Bladder Endometriosis Mimicking TCC - A Case Report

Endometriosis is the ectopic presence of endometrial tissue outside the uterus. Though on its own endometriosis is not a rare lesion, the involvement of the urinary tract is rare but with the bladder being the most commonly affected organ. Endometriosis is usually seen in females between the ages of 30-40 years and may occur due to fluctuating levels of oestrogen and progesterone. Clinically the patient maybe asymptomatic or show symptoms of dysmenorrhea, irregular or heavy periods, pain in the pelvic area, lower abdomen or in the back. It has been suggested that ultrasonography should be done either before or during menstruation as the lesion becomes more evident and a biopsy taken during this period is a strong aid in reaching a final diagnosis. We report here an unusual case of bladder endometriosis where the patient came with severe pelvic pain and an endoluminal mass seen on the ultrasonographic report. Based on these findings a differential of transitional cell carcinoma was given which was ruled out based on the cystoscopic findings.

Use of holmium laser for urethral strictures in pediatrics: A prospective study

INTRODUCTION

The management of urethral strictures is very challenging and requires the wide expertise of different treatment modalities ranging from endoscopic procedures to open surgical interventions.

OBJECTIVE

To assess the effectiveness and complications of retrograde endoscopic holmium: yttrium-aluminum-garnet laser (Ho: YAG) urethrotomy (HLU) for the treatment of pediatric urethral strictures.

PATIENTS AND METHODS

From January 2010 to January 2013, 29 male pediatric patients with a mean age of 5.9 years and primary urethral strictures 0.5-2 cm long were treated using HLU. The stricture length was <1 cm in 16 (55%) patients and >1 cm in 13 (45%). Fifteen (51.7%) patients had an anterior urethral stricture, while 14 (48.3%) had a posterior urethral stricture. No positive history was found in 14 (48.3%) patients for the stricture disease, while six (20.7%) had straddle trauma and nine (31%) had an iatrogenic stricture. All of the patients were pre-operatively investigated and at 3 and 6 months postoperation by uroflowmetry and voiding cystourethrography (VCUG). If there were suspicious voiding symptoms, selective uroflowmetry and VCUG were performed at 12 months postoperation.

RESULTS

The mean operation time was 31.7 min (20-45 min). Twenty-three (79.3%) and 18 (62.1%) patients showed normal urethra on VCUG with improvement of symptoms at 3 and 6 months, respectively. Thus, recurrence was 37.9% after 6 months of follow-up. The mean pre-operative peak urinary flow rate (Qmax) was 6.47 ml/s. The mean postoperative Qmax at 3 and 6 months was 17.17 ml/s and 15.35 ml/s, respectively. The success rate and flowmetry results did not show any statistical significance in relation to site, length and cause of the strictures. The other 11 patients who failed to improve underwent repeated HLU sessions: 4/11 (36.3%) achieved successful outcomes. Among the seven patients with failed HLU for the second time, a third session was conducted. However, only one patient (14.2%) was cured, while open repair was needed for the remaining six.

DISCUSSION

One study has previously been published on the management of pediatric urethral strictures using HLU. The present results are similar to short-term studies after a single session of visual internal urethrotomy using cold knife (VIU). In the present study, the length, location and cause of strictures did not significantly affect the results. However, the outcomes with strictures <1 cm were better than strictures >1 cm, although patients with strictures >2 cm were excluded. In the present study, the success rates among patients with second and third sessions of HLU were 36.3% and 14.2%, respectively. This was similar to other studies, which reported low success rate with the second session of VIU. The present study was limited by the relatively short period of follow-up and the small number of patients. However, it was the first prospective study evaluating HLU for pediatric strictures. The use of flowmetry and VCUG for evaluation of all patients added to the strength of the study.

CONCLUSION

HLU can be safely used with good success rates for the treatment of primary urethral strictures (<2 cm) in children. Repeat HLU (more than twice) adds little to success.

Suprapubic-assisted Transurethral Excision of a Vaginal Mesh Eroded Into the Bladder

A 56-year-old woman with irritative voiding symptoms and recurrent urinary infections was found to have erosion into the bladder of a tension-free vaginal tape placed 61 months before. To achieve radical excision, a 26Fr Amplatz sheath was placed suprapubically under endoscopic vision. A rigid nephroscope with grasping forceps was used to pull the eroded mesh out of the bladder wall while excising it transurethrally with a resectoscope. Postoperative course was uneventful; 12 months after surgery the patient remains asymptomatic. This novel technique provides an effective means of radically removing a mesh eroded into the bladder either transurethrally or suprapubically.

A Comparison of the Progression and Recurrence Risk Index in Non-Muscle-Invasive Bladder Tumors Detected by Narrow-Band Imaging Versus White Light Cystoscopy, Based on the EORTC Scoring System

Background:

Transitional cell carcinoma of the bladder, the second most common urologic malignancy, is amenable to early diagnosis. This study presents the potential prognostic benefit for a less invasive modification to the standard endoscopic approach.

Objectives:

To evaluate the risk index for the progression and recurrence of additional tumors detected with narrow-band imaging (NBI) cystoscopy compared to standard white light imaging (WLI) cystoscopy in non-muscle-invasive bladder cancer (NMIBC), based on the European organization for research and treatment of cancer (EORTC) scoring system.

Patients and Methods:

Patients with NMIBC, who were scheduled for resection between May 2012 and May 2013, were studied and mapped under NBI and WLI cystoscopy by independent surgeons prior to resection. Detection rates and tumor characteristics, including EORTC progression and the recurrence risk index, were compared.

Results:

Fifty patients, aged 63.86 ± 10.05 years, were enrolled. The overall detection rate was 98.9% for NBI vs. 89.4% for WLI (P = 0.001), and the false-positive rates were 9.6% and 5.8%, respectively (P = 0.051). Ten tumors were detected by NBI alone, including four grade I tumors, four grade III tumors, and two carcinomas in situ. The tumor progression index was not significantly reduced with NBI compared to WLI (P > 0.05); however, the recurrence index was significantly lower in the NBI group (P < 0.05).

Conclusions:

NBI cystoscopy improved the detection rate. Although false positives were more common with NBI, this was not statistically significant. NBI found additional aggressive tumors, which underscores the impact of detection in EORTC recurrence risk scoring.

Does Rigid Cystoscopy Affect the Total Serum Prostate-Specific Antigen Levels?

In the present study, we aim to prospectively evaluate the effect of performing rigid cystoscopy (CPE) in urological patients on the total serum prostate-specific antigen (PSA) levels. The study design was a prospective observational study. After giving informed consent, urological patients visiting the outpatient clinic of our institution from November 2010 to March 2012 who satisfied our protocol entry/exclusion criteria were recruited into the present study. Blood sample was withdrawn 1 h prior to CPE for serum PSA estimation, and CPE was performed with a 17-Fr rigid cystoscope. Blood was again withdrawn at 1 and 24 h after CPE for serum PSA estimation. The study used paired samples test (two tailed) for statistical analysis. A total of 50 patients with mean age of 60 years underwent CPE. The baseline, 1-h, and 24-h post CPE mean serum PSA levels were 1.98 ± 2.25 (0.02-12.33), 2.90 ± 2.81 (0.3-14.26), and 3.04 ± 2.95 (0.2-15.03) ng/dl, respectively. The paired samples test (two tailed) revealed that the rise in the baseline PSA versus 1-h PSA and baseline PSA versus 24-h PSA was highly significant at P < 0.001 and P < 0.002, respectively; however, the 1-h PSA versus 24-h PSA rise was not so significant (P < 0.043). The present study demonstrated that rigid cystoscopy may be associated with a variable rise in the serum PSA that may persist for a period of up to or beyond 24 h. Thus, we believe that the history of recent cystoscopy must be taken into consideration while interpreting the serum PSA value in the routine urological setting, as this will reduce unnecessary prostate biopsies in patients with an elevated serum PSA. Therefore, it may be advisable to wait for 24-48 h before withdrawing blood for serum PSA estimation in patients with history of CPE in the previous 24-48 h.

Clinical significance of ureteral stent removal by flexible cystoscopy on pain and satisfaction in young males: a prospective randomised control trial

The cystoscopic removal of ureteral stents causes discomfort and pain, especially in young male patients. We aimed to evaluate the usefulness of ureteral stent removal by flexible cystoscopy on pain and satisfaction in young males. In total, 104 patients undergoing ureteroscopic removal of stones with indwelling of ureteral stent (May 2013-July 2015) were randomised to receive a ureteral stent removal by either rigid cystoscopy (group 1) or flexible cystoscopy (group 2). Visual analogue scale (VAS) pain score and satisfaction scale score were assessed immediately after stent removal. All patients were males and the mean age was 22.72 ± 2.49 years. Group 2 showed significantly lower VAS pain score (p < 0.001) and higher satisfaction scale score (p < 0.001) than group 1. Ureteral stent removal by flexible cystoscopy may offer advantages on pain and satisfaction to young male patients.

[Melanosis of the urinary bladder]

Melanosis of the bladder is rare. Only 10 cases have been described in the literature. We present the case of an 80-year-old woman with neurogenic lower urinary tract dysfunction due to spinal paralysis. During the diagnostic work-up which included cystoscopy, black spots in the bladder wall were observed. Histopathological evaluation revealed a benign suburothelial melanosis. Thus, with cystoscopic suspicion of a malignancy (melanoma), a biopsy is mandatory and regular cystoscopic follow-up is recommended.

Transurethral Cystoscopy and Endoscopic Urolith Removal in Female Guinea Pigs (Cavia porcellus)

Urinary diseases are commonly found in guinea pigs. Diagnostic workup includes clinical examination, blood testing, imaging studies, urine culture, and urinalysis. This article describes the use of transurethral cystoscopy in female guinea pigs as an ancillary tool to diagnose abnormalities within the bladder and urethra. In addition, the transurethral cystoscopic removal of uroliths measuring up to 5 mm and situated within the urinary bladder is described.

Clinical Applications of Cystoscopy in Chelonians

The medical approach to chelonians can be challenging. Cystoscopy may be useful to evaluate morphologic changes in the viscera without the need of celiotomy, and is a valuable diagnostic tool. The size and transparency of the urinary bladder in chelonians allows visualization of most coelomic organs. Through cystoscopy the external aspect of stomach, intestine, heart, lungs, liver, pancreas, spleen, kidneys, testes, and ovaries may be visualized. Although a definitive diagnosis cannot be achieved, rapid identification of the diseased system through cystoscopy may be possible. Furthermore, cystoscopy is fundamental for diagnosis and treatment of lower urogenital disorders.

Laparoscopic Hysterectomy and Urinary Tract Injury: Experience in a Health Maintenance Organization

STUDY OBJECTIVES

To evaluate the incidence, detection, characteristics, and management of urinary tract injury in a cohort undergoing laparoscopic hysterectomy, and to identify potential risk factors for urinary tract injury with laparoscopic hysterectomy.

DESIGN

Retrospective analysis (Canadian Task Force classification II-2).

SETTING

Kaiser Permanente San Diego Medical Center, 2001 to 2012.

PATIENTS

Women who underwent attempted laparoscopic hysterectomy for benign indications.

INTERVENTIONS

Total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, and laparoscopic supracervical hysterectomy.

MEASUREMENTS AND MAIN RESULTS

Demographic and clinical characteristics, surgical techniques, and perioperative complications were abstracted from the medical record. Multivariable logistic regression analysis assessed independent risk factors for ureteral or bladder injury.

RESULTS

A total of 3523 patients (mean age, 45.9 ± 8.0 years; median parity, 2; range, 0-10), with a median body mass index (BMI) of 29 kg/m(2) (range, 16-72 kg/m(2)), underwent laparoscopic hysterectomy; 20% had intraoperative cystoscopy. The incidence of urinary tract injury was 1.3% (46 of 3523); of the 46 patients with injuries, 19 (0.54%) had ureteral injuries, 25 (0.71%) had bladder injuries, and 2 (0.06%) had both types. Of the 21 ureteral injuries, 6 (29%) were diagnosed intraoperatively and 15 (71%) were diagnosed postoperatively, including 4 with normal intraoperative cystoscopy. Of the 27 bladder injuries, 23 (85%) were identified intraoperatively. In multivariable logistic analysis, a BMI of 26 to 30 kg/m(2) (compared with >30 kg/m(2)) was associated with an increased risk of ureteral injury, and a BMI ≤25 kg/m(2) (compared with >30 kg/m(2)) and the presence of endometriosis were associated with an increased risk of bladder injury.

CONCLUSION

Urinary tract injury occurred in 1.3% of laparoscopic hysterectomies, with ureteral injuries almost as common as bladder injuries. Normal intraoperative cystoscopy findings did not exclude the presence of ureteral injury.

Cystoscopic-assisted excision of rectourethral fistulas in males with anorectal malformations

INTRODUCTION

We report a novel technique to label rectourethral fistulas in males with anorectal malformations who are undergoing posterior sagittal anorectoplasty (PSARP) to facilitate complete excision of the fistula.

METHODS

Prior to performing PSARP in 21 male patients with rectourethral fistulas, cystoscopy was carried out to identify the orifice of the fistula within the urethra. A 3Fr ureteral catheter with calibrations was then inserted into the orifice to label the fistula. During the PSARP procedure, the rectourethral fistula was dissected to the junction of the urethra, as identified by the presence of the ureteral catheter, and the fistula tract was completely excised.

RESULTS

Six prostatic and 15 bulbar rectourethral fistulas were found by cystoscopy. The orifices of the rectourethral fistulas were all located in the midline along the dorsal wall of the posterior urethra. The average length of the rectourethral fistulas was 10mm (range=5-15mm). During the PSARP procedure, the rectourethral fistula could be clearly identified, easily dissected and completely excised. Patients were followed up for 7-24 months. During the length of follow-up, micturition was normal and no urethral complications were found in any of the 21 patients.

CONCLUSION

Intraoperative cystoscopy with placement of a ureteral catheter in the fistula tract facilitates complete excision of rectourethral fistulas in males with anorectal malformations without risking injury to the urethra.

Postoperative ureteral obstruction after endoscopic treatment for vesicoureteral reflux

Purpose

We undertook this study to evaluate the incidence, risk factors, management, and outcome of postoperative ureteral obstruction after endoscopic treatment for vesicoureteral reflux (VUR).

Materials and Methods

Ninety patients undergoing endoscopic treatment for VUR were retrospectively reviewed and classified into two groups according to ureteral obstruction: the nonobstruction group (83 cases, 122 ureters; mean age, 7.0±2.8 years) and the obstruction group (7 cases, 10 ureters; mean age, 6.2±8.1 years). We analyzed the following factors: age, sex, injection material, laterality, voiding dysfunction, constipation, renal scarring, preoperative and postoperative ultrasound findings, endoscopic findings, injection number, and injection volume. Additionally, we reviewed the clinical manifestations, natural course, management, and outcome of ureteral obstruction after endoscopic treatment.

Results

The incidence of ureteral obstruction after endoscopic treatment was 7.6% (10/132 ureters). The type of bulking agent used and injection volume tended to be associated with ureteral obstruction. However, no significant risk factors for obstruction were identified between the two groups. Three patients showed no symptoms or signs after the onset of ureteral obstruction. Most of the patients with ureteral obstruction experienced spontaneous resolution within 1 month with conservative therapy. Two patients required temporary ureteral stents to release the ureteral obstruction.

Conclusions

In our experience, the incidence of ureteral obstruction was slightly higher than in previous reports. Our study identified no predictive risk factors for developing ureteral obstruction after endoscopic treatment. Although most of the ureteral obstructions resolved spontaneously within 1 month, some cases required drainage to relieve symptoms or to prevent renal function deterioration.

Carbonic anhydrase IX as a diagnostic urinary marker for urothelial bladder cancer

Urinary biomarkers are needed to improve the management and reduce the cost of urothelial bladder cancer (UBC); however, none have been recommended yet for clinical practice. This study evaluated carbonic anhydrase IX (CAIX) as a diagnostic urinary biomarker for UBC. CAIX was analyzed by quantitative polymerase chain reaction in urine samples of 196 patients with UBC and 123 controls with hematuria. Paired samples from urine and tumor tissue were evaluated in 16 cases. Data were validated in 155 independent samples. The sensitivity and specificity of CAIX for UBC detection were 86.2% and 95.1%, respectively (area under the curve [AUC]: 90.5%). There was a significant association of CAIX expression between the paired urine and tumor specimens (p=0.002). CAIX showed a significantly higher predictive accuracy than urinary cytology (90.5% vs 71.7%), specifically in low-grade tumors (90.0% vs 61.8%). CAIX expression decreased with increasing tumor stage and grade. Analyses in an independent validation cohort confirmed the high accuracy of CAIX for diagnosing UBC (AUC: 88.3%).

PATIENT SUMMARY

We evaluated carbonic anhydrase IX (CAIX) as a urinary marker for bladder cancer (BCa) using a large series of patients from a single hospital. We found that urinary CAIX has a high sensitivity and specificity for diagnosing BCa.

Urinary tuberculosis: a cohort of 79 adult cases

We aimed to investigate the demographic, clinical, diagnostic, treatment and outcome features of patients with urinary tuberculosis (UTB). Patients with UTB admitted to seven separate centers across Turkey between 1995 and 2013 were retrospectively evaluated. The diagnosis of UTB was made by the presence of any clinical finding plus positivity of one of the following: (1) acid-fast bacilli (AFB) in urine, (2) isolation of Mycobacterium tuberculosis, (3) polymerase chain reaction (PCR) for M. tuberculosis, (4) histopathological evidence for TB. Seventy-nine patients (49.36% male, mean age 50.1 ± 17.4 years) were included. Mean time between onset of symptoms and clinical diagnosis was 9.7 ± 8.9 months. The most common signs and symptoms were hematuria (79.7%), sterile pyuria (67.1%), dysuria (51.9%), weakness (51.9%), fever (43%) and costovertebral tenderness (38%). Cystoscopy was performed in 59 (74.6%), bladder biopsy in 18 (22.8%), kidney biopsy in 1 (1.26%) and nephrectomy in 12 (15.2%) patients. Histopathological verification of UTB was achieved in 12 (63.1%) patients who undergone biopsy and in 100% of those undergone nephrectomy. Mycobacterium tuberculosis was isolated in the urine of 50 (63.3%) cases. Four-drug standard anti-TB treatment was the preferred regimen for 87.3% of the patients. Mean treatment duration was 10.5 ± 2.7 months. Deterioration of renal function occurred in 15 (18.9%) patients two of whom progressed to end-stage renal disease and received hemodialysis. Only one patient died after 74-day medical treatment period. Cases with UTB may present with non-specific clinical features. All diagnostic studies including radiology, cyctoscopy and histopathology are of great importance to exclude UTB and prevent renal failure.

Gender Identification by Cloacoscopy and Cystoscopy in Juvenile Chelonians

Cloacoscopy and cystoscopy are simple, noninvasive to minimally invasive techniques that provide excellent visualization, and result in fast recovery. General or intrathecal anesthesia is sufficient. They can be performed in free-ranging turtles under field conditions. Cloacoscopic gender identification of external genitalia is not reliable because of the high degree of misinterpretation between phallus and clitoris, especially in juveniles. However, saline-infusion or air insufflation cystoscopy through the urinary bladder (or accessory vesicles/bladders) is often effective for the visualization of gonads and to identify the sex. Visualization of gonads is feasible through the urinary bladder or accessory vesicle wall in many species.

[Role of blue-light cystoscopy in the management of non-muscle invasive bladder cancer]

Blue-light cystoscopy aims to facilitate the detection of bladder tumors in order to optimize the completeness of resection. We performed a literature analysis using data from Medline and according to PRISMA guidelines. Several meta-analyses have confirmed the interest of the blue-light cystoscopy in terms of improved detection rate and disease-free survival compared to standard white-light cystoscopy. These benefits outweigh the initial costs related to the acquisition of specific equipment, allowing an improvement in quality-adjusted life-years and a reduction of costs over time. Indications vary according to guidelines and must take into account equipment and logistic constraints on each center. The objective of this article is to make a focus on the role and the interest of blue-light cystoscopy in the management of NMIBC in 2015.

A case of bladder endometriosis that became symptomatic during the third trimester

Background

The urinary tract endometriosis is observed in 1–2% of the patients and in 90% of these cases, there are endometriotic nodules in the bladder. With respect to knowledge, it is generally believed that pregnancy cures endometriosis. However in this case, symptoms developed during the third trimester of pregnancy.

Case report

We report a case of 31 year old, 30 week pregnant woman with a vegetative mass with 33 × 33 × 21 mm dimensions and irregular borders on the posterior wall of the bladder. After the cesarean section, the vegetative and superiorly localized mass on the internal wall of the bladder was excised with partial bladder excision. The patient had no other apparent findings of pelvic endometriosis at operation but the pathology result indicated endometriosis.

Conclusion

Although this case shows that endometriosis may become symptomatic during pregnancy, it has to be underlined that it cannot be discerned whether it is consequent to progress of the disease or to pregnancy-mediated modifications of a pre-existing lesion.

•

Endometriosis may become symptomatic during pregnancy.

•

When a mass detected in the bladder, the most appropriate tool for diagnosis is cystoscopic biopsy.

•

Cystoscopy during pregnancy may fail to detect bladder nodules.

•

With decidual changes endometriotic nodules in the bladder can mimic malignancy during pregnancy.

Bladder cancer detection in patients with gross haematuria: Computed tomography urography with enhancement-triggered scan versus flexible cystoscopy

OBJECTIVE

Computed tomography urography (CTU) can be used to direct further investigation of patients if the bladder tumour detection rate is high. The aim of this study was to compare a CTU protocol including an enhancement-triggered scan and flexible cystoscopy for detecting bladder tumours.

MATERIALS AND METHODS

Patients with gross haematuria undergoing CTU during 2005-2008 were included. For patients younger than 50 years the CTU protocol included unenhanced, enhancement-triggered corticomedullary, and excretory phases. Patients older than 50 years followed the same protocol plus a nephrographic phase. The entire urinary tract was examined in all phases.

RESULTS

Of 435 patients, 55 patients were diagnosed with bladder tumour. CTU detected bladder tumour in 48 patients (87%). Five CTU examination reports were false positive. With CTU, sensitivity for finding bladder tumour was 0.87, specificity 0.99, positive predictive value (PPV) 0.91 and negative predictive value (NPV) 0.98. Cystoscopy detected bladder tumour in 48 patients (87%) and had one false-positive finding, resulting in sensitivity of 0.87, specificity 1.0, PPV 0.98 and NPV 0.98.

CONCLUSIONS

The detection rate of bladder tumours for the CTU protocol including an enhancement-triggered scan was high and comparable to flexible cystoscopy. Hence, this protocol could be used to assess the bladder as the primary investigation and direct further investigation of the patient.

Decision Based on Narrow Band Imaging Cystoscopy without a Referential Normal Standard Rather Increases Unnecessary Biopsy in Detection of Recurrent Bladder Urothelial Carcinoma Early after Intravesical Instillation

Purpose

The purpose of this study was to calculate the operating characteristics of narrowband imaging (NBI) cystoscopy versus traditional white light cystoscopy (WLC) in common clinical scenarios involving suspicion of bladder urothelial carcinoma (UC).

Materials and Methods

Sixty-three consecutive patients initially underwent WLC and then NBI in a single session for evaluation of microscopic hematuria (group I, n=20), gross hematuria (group II, n=19), and follow-up for prior UC (group III, n=24), by an experienced urologist. All lesions that were abnormal in contrast with adjacent normal mucosa were diagnosed as positive and biopsied.

Results

Sixty-six biopsies from 47 patients were performed. Pathologic examination showed 17 cases of UC from 21 sites. While the overall sensitivity of NBI was similar to that of WLC (100% vs. 94.1%), the specificity of NBI was significantly lower than that of WLC (50% vs. 86.9%, p < 0.001), particularly in group III (38.9% vs. 88.9%, p=0.004). Based on identification by NBI only, 23 additional biopsies from 18 cases were performed for identification of one patient with UC, who belonged to group III. In this group, to identify this specific patient, 15 additional biopsies were performed from 10 patients. All seven cases with positive findings from NBI within 2 months after the last intravesical therapy were histologically proven as negative.

Conclusion

In evaluation for recurrence early after intravesical instillation, the decision based on NBI increased unnecessary biopsy in the absence of an established standard for judging NBI.

Diagnosis and staging of bladder cancer

Bladder cancer (BCa) is a heterogeneous disease with a variable natural history. Most patients (70%) present with superficial tumors (stages Ta, T1, or carcinoma in situ). However, 3 out of 10 patients present with muscle-invasive disease (T2-4) with a high risk of death from distant metastases. Moreover, roughly between 50% and 70% of superficial tumors do recur, and approximately 10% to 20% of them progress to muscle-invasive disease. However, BCa has a relatively low ratio of mortality versus incidence of new cases. In consequence, there is the danger of overdiagnosis and overtreatment.

Predicting results of daily-practice cystoscopies

OBJECTIVE

Our objective was to elaborate a predictive model of bladder cancer, in an unselected clinical population submitted to cystoscopy.

MATERIALS AND METHODS

We recruited consecutive patients that underwent cystoscopy due to suspicion of bladder cancer or surveillance of a previously diagnosed bladder cancer. Urine cytology and a BTA-stat® (BTA) test were carried out for all patients. To avoid an assessment bias, the BTA-tests, cytologies and cystoscopies were conducted in a blinded fashion. We used logistic regression to predict cystoscopy results from cytology, BTA-test and clinical variables.

RESULTS

From August 2011 to July 2012, we recruited 244 patients and 237 were valid for analysis. Newly diagnosed and surveillance cases were 13% and 87% respectively. Cytology and BTA-test sensitivities were 57.9% (CI 95: 42.2-72.1) and 63.2% (CI 95: 47.3-76.6) with specificities of 84.4% (CI 95: 78.7-88.8) and 82.9% (CI 95: 77.1-87.5). The predictive model included the BTA-test, cytology, time since previous tumour, and treatment with mitomicin or BGC during the last three months. The model predictive accuracy (AUC) was .85 (.78-.92), and dropped to 0.79 when excluding the BTA-test (P=.026). For the surveillance of bladder cancer, a 10% threshold on the model predicted probabilities resulted in an overall negative predictive value of 95.7%, and 95.0% in low grade tumours.

CONCLUSION

In a cost containment environment, our prediction model could be used to space out cystoscopies in patients with previous, low grade tumours, resulting in a more efficient use of resources in the healthcare system.

The role of transcavitary ultrasonography in diagnosis and staging of nonmuscle-ınvasive bladder cancer: a prospective non-randomized clinical study

To evaluate the efficacy of cystoscopy, computed tomography (CT), transcavitary ultrasound (TCUS) and cytology, separately and in combination, for the diagnosis and evaluation of superficial bladder cancer.

Initial cystoscopy and wash-out cytology were performed for 1548 patients. Of these, 206 with proven bladder tumors were included in this prospective study. CT and TCUS were performed for patients with bladder tumors without knowledge of their cystoscopy results. The lesions were classified as low- (pTa) and high- (pT1) risk superficial tumors according to multiplicity and size.

Patients were divided into three categories according to their cystoscopically evaluated tumor size: ≤1 cm (88 patients, 42.7%), 1–3 cm (51 patients, 24.8%) and ≥3 cm (67 patients, 32.5%). TCUS identified 46 (22.3%) high-risk patients with/without invasion and 160 (77.7%) low-risk patients with no invasion. Overall, the sensitivity, specificity, positive predictive value and negative predictive value of TCUS for tumor detection were 77.4%, 60%, 94.7% and 22.2%, respectively.

Cystoscopy remains the most widely used technique for the diagnosis of bladder cancer. The combined use of CT, TCUS and cytology detected 72% of cystoscopically proven tumors. Among the three, TCUS findings exhibited the strongest correlation with cystoscopy findings.

On demand urethral dilatation versus intermittent urethral dilatation: results and complications in women with urethral stricture

Background:

The treatment of urethral stricture in female patients is through dilatation of the urethra by tubes of increasing diameter. There are two main methods: intermittent dilatation and on demand dilatation.

Objectives:

The main aim of this study was to compare the results of these two methods, and to determine the best one.

Patients and Methods:

In this clinical trial study, we reviewed the documents of women diagnosed with urethral stricture, who came to the Baqiyatallah Clinic from 2007 and 2012. According to the method of dilatation, the patients were divided into two groups: intermittent dilatation and on demand dilatation. Patients’ data were then collected and analyzed.

Results:

Eighty-six patients were enrolled in the study. The mean age of the participants was 48.13 years (between 44 and 79 years). The mean urinary residual and maximum urinary flow speed changes, before and after on demand dilatation, were higher than in the intermittent method.

Conclusions:

For treating urethral stricture, on demand urethral dilatation is more effective than intermittent dilatation.

Optimal effect-site concentration of remifentanil when combined with dexmedetomidine in patients undergoing cystoscopy

Background

Cystoscopic procedure is a very common practice in the field of urology due to its ability to survey the bladder for a variety of indications. However, patients who undergo cystoscopy feel intense pain and discomfort. This study investigated the half maximal effective concentration (EC₅₀) of remifentanil in preventing cystoscope insertion pain under sedation using dexmedetomidine.

Methods

The study was prospectively conducted on 18 male patients, aged 18 to 65. Remifentail infusion was initiated together with dexmedetomidine, and started at a dose of 2.4 ng/ml on the first patient. The effect-site concentration (C_e) of remifentanil for each subsequent patient was determined by the previous patient's response using Dixon's up-and-down method with an interval of 0.3 ng/ml. Patients received a loading dose of 1.0 µg/kg dexmedetomidine over 10 minutes, followed by a maintenance dose of 0.6 µg/kg/hr. After the patient's OAA/S score (Observer's Assessment of Alertness/Sedation scale) reached 3-4, and the C_e of remifentanil reached target concentration, the urologist was allowed to insert the cystoscope and the pain responses were observed.

Results

The effect-site concentration of remifentanil required to prevent cystoscope insertion pain in 50% of patients under sedation using dexmedetomidine was 1.30 ± 0.12 ng/ml by Dixon's up-and-down method. The logistic regression curve of the probability of response showed that the EC₅₀ and EC₉₅ values (95% confidence limits) of remifentanil were 1.33 ng/ml (1.12-1.52 ng/ml) and 1.58 ng/ml (1.44-2.48 ng/ml), respectively.

Conclusions

Cystoscopic procedure can be carried out successfully without any pain or adverse effects by optimal remifentanil effect-site concentration (EC₅₀, 1.33 ng/ml; EC₉₅, 1.58 ng/ ml) combined with sedation using dexmedetomidine.