Screening cystoscopy and biopsy in patients with neuropathic bladder and chronic suprapubic indwelling catheters: is it valid?

Exploring the DNA Methylation Profile of Genes Associated with Bladder Cancer in Bladder Tissue of Patients with Neurogenic Lower Urinary Tract Dysfunction

DNA methylation is an epigenetic process that commonly occurs in genes' promoters and results in the transcriptional silencing of genes. DNA methylation is a frequent event in bladder cancer, participating in tumor initiation and progression. Bladder cancer is a major health issue in patients suffering from neurogenic lower urinary tract dysfunction (NLUTD), although the pathogenetic mechanisms of the disease remain unclear. In this population, bladder cancer is characterized by aggressive histopathology, advanced stage during diagnosis, and high mortality rates. To assess the DNA methylation profiles of five genes' promoters previously known to be associated with bladder cancer in bladder tissue of NLUTD patients, we conducted a prospective study recruiting NLUTD patients from the neuro-urology unit of a public teaching hospital. Cystoscopy combined with biopsy for bladder cancer screening was performed in all patients following written informed consent being obtained. Quantitative methylation-specific PCR was used to determine the methylation status of RASSF1, RARβ, DAPK, hTERT, and APC genes' promoters in bladder tissue samples. Twenty-four patients suffering from mixed NLUTD etiology for a median duration of 10 (IQR: 12) years were recruited in this study. DNA hypermethylation was detected in at least one gene of the panel in all tissue samples. RAR-β was hypermethylated in 91.7% samples, RASSF and DAPK were hypermethylated in 83.3% samples, APC 37.5% samples, and TERT in none of the tissue samples. In 45.8% of the samples, three genes of the panel were hypermethylated, in 29.2% four genes were hypermethylated, and in 16.7% and in 8.3% of the samples, two and one gene were hypermethylated, respectively. The number of hypermethylated genes of the panel was significantly associated with recurrent UTIs (p = 0.0048). No other significant association was found between DNA hypermethylation or the number of hypermethylated genes and the clinical characteristics of the patients. Histopathological findings were normal in 8.3% of patients, while chronic inflammation was found in 83.3% of patients and squamous cell metaplasia in 16.7% of patients. In this study, we observed high rates of DNA hypermethylation of genes associated with bladder cancer in NLUTD patients, suggesting an epigenetic field effect and possible risk of bladder cancer development. Recurrent UTIs seem to be associated with increased DNA hypermethylation. Further research is needed to evaluate the impact of recurrent UTIs and chronic inflammation in DNA hypermethylation and bladder cancer etiopathogenesis in NLUTD patients.

A Study of DNA Methylation of Bladder Cancer Biomarkers in the Urine of Patients with Neurogenic Lower Urinary Tract Dysfunction

Background: Bladder cancer (BCa) in patients suffering from neurogenic lower urinary tract dysfunction (NLUTD) is a significant concern due to its advanced stage at diagnosis and high mortality rate. Currently, there is a scarcity of specific guidelines for BCa screening in these patients. The development of urine biomarkers for BCa seems to be an attractive non-invasive method of screening or risk stratification in this patient population. DNA methylation is an epigenetic modification, resulting in the transcriptional silencing of tumor suppression genes, that is frequently detected in the urine of BCa patients. Objectives: We aimed to investigate DNA hypermethylation in five gene promoters, previously associated with BCa, in the urine of NLUTD patients, and in comparison with healthy controls. Design, setting and participants: This was a prospective case-control study that recruited neurourology outpatients from a public teaching hospital who had suffered from NLUTD for at least 5 years. They all underwent cystoscopy combined with biopsy for BCa screening following written informed consent. DNA was extracted and DNA methylation was assessed for the RASSF1, RARβ, DAPK, TERT and APC gene promoters via quantitative methylation-specific PCR in urine specimens from the patients and controls. Results: Forty-one patients of mixed NLUTD etiology and 35 controls were enrolled. DNA was detected in 36 patients' urine specimens and in those of 22 controls. In the urine specimens, DNA was hypermethylated in at least one of five gene promoters in 17/36 patients and in 3/22 controls (47.22% vs. 13.64%, respectively, p = 0.009). RASSF1 was hypermethylated in 10/17 (58.82%) specimens with detected methylation, APC in 7/17 (41.18%), DAPK in 4/17 (23.53%), RAR-β2 in 3/17 (17.56%) and TERT in none. According to a multivariate logistic regression analysis, NLUTD and male gender were significantly associated with hypermethylation (OR = 7.43, p = 0.007 and OR = 4.21; p = 0.04, respectively). In the tissue specimens, histology revealed TaLG BCa in two patients and urothelial squamous metaplasia in five patients. Chronic bladder inflammation was present in 35/41 bladder biopsies. Conclusions: DNA hypermethylation in a panel of five BCa-associated genes in the urine was significantly more frequent in NLUTD patients than in the controls. Our results warrant further evaluation in longitudinal studies assessing the clinical implications and possible associations between DNA hypermethylation, chronic inflammation and BCa in the NLUTD population.

Bladder cancer detection in patients with neurogenic bladder: are cystoscopy and cytology effective, and are biomarkers pertinent as future diagnostic tools? A scoping review

PURPOSE

To summarize the current state of knowledge on bladder cancer diagnosis and screening in neurogenic bladder patients, and to explore the potential contribution of biomarkers in this context.

METHODS

A scoping review was performed to retrieve cystoscopy and urinary cytology performance for bladder cancer detection in neurogenic bladder patients. We also retrieved information of certified urinary biomarkers in bladder cancer detection and their potential application for this specific population.

RESULTS

A total of 1092 articles were identified; 19 of them were included in the scoping review regarding cytology and cystoscopy performance in patients with neurogenic bladder and 33 were included as related to biomarkers in bladder cancer. No significant study stood out to recommend bladder cancer screening in this specific population using cytology and cystoscopy because of the scarcity of results, low level-of-evidence studies, and lack of studies specifically designed to assess the test performance in this population. Two biomarkers were retained as potential future diagnostic tools: FISH analysis to detect chromosomal changes, and PCR for TERT and FGFR3 promoter mutation detection, associated or not with KRAS mutation detection.

CONCLUSION

There is no sufficient quality data to support cystoscopy and urinary cytology as effective tools for the diagnostic and surveillance of bladder cancer in neurogenic bladder patients. FISH analysis to detect chromosomal changes, and PCR for TERT and FGFR3 promoter mutation detection, associated or not with KRAS mutation detection, stand out as candidates of interest for bladder cancer detection in this specific population and should be prospectively tested.

Urinary catheter management: what neurologists need to know

Patients with neurological disorders often have lower urinary tract dysfunction, manifesting as urinary retention or urinary incontinence, and so commonly use catheters. Neurologists should therefore be aware of the different types of catheters and appliances and their risks, benefits and complications. Clean intermittent self-catheterisation is preferable to an indwelling catheter; however, if this is not possible, then a suprapubic indwelling catheter is preferable to a urethral catheter for long-term management. We review the decision-making process when selecting catheters for neurological patients, the evidence base regarding the different options and how neurologists can recognise and address complications. We also discuss alternatives to catheterisation, such as non-invasive containment products and surgical treatments, and the indications for urological referral.

Recommendations for urological follow-up of patients with neurogenic bladder secondary to spinal cord injury

PURPOSE

To review currently available guidelines and recommendations regarding urological follow-up of patients after spinal cord injury (SCI) and present an evidence-based summary to support clinicians in their clinical practice.

METHODS

Maximum data were collected according to different methods, including searches with multiple and specific keywords, reference checks, gray literature searches (congress reports, working papers, statement documents), and browsing-related Web site access. Obtained data were analyzed with the modified version of the Oxford grading system for recommendations using levels of evidence (LE) and grades of recommendation (GR).

RESULTS

Different surveillance strategies exist, but there is no consensus among authors and organizations. As a result, practice patterns vary around the world. The present review indicates that proper urological follow-up of SCI patients should consist of medical history (LE 1-4, GR B-C), clinical examination (LE 4, GR C), renal laboratory tests (LE 1-3, GR B), imaging surveillance of the upper urinary tract (LE 1-3, GR A-B), urodynamic study (LE 2-4, GR B-C), and cystoscopy/cytology (LE 1-4, GR D). Clinicians agree that SCI patients should be followed up regularly with an individually tailored approach. A 1-year follow-up schedule seems reasonable in SCI patients without additional risk factors of renal deterioration (LE 3-4, GR C). In those who manifest risk factors, report changes in bladder behavior, or present with already developed complications of neurogenic bladder dysfunction, follow-up plans should be modified with more frequent checkups (LE 4, GR C). Urodynamic study should be repeated and considered as a routine monitoring strategy.

CONCLUSION

Individuals with neurogenic lower urinary tract dysfunction are at increased risk of multiple complications. Nevertheless, proper follow-up after SCI improves the prognosis for these patients and their quality of life.

Clinical usefulness of urine cytology in the detection of bladder tumors in patients with neurogenic lower urinary tract dysfunction

Introduction

Screening for bladder cancer in patients with neurogenic lower urinary tract dysfunction is a challenge. Cystoscopy alone is not sufficient to detect bladder tumors in this patient group. We investigated the usefulness of combined cystoscopy and urine cytology.

Materials and methods

By a systematic chart review, we identified all patients with neurogenic lower urinary tract dysfunction who underwent combined cystoscopy and urine cytology testing. In patients with suspicious findings either in cytology or cystoscopy, transurethral resection was performed.

Results

Seventy-nine patients (age 54.8±14.3 years, 38 female, 41 male) were identified; 44 of these used indwelling catheters. Cystoscopy was suspicious in 25 patients and cytology was suspicious in 17 patients. Histologically, no tumor was found in 15 patients and bladder cancer was found in 6 patients. Sensitivity for both cytology and cystoscopy was 83.3%; specificity was 43.7% for cytology and 31.2% for cystoscopy. One bladder tumor was missed by cytology and three tumors were missed by cystoscopy. If a biopsy was taken only if both findings were suspicious, four patients would have been spared the procedure, and one tumor would not have been diagnosed.

Conclusion

A combination of cystoscopy and urine cytology can improve bladder tumor detection rates and lower the number of unnecessary biopsies.

Prevalence, management, and prognosis of bladder cancer in patients with neurogenic bladder: A systematic review

AIM

To perform a systematic review of the literature regarding epidemiology, diagnosis, management and prognosis of bladder cancer in the neuro-urological patient population, in order to serve as a basis for future recommendations and research.

METHODS

A systematic review was performed according to the PRISMA-Preferred Reporting Items for Systematic Reviews and Meta-Analyzes Statement. Embase was searched for studies providing data on epidemiology, diagnosis, management and prognosis of bladder cancer in neuro-urological patients.

RESULTS

After screening 637 abstracts, 15 studies (13 retrospective and 2 prospective studies) were included in this study. We identified 332 patients (0.3%) who were diagnosed with bladder cancer. This mostly affected mostly men (59.3%) and spinal cord injured patients (98.8%). Mean age at diagnosis was 56.1 years. Bladder cancer occurred after a long period of evolution of the neurological disease (24.9 years). Gross hematuria was the predominating presenting symptom (31.6% of cases). Indwelling urethral or supra-pubic catheters were used in 44.5% of patients. The most frequent histological subtype of bladder cancer was transitional cell carcinoma (53.1%), followed by squamous cell carcinoma (33.5%). Muscle-invasive bladder cancer was reported in 67.7% of patients. The mean cancer-specific mortality rate was of 47.1%.

CONCLUSIONS

The prevalence and high mortality rate of bladder cancer in neuro-urological patients underlines the importance of long-term follow-up in this specific population. This highlights the necessity of further studies in this field.

Update on voiding dysfunction managed with suprapubic catheterization

As the population ages the prevalence of long-term urinary catheters, especially in the elderly, is going to increase. Urinary catheters are usually placed to manage urinary retention or incontinence that cannot be managed any other way. There is significant morbidity associated with an indwelling catheter. The commonest problems are catheter blockages, infection and bladder stones. These will occur with a similar incidence with either a suprapubic or a urethral catheter. Urethral complications such as strictures, scrotal infection and erosion are less common with suprapubic catheterization (SPC). However the benefit of having a SPC needs to be balanced against the risks involved in inserting the catheter suprapubically. Patient reported symptoms show that a SPC is more comfortable and better tolerated than a urethral catheter. However there needs to be more research into developing better catheters that reduce the frequency of urinary infections and blockages and hence catheter morbidity.

Clinical characteristics of bladder cancer in patients with spinal cord injury: the experience from a single centre

INTRODUCTION

Life expectancy for people with spinal cord injury has shown a marked increase due to modern advances in treatment methods and in neuro-urology. However, since life expectancy of people with paralysis increases, the risk of developing of urinary bladder cancer is gaining importance.

MATERIALS AND METHODS

Single-centre retrospective evaluation of patient data with spinal cord injuries and proven urinary bladder cancer and summary of the literature.

RESULTS

Between 1998 and 2014, 24 (3 female, 21 male) out of a total of 6599 patients with spinal cord injury were diagnosed with bladder cancer. The average age at bladder cancer diagnosis was 57.67 years, which is well below the average for bladder cancer cases in the general population (male: 73, female: 77). All but one patient had a latency period between the onset of the spinal paralysis and tumour diagnosis of more than 10 years. The median latency was 29.83 years. The median survival for these patients was 11.5 months. Of the 24 patients, 19 (79%) had muscle invasive bladder cancer at ≥T2 at the time of diagnosis. The type of neurogenic bladder (neurogenic detrusor overactivity or acontractility) and the form of bladder drainage do not appear to influence the risk. Long-term indwelling catheter drainage played only a minor role in the investigated patients.

CONCLUSIONS

The significantly younger age at onset and the frequency of invasive tumours at diagnosis indicate that spinal cord injury influences bladder cancer risk and prognosis as well. Early detection of bladder cancer in patients with spinal cord injury remains a challenge.

Incidentally-Discovered Squamous Cell Carcinoma after Endoscopic Sphincterotomy

The association between the development of bladder cancer and chronic bladder irritation is well established in the literature. Chronic urinary tract irritation can be the result of bacterial infections, foreign bodies, trauma of repeated catheterization, neurogenic bladder, urolithiasis, or chronic bladder outlet obstruction, all which have been implicated in the pathogenesis of non-bilharzial squamous cell carcinoma of the bladder (SCC). With many of the aforementioned factors present in patients with spinal cord injury, several retrospective studies have demonstrated a 16-28 fold increased relative risk of bladder cancer, with SCC accounting for 10 times more cases of bladder cancer compared to the general population. In this report, we present the case of incidentally-discovered SCC of the bladder found within sphincter/prostate chips of a patient with neurogenic bladder due to spinal cord injury n clean intermittent catheterization ho underwent sphincterotomy with negative cystoscopic findings.

Do We Need Surveillance Urethro-Cystoscopy in Patients with Neurogenic Lower Urinary Tract Dysfunction?

PURPOSE

To examine the value of surveillance urethro-cystoscopy in patients with neurogenic lower urinary tract dysfunction (NLUTD) in regard to the conflicting literature as it is generally agreed that patients with NLUTD are at increased risk for bladder cancer.

MATERIALS AND METHODS

In a cross-sectional study, a consecutive series of 129 patients (50 females, 79 males, mean age 51, range 18-88) suffering from NLUTD for at least 5 years was prospectively investigated using urethro-cystoscopy and bladder washing cytology at a single university spinal cord injury (SCI) center.

RESULTS

Due to suspicious urethro-cystoscopy and/or bladder washing cytology findings, 13 (10%) of 129 patients underwent transurethral resection of the bladder lesion and/or random bladder biopsies. Overall, 9 relevant histological findings were found in 5% (7/129) of our patients: bladder melanosis (n = 1), nephrogenic adenoma (n = 3), keratinizing squamous metaplasia (n = 1), intestinal metaplasia (n = 3), and muscle-invasive adenocarcinoma of the bladder (n = 1).

CONCLUSIONS

Using surveillance urethro-cystoscopy, we found relevant histological findings in 5% of our patients suffering from NLUTD for at least 5 years. Thus, surveillance urethro-cystoscopy might be warranted, although the ideal starting point and frequency remain to be determined in further prospective studies.

Systematic review of urological followup after spinal cord injury

PURPOSE

There is no consensus on the appropriate urological followup of individuals after spinal cord injury but it is well known that they are at risk for renal deterioration, bladder cancer and stones. We systematically reviewed the literature to evaluate evidence of urological screening in this population.

MATERIALS AND METHODS

We reviewed 385 abstracts, of which 50 met study inclusion criteria. We rated evidence using American Academy of Neurology 2004 guidelines.

RESULTS

A total of 12 articles evaluated urinary tract infection screening. Patient reported symptoms used to predict urinary tract infection yielded mixed results and urine dipstick testing had the same accuracy as microscopy. Routine urine culture was unnecessary in healthy, asymptomatic individuals with normal urinalysis. Urodynamics probably must be done periodically (6 articles) but there was no information on frequency. In 11 articles ultrasound was recommended as a useful, noninvasive and possibly cost-effective screening method. Renal scan was a good method for further testing, especially if ultrasound was positive (11 articles). Evidence was sufficient (11 articles) to recommend ultrasound of the urinary tract to detect urinary tract stones with good sensitivity but not plain x-ray of the kidneys, ureters and bladder (2 articles). There was insufficient evidence to recommend urine markers or cytology for bladder cancer screening (9 articles).

CONCLUSIONS

Based on this review no definitive recommendations for screening can be made except routine renal ultrasound. Urodynamics are an important part of screening but the frequency is unclear. The optimum bladder cancer screening method has not been defined.

Annual endoscopy and urine cytology for the surveillance of bladder tumors after enterocystoplasty for congenital bladder anomalies

PURPOSE

It is currently recommended that patients with congenital bladder anomalies managed by enterocystoplasty undergo annual surveillance with urine cytology and endoscopy. We reviewed our experience with this protocol and suggest modifications based on this experience.

MATERIALS AND METHODS

A total of 65 patients 10 years or more after enterocystoplasty were placed on an annual surveillance protocol consisting of interval medical history, renal-bladder ultrasound, serum B12, electrolytes, creatinine, urinalysis, urine cytology and endoscopy.

RESULTS

Of the 65 patients 50 (77%) with enterocystoplasty (ileal in 40 and colonic in 10) remain on the protocol. Median age at the initiation of surveillance was 28 years (range 24 to 40) with a median time from augmentation of 15 years (range 12 to 29). During the first 5 years of surveillance 26 of 250 cytology results (10.5%) were suspicious for cancer. Further evaluation revealed no evidence of malignancy. Specificity for cytology was 90% with unknown sensitivity. Of 250 surveillance endoscopic evaluations 4 lesions (1.6%) were identified and biopsied/removed. Pathological evaluation revealed 1 adenomatous polyp, 1 squamous metaplasia and 2 nephrogenic adenomas. Due to the low event rate and high cost routine cytology and endoscopy were discontinued after each patient completed 5 years of followup and annual evaluations were maintained. No tumors developed during the median surveillance interval of 15 years (range 12 to 20). Currently median patient age is 42 years (range 36 to 59) and median time since augmentation is 27 years (range 23 to 40).

CONCLUSIONS

Due to the low incidence of malignancy, lack of proven benefit and enhanced cost containment we recommend that annual surveillance endoscopy and cytology be discontinued.

Pathobiology and chemoprevention of bladder cancer

Our understanding of the pathogenesis of bladder cancer has improved considerably over the past decade. Translating these novel pathobiological discoveries into therapies, prevention, or strategies to manage patients who are suspected to have or who have been diagnosed with bladder cancer is the ultimate goal. In particular, the chemoprevention of bladder cancer development is important, since urothelial cancer frequently recurs, even if the primary cancer is completely removed. The numerous alterations of both oncogenes and tumor suppressor genes that have been implicated in bladder carcinogenesis represent novel targets for therapy and prevention. In addition, knowledge about these genetic alterations will help provide a better understanding of the biological significance of preneoplastic lesions of bladder cancer. Animal models for investigating bladder cancer development and prevention can also be developed based on these alterations. This paper summarizes the results of recent preclinical and clinical chemoprevention studies and discusses screening for bladder cancer.

Quality of life and urological morbidity in tetraplegics with artificial ventilation managed with suprapubic or intermittent catheterisation

STUDY DESIGN

Mono-centric, retrospective study.

OBJECTIVE

Analysis of correlation between bladder management and age in respirator-dependant high-tetraplegic patients. Additionally suprapubic catheter (SPC) and intermittent catheterisation (IC) were reviewed concerning urological complications and quality of life (QoL).

SETTING

Level 1 trauma centre.

METHODS

A QoL questionnaire 'International Consultation on Incontinence' (ICIQ-SF) was sent to 56 tetraplegic respirator device-dependant (RDD)-spinal cord injury (SCI) patients. Their scores concerning urological morbidity were reviewed. For analysis reasons they were divided in three groups: SPC, IC and others.

RESULTS

SPC 38, IC 12 and others 6 patients. Significant difference in age (SPC vs IC=49.9 vs 31.8 years) was observed but no disparity in gender. Within a follow-up period 2-26 years (median 8 years) significant urological complications in patients with IC (P<0.05) were ascertained. These were in general minor complications. Especially renal deterioration or bladder cancer was not diagnosed in any of the group. The questionnaire return rate was high (83.9%) with complete answers (SPC=32, IC=11). Self assessment of QoL with ICIQ-SF revealed no significant difference for both groups on low level, but SPC patients tend to score better.

CONCLUSION

In our study, tetraplegic RDD-SCI patients with SPC suffered less urological complications and tend to score a better QoL. Therefore we recommend SPC as a serious alternative for these selected patients and concurrently underline the necessity of close urological surveillance at least annually.

Intermittent self-catheterization and the risk of squamous cell cancer of the bladder: An emerging clinical entity?

There are only 7 cases reported in the literature of squamous cell cancer of the bladder in patients performing intermittent self-catheterization (ISC). We report on an eighth case, and the first case described in a patient with a Mitrofanoff continent appendicovesicostomy. A description of the case and review of the literature are presented. Risk factors for squamous cell cancer include recurrent urinary tract infections, keratinising squamous metaplasia (leukoplakia) and local mucosal trauma from intermittent self-catheterization. There is no recognized or validated monitoring program for patients performing ISC who may also have these risk factors. Reasonable protocols may include regular urinary cytology and cystoscopy with random or targeted bladder biopsies. Squamous cell cancer may present late in this cohort of patients and is associated with a dismal prognosis.

Infection: is it a cause of bladder cancer?

This article reviews the literature regarding the possible correlation between infection and occurrence of bladder cancer. The PubMed literature database was searched from inception to January 2008. Keywords of bladder, cancer, parasitic, bacterial, viral and infection, were used. Forty studies were included in the review. Several investigators support the idea that schistosomiasis is aetiologically related to the development of bladder cancer in individuals infected with Schistosoma haematobium. Approximately 70% of those with chronic schistosomiasis who have bladder cancer develop squamous cell rather than transitional cell carcinoma. Several investigators suggest that bacteria may play a role in inducing bladder cancer. Clinically, researchers have linked the development of infection, urinary stones and indwelling catheters with bladder cancer. Nevertheless, to date, no prospective study has examined the association between urinary tract infection and bladder cancer risk. The possibility that infection by human papilloma virus (HPV) is a risk factor contributing to bladder cancer has been investigated but no definite conclusions have been drawn. Thus, the debate remains open as to whether there is any direct link between chronic HPV infection and bladder cancer. Only 15 cases of vesical carcinoma have been reported, to date, in the setting of human immunodeficiency virus (HIV). The rare occurrence of bladder cancer during HIV infection and the lack of correlation with the laboratory markers of HIV disease progression may suggest a trivial association between two unrelated disorders. BK virus is oncogenic in newborn hamsters and can transfer to mammalian cells in vitro, but there is little consistent evidence of a link with human bladder cancer. Studies showed no correlation between herpes simplex virus (HSV) and bladder cancer, but bladder cancer becomes infected with HSV much more easily than non-neoplastic urothelium. In conclusion, with the exception of chronic infection with S. haematobium, the association between the occurrence of bladder cancer and chronic bacterial or viral infections could not be confirmed. Prospective studies with large numbers of patients and controls are required to confirm this issue.

Contemporary role of suprapubic cystostomy in treatment of neuropathic bladder dysfunction in spinal cord injured patients

BACKGROUND

The management of neuropathic bladder dysfunction secondary to spinal cord injury is controversial. With the introduction of clean intermittent catheterization (CIC) and anti-cholinergic medication, urinary tract deterioration in this population has declined. Nevertheless, this strategy is problematic for patients who are unable to perform CIC. Suprapubic cystostomy (SPC) is widely viewed as a secondary option, which has a high satisfaction rating among patients, with acceptable clinical efficacy. Despite early reports of long-term renal and bladder complications, recent evidence has demonstrated that improved anti-cholinergic pharmacotherapy and bladder maintenance strategies can enhance SPC efficacy, with diminished morbidity. We set out to review the current literature on SPC in the neuropathic bladder setting and to clarify future management direction.

MATERIALS

This investigation consisted of a literature search of the MEDLINE and PUBMED databases. Inclusion criteria were related to SPC, indwelling catheterization, urodynamics, spinal cord injury and bladder dysfunction. Our analysis comprised 56 studies, including retrospective analyses and case reports. Investigations regarding surgical technique as well as short and long-term efficacy were also included.

RESULTS

Early studies reported accelerated renal deterioration and lower urinary tract complications, including stones, recurrent infections and blocked catheters. Procedural complications were generally rare. In contrast, recent investigations, in which patients were managed with anti-cholinergics, frequent catheter changes and bladder washing, and volume maintenance procedures demonstrated similar morbidity profiles to CIC.

Patients With Spina Bifida and Bladder Cancer: Atypical Presentation, Advanced Stage and Poor Survival

PURPOSE

Patients with neurogenic bladder dysfunction due to spina bifida have been reported to be at increased risk for bladder cancer. Recent publications suggest that bladder augmentation is also a significant risk factor. We reviewed our experience with treating patients with spina bifida and bladder cancer.

MATERIALS AND METHODS

Patients with spina bifida treated for bladder cancer between 1995 and 2005 were identified. Patient demographics, mode of bladder management, risk factors and presenting symptoms were recorded along with therapy, pathological findings and outcome. This patient cohort was combined with all prior known published studies for analysis.

RESULTS

Eight patients with a median age of 41 years were treated. Only 1 patient (13%) had undergone bladder augmentation. Locally advanced stage (T3 or greater) or lymph node metastases were present in 88% of cases. Median survival was 6 months with only 1 patient alive with no evidence of recurrence at 20 months. A total of 11 prior published cases were identified and combined with this series. Transitional cell carcinoma was present in 58% of patients. Median survival was 6 months. Only 37% of patients had undergone bladder augmentation.

CONCLUSIONS

Patients with spina bifida and bladder cancer present at a young age with variable tumor histology and advanced stage, and they have poor survival. Presenting symptoms are often atypical and bladder cancer should be a consideration in this patient population, even in young adults. Due to poor survival further study is warranted in this population to determine whether screening would be beneficial for earlier detection and improved outcomes.

The atypical urothelial cancer patient: management of bladder cancers of non-transitional cell histology and cancers of the ureters and renal pelvis

Non-transitional cell neoplasms of the bladder and upper tract transitional cell carcinomas (ureter and renal pelvis) represent only a small fraction of urothelial carcinomas. Clinicians faced with the rare case are always confronted with management dilemmas complicated by the scarcity of published experience to guide decisions. The current review brings together the best of the limited published data in an attempt to provide some reasonable context to help in the management of these difficult neoplasms.

Chapitre B-5 B - Dérivation cutanée non continente en neuro-urologie

Non-continent urinary diversions can be proposed temporarily in neurological patients or at end-stage. They are especially proposed in patients in chronic retention in whom intermittent catheterization cannot be performed for anatomical or practical reasons (severity of neurological handicap). In this study, the authors present the various non-continent urinary diversions reported in the literature, describing the technical modalities of each diversion, their main complications and their short-term, medium-term and long-term results.

Chapitre C - Cancer de vessie et vessie neurologique

In 2006, the risk of developing bladder tumour remains an important aspect of the management and surveillance of spinal cord injury patients. Based on a review of the literature, the authors show that these patients present a particularly high risk of squamous cell carcinoma of the bladder Risk factors remain controversial, but the duration of neurogenic bladder and the voiding mode appear to be the main risk factors. The authors discuss the optimal diagnostic modalities in this setting and the particular case of bladder augmentation.