Is there a role for urine cytology following BCG therapy for non-muscle-invasive bladder cancer (NMIBC)?

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Background: Voided urine cytology has been used as an adjunct in the diagnosis of non-muscle invasive bladder cancer (NMIBC), with a sensitivity and specificity ranging between 13-75% and 76-100% respectively. There is limited data on the accuracy and utility of cytology following BCG therapy. We reviewed the results of cytology in patients undergoing induction and maintenance BCG immunotherapy in our institution. Methods: Newly diagnosed patients who had received induction and maintenance intravesical BCG therapy from 2004 - 2019 were identified from a prospective database and their outcomes reviewed retrospectively. Histopathology results of biopsies / resected specimens and voided urine cytology results were examined for 273 patients. Results: A total of 2567 cytology results and 638 biopsy results were recorded. The average age was 73.2 years and median number of BCG treatments was four (induction followed by three maintenance courses). Median follow up was 38 months. 94 patients (34.4%) had recurrence following BCG therapy. Of those 33 patients (12.1%) had progression to muscle invasive disease. The number of cytology samples per patient after BCG therapy ranged from 1-23 (median 7), with several patients having repeated, potentially unnecessary negative urine cytology. Overall accuracy of cytology (n = 526) was sensitivity 44.2%, specificity 84.7%, PPV 38.9%, NPV 87.3%. Patients that had an erythematous bladder or red patch at flexible cystoscopy underwent subgroup analysis; this gave a very high NPV of 95.9%, with additional sensitivity being 65.5%, specificity 85.9% and PPV 33.3%. Number of positive cytology results (Chi2 = 44.30, P = 0.002), any positive cytology (Chi2 = 27.94, P < 0.001) and positive cytology after induction BCG therapy (Chi2 = 30.381, P < 0.001) were all strongly associated with recurrence. Conclusions: Positive urine cytology in patients undergoing intravesical BCG therapy predicts increased risk of recurrence and has good specificity. We would recommend using voided urine cytology in patients who have an erythematous bladder or red patch at flexible cystoscopy. If the cytology is positive then proceed to biopsy, however, if it is negative continue with surveillance. [Table: see text]

Apnoea is not necessary for flexible ureteroscopy and lasertripsy of renal stones: a prospective study over 6 years

Introduction

Temporary apnoea is often practiced during flexible ureteroscopy and lasertripsy (FURSL) for renal stones to reduce the potential movement of kidney secondary to respiratory excursions. While apnoea can help, it can also lead to respiratory complications, longer operative duration and ultimately prolong the length of hospital stay (LOS). The aim of this study was to look at the outcomes of FURSL without the use of apnoea.

Material and methods

Over a 6-year period from March 2012–June 2018, consecutive cases of adult FURSL were prospectively evaluated. Patients underwent surgical and anaesthetic counselling, pre-operative assessment and protocol-based general anaesthetic without using apnoea. Data on patient and stone demographics, operative details, LOS, stone-free rate (SFR) and complication rates were collected and analysed.

Results

A total of 292 patients underwent FURSL, with a mean age of 57 years and male:female ratio of 1.6:1. Pre and post-operative stents were inserted in 28.8% and 81.2%, a ureteral access sheath (UAS) was used in 61.6%. The mean single and cumulative stone sizes were 10.2 ±5.9 mm and 14.3 ±10.4 mm respectively. For a mean operative time of 48.8 ±25.5 minutes, the SFR was 88.7%.

The median length of stay was 0 days with 216 (74.0%) patients discharged the same day and a further 48 (16.4%) discharged within 24 hours. There were 11 complications, of which 10 were Clavien I/II, and 1 was Clavien IV.

Conclusions

Ureteroscopy can be safely performed without respiratory apnoea, using anaesthetic and surgical protocols. It improves day-case rates for FURSL and minimizes complications.

Predictors and Results of Negative Ureteroscopy for Treatment of Consecutive Ureteric Stones Done as a Primary Procedure: Prospective Outcomes from a University Hospital

INTRODUCTION

While negative ureteroscopy (URS) can be considered as an unnecessary procedure with medico-legal consequences, this avoids radiation from repeat CT scan and sometimes may be the only way to reassure patients with ongoing symptoms. We wanted to analyze our predictors and results of negative URS for treatment of ureteric stones.

METHODS AND MATERIALS

Between March 2012 and August 2018, data on consecutive patients with ureteric stones undergoing a primary URS (without a pre-operative stent) were prospectively collected for patient demographics and outcomes. Comparison was done for patients with diagnostic and therapeutic primary URS for ureteric stones. Patients with renal stones were excluded from the study.

RESULTS

A total of 270 patients underwent URS for ureteric stones during the study period of which 35 (13%) had a negative diagnostic URS. The patients who had negative URS were younger (p = 0.001), had smaller stones (p < 0.001), and more stones located in the distal ureter or vesico-ureteric junction (VUJ; p= 0.036). None of the patients who underwent negative URS had a postoperative stent inserted or any complications.

CONCLUSION

Although the rates of negative URS should be as low as possible, it seems to be safe and reassures patients with on-going symptoms. Based on our data, patients with small distal ureteric or VUJ stones should undergo a repeat imaging to avoid this unnecessary procedure. Informed consent, patient counseling, and appropriate up-to-date imaging seem to be key to minimizing negative diagnostic URS.

Malignancies of suprapubic catheter (SPC) tracts in spinal cord injury patients: a case series and review of literature

Introduction

Spinal cord injury (SCI) patients are at increased risk of bladder cancer. A rare variation of this is a malignancy arising or including the suprapubic catheter (SPC) tract.

Case series

We present the first case series of malignancy of the SPC tract in SCI patients, including a case of mucinous adenocarcinoma, squamous cell carcinoma and sarcoma. Presentation of patients ranged from bleeding at the site of the SPC to a rapidly growing mass. All three patients were thoroughly investigated, and management was bespoke to the extent of disease and their physiological state at the time of diagnosis. This ranged from extensive surgical intervention including cystectomy, partial sigmoidectomy, excision of the abdominal wall with reconstruction and ileal conduit formation to palliation.

Discussion

SCI patients represent 50% of all known published cases of malignancy of the SPC tract. Presentation and diagnosis can be challenging; however, prompt investigation and intervention are essential given the high degree of morbidity and mortality. Routine check of the SPC site may be indicated in those patients in whom the SPC has been present for more than 5 years.

'Negative Ureteroscopy' for Stone Disease: Evidence from a Systematic Review

PURPOSE OF REVIEW

While ureteroscopy (URS) is a common procedure for ureteric stones, this window between diagnosis and treatment leaves the possibility for a 'negative', 'stoneless' or 'diagnostic' URS. We perform a systematic review to look at the rate of 'negative ureteroscopy' and risk factors associated with it.

RECENT FINDINGS

From a total of 3599 articles and 68 abstracts, 4 studies (1336 patients) were selected. The negative URS rate varied from 4 to 14%. Common predictors seem to be female gender, small stones, radiolucent stones and distal ureteric stones. Although infrequent, negative ureteroscopy should be avoided in patients with ureteric stones by performing a low-dose CT scan on the day of surgery. This should especially be performed for females and those with smaller, radiolucent or distal ureteric stones.

Ureteroscopy and stone treatment in the elderly (≥70 years): prospective outcomes over 5- years with a review of literature

Objective:

To assess outcomes of ureteroscopy for treatment of stone disease in the elderly. Ureteroscopy (URS) is an increasingly popular treatment modality for urolithiasis and its applications are ever expanding with the development of newer technologies. Its feasibility and outcomes within the elderly population to our knowledge remain under-reported.

Materials and Methods:

We examined the patient demographics and surgical outcomes from our prospective database for patients ≥70 years who underwent URS for urolithiasis, in a 5-year period between March 2012 and December 2016.

Results:

A total of 110 consecutive patients underwent 121 procedures (1.1 procedure/patient) with a mean age of 77.2 years (range: 70-91 years). Stone location was in the kidney/ pelviureteric junction (PUJ) in 29%, ureter in 37% and in multiple locations in 34%. The initial and final stone free rate (SFR) was 88% and 97% respectively. While 73% were done as true day case procedures, 89% patients were discharged within 24 hours. Eleven patients (9%) underwent complications of which 10 were Clavien I/II including acute urinary retention, urinary tract infection, stent symptoms and pneumonia. One patient underwent Clavien IV complication where they needed intensive care unit admission for urosepsis but fully recovered and were discharged home subsequently.

Conclusion:

Ureteroscopy is a safe and effective method of managing urolithiasis in elderly patients. Although most patients are discharged within 24-hours, consideration needs to be made for patients where social circumstances can impact their discharge planning.