Bladder instillations versus onabotulinumtoxinA injection for interstitial cystitis/bladder pain syndrome: A randomized clinical trial

BACKGROUND

Interstitial cystitis/bladder pain syndrome is an unpleasant sensation related to the bladder with lower urinary tract symptoms lasting more than six weeks, unrelated to an otherwise identifiable cause. The etiology is likely multifactorial including urothelial abnormalities, neurogenic pain upregulation, and potentially bladder and vaginal microbiome alterations. Despite treatment effectiveness of both bladder instillations and intradetrusor onabotulinumtoxinA injection for this condition, a head-to-head comparison has not been performed.

OBJECTIVES

To compare the efficacy of bladder instillations and intradetrusor onabotulinumtoxinA injection for treatment of interstitial cystitis/bladder pain syndrome.

STUDY DESIGN

Patients with O'Leary-Sant (OLS) questionnaire scores of ≥ 6, meeting clinical criteria for interstitial cystitis/bladder pain syndrome, and desiring procedural management were randomized to bladder instillations or intradetrusor onabotulinumtoxinA injection. The primary outcome was the difference in OLS scores at 2 months post-treatment between groups. Secondary outcomes included evaluation of sexual function, physical/mental health status, pain, patient satisfaction, treatment perception, retreatment, and adverse event rates.

RESULTS

47 patients were analyzed with 22 randomized to bladder instillations and 25 to onabotulinumtoxinA injection. There were no differences in demographic and clinical characteristics between groups. From baseline to 2 months post-treatment, there was a decrease in OLS subscales in all patients (Interstitial Cystitis Symptom Index (ICSI) -6.3 (CI -8.54, -3.95), p<.0001; Interstitial Cystitis Problem Index (ICPI) -5.9 (CI -8.18, -3.57), p<.0001). At 2 months post-treatment, patients in the onabotulinumtoxinA group had significantly lower OLS scores compared to those in the bladder instillation group (ICSI 6.3 ± 4.5 [onabotulinumtoxinA] versus 9.6 ± 4.2 [instillation], p=.008; ICPI 5.9 ± 5.1 [onabotulinumtoxinA] versus 8.3 ± 4.0 [instillation], p=.048). The difference in OLS scores between groups did not persist at 6-9 months post-treatment. There were no statistically significant differences between baseline and post-treatment time points for the remaining questionnaires. Eight percent of patients who received onabotulinumtoxinA injection experienced urinary retention requiring self-catheterization. Patients who underwent onabotulinumtoxinA injection were significantly less likely to receive retreatment within 6-9 months compared to patients who received bladder instillations (relative risk 13.6; 95% CI, 1.92-96.6; P=.0002). There were no differences between groups regarding patient satisfaction, perception of treatment convenience, or willingness to undergo retreatment.

CONCLUSIONS

Both onabotulinumtoxinA injection and bladder instillations are safe, effective treatments for patients with interstitial cystitis/bladder pain syndrome, with significant clinical improvement demonstrated at 2 months post-treatment. Our findings suggest that intradetrusor onabotulinumtoxinA injection is a more effective procedural treatment for this condition than bladder instillation therapy and associated with decreased rates of retreatment.

Fiberscopic pattern removal for optimal coverage in 3D bladder reconstructions of fiberscope cystoscopy videos

Purpose

In the current clinical standard of care, cystoscopic video is not routinely saved because it is cumbersome to review. Instead, clinicians rely on brief procedure notes and still frames to manage bladder pathology. Preserving discarded data via 3D reconstructions, which are convenient to review, has the potential to improve patient care. However, many clinical videos are collected by fiberscopes, which are lower cost but induce a pattern on frames that inhibit 3D reconstruction. The aim of our study is to remove the honeycomb-like pattern present in fiberscope-based cystoscopy videos to improve the quality of 3D bladder reconstructions.

Approach

Our study introduces an algorithm that applies a notch filtering mask in the Fourier domain to remove the honeycomb-like pattern from clinical cystoscopy videos collected by fiberscope as a preprocessing step to 3D reconstruction. We produce 3D reconstructions with the video before and after removing the pattern, which we compare with a metric termed the area of reconstruction coverage (A RC ), defined as the surface area (in pixels) of the reconstructed bladder. All statistical analyses use paired t -tests.

Results

Preprocessing using our method for pattern removal enabled reconstruction for all (n = 5 ) cystoscopy videos included in the study and produced a statistically significant increase in bladder coverage (p = 0.018 ).

Conclusions

This algorithm for pattern removal increases bladder coverage in 3D reconstructions and automates mask generation and application, which could aid implementation in time-starved clinical environments. The creation and use of 3D reconstructions can improve documentation of cystoscopic findings for future surgical navigation, thus improving patient treatment and outcomes.

Evaluation of a New Cystoscopic Cryocatheter and Method for the In Situ Destruction of Bladder Cancer: Preliminary In Vivo Study

Purpose: To assess the ability to deliver full-thickness bladder wall cryoablation through a cystoscopic approach using a new closed-loop 6F cryocatheter and thermal dose-controlled protocol. Materials and Methods: Evaluations were conducted using a chronic porcine model wherein 10 lesions/animal were created throughout the bladder (bladder wall, trigone region, ureteral orifice, and distal ureter). A 6F cryocatheter was passed through the working channel of a flexible cystoscope. Single 1- and 1.5-minute freeze protocols in a saline environment were evaluated and resultant lesion size was determined. A laparoscopic approach was utilized to observe the transmural extension of the ice propagation. Results: Studies demonstrated the generation of transmural lesions characterized by full-thickness histologic necrosis after freezing for 1.5 minutes regardless of tissue thickness (range 2-12 mm). All animals were found to have good overall health (maintained weight, appetite, mobility, and energy levels) throughout the recovery period. No significant deviations were noted in complete blood count and serum chemistry bloodwork except for elevated creatine kinase levels. Importantly, no fistulas or perforations were noted. Conclusions: The cryocatheter was able to rapidly and effectively freeze the bladder wall through a cystoscopic approach. The results showed the ability to consistently ablate an ∼1 cm diameter and up to 1.2 cm deep using a single 1.5-minute freeze protocol. Analysis of the ablation efficacy revealed ∼80% destruction within the frozen mass. Although further testing and refinement are needed, these studies demonstrate the potential of this new approach to provide a next-generation strategy for the treatment of bladder cancer.

Objective Evaluation of Gaze Location Patterns Using Eye Tracking During Cystoscopy and Artificial Intelligence-Assisted Lesion Detection

Background: The diagnostic accuracy of cystoscopy varies according to the knowledge and experience of the performing physician. In this study, we evaluated the difference in cystoscopic gaze location patterns between medical students and urologists and assessed the differences in their eye movements when simultaneously observing conventional cystoscopic images and images with lesions detected by artificial intelligence (AI). Methodology: Eye-tracking measurements were performed, and observation patterns of participants (24 medical students and 10 urologists) viewing images from routine cystoscopic videos were analyzed. The cystoscopic video was captured preoperatively in a case of initial-onset noninvasive bladder cancer with three low-lying papillary tumors in the posterior, anterior, and neck areas (urothelial carcinoma, high grade, and pTa). The viewpoint coordinates and stop times during observation were obtained using a noncontact type of gaze tracking and gaze measurement system for screen-based gaze tracking. In addition, observation patterns of medical students and urologists during parallel observation of conventional cystoscopic videos and AI-assisted lesion detection videos were compared. Results: Compared with medical students, urologists exhibited a significantly higher degree of stationary gaze entropy when viewing cystoscopic images (p < 0.05), suggesting that urologists with expertise in identifying lesions efficiently observed a broader range of bladder mucosal surfaces on the screen, presumably with the conscious intent of identifying pathologic changes. When the participants observed conventional and AI-assisted lesion detection images side by side, contrary to urologists, medical students showed a higher proportion of attention directed toward AI-detected lesion images. Conclusion: Eye-tracking measurements during cystoscopic image assessment revealed that experienced specialists efficiently observed a wide range of video screens during cystoscopy. In addition, this study revealed how lesion images detected by AI are viewed. Observation patterns of observers' gaze may have implications for assessing and improving proficiency and serving educational purposes. To the best of our knowledge, this is the first study to utilize eye tracking in cystoscopy. University of Tsukuba Hospital, clinical research reference number R02-122.

Active Surveillance in Non-Muscle Invasive Bladder Cancer, the Potential Role of Biomarkers: A Systematic Review

Bladder cancer (BC) is the tenth most common cause of cancer worldwide and is the thirteenth leading cause of cancer mortality. The non-muscle invasive (NMI) variant represents 75% of cases and has a mortality rate of less than 1%; however, it has a high recurrence rate. The gold standard of management is transurethral resection in the case of new lesions. However, this is associated with significant morbidity and costs, so the reduction of these procedures would contribute to reducing complications, morbidity, and the burden to the health system associated with therapy. In this clinical scenario, strategies such as active surveillance have emerged that propose to manage low-risk BC with follow-up; however, due to the low evidence available, this is a strategy that is underutilized by clinicians. On the other hand, in the era of biomarkers, it is increasingly known how to use them as a tool in BC. Therefore, the aim of this review is to provide to clinical practitioners the evidence available to date on AS and the potential role of biomarkers in this therapeutic strategy in patients with low-grade/risk NMIBC. This is the first review linking use of biomarkers and active surveillance, including 29 articles.

Outcomes of Bladder Washout for the Treatment of Recurrent Urinary Tract Infections After Renal Transplantation

Background Current literature suggests that anywhere from 2.9-27% of renal transplant recipients (RTR) will develop recurrent urinary tract infections (UTIs) (≥2 UTIs over six months or ≥3 UTIs over 12 months). Recurrent UTIs are of particular importance to RTR given its increased risk for allograft fibrosis and overall patient survival. Alternative solutions are needed for the management of recurrent UTIs, especially given the vulnerability of RTR to UTIs. We hypothesize that bladder washout (BW) reduces the incidence and recurrence of UTIs in RTR. Methods This is a retrospective study evaluating the utility of BW procedures on RTR diagnosed with recurrent UTIs between December 2013 and July 2021 at a single center. Results A total of 106 patients were included in the study with a total of 118 BW performed. 69% of patients were successfully treated with BW, meaning they no longer met the criteria for recurrent UTIs (<1 UTI) in the six-month post-BW period. The mean number of UTIs was 2.76 (range 2-7) before the BW and 1.16 (range 0-5) after the BW. On average, there were 1.60 fewer UTIs in the post-BW period compared to the pre-BW period (p<0.0001). There is no statistically significant difference in success rates stratified by bacterial class (p=1) or antimicrobial resistance class (p=0.6937). Conclusion BW decreased the incidence of UTIs in the six-month post-operative period as nearly 70% of patients did not have UTI recurrence. This data provides evidence that BW may have utility in transplant recipients with recurrent UTIs. We hope this will stimulate further prospective randomized studies in this area.

Optimizing practices to prevent urinary tract infection after cystoscopy and urodynamics in women: A quality improvement study

OBJECTIVE

The objective of this study was to reduce the incidence of urinary tract infection (UTI) in women undergoing outpatient cystoscopy and/or urodynamic studies (UDS) at our centre by identifying and then altering modifiable risk factors through an analysis of incidence variability among physicians.

METHODS

This was a quality improvement study involving adult women undergoing outpatient cystoscopy and/or UDS at an academic tertiary urogynecology practice. Prophylactic practices for cystoscopy/UDS were surveyed and division and physician-specific UTI rates following cystoscopy/UDS were established. In consultation with key stakeholders, this delineated change concepts based on associations between prophylactic practices and UTI incidence, which were then implemented while monitoring counterbalance measures.

RESULTS

Two "Plan-Do-Study-Act-Cycles" were conducted whereby 212 and 210 women were recruited, respectively. Change concepts developed and implemented were: (1) to perform routine urine cultures at the time of these outpatient procedures, and (2) to withhold routine prophylactic antibiotics for outpatient cystoscopy/UDS, except in patients with signs of cystitis. There was no change in the incidence of early presenting UTI (9.0% vs. 9.2%, p = 0.680), but there were significantly fewer antibiotic-related adverse events reported (8.5% vs. 1.5%, p = 0.001). There was no significant change in the total incidence of UTI rates between cycles (7.8% vs. 5.6%, p = 0.649).

CONCLUSIONS

No specific strategies to decrease the incidence of UTI following outpatient cystoscopy/UDS were identified, however, risk factor-specific antibiotic prophylaxis, as opposed to universal antibiotic prophylaxis, did not increase UTI incidence.

Diagnostic value of repeated comprehensive investigation with CT urography and cystoscopy for recurrent macroscopic haematuria

Objectives

To perform a descriptive analysis of a series of patients with recurrent macroscopic haematuria after a primary standard evaluation including computed tomography urography (CTU) and cystoscopy negative for urinary bladder cancer (UBC) and upper tract urothelial cancer (UTUC) and to identify potential factors associated with occurrence of recurrent macroscopic haematuria.

Methods

All patients older than 50 years who underwent urological investigation for macroscopic haematuria with both cystoscopy and CTU 2015-2017 were retrospectively reviewed. A descriptive analysis of the primary and later investigations for recurrent macroscopic haematuria was performed. To investigate the association between explanatory variables and the occurrence of recurrent macroscopic haematuria, a Poisson regression analysis was performed.

Results

A total of 1395 eligible individuals with primary standard investigation negative for UBC and UTUC were included. During a median follow-up of 6.2 (IQR 5.3-7) years, 248 (18%) patients had recurrent macroscopic haematuria, of whom six patients were diagnosed with UBC, two with prostate cancer, one with renal cell carcinoma and one had a suspected UTUC at the repeated investigation. Within 3 years, 148 patients (11%) experienced recurrent macroscopic haematuria, of whom two patients were diagnosed with low-grade UBC (TaG1-2), one with T2G3 UBC and one with low-risk prostate cancer. The presence of an indwelling catheter, use of antithrombotic medication, pathological findings at CTU or cystoscopy or history of pelvic radiotherapy were all statistically significant independent predictors for increased risk for recurrent macroscopic haematuria.

Conclusion

In the case of recurrent macroscopic haematuria within 3 years of primary standard evaluation for urinary tract cancer, there was a low risk of later urological malignancies in patients initially negative for UBC and UTUC. Therefore, waiting 3 years before conducting another complete investigation in cases of recurrent macroscopic haematuria might be appropriate.

Risk prediction of bladder cancer among person with diabetes: A derivation and validation study

AIMS

This study aimed to devise and validate a clinical scoring system for risk prediction of bladder cancer to guide urgent cystoscopy evaluation among people with diabetes.

METHODS

People with diabetes who received cystoscopy from a large database in the Chinese population (2009-2018). We recruited a derivation cohort based on random sampling from 70% of all individuals. We used the adjusted odds ratios (aORs) for independent risk factors to devise a risk score, ranging from 0 to 5: 0-2 'average risk' (AR) and 3-5 'high risk' (HR).

RESULTS

A total of 5905 people with diabetes, among whom 123 people with BCa were included. The prevalence rate in the derivation (n  = 4174) and validation cohorts (n  = 1731) was 2.2% and 1.8% respectively. Using the scoring system constructed, 79.6% and 20.4% in the derivation cohort were classified as AR and HR respectively. The prevalence rate in the AR and HR groups was 1.57% and 4.58% respectively. The risk score consisted of age (18-70: 0; >70: 2), male sex (1), ever/ex-smoker (1) and duration of diabetes (≥10 years: 1). Individuals in the HR group had 3.26-fold (95% CI = 1.65-6.44, p  = 0.025) increased prevalence of bladder than the AR group. The concordance (c-) statistics was 0.72, implying a good discriminatory capability of the risk score to stratify high-risk individuals who should consider earlier cystoscopy.

CONCLUSIONS

The risk prediction algorithm may inform urgency of cystoscopy appointments, thus allowing a more efficient use of resources and contributing to early detection of BCa among people planned to be referred.

Long-term outcomes and cost savings of office fulguration of papillary Ta low-grade bladder cancer

OBJECTIVES

To assess whether office-based fulguration (OF) under local anaesthesia for small, recurrent, pathological Ta low-grade (LG) non-muscle-invasive bladder cancer (NMIBC) is an effective alternative to transurethral resection of bladder tumour (TURBT), avoiding the costs and risks of procedure, and anesthesia.

PATIENTS AND METHODS

Of 521 patients with primary TaLG NMIBC, this retrospective study included 270 patients who underwent OF during follow-up for recurrent, small, papillary LG-appearing tumours at a university centre (University Health Network, University of Toronto, Canada). We assessed the cumulative incidence of cancer-specific mortality (CSM) and disease progression (to MIBC or metastases), as well as possible direct cost savings.

RESULTS

In the 270 patients with recurrent TaLG NMIBC treated with OF, the mean (sd) age was 64.9 (13.3) years, 70.8% were men, and 60.3% had single tumours. The mean (sd, range) number of OF procedures per patient was 3.1 (3.2, 1-22). The median (interquartile range) follow-up was 10.1 (5.8-16.2) years. Patients also underwent a mean (sd) of 3.6 (3.0) TURBTs during follow-up in case of numerous or bulkier recurrence. In all, 44.4% of patients never received intravesical therapy. The 10-year incidence of CSM and progression were 0% and 3.1% (95% confidence interval 0.8-5.4%), respectively. Direct cost savings in Ontario were estimated at $6994.14 (Canadian dollars) per patient over the study follow-up.

CONCLUSIONS

This study supports that properly selected patients with recurrent, apparent TaLG NMIBC can be safely managed with OF under local anaesthesia with occasional TURBT for larger or numerous recurrent tumours, without compromising long-term oncological outcomes. This approach could generate substantial cost-saving to healthcare systems, is patient-friendly, and could be adopted more widely.

Utility of CT Scan in Detecting Bladder Involvement Among Patients With Cervical Carcinoma

Background Cervical cancer is a widespread health issue in India, particularly affecting women as the second most common cancer. The burden of cervical cancer in the country necessitates accurate staging for treatment optimization. The revised International Federation of Gynecology and Obstetrics (FIGO) staging system is vital for this purpose, emphasizing the extent of parametrial and pelvic sidewall involvement. Cervical cancer's propensity to infiltrate neighboring pelvic organs, including the bladder, necessitates precise staging. In India, traditional methods like cystoscopy have been relied upon, but they have limitations. Recent advancements in medical imaging, notably the increased use of computed tomography (CT) scans, provide a non-invasive alternative for staging and evaluating bladder involvement. This study aimed to evaluate the utility and accuracy of CT scans in assessing bladder involvement. Methods This cross-sectional study examined 127 newly diagnosed cervical carcinoma cases in women over a two-year period from August 2021 to July 2023. Patients underwent CT scans (plain) and cystoscopy, and bladder involvement was determined following the revised FIGO staging. Data collected comprised patient demographics, medical history, clinical symptoms, and FIGO staging. Cystoscopy was performed using an Olympus CYF-5 flexible cystoscope, and CT scans utilized a 64-slice multidetector CT scanner. Radiological reports detailed primary tumor characteristics and proximity to the bladder. Statistical analysis encompassed descriptive statistics, and calculation of sensitivity, specificity, positive predictive value, and negative predictive value for CT scans in comparison to cystoscopy. Statistical significance was considered at p < 0.05. Results In our study, the mean participant age was 45.3 years, with 61.4% falling in the 40-60 years age group. Socioeconomic status (SES) varied, with 37.8% classified as low SES, 48.8% as middle SES, and 13.4% as high SES. Parity data showed that 76.4% had three or more pregnancies. Among presenting symptoms, abnormal vaginal bleeding (65.4%) was the most prevalent, and squamous cell carcinoma (78.7%) was the predominant histological type. The prevalence of bladder involvement was 9.4% by cystoscopy and 30.7% by CT scans. CT scan demonstrated a high sensitivity (100%) but lower specificity (76.52%), with 78.80% overall accuracy. Conclusion A combined approach, using CT scans as a screening tool and cystoscopy as a confirmatory method, could provide the most comprehensive and reliable assessment of bladder involvement in cervical carcinoma patients, ultimately contributing to improved patient care and management.

Foreign Body in the Male Urinary Bladder: A Case Report

A foreign body in the urinary bladder is an uncommon finding in urology emergencies. There are several ways in which intravesical foreign bodies can occur, including iatrogenic injuries, self-insertion for pleasure, sexual abuse, assault, and migration from adjacent sites. This case report is about an interesting presentation of a 36-year-old male who presented to the urology outpatient department with a burning sensation and dribbling while urinating for 1 month. An X-ray of the pelvis revealed multiple radiodensities (morphology was suggested as magnetic balls) in the pelvic soft tissues. Cystoscopy was performed and three-pronged forceps were utilized to remove the magnetic foreign bodies. The patient had an insignificant hospital course and was discharged with analgesics and antibiotics.

Role of cystoscopy as primary initial investigation in interstitial cystitis/bladder pain syndrome

INTRODUCTION

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic painful bladder condition characterized by pelvic pain and urinary symptoms without another identifiable cause. Cystoscopy as primary initial investigation for IC/BPS has not been accepted yet and needs more studies to definitely conclude.

AIMS AND OBJECTIVES

We aimed to assess cystoscopy findings in patients of interstitial cystitis/bladder pain syndrome and to prove role of cystoscopy as primary initial investigation for interstitial cystitis/bladder pain syndrome.

MATERIALS AND METHODS

Our prospective observational study included 35 female patients aged 18-69 years presenting to the Urology OPD at SMS Hospital with suprapubic or pelvic pain for 6 months, bladder pain that worsens with bladder filling and reduced with voiding, dysuria, urinary frequency and urgency, nocturia, dyspareunia. Those with history of bladder capacity more than 350 ml, duration of symptoms less than 6 months, day time frequency less than eight times per day, diagnosis of bacterial cystitis or prostatitis, bladder or ureteral calculi, active genital herpes, any existing urological malignancy, radiation cystitis were excluded from the study. They were then subject to cystoscopy and the findings of the cystoscopy were analyzed.

RESULTS

Out of the 35 patients, 11 (31.43%) had a normal cystoscopy. Of the 24 patients (68.57%) who had a positive cystoscopy, cystoscopy in seven patients (20.0%) revealed an ulcer. All these seven patients underwent fulguration. In the remaining 17 patients the abnormal findings were petechiae, large submucosal bleed. The sensitivity of cystoscopy in detecting the ulcerative type of Interstitial cystitis was found to be 20.0%.

CONCLUSION

Our study found that Cystoscopy, if employed in initial investigation can help early detection of ulcerative variety of IC/BPS and can act as therapeutic modality by using fulguration plus hydrodistension. Larger comparative studies are needed for diagnostic/Therapeutic value of cystoscopy.

The role of gel-infused translabial ultrasound as a new modality in evaluation of female urethral stricture

Introduction

To investigate the role of trans-labial ultrasound study in detection of female urethral stenosis (FUS) compared to former cysto-urethroscopy as the currently available definitive diagnostic modality.

Material and methods

In this cross-sectional study, 60 consecutive patients with bladder outlet obstruction diagnosed by clinical symptoms and urodynamic study, were included from 2019 to 2022. For additional assessment, all these patients underwent gel-Infused trans-labial ultrasound (GITLUS) and cystourethroscopy. Trans-labial real-time ultrasonography was performed following the insertion of 20 ml steady stream viscous jelly into the urethral meatus to assess the length of the urethra and exact location and length of the probable narrowing, as well as the presence of peri-urethral fibrosis (PUF).

Results

In GITLUS evaluation, urethral stricture was found in 27 patients. Mean urethral length and stricture length were 35.63 ±4.78 and 17.04 ±10.59, respectively. All these stenosis were confirmed via cysto-urethroscopy. PUF was found in 20 of 27 patients. In cysto-urethroscopy, urethral stricture was confirmed in 40 patients: 13 in urethral meatus and 27 in other parts or pan-urethra. GITLUS could not reveal urethral stricture in 13 patients with meatal stenosis, confirmed with cystoscopy. GITLUS detected FUS less accurately when it involves pure distal urethra compared to other parts of urethra or pan-urethral stenosis (p value = 0.002).

Conclusions

GITLUS is a safe, non-invasive, and valuable technique for detecting FUS. The location and the length of the stricture and probable peri-urethral fibrosis can be identified by this method. However, in meatal or pure short-length distal urethral strictures, this method should be used with caution.

Case Report: Iatrogenic trauma of the bladder due to long-term unidentified intrauterine device malposition inside the bladder with rectovesical fistula

According to reports, there are 1.9-3.6 incidences of IUD migration and uterine perforation for every 1000 IUD insertions. It is important to note that bladder perforation caused by a misplaced IUD is uncommon and is thought to happen most frequently during insertion. Here, we describe a patient who presented with symptoms related to the malposition of IUD inside the bladder. It is feasible to draw the conclusion that the cystoscopy technique should be taken into consideration as a suitable therapy option for such injuries in this organ. When a problem cannot be effectively treated by cystoscopy alone, laparotomy should be considered.

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.

Cystoscopy Accuracy in Detecting Bladder Tumors: A Prospective Video-Confirmed Study

BACKGROUND

Bladder cancer ranks as the 10th most common cancer globally. The diagnosis of bladder tumors typically involves cystoscopy.

OBJECTIVE

This study aimed to evaluate the sensitivity and specificity of cystoscopy in detecting bladder tumors within a surveillance program following a bladder cancer diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

This study utilized recordings of cystoscopies conducted at the Department of Urology, Zealand University Hospital, between July 2021 and November 2022. Clinical observations were cross-referenced with pathological results or follow-up cystoscopies. Clinically negative cystoscopies were further scrutinized for potential overlooked tumors.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Sensitivity and specificity of cystoscopy were assessed through ROC curve analysis.

RESULTS AND LIMITATIONS

A total of 565 cystoscopies were recorded, with 135 indicating clinical positivity. Among 181 cystoscopies with clinically negative results that underwent a follow-up cystoscopy, 17 patients (9.4%) were subsequently diagnosed with bladder cancer, with the lesions identified in the initial cystoscopy. The sensitivity and specificity of cystoscopy in these cases were 81% and 73%, respectively.

CONCLUSION

This trial underscores the underdiagnosis and undertreatment of bladder tumors within the current surveillance program. Additionally, aggressive malignant lesions may be overlooked, heightening the risk of disease progression. Therefore, it is recommended that cystoscopies be complemented by other diagnostic methods to ensure accurate diagnosis and proper patient treatment.

PATIENT SUMMARY

This study involved 316 patients who underwent video-recorded cystoscopies and subsequent follow-up. Of these patients, 181 initially exhibited no clinical signs of bladder cancer. However, upon reviewing the recorded cystoscopy, bladder cancer was identified in 17 patients (9.4%).

Quality of care perceived by patients during cystoscopy and affecting factors

It is necessary and important for quality of care to ensure the comfort of patients during the procedure, as well as before and after surgery. According to literature, it is necessary to know what patients experience and how they perceive the care they receive. This study aimed to investigate the quality of care perceived by patients during cystoscopy and the factors affecting it. This descriptive study was conducted in the surgical clinic of a teaching and research hospital, with 105 patients who underwent cystoscopy in 2022. Data collection forms consisting of a Sociodemographic and Disease Characteristics Questionnaire and the Good Perioperative Nursing Care Scale (for Patients) (GPNCS) were used for data collection, with face-to-face interviews on the first day after the procedure. This study was conducted in accordance with the principles of the Declaration of Helsinki. The study included patients with urinary tract stones, transurethral prostatectomy, and transurethral bladder resection. Of the participants, 72.4% were male, and 81.9% were married. The mean age of the patients was 50.09 ± 16.79 years. The mean total score was 143.56 ± 16.62. It was higher in single patients and those who had not previously undergone surgery. It was found that the mean of the environment sub-dimension was the highest at 18.57 ± 2.51 and the mean of the support sub-dimension was the lowest at 16.01 ± 3.44. The results of this study showed that patients undergoing cystoscopy have a good perception of the quality of their peri-operative nursing care.

Fremantle protocol: Multicenter clinical outcomes for a pragmatic protocol for intravesical bacillus Calmette-Guerin

OBJECTIVES

To examine the utility and efficacy of a multifaceted protocol for the administration of intravesical bacillus Calmette-Guerin (BCG) for non-muscle-invasive bladder cancer (NMIBC).

SUBJECTS AND METHODS

A multicenter retrospective review was conducted among 83 patients undergoing Fremantle protocol intravesical BCG for NMIBC within 4 major hospitals in Western Australia between January 2016 and December 2018. The Fremantle protocol consists of weekly BCG instillations for 6 weeks during the induction phase, followed by monthly BCG instillations for 10 months during the maintenance phase with integrated clearance-to-proceed algorithms for urine MSU checks, flexible cystoscopies performed at 3 monthly intervals during maintenance BCG, and repeat GA cystoscopies with four quadrant bladder biopsies routinely obtained following the completion of induction and maintenance treatment.

RESULTS

For patients undergoing Fremantle protocol BCG, 98.8% (82/83) and 75.9% (63/83) of patients completed their induction and maintenance courses of BCG, respectively. Induction BCG was delivered over a median duration of 35 days (range 34-84 days), and maintenance BCG was delivered over a median duration of 266 days (range 1-682 days). The tumor recurrence rate was 10.8% (9/83) at the time of post-induction biopsies, 2.4% (2/83) during maintenance treatment, 0% (0/60) at the time of post-maintenance biopsies, and 8.8% (5/57) after a median further follow-up of 16 months (range 0-51 months).

CONCLUSION

The Fremantle protocol appears to be a safe and effective BCG regimen with several advantages over other BCG protocols, including high completion rates, low recurrence rates, and being highly pragmatic.

Pelvic floor ultrasound evaluation in the diagnosis of exposure of synthetic implanted materials in the lower urinary tract

OBJECTIVE

To evaluate the diagnostic performance of pelvic floor ultrasound (PFUS) to recognize prosthetics exposure in the bladder and/or urethra in women with lower urinary tract symptoms (LUTS).

METHODS

A cross-sectional study evaluating patients with LUTS after mesh/sling surgery. PFUS was performed with both transvaginal (TVUS) and translabial (TLUS) approaches. A distance of 1 mm or less from the bladder and/or urethra was considered highly suspect for mesh exposure. After PFUS, patients underwent diagnostic urethrocystoscopy.

RESULTS

A total of 100 consecutive women were analyzed. According to urethrocystoscopy, the rate of tape exposure in the lower urinary tract was 3%. PFUS showed 100% sensitivity and 98%-100% specificity in detecting lower urinary tract mesh exposure. The negative predictive value was 100% and the positive predictive value ranged from 33% to 50% for urethral and 100% for bladder exposure.

CONCLUSIONS

PFUS represents an effective and reliable non-invasive screening test to exclude prosthetics exposure in the bladder and/or urethra in women with LUTS.

Sex identification in juvenile and adult Indonesian blue-tongued skinks (Tiliqua gigas) through cystoscopy and accuracy of contrast radiography

OBJECTIVE

To describe a nonsurgical endoscopic technique for sex identification in Indonesian blue-tongued skinks (Tiliqua gigas) and to assess accuracy of contrast radiography of the hemipenile/hemiclitoral pouches.

ANIMALS

42 clinically healthy Indonesian blue-tongued skinks between 6 months and 3 years old and weighing between 22 and 550 g.

METHODS

Cystoscopy was performed under general anesthesia. Gonads were visualized through the transparency of the urinary bladder, and their gross morphology was described. Contrast was applied in the tail pouches before obtaining full-body radiographs. Two radiologists, blinded to the sex of the skink, evaluated the radiographs.

RESULTS

Cystoscopy was achieved in all 42 skinks. Visualization of the gonads through the urinary bladder was possible in 41 (98%; 95% CI, 87% to 99%) of the skinks, with 18 of them identified as males and 23 identified as females. Median procedure time was 60 seconds (range, 25 to 180 seconds) and was not associated with procedure order (-0.69; 95% CI, -1.83 to 0.45) or with the weight (0.02 g; 95% CI, -0.07 to 1.0) or the identified sex (11.7; 95% CI, -15.07 to 38.45) of the skink. Radiographs had a sensitivity of 69.6% (95% CI, 47.1% to 86.8%) and a specificity of 75.0% (47.6% to 92.7%) to identify female skinks. All the skinks recovered uneventfully.

CLINICAL RELEVANCE

Cystoscopic sex identification is feasible in Indonesian blue-tongued skinks of various age and size. Considering the difficulty in identifying their sex otherwise, this technique could provide a significant improvement in the veterinary care of this species. In this population, contrast radiographs showed limited accuracy for sex identification.

Utility of preoperative urine cultures and cystoscopies before ureteral reimplantation in pediatrics

BACKGROUND

Ureteral reimplantation remains the primary surgical method used for patients with vesicoureteral reflux (VUR). Cystoscopy is commonly performed first to visualize anatomy and rule out possible abnormalities. Urine cultures may also be obtained. The objective of this study is to evaluate the prudency of preoperative urine cultures and cystoscopies in pediatric patients undergoing ureteral reimplantation.

METHODS

Pediatric urologists were surveyed regarding collecting urine cultures in asymptomatic patients and cystoscopies before reimplantation. A retrospective review was also conducted of patients who underwent ureteral reimplantation for VUR between March 2018 and April 2021 at Cook Children's Medical Center.

RESULTS

When physicians were asked the frequency they obtain urine cultures before reimplantation on asymptomatic patients, 36% said "never" and 38% said "always." Regarding cystoscopy, 53% said "never" and 32% said "always." Inclusion criteria were met by 101 patients. Cystoscopies were performed in 46 patients and never altered the reimplantation. There were 20 preoperative, 90 intraoperative, and 61 postoperative urine cultures. Complications were associated with positive cultures of urine collected intraoperatively and postoperatively only.

CONCLUSION

Cystoscopies and asymptomatic urine cultures obtained before ureteral reimplantation provide no additional benefit while increasing cost for patients' families. Further research is needed to thoroughly identify the prudency of such practices in ureteral reimplantation for VUR.

Intraoperative ultrasound assessment of ureteral patency after uterosacral ligaments apical suspension for prolapse surgical repair: A feasibility study

OBJECTIVE

To prospectively compare power Doppler ultrasound diagnostic performance with reference standard cystoscopy in evaluating ureteral patency in a population at high risk of ureteral lesions.

METHODS

We analyzed 100 women who underwent pelvic organ prolapse repair. All ultrasound scans were obtained, at the end of the procedures, before cystoscopic evaluation. Bilateral simultaneous ureteral jet evaluation with power Doppler was performed at the level of the ureterovesical junctions with a pulse repetition frequency set to detect low flow for a maximum of 3 min.

RESULTS

According to the reference standard urethrocystoscopy, at least one ureter not ejaculating was observed in 6% of patients, for a total of seven ureters jets not visualized. No false-negative results were obtained. Ultrasound with power Doppler showed 100% sensitivity and 95.9% specificity in detecting the lack of ureteral jet. The negative predictive value was 100%, and the positive predictive value was 46.7%.

CONCLUSIONS

Ultrasound with power Doppler represents an effective and reliable non-invasive screening test to exclude ureteral kinking and reduce the need for intraoperative cystoscopy.

Prospective Randomized Trial of Single-Use vs Reusable Cystoscope for Ureteral Stent Removal

Background: Reusable cystoscopes are associated with risks of cross-contamination, need for chemical reprocessing, mechanical breakdown, maintenance costs, and labor for cleaning. A sterile, single-use cystoscope may reduce or eliminate the source of these infections while also decreasing exposure to reprocessing chemical agents. In this multicenter, randomized trial, we sought to compare single use with reusable endoscopes for ureteral stent removal. Methods: A three-center, randomized, dual-arm postmarket clinical trial was performed to compare the single-use cystoscope (Ambu A/S) with standard-of-care flexible reusable cystoscopes for outpatient ureteral stent removal. A total of 102 patients were randomized and evaluated from baseline through day 10 postprocedure. Primary endpoint was successful stent removal. Secondary endpoints were time from preparation to disposal/reprocessing, adverse events (AEs), and clinician satisfaction. Results: A total of 102 subjects were randomized in a 1:1 manner. The successful stent removal rate was 51/51 (reusable) and 50/51 (single use). One patient required the conversion to reusable cystoscope owing to grasper passage issue. Median time from prep for the procedure to disposal/prep for reprocessing was 10.2 minutes for the single use and 18.4 minutes for the reusable (p < 0.001). There was no difference in clinician satisfaction between both arms. There was no difference in AEs between arms and no device causal attribution for any AE reports. There was one serious AE necessitating hospitalization for infection in the reusable arm. Conclusion: The randomized-controlled trial of single-use cystoscopes vs reusables showed comparable device success with significant time savings for single use and equivalent clinician satisfaction. The study was registered on clinicaltrials.gov database (NCT04829461) on April 2, 2021.

Uncommon Complications of Cystoscopy: Presentations of Concurrent Perirenal Hematoma and Candida albicans Sepsis

Subcapsular hematoma (SRH) or perirenal hematoma (PRH) can be seen after trauma, interventional radiological procedures, urological procedures, anticoagulant medications, coagulation disorders, infections, and spontaneously in some patients. Within the urological procedures, PRH can occur after percutaneous nephrolithotomy and extracorporeal shortwave lithotripsy but has only been reported a few times after cystoscopy/ureteroscopy. Here, we present the case of PRH as a complication from cystoscopy with retrograde pyelography in a patient with underlying chronic kidney disease (CKD) and an extensive surgical history for nephrolithiasis. In addition to this, our patient had a further complication of sepsis by Candida albicans, of which the source is proven to be urinary, and it appears that the fungemia was triggered during the procedure as well. The diagnosis was confirmed by abdominal computed tomography (CT), and PRH was proven to resolve with conservative management on repeat imaging months later.

Wireless Cystoscope the Future of Cystoscopy (With Video)

Background: The first modern cystoscope was developed with the invention of rod lens and optical fibers in the 1960s. Since then, many advances have been made in functionality and camera image analysis. The cost of purchasing equipment and volume of the endoscopic tower remains a challenge and a barrier to the spread of cystoscopy. Urinary tract injury is a significant complication in women undergoing gynecologic surgery. Selective intraoperative cystoscopy at laparoscopic hysterectomy or complex pelvic surgery is valuable for recognizing lower urinary tract injuries. We have developed a novel wireless cystoscope for performing diagnostic and operative cystoscopy. Methods: The new wireless cystoscopic setup consists of a rigid cystoscope 4 mm, 30° that joins a modified action camera to a c-mount adapter f 18-35 mm and a portable led light source. Results: The new setup has so far been effectively used in more than 50 diagnostic cystoscopies and pigtail catheter replacements without complications. Two cases performed with the new setup are presented in the video. Conclusions: The new cystoscopic setup has the advantage of a wireless video camera, 4K ultraHD, and is easy setup. Due to its low cost and portability, the wireless cystoscope is easy to obtain and use. Also, it is invaluable and ergonomic in managing the integrity or pathology of the bladder, urethra, and ureters.

Impact of the COVID-19 pandemic on bladder cancer patients: a multicenter real-world study

OBJECTIVE

Hospital management and medical treatment changed during the coronavirus disease 2019 (COVID-19) pandemic. This study investigated the impact of the COVID-19 pandemic on patients with bladder cancer.

METHODS

In this multicenter retrospective study, we collected information from the electronic medical records of outpatients who underwent cystoscopy and inpatients with confirmed bladder cancer in three hospitals in Nanjing (two province-level and one county-level hospitals) in 2019 and 2020. Patients' home addresses, treatment methods, length of stay, and pathology were compared between the periods.

RESULTS

In total, 4048 outpatients and 1242 inpatients were included. The average number of cystoscopies decreased significantly during the lockdown. In province-level hospitals, the number of cystoscopies increased gradually as the pandemic was brought under control but remained lower than that in 2019, whereas the number grew in 2020 in county-level hospitals. The rates of recurrence and radical cystectomy were higher in 2020 than in 2019. No significant difference in the pathological grade was observed. More patients who underwent radical cystectomy were diagnosed with muscle-invasive bladder cancer during the 2020 lockdown.

CONCLUSION

The pandemic severely affected patients with bladder cancer, mainly in their choice of institution and treatment.

Tumor detection under cystoscopy with transformer-augmented deep learning algorithm

Objective.Accurate tumor detection is critical in cystoscopy to improve bladder cancer resection and decrease recurrence. Advanced deep learning algorithms hold the potential to improve the performance of standard white-light cystoscopy (WLC) in a noninvasive and cost-effective fashion. The purpose of this work is to develop a cost-effective, transformer-augmented deep learning algorithm for accurate detection of bladder tumors in WLC and to assess its performance on archived patient data.Approach.'CystoNet-T', a deep learning-based bladder tumor detector, was developed with a transformer-augmented pyramidal CNN architecture to improve automated tumor detection of WLC. CystoNet-T incorporated the self-attention mechanism by attaching transformer encoder modules to the pyramidal layers of the feature pyramid network (FPN), and obtained multi-scale activation maps with global features aggregation. Features resulting from context augmentation served as the input to a region-based detector to produce tumor detection predictions. The training set was constructed by 510 WLC frames that were obtained from cystoscopy video sequences acquired from 54 patients. The test set was constructed based on 101 images obtained from WLC sequences of 13 patients.Main results.CystoNet-T was evaluated on the test set with 96.4 F1 and 91.4 AP (Average Precision). This result improved the benchmark of Faster R-CNN and YOLO by 7.3 points in F1 and 3.8 points in AP. The improvement is attributed to the strong ability of global attention of CystoNet-T and better feature learning of the pyramids architecture throughout the training. The model was found to be particularly effective in highlighting the foreground information for precise localization of the true positives while favorably avoiding false alarmsSignificance.We have developed a deep learning algorithm that accurately detects bladder tumors in WLC. Transformer-augmented AI framework promises to aid in clinical decision-making for improved bladder cancer diagnosis and therapeutic guidance.

Perception of urinary biomarker tests among patients referred with suspected urological malignancy

Objective

To determine the acceptability of a non-invasive urinary biomarker test in place of conventional flexible cystoscopy for the diagnosis of bladder cancer in patients referred to a Rapid Access Haematuria Clinic (RAHC) with suspected urological malignancy.

Patients and methods

Patients attending a RAHC were recruited to a prospective observational study evaluating a novel urinary biomarker (URO17™) for the detection of bladder cancer and invited to complete a two-part structured questionnaire. Questions related to demographics, attitudes towards conventional cystoscopy and the minimal acceptable sensitivity (MAS) at which a urinary biomarker would be considered an alternative to flexible cystoscopy both before and after undergoing the procedure.

Results

A total of 250 patients completed the survey; the majority of whom were referred with visible haematuria (75.2%). One hundred seventy-one (68.4%) would be willing to accept a urinary biomarker in place of cystoscopy, with 59 (23.6%) expressing preference for the biomarker with a MAS as low as 85%. Conversely, 74 patients (29.6%) would not be willing to accept a urinary biomarker, regardless of its sensitivity. A significant number of patients reported a change in MAS after undergoing cystoscopy, with 80 (32.0%) and 16 (6.4%) increasing and decreasing the required value respectively (P = 0.001). The greatest increase was seen in the proportion of patients unwilling to accept a urinary biomarker regardless of its sensitivity, rising from 29.6% to 38.4%.

Conclusions

Although many patients attending a RAHC would be willing to accept a urinary biomarker test in place of conventional flexible cystoscopy for the detection of bladder cancer, effective patient, public and clinician engagement will be necessary at all stages of implementation if it is to become an established component of the diagnostic pathway.

D-Mannose Plus Saccharomyces boulardii to Prevent Urinary Tract Infections and Discomfort after Cystoscopy: A Single-Center Prospective Randomized Pilot Study

Background and Objectives: Patients undergoing cystoscopy can experience discomfort or pain during the procedure. In some cases, a urinary tract infection (UTI) with storage lower urinary tract symptoms (LUTS) may occur in the days following the procedure. This study aimed to assess the efficacy of D-mannose plus Saccharomyces boulardii in the prevention of UTIs and discomfort in patients undergoing cystoscopy. Materials and Methods: A single-center prospective randomized pilot study was conducted between April 2019 and June 2020. Patients undergoing cystoscopy for suspected bladder cancer (BCa) or in the follow-up for BCa were enrolled. Patients were randomized into two groups: D-Mannose plus Saccharomyces boulardii (Group A) vs. no treatment (Group B). A urine culture was prescribed regardless of symptoms 7 days before and 7 days after cystoscopy. The International Prostatic Symptoms Score (IPSS), 0-10 numeric rating scale (NRS) for local pain/discomfort, and EORTC Core Quality of Life questionnaire (EORTC QLQ-C30) were administered before cystoscopy and 7 days after. Results: A total of 32 patients (16 per group) were enrolled. No urine culture was positive in Group A 7 days after cystoscopy, while 3 patients (18.8%) in Group B had a positive control urine culture (p = 0.044). All patients with positive control urine culture reported the onset or worsening of urinary symptoms, excluding the diagnosis of asymptomatic bacteriuria. At 7 days after cystoscopy, the median IPSS of Group A was significantly lower than that of Group B (10.5 vs. 16.5 points; p = 0.021), and at 7 days, the median NRS for local discomfort/pain of Group A was significantly lower than that for Group B (1.5 vs. 4.0 points; p = 0.012). No statistically significant difference (p > 0.05) in the median IPSS-QoL and EORTC QLQ-C30 was found between groups. Conclusions: D-Mannose plus Saccharomyces boulardii administered after cystoscopy seem to significantly reduce the incidence of UTI, the severity of LUTS, and the intensity of local discomfort.

Conversion to Disposable Cystoscopes Decreased Post-procedure Encounters and Infections Compared to Reusable Cystoscopes

PURPOSE

To evaluate for differences in post-procedure 30-day encounters or infections following office cystoscopy using disposable versus reusable cystoscopes.

MATERIALS AND METHODS

Cystoscopies performed from June - September 2020 and February - May 2021 in our outpatient practice were retrospectively reviewed. The 2020 cystoscopies were performed with reusable cystoscopes and the 2021 cystoscopies were performed with disposable cystoscopes (Ambu Inc., Columbia, MD, USA). The primary outcome was the number of post-procedural 30-day encounters defined as phone calls, patient portal messages, emergency department visits, hospitalizations or clinic appointments related to post-procedural complications such as dysuria, hematuria, or fever. Culture-proven urinary tract infection within 30 days of cystoscopy was evaluated as a secondary outcome.

RESULTS

We identified 1,000 cystoscopies, including 494 with disposable cystoscopes and 506 with reusable cystoscopes. Demographics were similar between groups. The most common indication for cystoscopy in both groups was suspicion of bladder cancer [disposable: 153 (30.2%) and reusable: 143 (28.9%)]. Reusable cystoscopes were associated with a higher number of 30-day encounters [35 (7.1%) vs. 11 (2.2%), P < .001], urine cultures [73 (14.8%) vs. 3 (0.6%), P = .005], and hospitalizations attributable to cystoscopy [1 (0.2%) vs. 0 (0%), P<.001] than the disposable scope group. Positive urine cultures were also significantly more likely after cystoscopy with a reusable cystoscope [17 (3.4%) vs. 1 (0.2%), P < .001].

CONCLUSIONS

Disposable cystoscopes were associated with a lower number of post-procedure encounters and positive urine cultures compared to reusable cystoscopes.

Novel urine-based DNA methylation biomarkers for urothelial bladder carcinoma detection in patients with hematuria

Background

Urothelial bladder carcinoma (UBC) is usually detected during work-up for hematuria. Cystoscopy and/or contrast-enhanced imaging are the gold standard tools for UBC diagnosis, despite limited by being invasive, expensive and low yield in small flat tumors.

Objectives

To assess the diagnostic performance of urine-based DNA methylation of six genes (GATA4, P16, P14, APC, CDH1 and CD99) for UBC detection in patients with hematuria.

Patients and methods

Voided urine was collected from consecutive patients presented with hematuria for urine cytology and DNA methylation assay of the assigned genes using methylation-specific Polymerase Chain Reaction (PCR). Further assessment by office cystoscopy and imaging with subsequent inpatient cystoscopic biopsy for positive findings was done. The diagnostic characteristics of DNA methylation and urine cytology were assessed based on its capability to predict UBC.

Results

We included 246 patients in the study with identified macroscopic hematuria in 204 (82.9%) patients. Positive cytology was found in 78 (31.7%) patients. DNA methylation of GATA4, P16, P14, APC, CDH1 and CD99 genes was identified in 127 (51.6%), 52 (21.1%), 117 (47.6%), 106 (43.1%), 90 (36.6%) and 71 (28.9%) patients, respectively. The sensitivity of the assigned genes for UBC detection ranges from 35% (95%CI: 31-39) to 83% (95%CI: 79-87). Optimal specificity (SP) (100%) was noted for P16, APC and CDH1 genes. While for the other genes (GATA4, P14 and CD99), the SP was 95% (95%CI: 92-98), 96% (95%CI: 92-99) and 97% (95%CI: 93-99), respectively. On multivariate logistic regression analysis, all genes exclusively demonstrated independent prediction of UBC. On receiver operator characteristic (ROC) analysis, all tested genes methylation showed superior area under the curve (AUC) when compared to urine cytology.

Conclusions

We have developed a novel urine-based DNA methylation assay for detection of UBC in patients with hematuria with superior diagnostic performance and independent predictive capacity over urine cytology.

Evaluating the utility of cystoscopy, distal colostography, and sonography for locating the fistula in patients with anorectal malformation: a case series

Anorectal malformations are congenital conditions ranging from a simple perianal fistula to a complex cloacal malformation. Since the precise determination of the location of the fistula is the central pillar in choosing the type of surgery, this study aims to evaluate and compare the efficacy of three techniques, transperineal ultrasound, distal colostography, and cystoscopy.

Materials and methods

This study was performed on patients with anorectal abnormalities who had undergone decompressive colostomy and were planned for anorectoplasty in the period from September 2017 to March 2019 in a pediatric surgical center. To answer our question, all three mentioned methods were conducted before the surgery and were compared with the intraoperative findings.

Results

Sonography, distal colostography, and the second cystoscopy findings were similar to intraoperative conclusions concerning the presence of a fistula in patients, whereas blind cystoscopy had 30% accuracy and similarity. Regarding the type of fistula sonography, distal colostography, and second cystoscopy each had 50, 37.5, and 10 inconsistency with the intraoperative findings. In all cases where a fistula was detected in blind cystoscopy, the location of the fistula was correctly determined by this modality. Data analysis on the pouch to perineum distance measurements obtained from sonography and colostography were significantly different from that of surgery.

Conclusion

The results of this study emphasize the need to perform several diagnostic modalities to determine the location and type of fistula to improve diagnostic accuracy.

A Rare Case of Primary Clear Cell Adenocarcinoma of the Urinary Bladder

Adenocarcinoma is a rare form of urinary bladder cancer, comprising only 2% of cases, with various histological patterns and levels of differentiation. Among these, clear cell adenocarcinoma is the least common. Contrary to other subtypes, clear cell adenocarcinoma of the bladder has been shown to have a female predominance, and typically presents at the age of 60 after being incidentally discovered on radiological and urinary studies. However, signs and symptoms such as visible and non-visible hematuria, and signs and symptoms of urinary tract infection refractory to antibiotic treatment could occur and clue into the diagnosis. Although imaging can reveal and characterise the lesion, definitive diagnosis requires cystoscopy with biopsy. The treatment of adenocarcinoma of the bladder often requires surgical resection, with adjuvant chemotherapy being utilized in a subset of patients. We report a 79-year-old patient complaining of gross hematuria. Ultrasound was performed and showed a calcified mass at the dome of the urinary bladder, which was confirmed by computerized tomography of the abdomen and pelvis. Subsequent cystoscopy confirmed the diagnosis of clear-cell adenocarcinoma and the tumor was resected using a trans-urethral approach. Radical cystectomy with regional lymphadenectomy and adjuvant chemotherapy were used as the primary therapeutic modality.

Utilising alternative cystoscopic schedules to minimise cost and patient burden after trimodality therapy for muscle-invasive bladder cancer

BACKGROUND

To assess urinary symptoms and urine cytology as screening tools for cystoscopic detection of local recurrence after bladder-preserving trimodality treatment (TMT).

METHODS

Patients with muscle-invasive bladder cancer receiving definitive TMT follow-up three monthly for 2 years, six monthly for the next 3 years and then yearly, with a clinical review, urine cytology and cystoscopy at each visit (triple assessment, TA). Grade 2+ cystitis/haematuria absent/present was scored 0/1, and urine cytology reported negative/suspicious or positive was scored 0/1, respectively. The performance of these two parameters for predicting local recurrence in cystoscopic biopsy was tested. Other hypothetical surveillance schedules included cystoscopy on alternate visits (COAV), or suspected recurrence (COSR), six-monthly COSR and six-monthly TA.

RESULTS

A total of 630 follow-up visits in 112 patients with 19 recurrences (7 muscle invasive, 12 non-muscle invasive) at a median follow-up of 19 months were analysed. The sensitivity and specificity of clinical symptoms were 47.4% and 92%, and for urine cytology 58% and 85%, respectively. The combination of clinical symptoms and cytology (COSR) was 95% sensitive and 78% specific for local recurrence but 100% sensitive for muscle-invasive recurrence. Both COAV and COSV schedules showed a high area under the curve (AUC) for detecting local recurrence (COAV = 0.84, COSR = 0.83), muscle-invasive recurrence (AUC = 0.848 each) and non-muscle-invasive recurrence (COAV = 0.82, COSR = 0.81); reducing the need for TAs by 64% and 67% respectively, and overall cost by 18% and 33%, respectively.

CONCLUSION

Cystoscopy at suspected recurrence during follow-up is safe and the most cost-effective for detecting muscle-invasive local recurrences, while cystoscopy at alternate visits may be more optimal for detecting any local recurrence.

[Experience in the use of confocal laser endomicroscopy for the diagnosis of bladder papillary tumors]

INTRODUCTION

Visual confirmation of suspicious changes in the urinary tract mucosa is the cornerstone in the diagnosis of urothelial cancer. However, with bladder tumors, it is impossible to obtain histopathological data during cystoscopy both in white light and in photodynamic and narrow-spectrum modes, as well as with computerized chromoendoscopy. Confocal laser endomicroscopy (probe-based confocal laser endomicroscopy - pCLE) is an optical imaging technique that provides high-resolution in vivo imaging and real-time evaluation of urothelial lesions.

AIM

To assess the diagnostic capabilities of pCLE in papillary bladder tumors and compare its results with standard pathomorphological study.

MATERIALS AND METHODS

A total of 38 patients (27 men, 11 women, aged 41-82 years) with primary bladder tumors diagnosed on the imaging methods were included in the study. For the diagnosis and treatment, all patients underwent transurethral resection (TUR) of the bladder. When a standard white light cystoscopy with assessment of the entire urothelium, 10% sodium fluorescein was administrated intravenously as a contrast dye. pCLE was performed with CystoFlexTMUHD 2.6 mm (7.8 Fr) probe, which was passed through the 26 Fr resectoscope using a telescope bridge to visualize normal and pathological urothelial lesions. A laser with a wavelength of 488 nm and a speed of 8 to 12 frames per second allowed to obtain an endomicroscopic image. These images were compared with standard histopathological analysis using hematoxylin-eosin (H&E) staining of tumor fragments removed during TUR of the bladder.

RESULTS

Based on real-time pCLE, 23 patients had a diagnosis of low-grade urothelial carcinoma, while in 12 patients the endomicroscopic picture corresponded to high-grade urothelial carcinoma, 2 patients had typical changes for inflammatory process and 1 case of carcinoma in situ was suspected, which was confirmed by histopathological study. Endomicroscopic images demonstrated clear differences between normal bladder mucosa and high- and low-grade tumors. In the normal urothelium, the larger umbrella cells are located most superficially, followed by smaller intermediate cells, as well as the lamina propria with blood vessels network. In contrast, low-grade urothelial carcinoma is characterized by denser, normal-shaped small cells located superficially than a central fibrovascular core. High-grade urothelial carcinoma exhibits markedly irregular cell architecture and cellular pleomorphism.

CONCLUSION

pCLE is a promising new method for in-vivo diagnosing of bladder cancer. Our results show its potential for endoscopic determination of the histological characteristics of bladder tumors and the ability to differentiate between benign and malignant processes, as well as the histological grade of tumor cells.

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.

A Randomized Controlled Trial on the Effect of Music Listening on Procedural Pain, Anxiety and Comfort Levels during Cystoscopy

This study aimed to determine the effect of music listening on procedural pain intensity, anxiety, and comfort levels in patients during cystoscopy. This study was a prospective, randomized controlled trial. Study participants were randomly assigned to either a control or music group. The outcome measures were assessed using the Visual Analogue Scale, State Anxiety Scale, and General Comfort Questionnaire. A total of 36 patients in each group completed the study. The mean scores of pain in the music and control groups immediately after cystoscopy were 3.22 (SD, 1.72) and 5.22 (SD, 1.92), respectively. A statistically significant difference (between-group effect) was found, indicating that pain scores in the music group were significantly lower than those of the control group (group: F = 15.756, p < .001). However, no statistically significant difference was noted between the two groups regarding anxiety and comfort scores 20 min after cystoscopy (t₁ = 1.156, p = .526; t₁ = -0.586, p = .560, respectively). Music listening is a safe, economical, and effective method in pain management in patients undergoing cystoscopy.

The potential role of preoperative cystoscopy for determining the depth of invasion in the placenta accreta spectrum

OBJECTIVES

This study aims to determine the role of preoperative cystoscopy in specifying the degree of placental invasion to the bladder in the placenta accreta spectrum (PAS), especially in percreta.

MATERIAL AND METHODS

This prospective observational cohort study included 78 PAS patients. All included patients underwent the preoperative cystoscopy before the cesarean hysterectomy operation. The preoperative cystoscopy procedure identified markers of PAS as neovascularization, arterial pulsatility in neovascularized zones, and posterior bladder wall bulging. Then the patients were divided into subgroups according to the histopathological results of their cesarean hysterectomy specimens. Finally, the histopathological subgroups of PAS were estimated using preoperative cystoscopy signs in the designed logistic regression analysis model.

RESULTS

The preoperative cystoscopic signs such as neovascularization, the posterior bladder wall bulging, and the arterial pulsatility in neovascularized zones were approximately associated with a 17-fold [OR = 16.9 (95% CI, 5.7-49.8)], 26-fold [OR = 26.1 (95% CI, 8.17-83.8)], and 9-fold [OR = 8.94 (95% CI, 2.94-27.1)] increase in the likelihood of placenta percreta, respectively.

CONCLUSIONS

Preoperative cystoscopy may significantly contributions to other standard imaging modalities to identify the degree of placental invasion, especially placenta percreta. Experienced obstetricians trained in hysteroscopic visualization may safely perform this preoperative cystoscopy procedure under the guidance of a specialist urologist. Accordingly, it may be possible to estimate the degree of invasion and the course of surgery in patients with PAS using the preoperative cystoscopy procedure.

A High-Efficiency Consultation Improves Urological Diagnosis in Patients with Complex LUTS-A Pilot Study

(1) Background: The diagnosis of moderate-severe lower urinary tract symptoms (LUTS) is not easy due to the complexity of the micturition act. Sequential diagnostic tests can be time consuming due to waiting lists. Thus, we developed a diagnostic model combining all the tests in a single one-stop consultation. (2) Methods: In a prospective pilot study in patients with complex LUTS, they received all diagnostic tests (ultrasound, uroflowmetry, cystoscopy, pressure-flow study) in a single consultation and by the same doctor. Patients' results were compared with those from a 2021 paired cohort that underwent the classical sequential diagnostic pathway. (3) Results: Per patient, the high-efficiency consultation saved: 175 days of waiting, 60 min doctor time and 120 nursing assistant time and over 300 euros on average. The intervention also saved 120 patient journeys to the hospital, lowering the total carbon footprint by 145.86 kg CO₂. In one-third of the patients, performing all the tests within the same consultation contributed to reaching a more appropriate diagnosis and thus more effective treatment. Patients' satisfaction was high, with good tolerability. (4) Conclusions: The high-efficiency urology consultation improves waiting times, therapeutic decisions and the degree of patient satisfaction while optimizing the use of resources and generating savings for the health system.

Resolution of urethral obstruction using temporary urethral stents in two female cats

Case summary

The management of urethral obstructions is well documented in male cats but is less established for females. These cases describe two female cats that presented with non-dissolvable urocystoliths. Urocystoliths were removed by laser lithotripsy and basket retrieval. Following urolith removal, urethral obstruction occurred in both cats. Both cats were successfully managed using temporary urethral stents in lieu of indwelling urethral catheters permitting outpatient, spontaneous recovery of the urethra.

Relevance and novel information

Use of temporary urethral stents has not been described in cats. These novel stents are constructed from materials available in most veterinary facilities, placed without advanced imaging and reside entirely within the urethra and vestibule. Temporary stents are used to bypass urethral disease, facilitating outpatient recovery, and are easily removed when no longer needed. For these reasons, temporary stents are a cost-efficient alternative to permanent stents or indwelling urinary catheters attached to closed urine-collection systems.

Overactive bladder with urodynamic study-induced bladder pain: An overactive bladder subtype with symptoms similar to those of interstitial cystitis/painful bladder syndrome

Overactive bladder (OAB) and interstitial cystitis/painful bladder syndrome (IC/PBS) are 2 lower urinary tract disorders with urgency and bladder pain for diagnosis and with several other shared symptoms. Because of their overlapping symptoms, precise differential diagnosis of OAB and IC/PBS remains difficult. Thus, we characterize a subgroup of OAB with bladder pain (OAB-BP) that can be differentiated from OAB alone by urodynamic study (UDS) findings. We also further examined the clinical presentations and urodynamic parameters of OAB alone, OAB-BP, and IC/PBS. Data were collected between September 2018 and April 2019. Patients were categorized into 3 groups, OAB-alone (no bladder pain during UDS, n = 39), OAB-BP (with bladder pain during UDS, n = 35), and IC/PBS (the comparator, n = 39). Chi-square tests were used to compare OAB alone, OAB-BP, and IC/PBS with respect to their clinical presentations and urodynamic parameters. Factors with P < .05 were further analyzed through post hoc comparisons with Bonferroni adjustment. An unique subgroup of OAB patients was identified (i.e., OAB-BP), bladder pain can only be induced at maximal cytometric capacity during UDS. We also identified that the case histories and UDS parameters (e.g., low first desire, normal desire, and maximum cytometric capacity) of the OAB-BP group were more similar to those of the IC/PBS group than to those of the OAB-alone group. The OAB-BP group and the IC/PBS group reported more intrusive, longer-lasting symptoms before their final diagnoses, more extensive family history of urinary tract disorder, and more associated comorbidities (e.g., irritable bowel syndrome, and myofascial pain) than the OAB-alone group. The UDS assessment induced bladder pain in the OAB-BP group to reveal their hidden symptoms. Careful attention to patient history and sophisticated UDS evaluation may help to identify this unique OAB group.

Preoperative accuracy of diagnostic evaluation of urachal carcinoma

BACKGROUND

We analyzed the clinical data of patients with urachal carcinoma (UrC) in order to strengthen urologists' understanding of UrC and improve preoperative diagnosis.

METHODS

The clinical data of 37 patients with UrC admitted to our hospital from October 2005 to April 2022 were retrospectively analyzed, and 40 patients with urothelial carcinoma (UCa) of bladder were enrolled as the control group. We compared and analyzed the imaging, cystoscopy and immunohistochemistry, serum tumor markers, fluorescence in situ hybridization (FISH) of UrC and bladder UCa for early diagnosis and evaluation of diagnostic accuracy.

RESULTS

A total of 37 patients with UrC were enrolled in this study, including 30 males and seven females, with a median age of 52.00 (44.50-63.50) years. Imaging and cystoscopy suggest that UrC grows primarily outside the bladder cavity and is found in the middle line of the dome or anterior wall of the bladder. There was a significant difference in tumor location between the UrC group and the UCa group (10.13 mm vs. -7.06 mm, p < 0.001). Immunohistochemistry revealed that CK20 and CDX-2 were both diffusely and strongly positive. β-catenin was strongly positive in cytoplasm and membrane, but negative in nuclear staining. Carcinoembryonic antigen (CEA) and carbohydrate antigen 72-4 (CA724) expression levels were significantly higher in the UrC group than in the UCa group (p < 0.05). In the diagnosis of UrC, the area under the curve (AUC) of CEA combined with CA724 was the greatest. FISH's sensitivity in diagnosing UrC (5/7, 71.43%) was not significantly different from that of UCa (71.43% vs. 77.50%, p = 0.659). Imaging examination has the highest sensitivity and specificity among the accuracy evaluation of different diagnostic methods.

CONCLUSIONS

Imaging and cystoscopy are the powerful diagnostic methods for UrC. Serum tumor markers may assist in diagnosis, prognosis, and monitoring. Positive urine FISH can easily misdiagnose UrC as UCa.

Single-Use Versus Reusable Cystoscope for Ureteral Stent Removal: A Comparative Study of Perceived Pain and Procedure Times

INTRODUCTION

The aim of this study was to compare the Isiris^TM cystoscope with a common reusable flexible cystoscope in terms of patient perceived pain and endoscopy time in the ureteral stent removal setting.

MATERIALS AND METHODS

A non-randomized prospective study comparing the Isiris^TM single-use cystoscope with a reusable flexible cystoscope. A visual analogue scale (VAS) was used for pain assessment and endoscopy time was recorded in seconds. Univariate and multivariate analyses were performed to assess the correlation between endoscope type and clinical variables with VAS score and endoscopy time.

RESULTS

A total of 85 patients were included in the study: 53 in the disposable cystoscope group and 32 in the reusable cystoscope group. Ureteral stent extraction was successful in all cases. The mean VAS score was similar between groups (single-use group was 2.09 +/- 2.53 vs 2.53 +/- 2.14 in the reusable cystoscope group) (p = 0.13). Same was observed endoscopy time (74.92 +/- 74.45 s. in the single-use group vs 98.87 +/- 153.33 s. in the reusable group) (p = 0.07). Age (coefficient β = -0.36, p < 0.04) and body mass index (BMI) (coefficient β = -0.22, p < 0.02) were inversely correlated with perceived pain during ureteral stent removal, measured by VAS score.

CONCLUSIONS

Ureteral catheter removal with a flexible cystoscope is a well-tolerated procedure in patients. Older age and high BMI are associated with better intervention tolerance. Use of a single-use flexible cystoscope is comparable to that of a common flexible cystoscope in terms of pain and endoscopy time.

Conceptual Framework and Documentation Standards of Cystoscopic Media Content for Artificial Intelligence

BACKGROUND

The clinical documentation of cystoscopy includes visual and textual materials. However, the secondary use of visual cystoscopic data for educational and research purposes remains limited due to inefficient data management in routine clinical practice.

METHODS

A conceptual framework was designed to document cystoscopy in a standardized manner with three major sections: data management, annotation management, and utilization management. A Swiss-cheese model was proposed for quality control and root cause analyses. We defined the infrastructure required to implement the framework with respect to FAIR (findable, accessible, interoperable, re-usable) principles. We applied two scenarios exemplifying data sharing for research and educational projects to ensure the compliance with FAIR principles.

RESULTS

The framework was successfully implemented while following FAIR principles. The cystoscopy atlas produced from the framework could be presented in an educational web portal; a total of 68 full-length qualitative videos and corresponding annotation data were sharable for artificial intelligence projects covering frame classification and segmentation problems at case, lesion and frame levels.

CONCLUSION

Our study shows that the proposed framework facilitates the storage of the visual documentation in a standardized manner and enables FAIR data for education and artificial intelligence research.

A rare case of small-cell neuroendocrine tumour of the lung metastasising to the urinary bladder

A 77-year-old woman with suspected lung carcinoma had multiple bladder masses and lymphadenopathy outside the normal urinary bladder drainage area. Fine needle aspiration and immunocytochemistry of the cervical lymph node complex and transurethral biopsy of the bladder masses confirmed metastatic small-cell neuroendocrine carcinoma.

Contribution

Clinical correlation, imaging findings, tumour markers and immunohistochemistry are necessary for metastatic bladder tumour work-up.

Renal venous malformation misdiagnosed as carcinoma: A report of one case and the review of literature

The present study reports the clinical data of a patient with renal venous malformation misdiagnosed as carcinoma. CT revealed hematocele in the left renal pelvis and ureter. CTU: the left renal pelvis and calyces showed a slightly high density shadow, a size of about 2.6 cm*1.5 cm, and mild-to-moderate enhancement was found at the edge of the lesion. Enhanced MR showed that irregular mass abnormal signal was observed in the lower calyx of the left kidney and the lesions were cast, with short T1 and slightly long T2 signals. The secondary bleeding or mucus of low-grade malignant tumor became suspicious. The patient underwent cystoscopy and left ureteroscopy under general anesthesia on December 3, 2021. Bloody urine can be seen on the left side, and multiple blood clots in the left renal pelvis can be detected. After washing, dark red bloody necrotic substances can be seen. Pathology suggests that renal venous malformation, accompanied by bleeding and thrombosis, is located in the renal medulla, involving the renal calyx, rupture and bleeding of the renal calyx, and obvious local bleeding of surrounding renal tissue. Follow-up for more than 1 year showed that the patient's condition was stable. When patients have renal colic with hematuria, enhanced CT suggests that renal mass is mild-to-moderate continuous enhancement, enhanced MRI suggests short T1 and long T2, considering that the mass may be accompanied by bleeding, and ureteroscopy suggests that dark red bloody necrotic substances should be considered in the diagnosis of renal venous malformation.

Patient and Provider Perception of Transurethral Resection of Bladder Tumor vs Chemoablation for Nonmuscle-invasive Bladder Cancer Treatment

PURPOSE

The aim of this mixed methods study was to investigate patient and provider perceptions of repeat transurethral resection of bladder tumors to improve counseling as new nonsurgical treatment modalities for nonmuscle-invasive bladder cancer emerge.

MATERIALS AND METHODS

Quantitative data were collected via a web-based survey through the Bladder Cancer Advocacy Network of patients with nonmuscle-invasive bladder cancer who had undergone at least 1 transurethral resection of bladder tumor. Bivariable and multivariable analyses were performed to evaluate associations of patient demographics and clinical variables with treatment preference. Qualitative data were collected with 60 in-depth telephone interviews with patients (n=40) and urologists (n=20) to understand experiences with bladder cancer and transurethral resection of bladder tumor. Telephone interviews were conducted by trained qualitative experts. Transcripts were imported into Dedoose to facilitate analysis.

RESULTS

Survey data of 352 patients showed 210 respondents (60%) preferred repeat transurethral resection of bladder tumor while 142 (40%) preferred intravesical chemoablation. Patients who preferred repeat transurethral resection of bladder tumor were more likely to prioritize initial treatment effectiveness (63%), whereas those who preferred chemoablation prioritized risk of recurrence (55%). Variables associated with a preference for intravesical chemoablation included U.S. residence (OR=2; 95% CI 1.1, 3.8), or if they expressed their reason for treatment preference as priority of recurrence risk over effectiveness (OR=14.6; 95% CI 7.4, 28.5). Predominant interview themes varied across participants, with patients but not urologists emphasizing the emotional toll of the procedure along with the need for improved counseling regarding recurrence, terminology, and cancer-related signs and symptoms.

CONCLUSIONS

Differences exist in the way patients and urologists perceive repeat transurethral resection of bladder tumor for bladder cancer. Understanding transurethral resection of bladder tumor perception will aid in shared decision making as novel treatments emerge for nonmuscle-invasive bladder cancer.