The Risk of Urinary Tract Infection after Flexible Cystoscopy in Patients with Bladder Tumor Who Did Not Receive Prophylactic Antibiotics

Simulation of the effects of molecular urine markers in follow-up of patients with high-risk non-muscle invasive bladder cancer

A plethora of urine markers for the management of patients with bladder cancer has been developed and studied in the past. However, the clinical impact of urine testing on patient management remains obscure. The goal of this manuscript is to identify scenarios for the potential use of molecular urine markers in the follow-up of patients with high-risk non-muscle-invasive BC (NMIBC) and estimate potential risks and benefits. Information on the course of disease of patients with high-risk NMIBC and performance data of a point-of-care test (UBC rapid™), an MCM-5 directed ELISA (ADXBLADDER™), and 2 additional novel assays targeting alterations of mRNA expression and DNA methylation (Xpert bladder cancer monitor™, Epicheck™) were retrieved from high-quality trials and/or meta-analyses. In addition, the sensitivity of white light cystoscopy (WLC) and the impact of a urine marker result on the performance of WLC were estimated based on fluorescence cystoscopy data and information from the CeFub trial. This information was applied to different scenarios in patient follow-up and sensitivity, estimated number of cystoscopies, and the numbers needed to diagnose were calculated. The sensitivity of guideline-based regular follow-up (SOC) at 1 year was calculated at 96%. For different marker-supported strategies sensitivities ranging from 77% to 97.9% were estimated. Calculations suggest that several strategies are effective for the SOC. While for the SOC 24.6 WLCs were required to diagnose 1 tumor recurrence (NND), this NND dropped below 5 in some marker-supported strategies. Based on the results of this simulation, a marker-supported follow-up of patients with HR NMIBC is safe and offers the option to significantly reduce the number of WLCs. Further research focusing on prospective randomized trials is needed to finally find a way to implement urine markers into clinical decision-making.

Potential of an mRNA-Based Urine Assay (Xpert® Bladder Cancer Detection1) in Hematuria Patients - Results from a Cohort Study

BACKGROUND AND OBJECTIVE

Assessment of patients with hematuria (aH) remains a challenge in urological practice, balancing the benefits of diagnosing a potentially underlying bladder cancer (UCa) against the risks of possibly unnecessary diagnostic interventions. This study analyzes the potential of an mRNA-based urine assay, the Xpert® Bladder Cancer Detection- CE-IVD (Xpert BC-D), in patients with hematuria.

MATERIALS AND METHODS

Overall, 368 patients with newly observed painless hematuria and no history of UCa were included in this observational study. Patients received urological workup, including urethrocystoscopy (WLC), upper tract imaging, urine cytology and Xpert BC-D. Patients with positive WLC were recommended to undergo tumor resection (TUR-B).

RESULTS

After excluding non-assessable cases, 324 patients were considered for analysis (188 males, 136 females; median age: 61 years). Eight of twenty-eight patients with a positive TUR-B had Ta low grade (LG) tumors; the others were diagnosed with high grade (HG) lesions (Ta: 4, CIS: 2, T1:11, > T1:3). The Xpert BC-D was more sensitive than urine cytology (96% vs. 61%) (p = 0.002). Increased risk ratios (RR) were observed for gross hematuria, gender, urine cytology, and positive Xpert BC-D (all p < 0.05). Age and positive Xpert BC-D remained independent predictors of UCa in multivariate analysis. Simulating a triage with WLC restricted to patients with positive Xpert BC-D could have saved 240 (74.1%) assessments at the cost of missing one pTa LG tumor.

CONCLUSIONS

The results suggest a potential role for Xpert BC-D in preselecting patients with hematuria for either further invasive diagnosis or an alternate diagnostic procedure.

Sterile versus non-sterile gloves during cystoscopy: A randomized prospective single-blind study

Objective

The objective of this study is to evaluate the need for sterile gloves during cystoscopy by comparing the incidence of UTI symptoms between patients in whom the procedure is performed with non-sterile gloves with those performed with non-sterile gloves.

Patients and Methods

This study had a randomized, prospective, single-blind design and included patients aged >20 years who underwent cystoscopy in either of two outpatient clinics between September 2015 and November 2021. The patients were allocated to a sterile group or a non-sterile group. Only the urologists were aware of whether or not the gloves were sterile. The patients were instructed to report any symptoms suggestive of UTI after cystoscopy.

Results

A total of 1258 patients were enrolled in the sterile group and 1376 in the non-sterile group. Symptoms of UTI were reported by six patients (0.48%) in the sterile group and six (0.44%) in the non-sterile group. The between-group difference was not statistically significant (p = 0.88).

Conclusion

It is not necessary to use sterile gloves during routine cystoscopy.

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.

Pseudomonas aeruginosa: Infections and novel approaches to treatment "Knowing the enemy" the threat of Pseudomonas aeruginosa and exploring novel approaches to treatment

Pseudomonas aeruginosa is an aerobic Gram-negative rod-shaped bacterium with a comparatively large genome and an impressive genetic capability allowing it to grow in a variety of environments and tolerate a wide range of physical conditions. This biological flexibility enables the P. aeruginosa to cause a broad range of infections in patients with serious underlying medical conditions, and to be a principal cause of health care associated infection worldwide. The clinical manifestations of P. aeruginosa include mostly health care associated infections and community-acquired infections. P. aeruginosa possesses an array of virulence factors that counteract host defence mechanisms. It can directly damage host tissue while utilizing high levels of intrinsic and acquired antimicrobial resistance mechanisms to counter most classes of antibiotics. P. aeruginosa co-regulates multiple resistance mechanisms by perpetually moving targets poses a significant therapeutic challenge. Thus, there is an urgent need for novel approaches in the development of anti-Pseudomonas agents. Here we review the principal infections caused by P. aeruginosa and we discuss novel therapeutic options to tackle antibiotic resistance and treatment of P. aeruginosa infections that may be further developed for clinical practice.

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.

Microscopic hematuria and pelvic ultrasonography could rule out flexible cystoscopy during surveillance for T1-low grade non-muscle invasive bladder cancer

Purpose

Cystoscopy (rigid/flexible [FC]) is the standard surveillance tool for non-muscle invasive bladder cancer (NMIBC). Nevertheless, it has its drawbacks. The objective of this study is to evaluate the performance of microscopic hematuria (MH), abdominal ultrasonography (US), and urine cytology (UC) as potential substitutes for FC in patients with T1-low-grade (T1-LG) NMIBC.

Methods

Over a 12-month period, patients attending our tertiary referral center for T1-LG NMIBC follow-up underwent urine analysis for MH and UC, and then US and FC were performed as outpatient surveillance procedures. Those with positive findings underwent inpatient rigid cystoscopy under anesthesia and biopsy. The negative predictive values (NPV) and sensitivity of different combinations of MH, UC, US, and FC were compared with the standard histopathology.

Results

In 218 evaluated patients, FC had the highest NPV (97.9%). However, this figure showed no statistically significant difference if compared with the combination of negative MH and US (93.8%) (difference = 0.04, p = 0.1) or the combination of MH, US, and UC (94.9%) (difference = 0.03, p = 0.2). The reported sensitivity results were similarly comparable between FC (94.2%) and the aforementioned combinations (90.4% and 92.3%; differences: 0.038 and 0.019; p = 0.4 and 0.7, respectively).

Conclusions

During the surveillance of NMIBC for patients diagnosed with T1-LG disease, the combination of MH/US has comparable sensitivity and NPV with FC. This non-invasive combination could be considered the first station that might preclude the need for FC in a considerable percentage of this group of patients.

Bladder EpiCheck urine test in the follow-up of NMIBC: a cost analysis

PURPOSE

In the Netherlands yearly more than 5000 patients are diagnosed with non-muscle invasive bladder cancer (NMIBC). With a specificity of 88.0% and a negative predictive value (NPV) for high grade NMIBC of 99.3%, the Bladder EpiCheck (BE) urine test may be used in NMIBC to reduce the burden of follow-up cystoscopies.

METHODS

In this study a cost analysis of the BE follow-up strategy in the Dutch healthcare system was performed. In half of the follow-up appointments, BE was used as a rule-in for cystoscopy. In addition, the possible delay in recurrence detection was estimated. A cost calculation tool was developed using Microsoft Excel.

RESULTS

The BE strategy results in an estimated cost reduction of 8%, 4% and 9% in low, intermediate and high risk patients, respectively. In the Netherlands this may result in a cost reduction of approximately 1.6 million euro per year. The estimated delay in the detection of recurrent disease would be 3.9, 1.7 and 1.3 months in low, intermediate and high risk NMIBC patients respectively.

CONCLUSION

To conclude, the BE can be used to reduce the costs of NMIBC follow-up, with a small delay in diagnosis of recurrent disease.

Considering the Effects of Modern Point-of-Care Urine Biomarker Assays in Follow-Up of Patients with High-Risk Non-muscle-Invasive Bladder Cancer

BACKGROUND

Although a plethora of urine markers for diagnosis and follow-up of patients with bladder cancer (BC) has been developed and studied, the clinical impact of urine testing on patient management remains unclear. The goal of this manuscript is to identify scenarios for a potential use of modern point-of-care (POC) urine marker assays in the follow-up of patients with high-risk non-muscle-invasive BC (NMIBC) and estimate potential risks and benefits.

METHODS

To permit comparison between different assays, the results of 5 different POC assays studied in a recent prospective multicenter study including 127 patients with suspicious cystoscopy undergoing TURB were used for this simulation. For the current standard of care (SOC), a "marker-enforced" procedure, and a combined strategy sensitivity (Se), estimated number of cystoscopies, and the numbers needed to diagnose (NND) over a 1-year follow-up period were calculated.

RESULTS

For regular cystoscopy (SOC), a Se of 91.7% and a NND of 42.2 repetitive office cystoscopies (WLCs) for 1 recurrent tumor at 1 year were calculated. For the "marker-enforced" strategy, marker sensitivities between 94.7% and 97.1% were observed. The "combined" strategy yielded for markers with a Se exceeding 50% an overall Se at 1 year similar or superior to the current SOC. Savings regarding the number of cystoscopies in the "marker-enforced" strategy vs. the SOC were small, while, depending on the marker, up to 45% of all cystoscopies may be saved using the "combined" strategy.

CONCLUSIONS

Based on the results of this simulation, a marker-supported follow-up of patients with high-risk (HR) NMIBC is safe and offers options to significantly reduce the number of cystoscopies without compromising the Se. Further research focusing on prospective randomized trials is needed to finally find a way to include marker results into clinical decision-making.

A Randomized Controlled Trial to Study the Rationale of Antibiotic Prophylaxis in Diagnostic Rigid Cystoscopy: A Relook in The Era of Antibiotic Stewardship

Background

In the era of widespread antibiotic (AB) resistance, the role of prophylaxis in diagnostic cystoscopy is controversial.

Aim

This study aimed to compare the incidence of postcystoscopy positive urinary culture (PC-PUC) and urinary tract infection (UTI) in patients undergoing diagnostic rigid cystoscopy with and without prophylaxis with preprocedural single-dose intravenous AB.

Materials and Methods

This prospective study was done in patients with preprocedural sterile urine undergoing elective diagnostic rigid cystoscopy. Patients were randomized into two groups, with one group receiving preprocedure single dose of intravenous cefuroxime sodium as prophylaxis half to 1 h before the procedure (Group AB prophylaxis) and the other group receiving no antibiotic prophylaxis (Group NAB). All patients were followed up till 1-month postprocedure, for any symptoms of urinary infection, mandatory urine microscopy and culture at 24-48 h, 1 week and 4 weeks post procedure, and addition sample in case of any urinary symptoms or fever.

Results

A total of 225 patients were studied, with 110 in AB prophylaxis and 115 in NAB groups. The use of prophylaxis did not decrease the incidence of PC-PUC (8.7%-3.6%; P = 0.167) or UTI (6.1%-1.8%; P = 0.102). Females and diabetics had significantly higher risk of PC-PUC, on univariate and multivariate analysis, not affected by prophylaxis.

Conclusion

Preprocedural AB prophylaxis does not decrease the incidence of postcystoscopy bacteriuria significantly. Females and diabetics have significantly increased risk, but prophylaxis has no role in them either.

Antibiotic use and survival of patients receiving pembrolizumab for chemotherapy-resistant metastatic urothelial carcinoma

OBJECTIVES

The use of antibiotics alters gut microbiota and has been reported to impact outcomes in immune checkpoint inhibitor (ICI) treatment in various types of cancer. We investigated the impact of antibiotics on patients with metastatic urothelial carcinoma (mUC) treated with pembrolizumab.

MATERIALS AND METHODS

The data of 67 patients with chemotherapy-resistant mUC who were treated with pembrolizumab were retrospectively evaluated. The patients were classified into groups according to antibiotic status (with-antibiotic and without-antibiotic), and the progression-free survival (PFS), overall survival (OS), objective response rate (ORR), and disease control rate (DCR) were compared between the 2 groups.

RESULTS

PFS (median: 1.1 vs. 8.9 months; P < 0.001) and OS (median: 2.3 vs. 19.5 months; P < 0.001) were significantly shorter in the with-antibiotic group (n = 15, 22%) than in the without-antibiotic group (n = 52, 78%). Patients in the with-antibiotic group had significantly higher Eastern Cooperative Oncology Group performance status scores (P = 0.042). Multivariable analyses revealed antibiotic use as an independent predictor of PFS (P < 0.001) and OS (P = 0.002). No patients in the with-antibiotic group achieved a complete response to pembrolizumab. The ORR (complete response (CR) + partial response (PR)) was higher among patients not treated with antibiotics than among patients treated with antibiotics, though the difference was not significant (34.6% vs. 13.3%, P = 0.093). The DCR (CR + PR + stable disease) was also higher among patients in the with-antibiotic group than in the without-antibiotic group (57.7% vs. 20.0%, P = 0.008).

CONCLUSION

The use of antibiotics was negatively associated with outcomes in patients with mUC who are administered pembrolizumab. Baseline performance status was worse for these patients. Further analyses are required to identify associations between antibiotic use, bacterial infection for which it was indicated or its influence on performance status, on treatment outcomes.

Apolipoprotein A1 as a novel urinary biomarker for diagnosis of bladder cancer: A systematic review and meta-analysis

INTRODUCTION

The emergence of urinary biomarkers for bladder cancer diagnosis could provide a reliable and less invasive diagnostic method. It could be also used as an adjuvant to the current gold standards of cytology and cystoscopy to improve diagnostic accuracy and decrease the percentage of false positives.

METHODS

We searched PubMed, SCOPUS, and Web of Science up to March 18, 2020. We selected four studies that assessed the diagnostic accuracy of urinary apolipoprotein A1 (ApoA-1) in detecting bladder cancer and met the inclusion and exclusion criteria. Two authors independently extracted the data and performed quality assessment of the studies.

RESULTS

Four studies with 771 participants were selected; 417 were bladder cancer patients and 354 were controls. Bladder cancer was either transitional cell carcinoma or squamous cell carcinoma, the stages varied between Ta to T3, and the grades varied between G1 and G3. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were 90.7%, 90%, 9.478, 0.1, and 99.424, respectively. Summary receiver operating characteristic curve showed an area under the curve of 0.9544 and Q* index of 0.8965.

CONCLUSIONS

ApoA-1 showed high sensitivity and specificity, so it could be a useful biomarker in diagnosis of bladder cancer.

Recommendations of the AFU Infectious Diseases Committee on the prevention, diagnosis and treatment of infections of endo-ureteral equipment

INTRODUCTION

No recent national guidelines exist regarding the management of urinary tract infections (UTIs) in the presence of ureteral stent. This situation could lead to discrepancies in clinical management and less opportunity for a favorable patient's outcome.

METHODS

All available data published on Medline® between 1998 and 2018 were systematically searched and reviewed. All papers assessing adult patients carrying ureteral stent were included for analysis. After studies critical analysis, national guidelines for clinical management were elaborated in order to answer clinical questions.

RESULTS

A total of 451 articles were identified, of which 58 have been included. The prevalence of urinary tract infections in the presence of ureteral stent remains unknown. After 3 months, all endo-ureteral devices were colonized on microbiological study. These patients also presented a positive urine culture in 25 to 70% of the cases, often polymicrobial. Staphylococci, E. coli, Klebsiella, Pseudomonas, Enterococcus and Candida were the commonest micro-organisms responsible for urinary colonization or infection. The risk of UTI on endo-ureteral devices seemed higher the longer it stayed implanted. There is no justification in the literature to recommend a systematic change of endo-ureteral devices following a urinary tract infection.

DISCUSSION

The existing literature is rich but of poor methodological quality, and therefore does not allow to draw robust conclusions. The greatest difficulty faced in this work was to accurately differentiate urinary colonizations from true infections, including clinical symptoms and not only microbiological results.

CONCLUSION

These guidelines propose a standardized management of such common clinical situations. Well-designed studies are needed to upgrade the level of evidence of these guidelines.

A micro-costing analysis of outpatient flexible cystoscopy: implications for adoption of single-use flexible cystoscopes

PURPOSE

To evaluate the total cost of outpatient flexible cystoscopy associated with reusable device purchase, maintenance, and reprocessing, and to assess potential cost benefits of single-use flexible cystoscopes.

METHODS

Cost data regarding the purchasing, maintaining, and reprocessing of reusable flexible cystoscopes were collected using a micro-costing approach at a high-volume outpatient urology clinic. We estimated the costs to facilities with a range of annual procedure volumes (1000-3000) performed with a fleet of cystoscopes ranging from 10 to 25. We also compared the total cost per double-J ureteral stent removal procedure performed using single-use flexible cystoscopes versus reusable devices.

RESULTS

The cost associated with reusable flexible cystoscopes ranged from $105 to $224 per procedure depending on the annual procedure volume and cystoscopes available. As a practice became more efficient by increasing the ratio of procedures performed to cystoscopes in the fleet, the proportion of the total cost due to cystoscope reprocessing increased from 22 to 46%. For ureteral stent removal procedures, the total cost per procedure using reusable cystoscopes (range $165-$1469) was higher than that using single-use devices ($244-$420), unless the annual procedure volume was sufficiently high relative to the number of reusable cystoscopes in the fleet (≥ 350 for a practice with ten reusable cystoscopes, ≥ 700 for one with 20 devices).

CONCLUSION

The cost of reprocessing reusable cystoscopes represents a large fraction of the total cost per procedure, especially for high-volume facilities. It may be economical to adopt single-use cystoscopes specifically for stent removal procedures, especially for lower-volume facilities.

Incidence of Significant Findings of Microhematuria Workup in Women-What Guidelines Work Best?

OBJECTIVE

To apply the American Urogynecological Society (AUGS)/American College of Obstetricians and Gynecologists (ACOG) recommendations of foregoing workup in patients under 50 years of age with less than 25 red cells per high-powered field, to a cohort of asymptomatic microscopic hematuria (AMH) patients, and assess diagnostic accuracy, sensitivity, specificity, positive, and negative predictive value compared to the American Urologic Association (AUA) guidelines.

METHODS

Retrospective review of female patients who underwent AMH evaluation from 2012 to 2015. The number of patients who would have avoided workup following the AUGS/ACOG recommendations was determined. Sensitivity, specificity, positive- and negative-predictive value and accuracy of the AUGS/ACOG recommendations compared to AUA guidelines were determined.

RESULTS

Six hundred twenty women underwent AMH workup with 265 women undergoing full workup as per the AUA guidelines. Applying the AUGS/ACOG recommendations to this cohort would not have resulted in missed malignant diagnoses. Two tumors were found, both in patients who had undergone complete workup, and for whom AUGS/ACOG recommends workup. Following the AUGS/ACOG recommendations would have avoided workup in 126/620 of all women and 44/265 women who underwent the full AUA workup. In looking at findings of malignancy, the AUGS/ACOG workup had a sensitivity of 100% and a negative predictive value of 100% as compared to the AUA guidelines.

CONCLUSION

AUA guidelines may over screen female low risk AMH patients. Extensive workup in a low risk group of female patients does not result in increased cancer diagnoses. Perhaps a more nuanced approach could result in fewer workups without compromising cancer detection.

Diagnostic accuracy of urinary survivin mRNA expression detected by RT-PCR compared with urine cytology in the detection of bladder cancer: A meta-analysis of diagnostic test accuracy in head-to-head studies

Survivin is a promising marker for the diagnosis of bladder cancer. The accuracy and clinical value of urinary survivin mRNA expression were compared with urine cytology, which is the standard diagnostic method for bladder cancer. Scientific databases, including PubMed, Web of Science, Cochrane Library and China National Knowledge Infrastructure, were searched in order to find studies that examined urinary survivin mRNA expression and urine cytology in the diagnosis of bladder cancer. Quality assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool in Revman 5.3 and data analysis was conducted using Stata/MP. The I² statistic was used to evaluate heterogeneity and Deeks' funnel plot was generated to assess the possibility of publication bias. A total of 15 studies that evaluated a total of 1,624 patients were included in the present meta-analysis. The pooled sensitivity and specificity values for the detection of urinary survivin mRNA expression in the diagnosis of bladder cancer were 0.86 [95% confidence interval (CI), 0.81-0.90] and 0.95 (95% CI, 0.93-0.96), respectively. Regarding urine cytology, the pooled sensitivity and specificity values were 0.42 (95% CI, 0.36-0.48) and 1.00 (95% CI, 0.98-1.00), respectively. Furthermore, the differences in pooled sensitivity were statistically significant in the diagnosis of grade 1 and 2 bladder tumors. Summary receiver operating characteristic curve values for urinary survivin mRNA expression and urine cytology were 0.95 (95% CI, 0.93-0.97) and 0.86 (95% CI, 0.83-0.89), respectively. Urinary survivin mRNA expression was also more accurate compared with other diagnostic indicators, including positive likelihood ratios, negative likelihood ratios, diagnostic odds ratios and Youden's index. Compared with traditional urine cytology, urinary survivin mRNA detection using reverse transcription-PCR was identified to be more effective in the diagnosis of early bladder cancer.

Comparison of the Harms, Advantages, and Costs Associated With Alternative Guidelines for the Evaluation of Hematuria

IMPORTANCE

Existing recommendations for the diagnostic testing of hematuria range from uniform evaluation of varying intensity to patient-level risk stratification. Concerns have been raised about not only the costs and advantages of computed tomography (CT) scans but also the potential harms of CT radiation exposure.

OBJECTIVE

To compare the advantages, harms, and costs associated with 5 guidelines for hematuria evaluation.

DESIGN, SETTING, AND PARTICIPANTS

A microsimulation model was developed to assess each of the following guidelines (listed in order of increasing intensity) for initial evaluation of hematuria: Dutch, Canadian Urological Association (CUA), Kaiser Permanente (KP), Hematuria Risk Index (HRI), and American Urological Association (AUA). Participants comprised a hypothetical cohort of patients (n = 100 000) with hematuria aged 35 years or older. This study was conducted from August 2017 through November 2018.

EXPOSURES

Under the Dutch and CUA guidelines, patients received cystoscopy and ultrasonography if they were 50 years or older (Dutch) or 40 years or older (CUA). Under the KP and HRI guidelines, patients received different combinations of cystoscopy, ultrasonography, and CT urography or no evaluation on the basis of risk factors. Under the AUA guidelines, all patients 35 years or older received cystoscopy and CT urography.

MAIN OUTCOMES AND MEASURES

Urinary tract cancer detection rates, radiation-induced secondary cancers (from CT radiation exposure), procedural complications, false-positive rates per 100 000 patients, and incremental cost per additional urinary tract cancer detected.

RESULTS

The simulated cohort included 100 000 patients with hematuria, aged 35 years or older. A total of 3514 patients had urinary tract cancers (estimated prevalence, 3.5%; 95% CI, 3.0%-4.0%). The AUA guidelines missed detection for the fewest number of cancers (82 [2.3%]) compared with the detection rate of the HRI (116 [3.3%]) and KP (130 [3.7%]) guidelines. However, the simulation model projected 108 (95% CI, 34-201) radiation-induced cancers under the KP guidelines, 136 (95% CI, 62-229) under the HRI guidelines, and 575 (95% CI, 184-1069) under the AUA guidelines per 100 000 patients. The CUA and Dutch guidelines missed detection for a larger number of cancers (172 [4.9%] and 251 [7.1%]) but had 0 radiation-induced secondary cancers. The AUA guidelines cost approximately double the other 4 guidelines ($939/person vs $443/person for Dutch guidelines), with an incremental cost of $1 034 374 per urinary tract cancer detected compared with that of the HRI guidelines.

CONCLUSIONS AND RELEVANCE

In this simulation study, uniform CT imaging for patients with hematuria was associated with increased costs and harms of secondary cancers, procedural complications, and false positives, with only a marginal increase in cancer detection. Risk stratification may optimize the balance of advantages, harms, and costs of CT.

[Is it necessary to perform urine culture systematically prior to double J ureteral stent removal?]

OBJECTIVE

To assess the value of systematic urine culture before ureteric double j removal.

MATERIAL AND METHODS

This prospective audit was performed to assess the validity of our current clinical practice. A cohort of informed patients without clinical signs of urinary tract infection and without predefined risk factors were programmed for ureteral double j stent removal in an outpatient setting. Urine was sampled for culture immediately before the procedure. Patients had to complete a self-questionnaire 15 days following stent removal, inquiring about tolerance and complications which were to be analyzed according to the culture results. The primary endpoint was the occurrence of febrile urinary tract infection.

RESULTS

Among the 56 participants, immediate preoperative urine culture revealed colonization in 9 patients (16.1%) and contamination in 6 patients (10.7%). A significant association was found between bacteriuria and double j placement following surgery with urinary tract injury (P<0.02) and diabetes (P<0.009). Two patients had fever including a man with sterile urine and a woman with Staphylococcus Aureus infection. No hospitalization was necessary. Twelve patients reported functional signs with lumbar pain being the most common. There was no significant association between functional signs and patients' clinical characteristics.

CONCLUSION

This evaluation was not in favor of modifying our protocol of care i.e. the lack of performing neither antibiotic prophylaxis nor systematic urine culture before JJ ureteral stent removal in a selected population.

LEVEL OF EVIDENCE

4.

Cost-effectiveness analysis of a single-use digital flexible cystoscope for double J removal

Introduction and objective:

The novel single-use digital flexible cystoscope Isiris™ has been developed to perform in-office JJ stent removal, without the need of special equipment nor limitations linked to the disinfection of a reusable device. The aim of our study was to perform a cost-effectiveness analysis of Isiris™ in our institution.

Patients and methods:

A total of 127 consecutive patients undergoing in-office stent removal with Isiris™ were prospectively included in study. After each procedure, the urologist filled a questionnaire specifically developed to evaluate the efficiency of the device and the invasiveness of the procedure. We performed a cost analysis of the main variables involved in JJ removal using Isiris™ versus the traditional Storz™ reusable flexible cystoscope used for all our previous patients.

Results:

The procedure was successful in all cases except for one, where the device did not work due to the failure of the grasper and had to be replaced. Overall, the performance of Isiris™ was judged by the physician “very good” and “good” in 90.6% of the cases. Both median pain and invasiveness felt by the patient were 0 (range = 0–8). The mean cost of procedure was estimated at €361 for in-office stent removal with Isiris™, and €1.126.8 for stent removal in operatory room with a reusable flexible cystoscope. Considering the 127 procedures performed in office, 64 h of operatory room time was saved.

Conclusion:

In institutions where JJ removal is performed in the operatory room, Isiris™ leads to a significant advantage in terms of money saved per procedure, operatory room time gained and patient satisfaction.

Antimicrobial agents for preventing urinary tract infections in adults undergoing cystoscopy

BACKGROUND

Cystoscopy is commonly performed for diagnostic purposes to inspect the interior lining of the bladder. One disadvantage of cystoscopy is the risk of symptomatic urinary tract infection (UTI) due to pre-existing colonization or by introduction of bacteria at the time of the procedure. However, the incidence of symptomatic UTI following cystoscopy is low. Currently, there is no consensus on whether antimicrobial agents should be used to prevent symptomatic UTI for cystoscopy.

OBJECTIVES

To assess the effects of antimicrobial agents compared with placebo or no treatment for prevention of UTI in adults undergoing cystoscopy.

SEARCH METHODS

We comprehensively searched electronic databases of the Cochrane Library, PubMed, Embase, LILACS, and CINAHL. We searched the WHO ICTRP and ClinicalTrials.gov for ongoing trials. We used no language or date restrictions in the electronic searches. We searched the reference lists of identified articles and contacted authors for related information. The last search of the electronic databases was 4 February 2019.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) or quasi-RCTs that compared any prophylactic antibiotic versus placebo, no treatment, or other non-antibiotic prophylaxis in adults undergoing cystoscopy. There was no restriction on the dose, frequency, formulation, duration, or mode of administration of the antibiotics.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Our primary outcomes were systemic UTI, symptomatic UTI (composite of systemic and/or localized UTI), and serious adverse events. Secondary outcomes were minor adverse events, localized UTI, asymptomatic bacteriuria, and bacterial resistance. We assessed the quality of evidence using GRADE.

MAIN RESULTS

We included 20 RCTs and two quasi-RCTs with 7711 participants, all of which compared antibiotic prophylaxis with placebo or no treatment control. We found no studies comparing antibiotic prophylaxis with non-antibiotic prophylaxis.Primary outcomesSystemic UTI: antibiotic prophylaxis may have little or no effect on the risk of systemic UTI compared with placebo or no treatment (risk ratio (RR) 1.12, 95% confidence interval (CI) 0.38 to 3.32; 5 RCTs; 504 participants; low-quality evidence); this corresponds to two more people (95% CI 12 fewer to 46 more) per 1000 people developing a systemic UTI. We downgraded the quality of the evidence for study limitations and imprecision.Symptomatic UTI: antibiotic prophylaxis may reduce the risk of symptomatic UTI (RR 0.49, 95% CI 0.28 to 0.86; 11 RCTs; 5441 participants; low-quality evidence); this corresponds to 30 fewer people (95% CI 42 fewer to 8 fewer) per 1000 people developing a symptomatic UTI when provided with antibiotic prophylaxis. We downgraded the quality of the evidence for study limitations and potential publication bias.Serious adverse events: the studies reported no serious adverse events in either the intervention group or control group and no effect size could be calculated. Antibiotic prophylaxis may have little or no effect on serious adverse events (4 RCTs, 630 participants; very low-quality evidence), but we are very uncertain of this finding. We downgraded the quality of the evidence for study limitations and very serious imprecision.Secondary outcomesMinor adverse events: prophylactic antibiotics may have little or no effect on minor adverse events when compared with placebo or no treatment (RR 2.82, 95% CI 0.54 to 14.80; 4 RCTs; 630 participants; low-quality evidence). We downgraded the quality of the evidence for study limitations and imprecision.Localized UTI: prophylactic antibiotics may have little or no effect on the risk of localized UTI (RR 1.0, 95% CI 0.06 to 15.77; 1 RCT; 200 participants; very low-quality evidence), but we were very uncertain of this finding. We downgraded the quality of the evidence for study limitations and very serious imprecision.Bacterial resistance: prophylactic antibiotics may increase bacterial resistance (RR 1.73, 95% CI 1.04 to 2.87; 38 participants; 2 RCTs; very low-quality evidence), but we were uncertain of this finding. We downgraded the quality of the evidence for study limitations, indirectness, and imprecision.We were able to perform few secondary analyses; these did not suggest any subgroup effects.

AUTHORS' CONCLUSIONS

Antibiotic prophylaxis may reduce the risk of symptomatic UTI but not systemic UTIs. Serious and minor adverse events may not be increased with the use of antibiotic prophylaxis. The findings are informed by low- and very low-quality evidence ratings for all outcomes.

Reduced Recurrence of Low-grade Papillary Bladder Tumors Associated With Asymptomatic Bacteriuria

OBJECTIVE

To determine tumor recurrence rate of low-grade, papillary, and non-muscle-invasive (TaLG) bladder tumors in patients who have asymptomatic bacteriuria (ABU). Microbes in the urine trigger immune responses like intravesical Bacillus Calmette-Guerin, suggesting that common bacteria may also exert an antitumor effect.

METHODS

We investigated recurrence rates in 387 patients with low-grade, papillary noninvasive bladder tumors TaLG, with or without ABU. They were followed every 6 months for 36 months, and did not receive antibiotics or intravesical chemotherapy. Recurrent tumors were treated generally by outpatient fulguration. Before cystoscopy, patients submitted a voided urine sample for culture, stratified as no growth, <10⁴, >10⁴, or >10⁵ CFU/mL single organism. Any degree of bacteria on culture was classified as ABU. We also measured absolute neutrophil counts (ANC) and the presence of pyuria, as surrogate indicators of local immune response.

RESULTS

Of the 387 cases, 200 (52%) had ABU, including 102 (27%) with >10⁴ CFU/mL bacteriuria. With absolute 3-year follow-up, 75% of patients with ABU survived tumor-free compared to 40% of 187 uninfected patients (P = .001). Sixty percent of patients with negative cultures recurred vs 25%, 14%, and 29% of patients with <10⁴, >10⁴, or >10⁵ CFU/mL. (P = .001). Mean number of recurrent tumors in colonized patients was 4.2 vs 8.4 in uninfected patients (P = .009). ANC averaged 6.3 K/mcL in bacteriuric vs 4.1 K/mcL in uninfected patients (P = .01).

CONCLUSION

Patients with papillary TaLG tumors and chronic ABU had fewer recurrences, fewer numbers of recurrent tumors, and longer tumor-free survival times than similarly staged uninfected patients. Bladder-resident bacteria may reduce bladder tumor recurrences through local immune mechanisms.

Clinical utility of a non-invasive urine test for risk assessing patients with no obvious benign cause of hematuria: a physician-patient real world data analysis

Background

The non-invasive Cxbladder urine test system has demonstrated clinical utility in ruling out urothelial carcinoma (UC) in patients with asymptomatic microscopic hematuria (AMH), suggesting that the number of invasive diagnostic tests, including cystoscopy, used in this patient population may be reduced by Cxbladder testing prior to conducting a full urological work-up. The aim of this study was to demonstrate the enhanced clinical utility of communicating objective information on diagnostic decisions made by individual physicians on individual patients with AMH.

Methods

Three hundred ninety-six physician-patient decisions were generated from twelve participant physicians evaluating real world case notes from the same 33 patients presenting with AMH. Each physician reviewed and recommended diagnostic tests and procedures based on each patient’s referral data and then re-evaluated their clinical recommendation following disclosure of the non-invasive Cxbladder urine test result. Changes assessed were the total number of requested diagnostic procedures and the number of invasive procedures, including cystoscopy, following addition of information from Cxbladder in the Triage and Triage and Detect modalities.

Results

Physicians made significant changes to their diagnostic behavior for patients with AMH when presented with Cxbladder test results, including a reduction in the number of total and invasive procedures including cystoscopy for individuals identified as having a low probability of UC. The intensity of investigation was targeted and increased, including use of total procedures and cystoscopy, for patients identified by Cxbladder tests as having a high probability of UC: urologists increased the level of investigation for both total procedures and invasive procedures. The outcome resulted in patients with a high risk of UC receiving appropriate guideline-recommended invasive diagnostic tests. Patients who tested negative were offered fewer and significantly less invasive procedures. This change in physician behavior results in an increased clinical and patient utility, lower risk of missed UC and invasive test-related harm incidents.

Conclusions

This study demonstrated the potential for increased clinical resolution and significantly enhanced patient management, when physicians consider Cxbladder test results in their clinical evaluation. The change in physician behavior led to more appropriate diagnostic procedure selection and resource allocation to the benefit of both patients and healthcare systems.

Electronic supplementary material

The online version of this article (10.1186/s12894-018-0327-6) contains supplementary material, which is available to authorized users.

Follow-up of high-risk bladder cancer-Is it safe to perform fluorescence endoscopy multiple times in the same patient?

PURPOSE

As the use of fluorescence endoscopy is recommended today by different guidelines during the follow-up of high-grade non-muscle-invasive bladder cancer, the aim of this study is to analyze whether the multiple use of hexylaminolevulinate (HAL) for TUR-BT can be performed safely within the same patient over a time interval.

METHODS

Data of patients diagnosed and treated with HAL-TUR-B at our institute between 2008 and 2013 were analyzed. Special interest was given to side effects observed during the instillation of the substance, on the whole day of the instillation and during the entire hospital stay. We focussed on side effects associated with the use of HAL, such as allergic reactions, urinary tract infections, photosensitization of the skin, and relevant changes in blood pressure.

RESULTS

In the time between 2008 and 2013, 2480 HAL-TUR-BTs were performed in total at our institute. In 80 patients, HAL-TUR-BT was used at least 2 times, and on average 4 times (2-12 times). Only patients with multiple uses were included for our final analysis. We observed no allergizations in any of the treated patients. Minor side effects were urinary tract infections (n = 4), dysuria (n = 4), pollakisuria (n = 9), and bladder spasms (n = 17).

CONCLUSION

In our study cohort, the multiple use of HAL-TUR-BT within the same patient caused no major side effects or an induction of allergization against the substance. We, therefore, conclude that HAL-TUR-BT can be performed safely in the same patient during the follow-up of aggressive tumors as recommended by different guidelines today.

Cost-effectiveness of Common Diagnostic Approaches for Evaluation of Asymptomatic Microscopic Hematuria

IMPORTANCE

Asymptomatic microscopic hematuria (AMH) is highly prevalent and may signal occult genitourinary (GU) malignant abnormality. Common diagnostic approaches differ in their costs and effectiveness in detecting cancer. Given the low prevalence of GU malignant abnormality among patients with AMH, it is important to quantify the cost implications of detecting cancer for each approach.

OBJECTIVE

To estimate the effectiveness, costs, and incremental cost per cancer detected (ICCD) for 4 common diagnostic approaches evaluating AMH.

DESIGN, SETTING, AND PARTICIPANTS

A decision-analytic model-based cost-effectiveness analysis using inputs from the medical literature. PubMed searches were performed to identify relevant literature for all key model inputs, each of which was derived from the clinical study with the most robust data and greatest applicability. Analysis included adult patients with AMH on routine urinalysis with subgroups of high-risk patients (males, smokers, age ≥50 years) seen in the primary care or urologic referral setting.

INTERVENTIONS

Four diagnostic approaches were evaluated relative to the reference case of no evaluation: (1) computed tomography (CT) alone; (2) cystoscopy alone; (3) CT and cystoscopy combined; and (4) renal ultrasound and cystoscopy combined.

MAIN OUTCOMES AND MEASURES

At termination of the diagnostic period, cancers detected, costs (payer perspective), and ICCD per 10 000 patients evaluated for AMH.

RESULTS

Of the 4 diagnostic approaches analyzed, CT alone was dominated by all other strategies, detecting 221 cancers at a cost of $9 300 000. Ultrasound and cystoscopy detected 245 cancers and was most cost-effective with an ICCD of $53 810. Replacing ultrasound with CT detected just 1 additional cancer at an ICCD of $6 480 484. Ultrasound and cystoscopy remained the most cost-effective approach in subgroup analysis. The model was not sensitive to any inputs within the proposed ranges. Using probabilistic sensitivity analysis, ultrasound and cystoscopy was the dominant strategy in 100% of simulations.

CONCLUSIONS AND RELEVANCE

The combination of renal ultrasound and cystoscopy is the most cost-effective among 4 diagnostic approaches for the initial evaluation of AMH. The use of ultrasound in lieu of CT as the first-line diagnostic strategy will optimize cancer detection and reduce costs associated with evaluation of AMH. Given our findings, we need to critically evaluate the appropriateness of our current clinical practices, and potentially alter our guidelines to reflect the most effective screening strategies for patients with AMH.

Clinical Utility of Cxbladder for the Diagnosis of Urothelial Carcinoma

Introduction

This study aimed to demonstrate the clinical utility of non-invasive multigene Cxbladder urine tests in reducing the overall number of diagnostic tests and invasive procedures used in the clinical evaluation of patients presenting with microhematuria, a key symptom of urothelial carcinoma (UC). There is a belief that using non-invasive molecular diagnostic tests in patients with hematuria may lead to patients undergoing unnecessary and costly invasive procedures that can cause adverse events and decrease patient quality of life. The objective of this study was to determine whether or not this was the case, using Cxbladder.

Methods

Data from 396 patient-by-urologist interactions generated 792 decision points from a standardized cohort of 33 patients evaluated by 12 urologists. Participant physicians recommended a selection of tests and procedures based on referral data, then reviewed and amended their recommendations in the context of diagnostic information from Cxbladder used in the Triage and Triage and Detect clinical modalities.

Results

All urologists changed their diagnostic behavior in at least one patient case with the addition of Cxbladder results. The total number of diagnostic procedures was reduced by 5% and 25% following disclosure of results from Cxbladder in the Triage and the Triage and Detect modalities, respectively. The total number of requested invasive procedures was reduced from 425 at referral to 379 (−11%) and 292 (−31%) following disclosure of Cxbladder information in the Triage and Triage and Detect modalities, respectively.

Conclusions

Urologists made compelling changes to their clinical decision-making when they were provided with Cxbladder results for patients presenting with hematuria. Cxbladder provides an increase in clinical utility by focusing the use of invasive diagnostic procedures to appropriate patients, reducing both the total number and number of invasive procedures used in the clinical management of patients with hematuria, thereby improving the diagnostic experience and outcomes for patients.

Funding

Pacific Edge Ltd.

Electronic supplementary material

The online version of this article (doi:10.1007/s12325-017-0518-7) contains supplementary material, which is available to authorized users.

Outbreak of urinary tract infections by Salmonella spp. after cystoscopic manipulation

INTRODUCTION

Cystoscopes are used for diagnostic and therapeutic purposes and can be vehicles for transmitting healthcare-associated infections. Performing urine cultures before manipulation or administering prophylaxis is determined by the presence or not of risk factors for urinary tract infection.

METHODS

Between October and November 2014, we identified an unusual aggregation of Salmonella spp. isolates in urine cultures at the University Hospital Santa Lucía of Cartagena (Murcia). An epidemiological investigation was conducted to assess the possible relationship between the cases.

RESULTS

Four patients had a urinary tract infection by Salmonella spp. within a short period, which suggests the presence of an outbreak. All of the patients had undergone cystoscopy. The index case had a urinary colonisation by Salmonella spp. prior to the procedure, and none of the reported cases had received prophylaxis. The environmental control cultures and the involved material cultures resulted negative. Intensification of the cystoscope cleaning and disinfection protocol achieved eradication of the outbreak.

CONCLUSION

This is the first reported outbreak of Salmonella spp. related to the use of cystoscopes. The indication for a urine culture should be carefully assessed before conducting invasive urological procedures, as should the need for antibiotic prophylaxis, for patients with risk factors for severe infection. Strict control in the cleaning and disinfection of endoscopy material can prevent the transmission of infections related to this type of procedure.

Is Preoperative Assessment and Treatment of Asymptomatic Bacteriuria Necessary for Reducing the Risk of Postoperative Symptomatic Urinary Tract Infections After Urologic Surgical Procedures?

OBJECTIVE

To evaluate whether it is always necessary to test for the presence of asymptomatic bacteriuria (AB) in patients undergoing urologic surgical procedures, and if present, whether to treat AB with antimicrobial prophylaxis.

MATERIALS AND METHODS

All patients who underwent urologic surgical procedures from December 2008 to October 2013 in a tertiary referral urologic center were considered for this study. All patients received antimicrobial prophylaxis in line with European Association of Urology guidelines on urologic infections. AB was diagnosed if ≥10⁵ colony-forming units/mL were cultured. The population was subdivided into 2 groups: group A, patients with preoperative AB, and group B, patients without AB. Data on postoperative symptomatic urinary tract infections (UTIs) were compared for the 2 groups.

RESULTS

A total of 2201 patients were considered eligible for this study and were analyzed; 668 (30.4%) patients were found to harbor AB (group A), and 1533 (69.6%) patients did not have AB (group B). Microbiologically verified symptomatic postoperative UTIs occurred in 198 patients (8.9%). No difference in terms of overall rate of postoperative symptomatic UTI was found between the 2 groups (group A: 70 [10.4%] and group B: 128 [8.3%]; OR: 1.28 95%CI 0.94-1.74; P = .12), as well as in terms of urosepsis (group A: 2 [0.30%] and group B: 4 [0.26%]; P = 1.0).

CONCLUSION

In patients undergoing urologic surgical procedures who are receiving antimicrobial prophylaxis in accordance with European Association of Urology guidelines, the preoperative presence of AB in this study was not associated with a higher incidence of postoperative symptomatic UTI.

Cystoscopy and intravesical bacille Calmette-Guérin therapy in antibiotic-naïve patients with bladder cancer with asymptomatic bacteriuria: An update

Urologists often insist on sterile urine before invasive outpatient urological procedures, and urine culture and antibiotics are usually given before cystoscopy or instillation of bacille Calmette–Guérin (BCG) therapy, especially in patients who have positive urine cultures. Our experience suggests that cystoscopy and induction BCG therapy can be performed safely, even in patients with asymptomatic bacteriuria, without pretreatment or prophylactic antibiotics. The rate of subsequent febrile urinary tract infection is <4% in both infected and uninfected patients. Pretreatment antibacterial therapy does not appear to be necessary before these two outpatient urological procedures in patients with bladder cancer. Such strategy facilitates timely interventions and reduces the possibility of antibiotic resistance.

Risk for Clostridium difficile infection after radical cystectomy for bladder cancer: Analysis of a contemporary series

INTRODUCTION

This study seeks to evaluate the incidence and associated risk factors of Clostridium difficile infection (CDI) in patients undergoing radical cystectomy (RC) for bladder cancer.

METHODS

We retrospectively reviewed a single institution׳s bladder cancer database including all patients who underwent RC between 2010 and 2013. CDI was diagnosed by detection of Clostridium difficile toxin B gene using polymerase chain reaction-based stool assay in patients with clinically significant diarrhea within 90 days of the index operation. A multivariable logistic regression model was used to identify demographics and perioperative factors associated with developing CDI.

RESULTS

Of the 552 patients who underwent RC, postoperative CDI occurred in 49 patients (8.8%) with a median time to diagnosis after RC of 7 days (interquartile range: 5-19). Of the 122 readmissions for postoperative complications, 10% (n = 12) were related to CDI; 2 patients died of sepsis directly related to severe CDI. On multivariate logistic regression, the use of chronic antacid therapy (odds ratio = 1.9, 95% CI: 1.02-3.68, P = 0.04) and antibiotic exposure greater than 7 days (odds ratio = 2.2, 95% CI: 1.11-4.44, P = 0.02) were independently associated with developing CDI. The use of preoperative antibiotics for positive findings on urine culture within 30 days before surgery was not statistically significantly associated with development of CDI (P = 0.06).

CONCLUSIONS

The development of CDI occurs in 8.8% of patients undergoing RC. Our study demonstrates that use of chronic antacid therapy and long duration of antimicrobial exposure are associated with development of CDI. Efforts focusing on minimizing antibiotic exposure in patients undergoing RC are needed, and perioperative antimicrobial prophylaxis guidelines should be followed.

A segregation index combining phenotypic (clinical characteristics) and genotypic (gene expression) biomarkers from a urine sample to triage out patients presenting with hematuria who have a low probability of urothelial carcinoma

Background

Hematuria can be symptomatic of urothelial carcinoma (UC) and ruling out patients with benign causes during primary evaluation is challenging. Patients with hematuria undergoing urological work-ups place significant clinical and financial burdens on healthcare systems. Current clinical evaluation involves processes that individually lack the sensitivity for accurate determination of UC. Algorithms and nomograms combining genotypic and phenotypic variables have largely focused on cancer detection and failed to improve performance. This study aimed to develop and validate a model incorporating both genotypic and phenotypic variables with high sensitivity and a high negative predictive value (NPV) combined to triage out patients with hematuria who have a low probability of having UC and may not require urological work-up.

Methods

Expression of IGFBP5, HOXA13, MDK, CDK1 and CXCR2 genes in a voided urine sample (genotypic) and age, gender, frequency of macrohematuria and smoking history (phenotypic) data were collected from 587 patients with macrohematuria. Logistic regression was used to develop predictive models for UC. A combined genotypic-phenotypic model (G + P INDEX) was compared with genotypic (G INDEX) and phenotypic (P INDEX) models. Area under receiver operating characteristic curves (AUC) defined the performance of each INDEX: high sensitivity, NPV >0.97 and a high test-negative rate was considered optimal for triaging out patients. The robustness of the G + P INDEX was tested in 40 microhematuria patients without UC.

Results

The G + P INDEX offered a bias-corrected AUC of 0.86 compared with 0.61 and 0.83, for the P and G INDEXs respectively. When the test-negative rate was 0.4, the G + P INDEX (sensitivity = 0.95; NPV = 0.98) offered improved performance compared with the G INDEX (sensitivity = 0.86; NPV = 0.96). 80% of patients with microhematuria who did not have UC were correctly triaged out using the G + P INDEX, therefore not requiring a full urological work-up.

Conclusion

The adoption of G + P INDEX enables a significant change in clinical utility. G + P INDEX can be used to segregate hematuria patients with a low probability of UC with a high degree of confidence in the primary evaluation. Triaging out low-probability patients early significantly reduces the need for expensive and invasive work-ups, thereby lowering diagnosis-related adverse events and costs.