man with obstructive voiding symptoms undergoes flexible cystoscopy (urethroscopy). However, a more complete and definitive diagnosis is then achieved when the urethra is subsequently evaluated with a retrograde urethrogram, and in many cases, a voiding cystourethrogram (VCUG). In situations where there is stricture disease involving the meatus or fossa navicularis that prevents the passage of adult flexible cystoscope, other testing appropriate in these cases include distal urethral calibration using bougie-a-boules and possibly the advancement of a pediatric cystoscope. It is only after the exact location and length and severity of the stricture is assessed that patients can be properly advised of all options before decision-making and the implementation of a treatment plan. This section will review the evaluation of the male urethra.

[Flexible cystoscope for the treatment of urinary stones in intestinal reservoirs.]

OBJECTIVE

Stones are common mid- and long-term complications in urinary diversions built with bowel. However the reservoir intestinal loops can lead to difficult endoscopic approach.

METHODS

We report two challenging cases with unfavourable anatomy successfully treated by gently handling a flexible cystoscope in a low pressure system.

RESULTS

One patient with stones in a continent pouch was cleaned up with a grasping basket through the efferent umbilical limb. Another patient with an orthotopic ileal neobladder not accessible by rigid cystoscope due to high pelvic floor was treated with holmiun laser lithotripsy.

CONCLUSIONS

Urologists should consider the versatility of flexible cystoscope to obviate the need for percutaneous lithotripsy or open lithotomy.

Cavoscopy in the surgical treatment of renal cell carcinoma with vena cava thrombus. Systematic review

OBJECTIVE

To perform a literature review on the use of cavoscopy during surgery for renal cell carcinoma with vena cava thrombus (RCCVCT), according to the criteria of Evidence-Based Medicine.

MATERIAL AND METHODS

We performed a Pubmed search for studies published with the following keywords: "renal tumor thrombus", "renal tumor cavoscopy" and "cystoscopy thrombus", without time limit and in English. With these criteria, 5 articles were identified with a total of 41 patients. All studies found are case series and expert opinions, so the degree of evidence in the use of cavoscopy in RCCVCT is low.

RESULTS

RCCVCT surgery is a complex technique, which can reach over 50% 5-year survival, when a complete oncological resection is achieved. One of the keys for surgical success is complete resection of tumor thrombus, having used different techniques for its verification. One of them is cavoscopy, which consists on the introduction of a flexible cystoscope through the cavotomy incision after thrombectomy, checking the lumen of the vena cava with saline serum irrigation. In two series of clinical cases, cavoscopy detected thrombus persistence in 22% and 43% of patients respectively, allowing resection. The entire resected thrombus showed malignancy in several cases.

CONCLUSION

Cavoscopy is a technique that improves detection of tumor remnants after thrombectomy in comparison to indirect review methods. Although oncological impact of caval thrombus is controversial, the use of cavoscopy allows a more complete resection of the thrombus, and it may offer a possible increase in the recurrence-free survival of these patients.

Use of flexible cystoscopy at time of artificial urinary sphincter placement

INTRODUCTION

Artificial urinary sphincters (AUS) are used to treat significant urinary incontinence. Flexible cystoscopy at the time of AUS placement provides relevant intraoperative feedback including confirmation that the AUS is functioning, visualization of coaptation, and evaluation for urethral injury. Current guidelines for placement of an AUS do not include flexible cystoscopy. The objective was to evaluate whether flexible cystoscopy at time of AUS placement changed cuff size at the time of surgery.

MATERIALS AND METHODS

A retrospective cohort study was performed to evaluate all patients undergoing AUS placement by a single surgeon between March 2013 and March 2017. The primary endpoint of the study was change in cuff size based on cystoscopy.

RESULTS

A total of 109 AUS were placed in 96 patients. In five (4.6%) cases flexible cystoscopy identified a lack of coaptation of the urethra despite appropriate sizing which resulted in down-sizing of the cuff. Five patients were identified as having a bladder neck contracture that was previously unrecognized as clinic cystoscopy was performed by the referring urologist and was reportedly normal. Three patients developed postoperative infections, two of these patients had a history of multiple AUS placement and revisions and the third patient had a history of cystectomy and neobladder.

CONCLUSIONS

Flexible cystoscopy at time of AUS placement changed the cuff size in nearly 5% of cases. Flexible cystoscopy at time of AUS placement provides valuable feedback and should be recommended for low volume prosthetic surgeons.

[Influence of systematic antibiotic prophylaxis and/or cystoscope cleaning/disinfecting method on urinary culture becoming positive after outpatient flexible cystoscopy.]

INTRODUCTION AND OBJECTIVES

To evaluate the efficacy of antibiotic prophylaxis as well as the cleaning/disinfection procedures to prevent urinary tract infection in patients undergoing office flexible cystoscopy.

METHODS

A prospective, randomized study was performed between June 2015 to May 2016 including every patient who underwent flexible cystoscopy at the Urology outpatient unit. Patients with temporary or permanent urinary stents were excluded from the study as well as procedures that involved bladder biopsies. A total of 251 patients were recruited. Urinary culture was collected in all of the patients before and after the procedure. Patients were randomized in two groups: Antibiotic prophylaxis versus no prophylaxis. Antibiotic prophylaxis consisted in 4 doses of Norfloxacin ( 400mg ): twice a day during two days. Three different cleaning/ disinfection methods were used: manual adasport (5% peracetic acid), manual oxide (instrunet sporicidal; Inibsa) and washing machine (Olympus, mini ETD 2). Demographic characteristics such as gender and age were collected during the study. Relationship between antibiotic prophylaxis, type of cleaning/disinfection procedure, demographic characteristics and positive urinary culture after procedure were analysed. Measures to avoid bias: Randomization.

RESULTS

Urinary culture before cystoscopy was negative in 231 patients (92.4%), positive in 19 (7.6%) and not valid in 1. After randomization, 129 patients were included in Group 1(no prophylaxis) and 117 in Group 2 (antibiotic prophylaxis), 5 patients dropped from the study. After-procedure culture was negative in 224 patients (91.1%) and positive in 22 (8.9%). There was no statistical significance between urine culture results before and after cystoscopy and the demographic characteristics collected. Furthermore, no statistical differences were seen between urine culture after cystoscopy and cystoscope cleaning method ( p = 0.7), or between urine culture and type of cleaning with or without antibiotic prophylaxis ( p = 0.5, p = 0.9 ).

CONCLUSIONS

None of the analyzed variables influenced the positivity of urine culture after flexible cystoscopy. Routine antibiotic prophylaxis should not be further recommended.

Blue light flexible cystoscopy with hexaminolevulinate in non-muscle-invasive bladder cancer: review of the clinical evidence and consensus statement on optimal use in the USA - update 2018

Blue light cystoscopy (BLC) with hexaminolevulinate (HAL) during transurethral resection of bladder cancer improves detection of non-muscle-invasive bladder cancer (NMIBC) and reduces recurrence rates. Flexible BLC was approved by the FDA in 2018 for use in the surveillance setting and was demonstrated to improve detection. Results of a phase III prospective multicentre study of blue light flexible cystoscopy (BLFC) in surveillance of intermediate-risk and high-risk NMIBC showed that 20.6% of malignancies were identified only by BLFC. Improved detection rates in the surveillance setting are anticipated to lead to improved clinical outcomes by reducing future recurrences and earlier identification of tumours that are unresponsive to therapy. Thus, BLFC has a role in surveillance cystoscopy, and determining which patients will benefit from BLFC and optimal and cost-effective ways of incorporating this technology into surveillance cystoscopy must be developed.

[Spiral thermo-expandable prostatic stent implantation for benign prostatic hyperplasia: Clinical analysis of 26 cases]

OBJECTIVE

To investigate the surgical techniques and clinical effect of Memokath transurethral spiral thermo-expandable prostatic stent (STEPS) implantation in the treatment of BPH.

METHODS

From January 2017 to January 2018, 26 BPH patients underwent Memokath transurethral STEPS implantation, 9 under the flexible cystoscope and the other 17 under the rigid cystoscope. The patients were aged 62－91 years old, with a prostate volume of 32－78 ml, postvoid residual urine volume (PVR) of (67.3 ± 11.2) ml, maximum urinary flow rate (Qmax) of (6.3 ± 1.8) ml/s, and IPSS score of 26.7 ± 5.7. Eight of the patients had preoperative urinary retention, of whom, 6 received catheterization and 2 had undergone cystostomy for bladder fistula before STEPS implantation.

RESULTS

The operations lasted 15－30 minutes and were successfully completed in 24 cases while stent-shedding occurred in the other 2. Twenty-two of the patients achieved spontaneous urination immediately after surgery and 2 experienced bladder clot embolism. At 3 month after surgery, 24 of the patients showed significant improvement in PVR (［21.4 ± 7.7］ ml), Qmax (［18.3 ± 4.7］ ml/s) and IPSS (8.3 ± 2.1), and 13 exhibited no statistically significant difference from the baseline in the IIEF-5 score (14.1 ± 1.1 vs 14.3 ± 1.0, P > 0.05). At 12 months, all the patients were found with markedly improved urination but no adverse events except recurrent urinary tract infection in 2 cases.

CONCLUSIONS

Memokath STEPS implantation, with its advantages of simple operation, high safety, definite effectiveness, non-influence on sexual function, is a new effective surgical option for the treatment of BPH.

Direct Observation vs. Video-Based Assessment in Flexible Cystoscopy

OBJECTIVE

Direct observation in assessment of clinical skills is prone to bias, demands the observer to be present at a certain location at a specific time, and is time-consuming. Video-based assessment could remove the risk of bias, increase flexibility, and reduce the time spent on assessment. This study investigated if video-based assessment was a reliable tool for cystoscopy and if direct observers were prone to bias compared with video-raters.

DESIGN

This study was a blinded observational trial. Twenty medical students and 9 urologists were recorded during 2 cystoscopies and rated by a direct observer and subsequently by 2 blinded video-raters on a global rating scale (GRS) for cystoscopy. Both intrarater and interrater reliability were explored. Furthermore, direct observer bias was explored by a paired samples t-test.

RESULTS

Intrarater reliability calculated by Pearson's r was 0.86. Interrater reliability was 0.74 for single measure and 0.85 for average measures. A hawk-dove effect was seen between the 2 raters. Direct observer bias was detected when comparing direct observer scores to the assessment by an independent video-rater (p < 0.001).

CONCLUSION

This study found that video-based assessment was a reliable tool for cystoscopy with 2 video-raters. There was a significant bias when comparing direct observation with blinded video-based assessment.

Prospective non-randomized study on the use of antibiotic prophylaxis with ciprofloxacin in flexible urethrocystoscopy

OBJECTIVE

The goal of this study is to analyze whether there is a need for antibiotic prophylaxis in this outpatient procedure.

METHODS

Prospective observational non-randomized study including 100 patients divided into two groups: - Group 1: 48 patients receiving 500 mg of ciprofloxacin prophylaxis 1 hour before urethrocystoscopy; - Group 2: 52 patients without antibiotic prophylaxis. Before inclusion of the patients in the study, we checked the absence of urinary tract infection by means of a urinalysis obtained 3 days before the procedure. We analyze: cystoscopy indication, cystoscopy results, presence of comorbidities, urinalysis 7 days after the procedure, and urinary symptoms within 7 days of the procedure. The statistical analysis was performed using SPSS 20.0 and the statistical significance was p=0.05.

RESULTS

The average age of patients in group 1 was 66.7±12.4 versus 65.6±10.8 years in group 2 (p=0.6). There are no differences in the percentage of men/women included in the groups. 14% of patients of group 1 and 12% of group 2 presented bacteriuria, without showing any significant differences. In the multivariate study, it is observed that neither age, nor diabetes, smoking, lower urinary tract symptoms, nor immunosuppression are related with the onset of bacteriuria in the groups.

CONCLUSION

We do not consider the use of ciprofloxacin as prophylaxis for flexible cystoscopy is appropriate in this area of health, since it does not reduce the presence of urinary infection or bacteriuria.

Laparoscopic Ureterolithotomy with Concomitant Pyelolithotomy Using Flexible Cystoscope

PURPOSE

To report and discuss the treatment of ipsilateral upper ureteral and renal stones by laparoscopic ureterolithotomy with concomitant pyelolithotomy using flexible cystoscope.

MATERIALS AND METHODS

A total of 19 patients (14 men and 5 women) underwent laparoscopic retroperitoneal ureterolithotomy with concomitant pyelolithotomy using flexible cystoscope through the ureterotomy site. The mean age of the patients was 37.9 (22-61) years. Stones were on the right side in 12, on the left side in 7, and multiple in 6 patients. All ureteral stones were located in the upper ureter. Most renal stones were in the pelvis or in the calices.

RESULTS

All procedures were completed laparoscopically without conversion to open surgery. Mean operation duration was 86.5 (range: 80-93) minutes, thus operation duration was prolonged by a mean of 24.4 minutes in patients with concomitant stone extraction. Fifteen cases were treated using flexible cystoscope and a nitinol basket; in the remaining four cases holmium laser lithotripsy was performed. Complete stone clearance was confirmed by postoperative imaging in all patients.

CONCLUSIONS

Laparoscopic ureterolithotomy with concomitant pyelolithotomy is a feasible and effective technique for patients with large ureteral stone and low renal stone burden.&nbsp.

The Use of Flexible Fiberoptic Cystoscope for Difficult Endotracheal Intubation in TMJ Ankylosis Patients: A Case Series

BACKGROUND

Fiberoptic bronchoscopes might be vital for the safe performance of difficult endotracheal intubations. However, many hospitals in low or middle-income countries are unable to afford the equipment. We describe the use of a flexible fiberoptic cystoscope, as an alternative to a bronchoscope, for difficult nasoendotracheal intubation in patients with temporomandibular joint ankyloses.

METHODS

Eight Jordanian patients (five females and three males) with severe restriction of mouth opening, due to ankylosis of the temporomandibular joint, underwent awake nasoendotracheal intubation using a flexible fiberoptic cystoscope under local anesthesia.

RESULTS

The procedure was successful and well tolerated in all eight patients.

CONCLUSION

A flexible cystoscope can be a successful alternative to a flexible bronchoscope, for difficult nasoendotracheal intubation in hospitals at rural areas in low-or middle-income countries with limited financial resources.

Application of cystoscope in surgical treatment of hepatocellular carcinoma with portal vein tumor thrombus

Development of portal vein tumor thrombus deteriorates the prognosis of hepatocellular carcinoma, while surgical treatment can offer a promising prognosis for selected patients. However, the possibility of residual lesions in portal vein after conventional thrombectomy is a main risk factor leading to postoperative recurrence. Therefore, ensuring the complete removal of tumor thrombus during operation is critical to improve prognosis. For the first time, we report here one case of hepatocellular carcinoma with portal vein tumor thrombus in which cystoscope was successfully applied as a substitute of intravascular endoscope to visualize the cavity of the portal vein. The patient was a 61-year-old man with a 7-cm tumor in the right lobe of the liver, with tumor thrombus invading the right branch and adjacent to the conjunction of the portal vein. After removal of the tumor, the Olympus CYF-VA2 cystoscope was used to check the portal vein from the opening stump of the right branch of the portal vein. In this case, residual thrombus tissue was found near the opening stump and the conjunction of the portal vein. The residual lesion was carefully retrieved from the stump after retraction of the cystoscope. The procedure was repeated until no residual lesion was found. The whole duration time of thrombectomy was 22.5 (15 + 7.5) min. The patient was free from recurrence at 8 months after the procedure. Our work indicated that the cystoscope is a suitable substitute, with a proper size and function to check the portal vein system and ensure the curability of thrombectomy. Although well-designed clinic trails are still needed, this procedure may further improve the postoperative prognosis of hepatocellular carcinoma with portal vein tumor thrombus.

Transurethral Pneumatic Cystolithotripsy: A Novel Approach

OBJECTIVE

Various endoscopic instruments used in treating renal stones have been used in managing bladder calculi. Our aim is to evaluate the use of transurethral ureteroscopic pneumatic cystolithotripsy for the management of large bladder calculi.

PATIENTS AND METHODS

In a retrospective study conducted between May 2005 and July 2011, 53 patients with solitary bladder stones were subjected to our technique, transurethral ureteroscopic pneumatic cystolithotripsy. The mean patient age was 54.3 years. The mean stone size was 4.8 cm. Diagnostic cystoscopy was performed first. A semirigid ureteroscope with a pneumatic probe was introduced through the cystoscope sheath, and pneumatic lithotripsy was performed. The cystoscope sheath works as a draining channel, allowing bladder evacuation. The bladder collapses over the stone and, subsequently, prevents stone migration, which shortens the lithotripsy's duration. Stone immobilization allows the transmission of full pneumatic power to the stone. The stone fragments were removed through periodic bladder irrigation using an Ellick evacuation-irrigation system, and a 16F Foley catheter was placed at the end of the procedure.

RESULTS

Our technique was effective in all cases, including stone-free bladders. No surgical complications were detected. The mean operative time was 83 ± 21.0 minutes, which is comparable to that of standard management. The mean duration of lithotripsy and evacuation was 29.7 ± 18.4 minutes. In the postoperative period, patients were followed up for 18 months, with no urethral stricture being reported in any case.

CONCLUSION

The transurethral ureteroscopic pneumatic cystolithotripsy procedure is a safe technique for the management of large bladder calculi. It allows the bladder to collapse over the stone, leading to stone immobilization and, subsequently, decreasing lithotripsy duration. Our procedure is associated with a minimal chance of postoperative urethral injury because all stone fragments are evacuated through the cystoscope sheath, without contact with the urethral urothelium.

[Semen expulsion under the ureterocystoscope]

OBJECTIVE

To determine the exact location of the opening of the ejaculatory duct in men and provide some basic anatomical evidence for seminal vesiculoscopy and the treatment of ejaculatory duct obstruction.

METHODS

We performed ureterocystoscopy for 21 male patients aged 26 - 47 years with hematuria (n = 12), hematospermia (n = 2), glandular cystitis (n = 6), and anejaculation after radical resection of rectal carcinoma (n = 1), and meanwhile, with the consent of the patients, massaged the prostate and ejaculatory duct and observed the outlet of the expelled fluid. Under the microscope, we described the fluid samples with sperm as the expulsion from the ejaculatory duct.

RESULTS

Ureterocystoscopy showed that the exact anatomical sites of the expulsion of prostatic fluid and semen in the patients were the side and lower side of the prostatic utricle opening above the verumontanum and the ventral side of the verumontanum. Quantities of sperm were found in the expulsion fluid of 13 of the patients, and no expulsion, including semen, was seen from the prostatic utricle opening.

CONCLUSION

Anatomically, the ejaculatory duct openings of males are located at the two sides of the verumontanum adjacent to the opening of the prostatic utricle, rather than in the prostatic utricle above the verumontanum.

Randomized clinical trial on antimicrobial prophylaxis for flexible urethrocystoscopy

OBJECTIVES

One of the main drawbacks of flexible urethrocystoscopy is the risk of urinary tract infection (UTI). In order to reduce this risk, antimicrobial prophylaxis has been considered, however there is not a unanimous view regarding indications, dosage, type of antibiotic, and so on. To clarify this uncertainty, we practiced a pilot and experimental study aimed at assessing the effectiveness of chemoprophylaxis with 3 grams of fosfomycin trometamol in the prevention of UTI after urethrocystoscopy.

METHODS

Sixty patients were entered into a pilot randomized clinical trial between March and August 2011. Thirty patients were assigned to a control group without receiving any antibiotic dose, and the intervention group (30 patients) received 3 g fosfomycin trometamol. Ten days later urine culture and sediment analysis were performed in all patients. Significant bacteriuria was considered from > 105 CFU /ml. One month later a telephone survey was developed to assess urinary symptoms, and assistance to the family doctor. We estimated the cumulative incidence of bacteriuria, pyuria and microhematuria in both groups, and we compared the results using a strategy of analysis per protocol and intention to treat.

RESULTS

The incidence of bacteriuria, pyuria and microhematuria in the control group was 10%, 23.3% and 26.7% respectively and in the intervention groups the values differed depending on the type of analysis. Considering only the 27 patients (per protocol analysis), the incidence would be 11.1%, 37.0% and 29.6% respectively. If we include the three patients who did not completed the study (per intention to treat analysis) and considering their results as negative, the results were 10%, 33.3% and 26.7% respectively. Finally, in the case the three cultures not performed in this group had produced a positive result, the impact would have been 20.0%, 43.3% and 36.7%. In any of the three cases, the differences with the control group were not statistically significant.

CONCLUSIONS

In a selected population and with appropriate aseptic measures, antibiotic chemoprophylaxis does not appear to show a clinically relevant reduction in the incidence of UTI in patients undergoing flexible urethrocystoscopy.

Effectiveness of fetal cystoscopy as a diagnostic and therapeutic intervention for lower urinary tract obstruction: a systematic review

OBJECTIVE

To determine the effectiveness of fetal cystoscopy in the prenatal diagnosis of and intervention for congenital lower urinary tract obstruction.

METHODS

This study was a literature search using MEDLINE, Embase, Cochrane Library, MEDION, Web of Science reference lists and contact with experts. All studies reporting on fetal cystoscopy in lower urinary tract obstruction with data for a 2 × 2 table were selected for review. No language restrictions were applied. There was independent selection of studies, data extraction and quality assessment by two reviewers. Peto odds ratios were calculated as a summary measure of effect.

RESULTS

A total of 2071 citations were identified and 66 papers selected for detailed evaluation, from which four papers with a total of 63 patients were selected for inclusion. Two papers had results for the use of cystoscopy in diagnosis, showing that fetal cystoscopy altered the ultrasound diagnosis of the underlying pathology in 36.4 and 25.0% of fetuses, respectively. Compared to no treatment, fetal cystoscopic intervention demonstrated an odds ratio for improved perinatal survival of 20.51 (95% CI, 3.87-108.69). However, comparing vesicoamniotic shunt (VAS) with fetal cystoscopy there appeared to be no significant improvement in the perinatal survival odds ratio of 1.49 (95% CI, 0.13-16.97). These results had wide CIs and for cystoscopy vs. VAS, all results crossed the line of no effect.

CONCLUSION

There is little published evidence for the effectiveness of therapeutic fetal cystoscopy as an intervention for congenital lower urinary tract obstruction and the quality of this evidence is poor. It should thus be considered to be an 'experimental intervention' and subjected to further investigation.

[Beyond the photodynamic diagnosis: Searching for excellence in the diagnosis of non-muscle-invasive bladder cancer]

Cystoscopy is gold-standard method in non muscule invasive bladder cancer diagnosis. In the cistoscopic exploratión 30% of tumors could be overlooked: it is due to a flat forms, little size tumours or difficult visualization. Photodynamic diagnosis reduces overlooked tumours rate, and has improved diagnosis on flat forms, with the consequence of increasing lap time to recurrence and decreasing the number of iterative cistoscopy; nevertheless the false positive rate is high. In the last years developed new optical devices who try to improve alone or associated diagnostic sensibility in cistoscopy without reduction of specificity. Among new devices we must emphasize some like Narrow Band Imaging, Optical Coherence Tomography or Laser Confocal Endomicroscopy.

High-magnification vascular imaging to reject false-positive sites in situ during Hexvix® fluorescence cystoscopy

Fluorescence imaging for detection of non-muscle-invasive bladder cancer is based on the selective production and accumulation of fluorescing porphyrins-mainly, protoporphyrin IX-in cancerous tissues after the instillation of Hexvix®. Although the sensitivity of this procedure is very good, its specificity is somewhat limited due to fluorescence false-positive sites. Consequently, magnification cystoscopy has been investigated in order to discriminate false from true fluorescence positive findings. Both white-light and fluorescence modes are possible with the magnification cystoscope, allowing observation of the bladder wall with magnification ranging between 30× for standard observation and 650×. The optical zooming setup allows adjusting the magnification continuously in situ. In the high-magnification (HM) regime, the smallest diameter of the field of view is 600 microns and the resolution is 2.5 microns when in contact with the bladder wall. With this cystoscope, we characterized the superficial vascularization of the fluorescing sites in order to discriminate cancerous from noncancerous tissues. This procedure allowed us to establish a classification based on observed vascular patterns. Seventy-two patients subject to Hexvix® fluorescence cystoscopy were included in the study. Comparison of HM cystoscopy classification with histopathology results confirmed 32∕33 (97%) cancerous biopsies and rejected 17∕20 (85%) noncancerous lesions.

[Mini-invasive approach in the treatment of acute necrotizing pancreatitis]

OBJECTIVES

The study aims to evaluate the efficacy of percutaneous necrosectomy performed under ultrasound control and endoscopic necrosectomy trough secondary sinus track (ENTSST) using nephroscope and cystoscope.

MATERIAL AND METHOD

Puncture of fluid collections in the pancreas was performed under ultrasonographic control to 23 patients with acute necrotizing pancreatitis (ANP). ENTSST using nephroscope and cystoscope was performed to 47 patients after open or percutaneous necrosectomy and persistent sepsis (without satellite collection of CT).

RESULTS

Seventeen (74%) patients treated with percutaneous necrosectomy recovered without open surgery. Two of this group died. The average hospital stay was 42 days. Twenty-three patients required an average of two (from 1 to 4) ENTSST.

CONCLUSIONS

Based on our initial results we believe that the percutaneous necrosectomy and ENTSST in well selected patients might be the better choice than the open necrosectomy and postoperative lavage. Common solution of these methods has not been reached yet.

[Narrowband fibrocystoscopy in diagnosis of bladder cancer]

A total of 97 patients (59 males, 38 females, age 26-88 years) with cancer of the urinary bladder (pTa, pT1, pT2) were initially examined with white-light cystoscopy, then narrowband cystoscopy (Narrow Band Imaging, NBI) with application of videofibrocystoscope Okympus. A total of 147 procedures were performed. Videofibrocystoscopy in white light has detected 18 recurrent tumors (sensitivity 0.12 tumor/operation). Narrowband videofibrocystoscopy has detected 17 more recurrencies (sensitivity 0.24 tumor/operation). A histological recurrence was confirmed at standard cystoscopy in 17 of 18 cases (specificity 94%), at narrowband fibrocystoscopy--in 30 of 35 cases (specificity 86%). The above pilot experience with narrowband videofibrocystoscopy has demonstrated that this technique has much higher contrast and acutance of imaging as well as sensitivity vs standard rigid cystoscopy in white light.

Primary obstructive megaureter: initial experience with endoscopic dilatation

BACKGROUND AND PURPOSE

Primary obstructive megaureter (POM) without vesicoureteral reflux has classically been managed by open surgery with ureteral reimplantation. We present seven patients with POM who were treated endoscopically with balloon dilatation of the distal ureter.

PATIENTS AND METHODS

Six boys and one girl with POM were treated from June 2000 through July 2004. Six of the cases were diagnosed prenatally when ectasia of the urinary tract was seen on ultrasound scans. The postnatal diagnosis was also achieved by ultrasonography, along with a diuretic isotopic renogram with MAG-3, intravenous urography, and filling cystography. The age at surgery was 1 to 3 years. In all cases, a compact 10F infant cystoscope with a 5F working channel was used. Dilatation of the stenotic area was performed under fluoroscopic monitoring. A 4F dilating balloon was used, which was insufflated to between 12 and 14 atm for 3 to 5 minutes, and disappearance of the narrowed ring was verified. A Double-J catheter was positioned and withdrawn 2 months after the procedure. Clinical, analytical, and imaging follow-up was carried out with ultrasonography and MAG-3 renography.

RESULTS

The mean follow-up of the patients is 31 months (range 12-56 months). Their clinical progress was highly satisfactory. Five patients exhibited reduced obstruction at MAG-3. One patient needed a second dilatation, and the obstructive curve improved after this additional procedure. One of the patients presented with a febrile urinary infection after the dilatation, but there were no other complications.

CONCLUSIONS

Endoscopic management of POM by balloon dilatation has yielded very good results in the short term. Longer follow-up will enable us to determine the final indications for this treatment.

Internal urethrotomy combined with antegrade flexible cystoscopy for management of obliterative urethral stricture

INTRODUCTION

We studied the safety and efficacy of flexible cystoscopy-guided internal urethrotomy in the management of obliterative urethral strictures.

MATERIALS AND METHODS

Forty-three flexible cystoscopy-guided internal urethrotomies were performed between 1999 and 2005. The indication for the procedure was nearly blinded bulbar or membranous urethral strictures not longer than 1 cm that would not allow passage of guide wire. Candidates were those who refused or were unable to undergo urtheroplasty. By monitoring any impression of the urethrotome on the monitor through the flexible cystoscope, we were able to do under-vision urethrotomy. All of the patients were started clean intermittent catheterization afterwards which was tapered over the following 6 months. Follow-up continued for 24 months after the last internal urethrotomy.

RESULTS

Seventeen patients were younger than 65 years with a history of failed posterior urethroplasty, and 26 were older than 65 with poor cardiopulmonary conditions who had bulbar urethral stricture following straddle or iatrogenic injuries. Urethral stricture stabilized in 16 patients (37.2%) with a single session of urethrotomy and in 17 (39.5%) with 2 urethrotomies. Overall, urethral stricture stabilized in 76.7% of patients with 1 or 2 internal urethrotomies within 24 months of follow-up. No severe complication was reported.

CONCLUSION

Flexible cystoscopy-guided internal urethrotomy is a simple, safe, and under-vision procedure in obliterative urethral strictures shorter than 1 cm. It can be an ideal option for patients who do not accept posterior urethroplasty or are in a poor cardiopulmonary condition that precludes general anesthesia.

Management of transitional cell carcinoma of the urinary bladder at Kenyatta National Hospital, Nairobi

OBJECTIVES

To highlight the management of patients with transitional cell carcinoma of the urinary bladder with regards to clinical presentation, treatment and outcome.

DESIGN

A retrospective study.

SETTING

Kenyatta National Hospital, Nairobi, Kenya.

SUBJECTS

Fifty two patients who presented at Kenyatta National Hospital over a ten year period with histologically proven transitional cell carcinoma of the urinary bladder. There were 41 males and 11 females aged 27 to 84 years. The mean age was 57 years.

RESULTS

An average of 5.2 patients per year were seen. The male to female ratio was 3.7:1. Most common clinical presentations were haematuria 98%, Lower abdominal pains 71%. The main investigative procedures done in these patients included cystoscopy in 71.2%, ultrasound 46.2%, IVU 32.7% among others. The treatment modalities were based on the stage of the disease and included surgery 48.1%, combination therapy in 23.1%, chemotherapy in 5.8% and radiotherapy in 3.8%. Surgery was the mainstay of treatment, cystectomy was done in 26.9% and cystostomy and resection of tumour 26.9%. Other surgical methods carried out were transurethral resection of bladder tumour(TURBT), cystectomy and bladder augumentation, channel transurethral resection, cystectomy and ileocondult. Nine patients (17.3%) were not given any treatment because either the disease was too advanced and died before any treatment was instituted or were lost to follow up. Mortality and outcome of the disease was difficult to assess due to poor follow up, however 65.4% of the patients were still alive, 17.3% had died and 17.3% were lost to follow up by the end of the study period.

CONCLUSION

Haematuria was the most important presenting clinical feature. Poor record keeping may have contributed to the low number of patients enrolled into the study. The TCC in this study was not thoroughly managed. It is suggested that early diagnosis, early surgery and combination of other treatment modalities should improve the outcome. This can only be possible with further training of health personnel, the education of the public and availability of improved diagnostic as well as treatment facilities especially cystoscopes and resectoscopes. There is need for developing proper management protocols for bladder tumours.

Sachgerechte Aufbereitung starrer und flexibler Zystoskope

Infection control visits of the public health department in the city of Frankfurt a.M., Germany, revealed the need for easily understandable and practicable information and recommendations for the reprocessing of rigid and flexible cystoscopes. Based on the German Guidelines for reprocessing medical devices and cystoscopes practical information and examples of specific reprocessing schedules are given in this article in order to enable the personnel in the practices to comply with the guidelines and to prevent nosocomial infections.

Transurethrale Resektion von Blasentumoren und Prostataadenomen in physiologischer Kochsalzlösung (TURIS)

BACKGROUND

Transurethral resection in a conductive irrigant medium is a new procedure in the surgical therapy of bladder tumors and prostate enlargement. In this prospective randomized trial we compared conventional TUR with TUR in saline regarding safety and efficiency.

PATIENTS AND METHODS

Between November 2004 and February 2005 a total number of 128 patients were included in this study. After randomization 58 patients were treated by conventional TUR and 70 patients by TURIS (Olympus, SurgMasterSystem). We evaluated resection time, weight of resected tissue, complications, blood loss, changes in serum sodium, and duration of catheterization.

RESULTS

Among the tested procedures no statistically significant difference could be observed concerning blood loss, change of serum sodium, and complications. The mean weight of resected tissue of the prostate per time was 0.9 g/min with the TUR procedure and 0.8 g/min with the TURIS procedure. Severe complications like TUR syndrome or perforation of the bladder were not observed at all. In the TURIS group time until catheter removal was longer but also the mean weight of resected tissue of the prostate was higher in the TURIS group (42 g) than in the conventional TUR group (31 g).

CONCLUSIONS

Transurethral resection in a conductive irrigant medium (TURIS) can be considered as a safe and effective surgical procedure in the treatment of BPH and superficial urothelial carcinoma. Moreover the risk of TUR syndrome and perforation of the bladder due to nerve stimulation is reduced.

Post-operative drain output as a predictor of bladder neck contracture following radical prostatectomy

BACKGROUND

Bladder neck contracture (BNC) following prostatectomy has been reported in 0.5-32% of cases. While the etiology of a BNC is unclear, several factors have been associated with this complication, including blood loss, devascularization of bladder neck tissue, poor mucosal apposition and urinary extravasation. To study the impact of urinary extravasation on BNC formation, we used postoperative drain output as a surrogate measure for anastomotic leakage.

METHODS

All patients undergoing a radical retropubic prostatectomy (RRP) or a robotic assisted radical prostatectomy (RARP) from January 2000 to April 2006 have been entered into a prospective review board-approved database. All RRP patients had their anastomosis performed in an interrupted fashion using six monofilament 2-0 sutures. All robotic-assisted radical prostatectomy anastomoses were performed in a running fashion using 2-0 monofilament sutures. A single, closed suction Jackson Pratt drain was placed over the surgical bed at the conclusion of the case. Post-operative drain outputs were recorded. All patients were evaluated at 3, 6, 9, 12 and 24 months post-operatively. All patients who reported a diminished urinary stream or incontinence were evaluated by office cystoscopy. The inability to navigate an 18 French cystoscope through the bladder neck was defined as a bladder neck contracture.

RESULTS

A total of 576 patients underwent a radical prostatectomy over this time span. Complete records were available for 535 (93%) of these patients. There were 21 bladder neck contractures (3.9%) overall. The post-operative drain output ranged from 5-5,465 ml (median 119 ml). Eight patients who had drain outputs less than 119 ml developed a BNC while 13 BNC developed in patients with Jackson Pratt drain output > 119 ml (P = 0.343). In patients who underwent an open RRP, 19/424 (4.5%) developed contractures while 2/108 (1.9%) RARP patients developed a BNC (P = 0.105).

CONCLUSION

The amount of post-operative drain output is not statistically associated with the development of a bladder neck contracture.

Intravesical markers for delineation of target volume during external focal irradiation of bladder carcinomas

A clip forceps was developed which can insert markers at the border of a bladder tumour through a rigid cystoscope. This technique proved to be simple and safe and is of help for delineation of the target volume during CT simulation for focal boost irradiation of bladder cancer.

Funktionelle Ergebnisse nach Laservaporisation der Prostata mit dem KTP-Laser

BACKGROUND

Treatment for bladder outlet obstruction (BOO) caused by benign prostatic hyperplasia (BPH) impairs the quality of life. The potassium tintanyl phosphate (KTP) vaporisation of the prostate offers promising modalities in treatment of BOO. We prospectively determined the impact of KTP-lasertherapy on voiding function, quality of life and sexual function.

PATIENTS AND METHODS

So far a total of n=123 patients complaining of symptomatic BPH were treated with an 80 watt Laser. N= 40 of them agreed to participate in the study and were evaluated prospectively. Preoperative pressure-flow-studies verified significant bladder outlet obstruction in all cases. Disease specific quality of life and sexual function were assessed using the International Prostate Symptom Score (IPSS) and International Inventory of Erectile Function (IIEF). Three months after treatment follow-up video-urodynamics were carried out to determine changements in pressure flow and bladder function.

RESULTS

All patients showed significant improvement after a hospital stay of 4,9 days. The maximum flow rate increased from 9,1 ml/sec preoperatively to 20,2 ml/sec and the amount of residual urine decreased from 98 ml preoperatively to 17 ml immediately after removal of the catheter. Urodynamics after the follow up period showed that the maximum urinary flow improved from 9.7 ml/s preoperatively to 17,6 ml/s and the volume of residual urine decreased from a median of 127.5 ml preoperatively to 45 ml postoperatively. The IPSS and IIEF decreased from a median of 20,4 preoperatively to 8,16 and from a median of 14 preoperatively to 12,7 respectively. The pressure-flow study verified the desobstruction and showed a decline in detrusor pressure at maximum flow from 76,66 cm H2O to 33,79 cm H2O. The urethral opening pressure sank from 75.86 cm H2O preoperatively to 37,51 cm H2O postoperatively.

CONCLUSION

The potassium tintanyl phosphate (KTP) vaporisation of the prostate is a promising new method in the treatment of benign prostatic hyperplasia as shown by the data. Beside its low perioperative and postoperative morbidity due to a high hemostatic property it offers a good tissue debulking effect.

Disappearing drain--disaster averted and lesson learnt!

The use of postoperative drains date back to Hippocrates. We report an iatrogenic case of migrated drain into the retroperitoneum. A novel technique using a rigid cystoscope for retrieval is described that prevented another laparotomy.

[Greenlight laser vaporization or conventional electroresection of the prostate for the treatment of symptomatic benign prostatic hyperplasia--David against Goliath?]

Die Elektroresektion der Prostata (TURP) gilt als «Goldstandard» bei der operativen Therapie der benignen Prostatahyperplasie (BPH). Trotz technischer Neuerungen bleibt die TURP ein potenziell komplikationsträchtiges Operationsverfahren. Während des letzten Jahrzehnts wurden zahlreiche neue Laserverfahren für die operative Therapie der BPH vorgestellt. Der wesentliche Vorteil der meisten Laserverfahren sind die durchwegs guten hämostatischen Eigenschaften, die ein fast blutfreies und für den Patienten sicheres Operieren ermöglichen. Jedoch weisen v.a. nicht-ablative Laserverfahren durch die notwendige postoperative Langzeitkatheterisierung eine postoperativ störende Dysurie, das verlängerte Ausscheiden von nekrotischem Material (sloughing) sowie eine erhöhte Reoperationsrate eindeutig Nachteile gegenüber der herkömmlichen TURP auf. Bei der Greenlight-Laservaporisation der Prostata handelt es sich um ein neues viel versprechendes Operationsverfahren für Patienten mit symptomatischer benigner Prostatahyperplasie. Infolge der Kombination von guten ablativen und exzellenten hämostyptischen Eigenschaften stellt dieses Operationsverfahren zudem eine sichere Option für ältere Patienten, bei denen die TURP zu gefährlich wäre, oder für sog. Hochrisikopatienten dar, bei denen die Notwendigkeit einer oralen Antikoagulation besteht.