Uncoiling of a Cook Resonance Metallic Ureteral Stent

Introduction and Background: The Cook Resonance^® metallic ureteral stent's unique configuration allows adequate urine drainage while providing improved resistance to external ureteral compression. We report a case in which a stent broke and subsequently uncoiled during stent removal under cystoscopy. Case Presentation: A 46-year-old woman with a history of cervical carcinoma treated with radiation therapy and chemotherapy and bilateral ureteral strictures presented for cystoscopic removal of bilateral Cook Resonance ureteral stents. During removal of the right ureteral stent, a snap was felt with subsequent uncoiling of the stent. Firm tension to the inner wire and outside curls allowed eventual complete removal of the stent without any retained fragments. Discussion: The all-metal Cook Resonance stent is an attractive alternative to polymeric stents because of reduced frequency of stent exchange and resistance to external compression. However, the metal stent possesses risks such as increased urothelial hyperplasia and stent embedment.

Spontaneous remission of untreated primary amyloidosis of the bladder after transurethral resection biopsy: a case report and literature review

We herein present a case involving a 23-year-old woman with gross hematuria. Cystoscopy revealed abnormal areas of the mucosa along the anterior and posterior bladder walls. These abnormalities were suspicious for neoplasia; however, a diagnosis was not established by subsequent biopsy. The patient underwent transurethral resection biopsy in which an isolated lesion along the anterior wall was completely resected and the others were left untreated. Pathologic examination and special staining led to a diagnosis of amyloidosis, and the patient elected to undergo transurethral surgery 1 month later. During the operation, the intravesical lesions were found to have significantly improved in both the treated and untreated sites. The operation was cancelled, follow-up was arranged, and no other treatment was administered. Repeat cystoscopy examinations at 3 and 9 months after surgery showed that the lesions had almost completely disappeared.

Antibiotics are not necessary during routine cystoscopic stent removal: A randomized controlled trial at UC San Diego

Introduction:

Current American Urological Association (AUA) Best Practice Statement recommends antibiotic prophylaxis for cystoscopy with manipulation, including stent removal; although no Level 1b trials explicitly address prophylaxis for stent removal. We sought to determine the efficacy of prophylactic antibiotics to prevent infectious complications after stent removal.

Materials and Methods:

Following institutional review board approval, patients undergoing removal of ureteral stent placed during stone surgery were recruited from July 2016 to March 2019. Patients were recruited at the time of stent removal and randomized to treatment (single dose 500 mg oral ciprofloxacin) or control group (no antibiotics). Telephone contact was attempted within 14 days of stent removal to assess for urinary tract infection (UTI) symptoms, antibiotic prescriptions, or Emergency Department visits. Primary outcome was UTI within 1 month of stent removal – defined by irritative voiding symptoms, fever or abdominal pain associated with positive urine culture (Ucx) (>100k colony-forming units/mL).

Results:

Seventy-seven patients were enrolled, with 58 meeting final inclusion criteria for the analysis (33 treatment, 25 controls). No differences were seen with clinical and demographic variables, except a higher body mass index in the treatment group (P = 0.007). Positive Ucx rate before stone surgery (16.7% vs. 11.8%, P = 0.819) and at the time of stent removal (16.0% vs. 11.1%, P = 0.648) was not significantly different in treatment versus control groups, respectively. Primary outcome: No patients in either cohort developed symptomatic culture-diagnosed UTI within 1 month of stent removal. Of patients with documented phone follow-up (treatment n = 29, control n = 22), only one patient (control) reported any positive response on phone survey.

Conclusions:

We found a low infectious complication rate regardless of antibiotic prophylaxis use during cystoscopic stent removal. The necessity of antibiotics during routine cystoscopic stent removal warrants possible reevaluation of the AUA best practice statement.

Global Assessment of Urological Endoscopic Skills (GAUES): development and validation of a novel assessment tool to evaluate endourological skills

OBJECTIVE

To develop and evaluate an assessment tool for endourological skills during simulation including cystoscopy, ureteroscopy (URS) and transurethral resection (TUR) procedures.

METHODS

We designed a Global Assessment of Urological Endoscopic Skills (GAUES) tool, comprised of nine endourology task-specific and two global-rating skills items. The tool was developed through two rounds of the Delphi process. The GAUES tool was used to assess acquisition of URS and TUR skills of novices (Year 2 core surgical trainees, CT2) and intermediate level trainees (residents at the start of the UK higher surgical training programme in Urology, Speciality Trainee Year 3, ST3) at the Urology Simulation Boot Camp (USBC) between 2016 and 2018. Validity was evaluated by comparing scores between trainees with different levels of urological experience. Inter-rater reliability was also assessed.

RESULTS

We evaluated 130 residents, 52% of trainees were at an intermediate stage of training and 39% were novices. In all, 9% of the anonymous forms were missing demographics. The completion rate of the GAUES tool during the USBC for URS and TUR was 85% and 89%, respectively. Our analysis demonstrated a significant difference in all domains between intermediates and novices at assessment in URS, except for one domain more suited to clinical assessment (P = 0.226). There was excellent intraclass correlation (ICC) overall between the two experts' judgements, ICC = 0.841 (95% confidence interval 0.767-0.893; P < 0.001, n = 88).

CONCLUSIONS

We have developed the novel GAUES tool for cystoscopic, URS and TUR skills. Overall, we demonstrated good face, content and construct validity and excellent reliability, suggesting that the GAUES tool can be useful for endourological skills assessment.

Surgeon Scorecards Improve Muscle Sampling on Transurethral Resection of Bladder Tumor and Recurrence Outcomes in Patients with Nonmuscle Invasive Bladder Cancer

PURPOSE

The presence of detrusor muscle is essential for accurate staging of T1 cancers. Detrusor muscle presence can be a quality indicator of transurethral resection of bladder tumor for nonmuscle invasive bladder cancer. We hypothesized that increasing surgeon awareness of personal and institutional detrusor muscle sampling rates could improve resection quality and long-term oncologic outcomes.

MATERIALS AND METHODS

A retrospective review of transurethral resections of bladder tumor from 1/2006 to 2/2018 was performed. The presence of detrusor muscle in the pathology report and transurethral resection specimen were extracted from records. Individual surgeon scorecards were created and distributed. Rates of detrusor muscle sampling were compared prior to and 12 months after distribution. Chart review was done to compare 3-year recurrence and progression outcomes before and after distribution of scorecards.

RESULTS

The rate of detrusor muscle sampling increased from 36% (1,250/3,488) to 54% (202/373) (p=0.001) in the 12 months after scorecard distribution, ie from 30% (448/1,500) to 55% (91/165) (p <0.001) in Ta tumors and from 47% (183/390) to 72% (42/58) (p <0.001) in T1 tumors. Pathological reporting of muscle also improved for all samples (73%, 2,530/3,488 to 90%, 334/373, p <0.001), Ta (75%, 1,127/1,500 to 94%, 155/165, p <0.001) and T1 (93%, 362/390 to 100%, 58/58, p=0.04). On multivariate Cox regression analysis, the surgeon scorecard was associated with decreased 3-year risk of recurrence (HR 0.63, 95% CI 0.40-0.99).

CONCLUSIONS

Creation and distribution of individual surgeon scorecards improved detrusor muscle sampling on transurethral resection and was associated with decreased risk of disease recurrence. Quality evaluation of transurethral resection of bladder tumor may contribute to improved outcomes of patients with nonmuscle invasive bladder cancer.

Clinical Validation of a Urine Test (Uromonitor-V2®) for the Surveillance of Non-Muscle-Invasive Bladder Cancer Patients

The costly and burdensome nature of the current follow-up methods in non-muscle-invasive bladder cancer (NMIBC) drives the development of new methods that may alternate with regular cystoscopy and urine cytology. The Uromonitor-V2^® is a new urine-based assay in the detection of hotspot mutations in three genes (TERT, FGFR3, and KRAS) for evaluation of disease recurrence. The aim of this study was to investigate the Uromonitor-V2^®’s performance in detecting NMIBC recurrence and compare it with urine cytology. From February 2018 to September 2019 patients were enrolled. All subjects underwent a standard-of-care (SOC) cystoscopy, either as part of their follow-up for NMIBC or for a nonmalignant urological pathology. Urine cytology was performed in NMIBC patients. Out of the 105 patients enrolled, 97 were eligible for the study. Twenty patients presented nonmalignant lesions, 29 had a history of NMIBC with disease recurrence, and 49 had a history of NMIBC without recurrence. In NMIBC, the Uromonitor-V2^® displayed a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 93.1%, 85.4%, 79.4%, and 95.3%, respectively. Urine cytology was available for 52 patients, and the sensitivity, specificity, PPV, and NPV were 26.3%, 90.9%, 62.5%, and 68.2%, respectively. With its high NPV of 95.3%, the Uromonitor-V2^® revealed promising properties for the follow-up of patients with NMIBC.

Optimizing Telemedicine Technologic Infrastructure with Animal Models: A Case in Telecystoscopy

Background: Rapid evolution of telemedicine technology requires procedures in telemedicine to adapt frequently. An example in urology, telecystoscopy, allows certified advanced practice providers to perform cystoscopy, endoscopic examination of the bladder, in rural areas with real-time interpretation and guidance by an off-site urologist. We have previously shown the technological infrastructure for optimized video quality. Introduction: Newer models of cystoscope and coder/decoder (codec) are available with anticipation that components used in our original model will become unavailable. Our objective is to assess the diagnostic ability of two cystoscopes (Storz, Wolf) with old (SX20) and new (DX70) codecs. Materials and Methods: A single urologist performed flexible cystoscopy on an ex vivo porcine bladder. Combinations of cystoscope (Storz vs. Wolf), codec (SX20 vs. DX70), and internet transmission speed were used to create eight distinct recordings. Deidentified videos were reviewed by expert urologist reviewers via electronic survey with questions on video quality and diagnostic ability. A logistic regression model was used to assess the ability to make a diagnosis. Results: Eight transmitted cystoscopy videos were reviewed by 16 urologists. Despite new technology, the Storz cystoscope combined with the SX20 codec (the original combination) provides the best diagnostic capacity. Discussion: Technical infrastructure must be routinely validated to assess the component impact on overall quality because newer is not always better. Should the SX20 become obsolete, ex vivo animal models are safe, inexpensive anatomic models for testing. Conclusions: As technology continues to evolve, procedures in telemedicine must critically scrutinize the impact of new technologic components to uphold quality.

Presenting an atlas of Hunner lesions in interstitial cystitis which can be identified with office cystoscopy

AIM

To assist clinicians in proper visual diagnosis of Hunner lesions by providing an atlas of representative images of the variability in Hunner lesion appearance.

METHODS

Available cystoscopic images of Hunner lesions were reviewed from patients with interstitial cystitis or bladder pain syndrome (IC/BPS) treated by a single clinician between 2011 and 2020. For most patients, initial cystoscopy was performed in the office under local anesthesia. Images were categorized by variations in appearance. Data including Hunner lesion descriptions and patient demographics were retrospectively collected from the medical record. Only patients who had images available, received triamcinolone injection and/or fulguration of Hunner lesions, and reported improvement of their symptoms following treatment were included in the atlas.

RESULTS

Thirty-one IC/BPS patients with Hunner lesions had cystoscopic images available for review. We created an atlas of representative images. Variations in appearance include classic lesions with or without a central coagulum, inflamed lesions, non-inflamed lesions, groupings of lesions, and lesions with a red waterfall bleeding appearance.

CONCLUSION

There is variation in cystoscopic appearance of Hunner lesions. Most Hunner lesions can be identified during office visits using flexible cystoscopy and local anesthesia without hydrodistention or general anesthesia. Proper visual diagnosis of Hunner lesions is of upmost importance as these patients with IC/BPS respond greatly to endoscopic intervention. This atlas will serve as a reference for clinicians and researchers, so they are able to better identify and manage these patients.

Cystoscopy with antibiotic irrigation during pelvic reconstruction and minimally invasive gynecologic surgery: A double-blind randomized controlled trial

AIMS

After pelvic reconstructive surgery, the risk of postoperative urinary tract infection (UTI) is significant; intraoperative cystoscopy may contribute to this risk. Intravesical antibiotics are used in the ambulatory setting and may be applied to the surgical arena. Our objective was to evaluate the efficacy of antibiotic irrigation during intraoperative cystoscopy to prevent postoperative UTI.

METHODS

This double-blind randomized controlled trial enrolled 216 women undergoing cystoscopy with elective surgery for pelvic organ prolapse, stress urinary incontinence, or laparoscopic gynecologic surgery at an academic medical center 2016-2019. Participants were randomized to cystoscopic irrigation fluid type: normal saline (control) or 200,000 U polymyxin B + 40 mg neomycin solution in normal saline (antibiotic). Patients and providers who treated UTIs were blinded. The primary outcome was treatment of UTI within 6 weeks postoperatively, defined as positive culture or treatment for a symptomatic UTI. χ² and multivariable logistic regression analyses were performed.

RESULTS

We enrolled 216 women: 111 control (51.4%) and 105 antibiotic (48.6%). Mean age was 51.6 years. Groups were well matched in medical comorbidities and surgery type. Primary vaginal surgery was most common (n = 127, 58.8%). Overall, 10.7% of patients developed a postoperative UTI with no difference in incidence between groups: 9.9% of control (n = 11, 95% confidence interval [CI]: 4.0%-16.0%) versus 11.4% of antibiotic subjects (n = 12, 95% CI: 5.0%-18.0%), on χ² (p = .718) and logistic regression analysis (adjusted odds ratio, 1.3; CI: 0.53-3.16; p = .569).

CONCLUSION

When cystoscopy is performed during elective pelvic surgery, use of antibiotic irrigation does not impact the rate of postoperative UTI.

"Central Road" cystoscopic finding: The road to worsened incontinence following laparoscopic sacrocolpopexy

INTRODUCTION

This paper presents the "Central Road" cystoscopic finding accompanied by magnified mixed urinary incontinence following laparoscopic sacrocolopopexy.

CASE PRESENTATION

A 70-year-old female experienced severe mixed urinary incontinence upon completing laparoscopic sacrocolopopexy. The cystoscopy showed a cord-like appearance in the center of the bladder trigon and posterior wall. Videourodynamics confirmed stress urinary incontinence, and chain cystourethrography indicated that the proximal urethra was open and the posterior vesicourethral angle was atypically widened. After implanting a midurethral sling, mixed urinary incontinence was cured subjectively and objectively without medication.

CONCLUSION

The "Central Road" cystoscopic finding can be a signpost pointing to laparoscopic sacrocolopopexy mesh overtensioning, which can cause dekinking of the bladder neck, exacerbate stress urinary incontinence, and possibly lead to stress-induced instability. A midurethral sling successfully relieved mixed urinary incontinence in this case, but it might be necessary to loosen the laparoscopic sacrocolopopexy mesh in some other cases.

[Influence of phenazopyridine on the well-being of patients during and after cystoscopy]

INTRODUCTION

Cystoscopy is one of the most common procedures in urology. There is no single approach to pain relief. In the literature, there are conflicting data on the efficiency of intra-urethral gels. The use of non-steroidal anti-inflammatory drugs, intravenous sedation, and nitric oxide analgesia has been described. Phenazopyridine has been known for a long time. Acting on the bladder mucosa, it has a local analgesic effect. AN evaluation of phenazopyridine intake prior to cystoscopy in order to decrease pain during procedure and facilitate subsequent urination was performed.

MATERIALS AND METHODS

A total of 97 patients were included in the study. Indications for cystoscopy were as following: hematuria, lower urinary tract symptoms/pain, a need to remove ureteral stent. The patients were randomized into two groups. In the main group (n=50), phenazopyridine 200 mg was administered 20 minutes before cystoscopy and then at a dose of 200 mg every 8 hours (in total three doses) in combination with lidocaine gel. In the control group (n=47), only lidocaine gel was used. Heart rate was measured before and after the procedure. All patients were asked to complete a visual analogue scale (VAS) 3, 8 and 24 hours after cystoscopy with the assessment of the first urination.

RESULTS

After cystoscopy, the difference between groups in VAS score was 27.7% in favor of the main group (p<0.001). After 3 hours, the average score in the main group was two times less than in the Control (p=0.012), while 3 and 8 hours after cystoscopy, the proportion of "zero" results was 10% and 0%, 28% and 4%, respectively, p<0.005. The heart rate after the procedure in the main group was 75.1 beats/min, compared to 77.9 beats/min in the control group (p=0.016).

CONCLUSION

The intake of phenazopyridine allows to reduce pain intensity during and after cystoscopy and alleviate pain during first urination.

Evaluation of cross-linked gelatin as a bulking agent for the management of urinary sphincter mechanism incompetence in female dogs

BACKGROUND

Bulking agent implantation is a minimally invasive intervention for the management of urethral sphincter mechanism incompetence (USMI).

HYPOTHESIS/OBJECTIVES

To evaluate the efficacy and safety of the novel bulking agent VetFoam for the management of urinary incontinence in female dogs diagnosed with USMI.

ANIMALS

Fifteen client-owned female dogs.

METHODS

Prospective study. Female dogs diagnosed with USMI, refractory, or unamenable to medical treatment were included. VetFoam was injected under endoscopic guidance into the urethral submucosa. Continence score was evaluated before and after the procedure and monthly thereafter.

RESULTS

Twenty-two injection procedures were performed in 15 dogs (5 dogs underwent >1 procedure). Median age of all dogs at the time of the procedure was 111 months (range, 18-180). Median continence score significantly increased after, compared with before bulking agent injection (1.5; range, 1.0-3.5 versus 4.0; range, 1.5-5 respectively; P < .001; effect size, 2.6). Continence was achieved in 13/15 (87%) dogs after the first procedure and in 7/7 (100%) repeated procedures. Overall, 20/22 (91%) procedures resulted in high (≥4) continence scores at time of first follow-up. Mean duration of continence was 11.1 months (SD, 10.7) after the first injection. One dog (7%) developed self-limiting stranguria, pollakiuria, and tenesmus while no other apparent adverse effects were recognized in the other dogs.

CONCLUSIONS AND CLINICAL IMPORTANCE

VetFoam is an apparently safe, effective novel bulking agent, which can be used as an alternative for the management of USMI.

Comparison of ureteric stent removal procedures using reusable and single-use flexible cystoscopes following ureteroscopy and lasertripsy: a micro cost analysis

Introduction

Diagnostic pressure on endoscopy suite can lead to delay in flexible cystoscopic stent removal. We compare the cost and organizational impact of reusable flexible cystoscope versus single-use, flexible cystoscope with a built-in stent grasper (Isiris^®).

Material and methods

Data for the reusable cystoscopic stent removal performed in endoscopy room, group A (period 1) were compared to Isiris disposable stent removal performed in outpatient clinic, group B (period 2). We chose the same calendar months in successive years for these two different groups (9 months each). A micro cost analysis was performed evaluating the impact on costs, complications and organizational benefit.

Results

A total of 72 patients (37, group A; 35, group B) were included with no significant differences in age and gender ratio. The mean procedure time was 14.4 and 2.2 minutes, and the mean stent dwell time was 26.8 and 15.4 days in groups A and B respectively (p <0.001). In group A, 5 patients (14%) developed stent encrustation, of which 3 needed a ureteroscopic removal subsequently. No complication occurred in group B. More staff on average were needed for procedures done in group A, than group B (p <0.001).

The number of patients who had cancer diagnostic wait of >2 weeks for flexible cystoscopy and the mean number of days they waited, reduced from 16 to 3, and 21 days to 3 days respectively between period 1 to period 2. The cost per procedure between group A and group B was £267.2 and £252.62 (p <0.05) if the cost of managing complications was not considered, and £365.40 and £252.62 (p <0.001) if the cost of managing complications was also considered.

Conclusions

Isiris significantly reduced stent dwell time, procedural time and staff needed to carry out the stent removals. It also allowed the procedures to be done in the outpatient setting thereby reducing the organizational pressure on endoscopy related diagnostic procedures.

Cystoscopy-Guided Laparoscopic Excision of Prostatic Utricle: Report of a Case

Prostatic utricle (PU) is incomplete regression of Müllerian duct and may cause recurrent urinary tract infections (UTIs), stone formation, postvoid dribbling, and recurrent epididymitis. Although surgical excision is recommended to avoid complications, surgical access to PU has been challenging. Cystoscopy-guided laparoscopic management of PU in a 3-year-old boy is reported to discuss use of other endoscopic aids in the surgical treatment of PU. He was admitted with disordered sexual development with karyotype of 47,XYY/46,XY and has been experiencing recurrent UTIs. Voiding cystourethrogram (VCU) demonstrated large PU (IKOMA II). Cystoscopy was performed confirming PU and the cystoscope was left in situ to aid laparoscopic exploration after bladder was emptied. A 5-mm umbilical port and two 5-mm ports in both lower quadrants were inserted. The peritoneum was dissected behind bladder. The cystoscope in PU was used as guidance in identification and dissection of PU. The vas deferens was identified and could be secured. The neck of PU was ligated with surgiloop. PU was retrieved from umbilical port. Postoperative VCU revealed normal posterior urethra. He has been free of UTIs for the last 6 months. Laparoscopy is safe and feasible alternative in surgical management of PU, by providing good visual exposure, easy dissection in deep pelvis, and improved cosmesis. The cystoscopic guidance is an important aid in identification and dissection of PU.

A Prospective Randomized Controlled Trial of Irrigation "Bag Squeeze" to Manage Pain for Patients Undergoing Flexible Cystoscopy

PURPOSE

We determined if the "bag squeeze" technique decreases pain during flexible cystoscopy in men.

MATERIALS AND METHODS

This single center, prospective, double-blind, randomized controlled trial recruited 200 consenting participants who were ambulatory, outpatient males who had undergone prior cystoscopy and were not expected to require any secondary procedures. Men with prior urethral stricture or bladder neck contracture were excluded from study. Once eligibility was assessed and consent obtained, participants were randomized to undergo cystoscopy with the bag squeeze (group A) or the sham bag squeeze procedure (group B). Following cystoscopy, participants completed a pain questionnaire (visual analogue scale). Differences in mean pain score between groups were evaluated using Students' t-test with a 2-sided alpha of 0.05.

RESULTS

A total of 200 patients were randomized and underwent flexible cystoscopy. Ten participants were ineligible because they required secondary procedures. Among the 190 eligible patients 97 were randomized to bag squeeze (group A) and 93 to sham bag squeeze (group B) with mean pain scores of 1.91 and 3.39, respectively (p <0.005).

CONCLUSIONS

This study demonstrated a clinically meaningful decrease in pain for men undergoing flexible cystoscopy when the irrigation bag squeeze technique was used vs placebo bag squeeze. Accordingly, this useful, simple and free method to improve patient comfort during flexible cystoscopy should be adopted by clinicians.

Support System of Cystoscopic Diagnosis for Bladder Cancer Based on Artificial Intelligence

Introduction: Nonmuscle-invasive bladder cancer has a relatively high postoperative recurrence rate despite the implementation of conventional treatment methods. Cystoscopy is essential for diagnosing and monitoring bladder cancer, but lesions are overlooked while using white-light imaging. Using cystoscopy, tumors with a small diameter; flat tumors, such as carcinoma in situ; and the extent of flat lesions associated with the elevated lesions are difficult to identify. In addition, the accuracy of diagnosis and treatment using cystoscopy varies according to the skill and experience of physicians. Therefore, to improve the quality of bladder cancer diagnosis, we aimed to support the cystoscopic diagnosis of bladder cancer using artificial intelligence (AI). Materials and Methods: A total of 2102 cystoscopic images, consisting of 1671 images of normal tissue and 431 images of tumor lesions, were used to create a dataset with an 8:2 ratio of training and test images. We constructed a tumor classifier based on a convolutional neural network (CNN). The performance of the trained classifier was evaluated using test data. True-positive rate and false-positive rate were plotted when the threshold was changed as the receiver operating characteristic (ROC) curve. Results: In the test data (tumor image: 87, normal image: 335), 78 images were true positive, 315 true negative, 20 false positive, and 9 false negative. The area under the ROC curve was 0.98, with a maximum Youden index of 0.837, sensitivity of 89.7%, and specificity of 94.0%. Conclusion: By objectively evaluating the cystoscopic image with CNN, it was possible to classify the image, including tumor lesions and normality. The objective evaluation of cystoscopic images using AI is expected to contribute to improvement in the accuracy of the diagnosis and treatment of bladder cancer.

Zinner syndrome mimicking bladder outlet obstruction managed with aspiration

Zinner syndrome is a rare cystic malformation of seminal vesicle which consists a triad of unilateral renal agenesis, ipsilateral seminal vesicle cyst, and ejaculatory duct obstruction. The usual presentation is between the third and fourth decades of life, with infertility being the most common complaint. Ultrasound, cystoscopy, and magnetic resonance tomography (MRI) can easily detect this condition. Treatment option varies according to the presenting symptoms of the patient. We present a case of a 19-year-old male with recurrent episodes of urinary tract infection (UTI) and poor urinary stream. On ultrasound examination, the patient was found to have absent right kidney with a cystic swelling noted to be arising from prostate or seminal vesicle region which was further confirmed on MRI examination. Cystoscopy reveals a bulge on the right side of the verumontanum abutting the neck of the bladder. An ultrasound-guided aspiration of the cyst was performed which relieved the symptoms of the patient. Cystic abnormalities of the seminal vesicle are very uncommon. Symptomatic cases may present as recurrent UTI, infertility, bladder outlet obstruction, and painful ejaculation. Surveillance may be the option in the absence of clinical manifestations. Interventions such as image-guided aspiration or surgical procedures are appropriate when conservative measures prove ineffective.

How can we improve the diagnosis and management of bladder pain syndrome? Part 1: ICI-RS 2018

BACKGROUND

This paper summarizes the discussion in a think tank at the ICI-RS 2018 about the diagnosis of bladder pain syndrome (BPS).

AIMS

To review the guidelines, investigations and subtypes of BPS.

MATERIALS AND METHODS

Review of literature in the light of the think tank discussion.

RESULTS

All guidelines recommend completing history, physical examination, urine analysis, urine culture, and urine cytology to define the BPS phenotype but there are differences on further investigations. In those guidelines which recommend cystoscopy, the identification of Hunner's lesions (HLs) is recommended as this changes the treatment plan and outcome.

CONCLUSION

We propose that the differentiation of Hunner's ulcers is an important step in the assessment of these patients. Further suggestions for research are suggested.

Efficacy of fluorescent cystoscopy-assisted transurethral resection in patients with non-muscle invasive bladder cancer and quality of surgery: post-hoc analysis of а prospective randomized study

Introduction

This paper aims to evaluate the influence of quality of transurethral resection in patients with non-muscle invasive bladder cancer on the benefit of fluorescent cystoscopy-assisted transurethral resection in the post hoc analysis of the single-center randomized controlled trial.

Material and methods

We retrospectively analyzed the results of the prospective randomized study assessing the efficacy of fluorescent cystoscopy-assisted transurethral resection. The quality of transurethral resection was defined on the basis of a separate retrospective study estimating the variability in recurrence risk for the individual surgeon. The subgroup analysis of fluorescent cystoscopy-assisted transurethral resection efficacy depending on surgical experience was performed.

Results

Of 377 eligible patients, transurethral resection was performed in 365 (97%) by surgeons with available grading information. Two ‘experienced’ surgeons performed 238 (63%) of all transurethral resections and three ‘less experienced’ surgeons completed 127 (34%) surgeries. The two surgical groups were comparable with respect to basic prognostic factors and subsequent therapy. The median follow-up was 56 months.

In the total cohort of patients, fluorescent cystoscopy significantly decreased the risk of recurrence with hazard ratio 0.58 (p = 0.004). In the ‘experienced surgeons' subgroup the benefit of fluorescent cystoscopy was not significant (hazard ratio 0.81, p = 0.34), whereas the ‘less experienced’ subgroup showed a marked difference in favor of fluorescent cystoscopy-assisted transurethral resection (hazard ratio 0.31, p = 0.001), with a P-value for interaction of 0.021.

Conclusions

Baseline quality of surgery may be a significant interacting factor affecting the magnitude of the benefit of fluorescent cystoscopy-assisted transurethral resection in patients with non-muscle invasive bladder cancer.

Health-related quality of life among non-muscle-invasive bladder cancer survivors: a population-based study

OBJECTIVE

To examine the effect of non-muscle-invasive bladder cancer (NMIBC) diagnosis and treatment on survivors' quality of life (QoL).

PATIENTS AND METHODS

Of the 5979 patients with NMIBC diagnosed between 2010 and 2014 in North Carolina, 2000 patients were randomly selected to be invited to enroll in this cross-sectional study. Data were collected by postal mail survey. The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core (QLQ-C30) and the NMIBC-specific module were included in the survey to measure QoL. Descriptive statistics, t-tests, anova, and Pearson's correlation were used to describe demographics and to assess how QoL varied by sex, cancer stage, time since diagnosis, and treatment.

RESULTS

A total of 398 survivors returned questionnaires (response rate: 23.6%). The mean QoL score for QLQ-C30 (range 0-100, higher = better QoL in all domains but symptoms) for global health status was 73.6, function domain scores ranged from 83.9 to 86.5, and scores for the top five symptoms (insomnia, fatigue, dyspnoea, pain, and financial difficulties) ranged from 14.1 to 24.3. The lowest NMIBC-specific QoL domain was sexual issues including sexual function, enjoyment, problems, and intimacy. Women had worse bowel problems, sexual function, and sexual enjoyment than men but better sexual intimacy and fewer concerns about contaminating their partner. Stage Ta had the highest global health status, followed by T1 and Tis. QoL did not vary by time since diagnosis except for sexual function. The cystectomy group (n = 21) had worse QoL in sexual function, discomfort with sexual intimacy, sexual enjoyment, and male sexual problems than the non-cystectomy group (n = 336).

CONCLUSION

Survivors of NMIBC face a unique burden associated with their diagnosis and the often-lifelong surveillance and treatment regimens. The finding has important implications for the design of tailored supportive care interventions to improve QoL for NMIBC survivors.

Comparing 2% lidocaine gel (Dispogel and Cathejell) in cystoscopy

Objective

Cystoscopy is a common urologic procedure. Analgesics are often used to reduce any pain associated with this procedure. The aim of this study was to investigate the efficacy in reducing pain and the cost-effectiveness of two forms of lidocaine gel in patients undergoing cystoscopy.

Methods

In this double-blind, randomized clinical trial, 77 male patients who were referred for double J removal, urethral dilatation, or cystoscopy were enrolled. The patients were divided into two groups: Dispogel and Cathejell. All patients received 20 mL of intraurethral lidocaine gel 2% and cystoscopy was performed 5 minutes thereafter. The primary outcome was the pain score (visual analogue scale, VAS) during and 5 minutes after cystoscopy.

Results

There were no statistically significant differences between the VAS scores, blood pressure, and pulse rate in the groups in either observation period. No patient required additional anesthetic agents or sedatives for insufficient pain relief.

Conclusion

The results of this study show that the analgesic efficacy of Dispogel and Cathejell in the treatment of pain during and after elective cystoscopy was the same, but Dispogel was more cost-effective.

A closer look at the health of cats showing urinary house-soiling (periuria): a case-control study

OBJECTIVES

The aim of this study was to perform a case-control medical evaluation of cats from multi-cat households presenting with inappropriate latrining and spraying behavior.

METHODS

Owners of 18 'spraying' and 23 'latrining' cats with normal control subjects available from the same households were recruited for a case-control study. Otherwise overtly healthy dyads (each dyad consisting of a case cat and a control cat) were brought together to the veterinary hospital of the University of São Paulo for a medical work-up (ie, physical examination, complete blood count, biochemical profile, urinalysis and urine culture, abdominal ultrasound of the urinary system and in females, where possible, cystoscopy).

RESULTS

Medical problems were identified with similar frequency in the 'sprayers' (38.9%), 'latriners' (39.1%) and controls of the latrining group (26.1%), but not the controls of the spraying group (5.5%). The difference between 'cases' and 'controls' from spraying households was significant. Common potential health-related changes include renal insufficiency, cystitis and bladder lithiasis. Renal calculi, higher creatinine levels (within normal reference interval) and 'glomerulations' (detected during cystoscopy) were also found in the remaining sprayers and latriners that were considered clinically healthy. Post-cystoscopy, a new form of periuria occurred in two cats (one sprayer and one latriner).

CONCLUSIONS AND RELEVANCE

These results indicate that spraying or latrining behavior in the home, as well as living with a cat that is not using the litter box as a latrine, are all associated with a higher level of urinary tract abnormalities; living with a cat that is spraying, however, does not have this association. The findings also suggest that both forms of periuria might be associated with interstitial cystitis. We therefore conclude that all cats with periuria need to be carefully evaluated medically and that treatment of latrine-related problems should consider all cats in the house, whereas spraying may be more focused on the individual displaying the problem.

Reduction of Pain during Flexible Cystoscopy: A Systematic Review and Meta-Analysis

PURPOSE

The BCAN (Bladder Cancer Advocacy Network) Patient Survey Network identified pain during intravesical procedures as a research priority for patients. Although intraurethral lidocaine is the standard of care in this setting, evidence of its use is equivocal. We systematically reviewed studies of interventions to reduce discomfort during cystoscopy and intravesical therapy of bladder cancer. We performed a meta-analysis of interventions using available randomized, controlled trials.

MATERIALS AND METHODS

Search terms derived from the key questions were incorporated into the literature search constructed by a research librarian and the English medical literature from 1990 to 2017 was accessed. The initial search yielded 626 potential studies and the final review incorporated 62. We combined 12 trials into a meta-analysis with a random effects model of the efficacy of intraurethral lidocaine vs plain lubricant to reduce pain during flexible cystoscopy as measured on a 10-point visual analogue scale.

RESULTS

Data from 12 randomized controlled trials in a total of 1,549 patients were included in the final intraurethral lidocaine meta-analysis. The standardized mean difference between visual analogue scale pain scores in patients who underwent flexible cystoscopy with intraurethral lidocaine and plain lubricant was -0.22 (95% CI -0.39--0.05). Evidence was insufficient to evaluate other interventions to mitigate the discomfort of invasive bladder procedures.

CONCLUSIONS

Intraurethral lidocaine provides statistically significant pain reduction in men who undergo flexible cystoscopy, particularly with a longer dwell time. The evidence was insufficient for other tested interventions. A prospective study is needed to further clarify interventions to decrease patient discomfort during cystoscopy and other intravesical procedures in a diverse population.

Neuroblastoma involving urinary bladder: A rare type of tumor with diagnostic ambiguity

Introduction

Neuroblastoma of urinary tract is an extremely rare type of tumor and only a few cases have been reported worldwide.

Case presentation

We presented an adult case of neuroblastoma involving urinary bladder. Patient was a 24‐year‐old man with a history of repeated attack of hematuria. Patient underwent cystoscopy and transuretheral resection of bladder tumor. Biopsy result was “Blastema cell (suggestive of neuroblastoma) with immature ganglion cells.” Immunohistochemistry workup was continued and neuron‐specific enolase and S100 staining were positive. Patient lost to further follow‐up visit.

Conclusion

Although neuroblastoma of skin and peripheral nerve is not a rare disease entity, involvement of deeper structures (especially urinary bladder) is exceptional.