Intravenous urography-virtual cystoscopy is a better preliminary examination than air virtual cystoscopy

OBJECTIVE: To describe a new technique of virtual cystoscopy (VC, used previously but with catheterization to drain residual urine and insufflation with air or carbon dioxide) with no invasive catheterization, used in parallel with intravenous urography (IVU), as conventional cystoscopy is an invasive but essential examination, and VC with multislice computed tomography (CT) was introduced to make preliminary examinations noninvasive. PATIENTS AND METHODS: Using multislice CT and a device with 16 rows of detectors, we examined five patients using VC that previously involved catheterization, termed 'air VC' and 16 using VC with the new technique, termed 'IVU VC'. We assessed the new technique by evaluating the tumour detection rate, and merits and demerits of both types of VC. RESULTS: The detection rate of bladder tumours by IVU VC was similar to that from air VC; moreover, IVU VC overcame two significant disadvantages of air VC, i.e. the appearance of the water surface and the need for catheterization. CONCLUSION: Conventional cystoscopy is still an essential examination but this new method of IVU VC may be ideal for preliminary examination of the bladder.     

Evaluation of diagnostic strategies for bladder cancer using computed tomography (CT) urography, flexible cystoscopy and voided urine cytology: results for 778 patients from a hospital haematuria clinic

Study Type – Diagnostic (exploratory cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Haematuria clinics with same day imaging and flexible cystoscopy are an efficient way for investigating patients with haematuria. The principal role of haematuria clinics with reference to bladder cancer is to determine which patients are ‘normal’ and may be discharged, and which patients are abnormal and should undergo rigid cystoscopy. It is well recognised that CT urography offers a thorough evaluation of the upper urinary tract for stones, renal masses and urothelial neoplasms but the role of CT urography for diagnosing bladder cancer is less certain. The aim of the present study was to evaluate the diagnostic accuracy of CT urography in patients with visible haematuria aged >40 years and to determine if CT urography has a role for diagnosing bladder cancer. This study shows that the optimum diagnostic strategy for investigating patients with visible haematuria aged >40 years with infection excluded is a combined strategy using CT urography and flexible cystoscopy. Patients positive for bladder cancer on CT urography should be referred directly for rigid cystoscopy and so avoid flexible cystoscopy. The number of flexible cystoscopies required therefore may be reduced by 17%. The present study also shows that the diagnostic accuracy of voided urine cytology is too low to justify its continuing use in a haematuria clinic using CT urography and flexible cystoscopy.

OBJECTIVES

• ? To evaluate and compare the diagnostic accuracy of computed tomography (CT) urography with flexible cystoscopy and voided urine cytology for diagnosing bladder cancer.
• ? To evaluate diagnostic strategies using CT urography as: (i) an additional test or (ii) a replacement test or (iii) a triage test for diagnosing bladder cancer in patients referred to a hospital haematuria rapid diagnosis clinic.

PATIENTS AND METHODS

• ? The clinical cohort consisted of a consecutive series of 778 patients referred to a hospital haematuria rapid diagnosis clinic from 1 March 2004 to 17 December 2007. Criteria for referral were at least one episode of macroscopic haematuria, age >40 years and urinary tract infection excluded. Of the 778 patients, there were 747 with technically adequate CT urography and flexible cystoscopy examinations for analysis.
• ? On the same day, patients underwent examination by a clinical nurse specialist followed by voided urine cytology, CT urography and flexible cystoscopy. Voided urine cytology was scored using a 5‐point system. CT urography was reported immediately by a uroradiologist and flexible cystoscopy performed by a urologist. Both examinations were scored using a 3‐point system: 1, normal; 2, equivocal; and 3, positive for bladder cancer.
• ? The reference standard consisted of review of the hospital imaging and histopathology databases in December 2009 for all patients and reports from the medical notes for those referred for rigid cystoscopy. Follow‐up was for 21–66 months.

RESULTS

• ? The prevalence of bladder cancer in the clinical cohort was 20% (156/778). For the diagnostic strategy using CT urography as an additional test for diagnosing bladder cancer, when scores of 1 were classified as negative and scores of 2 and 3 as positive, sensitivity was 1.0 (95% confidence interval [CI] 0.98–1.00), specificity was 0.94 (95% CI 0.91–0.95), the positive predictive value (PPV) was 0.80 (95% CI 0.73–0.85) and the negative predictive value (NPV) was 1.0 (95% CI 0.99–1.00).
• ? For the diagnostic strategy using CT urography as a replacement test for flexible cystoscopy for diagnosing bladder cancer, when scores of 1 were classified as negative and scores of 2 and 3 as positive, sensitivity was 0.95 (95% CI 0.90–0.97), specificity was 0.83 (95% CI 0.80–0.86), the PPV was 0.58 (95% CI 0.52–0.64), and the NPV was 0.98 (95% CI 0.97–0.99). Similarly using flexible cystoscopy for diagnosing bladder cancer, if scores of 1 were classified as negative and scores of 2 and 3 as positive, sensitivity was 0.98 (95% CI 0.94– 0.99), specificity was 0.94 (95% CI 0.92–0.96), the PPV was 0.80 (95% CI 0.73–0.85) and the NPV was 0.99 (95% CI 0.99–1.0).
• ? For the diagnostic strategy using CT urography and flexible cystoscopy as a triage test for rigid cystoscopy and follow‐up (option 1), patients with a positive CT urography score are referred directly for rigid cystoscopy, and patients with an equivocal or normal score were referred for flexible cystoscopy. Sensitivity was 1.0 (95% CI 0.98–1.0), specificity was 0.94 (95% CI 0.91–0.95), the PPV was 0.80 (95% CI 0.73–0.85), and the NPV was 1.0 (95% CI 0.99–1.0).
• ? For the diagnostic strategy using CT urography and flexible cystoscopy as a triage test for rigid cystoscopy and follow‐up (option 2), patients with a positive CT urography score are referred directly for rigid cystoscopy, patients with an equivocal score are referred for flexible cystoscopy and patients with a normal score undergo clinical follow‐up. Sensitivity was 0.95 (95% CI 0.90–0.97), specificity was 0.98 (95% CI 0.97–0.99), the PPV was 0.93 (95% CI 0.87–0.96), and the NPV was 0.99 (95% CI 0.97–0.99).
• ? For voided urine cytology, if scores of 0–3 were classified as negative and 4–5 as positive for bladder cancer, sensitivity was 0.38 (95% CI 0.31–0.45), specificity was 0.98 (95% CI 0.97–0.99), the PPV was 0.82 (95% CI 0.72–0.88) and the NPV was 0.84 (95% CI 0.81–0.87).

CONCLUSIONS

• ? There is a clear advantage for the diagnostic strategy using CT urography and flexible cystoscopy as a triage test for rigid cystoscopy and follow‐up (option 1), in which patients with a positive CT urography score for bladder cancer are directly referred for rigid cystoscopy, but all other patients undergo flexible cystoscopy.
• ? Diagnostic accuracy is the same as for the additional test strategy with the advantage of a 17% reduction of the number of flexible cystoscopies performed.
• ? The sensitivity of voided urine cytology is too low to justify its continuing use in a hospital haematuria rapid diagnosis clinic using CT urography and flexible cystoscopy.

     

A comparison of white-light cystoscopy and narrow-band imaging cystoscopy to detect bladder tumour recurrences

OBJECTIVE

To determine whether narrow‐band imaging (NBI) cystoscopy enhances the detection of non‐muscle‐invasive bladder tumours over standard white‐light imaging (WLI) cystoscopy, as surveillance WLI is the standard method used to diagnose patients with recurrent bladder tumours, but they can be missed by WLI cystoscopy, possibly accounting for early recurrences.

PATIENTS AND METHODS

We evaluated 427 patients for recurrent bladder tumours by WLI cystoscopy, followed by NBI cystoscopy as a further procedure, using the same video‐cystoscope. Recurrent tumours visualized by WLI or NBI cystoscopy were mapped, imaged, biopsied and subsequently treated by transurethral resection (TUR) or fulguration. Biopsies or TUR specimens obtained by WLI and NBI were examined separately for presence of tumour.

RESULTS

In all, 103 patients (24%) had tumour recurrences; 90 (87%) were detected by both WLI and NBI and another 13 (100%) only by NBI cystoscopy. NBI detected extra papillary tumours or more extensive carcinoma in situ in 58 (56%) patients found to have recurrences. The mean number of recurrent tumours visualized on WLI cystoscopy was 2.3, vs to 3.4 seen on NBI cystoscopy (P = 0.01).

CONCLUSION

NBI cystoscopy improved the detection of recurrent non‐muscle‐invasive bladder tumours over standard WLI cystoscopy.     

The effect on pain experienced by male patients of watching their office-based flexible cystoscopy

OBJECTIVE

To confirm the recently published positive effect on visual analogue pain (VAS) scale levels for men watching their flexible cystoscopy.

PATIENTS AND METHODS

From June 2007 to September 2007, 154 men had a flexible cystoscopy for various indications, all carried out by one urologist. Patients were randomized into two groups; those in group 1 were allowed to watch the video screen together with the urologist during the procedure; those in group 2 were not allowed to watch the procedure on the video screen. All patients received the same real‐time explanation during the cystoscopy. After the cystoscopy procedure the patients were asked to record their experience of pain on the 100 mm VAS as soon as they left the room. The two groups were further stratified by the number of previous cystoscopies experienced to evaluate the possible modifying effect of their previous experience.

RESULTS

Although the results suggested a small decrease in perceived pain there were no statistically significant differences between the groups, regardless of cystoscopy experience.

CONCLUSIONS

Our results show that, in contrast to an earlier report, the pain experienced by men undergoing a first or repeated flexible cystoscopy is not strongly influenced by watching the procedure.     

The use of blue-light cystoscopy in the detection and surveillance of nonmuscle invasive bladder cancer

Nonmuscle invasive bladder cancer is associated with a high risk of recurrence as well as progression to muscle-invasive disease. Therefore, adequate visualization and identification of malignant lesions as well as complete resection are critical. Traditional white-light cystoscopy is limited in its ability to detect bladder cancer, specifically carcinoma in situ. Blue-light cystoscopy makes use of the intravesical instillation of a heme precursor to differentiate areas of malignancy from normal tissue. A narrative review of the literature on the use of blue-light cystoscopy in bladder cancer was conducted. Blue-light cystoscopy has been shown in several randomized clinical trials to increase detection of Ta, T1, and carcinoma in situ, as well as reduce risk of recurrence at 12 months as compared with traditional white-light cystoscopy. Research into the effects of blue-light cystoscopy on risk of disease progression has produced mixed results, in part due to changing definitions of progression. However, more recent research suggests a correlation with decreased risk of progression. Whereas the use of blue-light was initially limited to rigid cystoscopy in the operating room, results from a recent randomized clinical trial showing enhanced detection of recurrent disease using blue-light in-office surveillance flexible cystoscopy have led to expanded Food and Drug Administration approval. Overall, blue-light cystoscopy offers promise as an enhancement to white-light cystoscopy for the detection of nonmuscle invasive bladder cancer and may yield additional benefits in reducing disease recurrence and progression. Further prospective research is needed to evaluate the true benefit of blue-light cystoscopy in terms of disease progression as well as the cost-effectiveness of this technique.     

A comparison of hexaminolevulinate fluorescence cystoscopy and white light cystoscopy for the detection of carcinoma in situ in patients with bladder cancer: a phase III, multicenter study

PURPOSE: We compared hexaminolevulinate (Hexvix) fluorescence cystoscopy with white light cystoscopy for detecting carcinoma in situ. MATERIALS AND METHODS: In this multicenter study 298 patients with known or suspected bladder cancer underwent bladder instillation with 50 ml 8 mM hexaminolevulinate for 1 hour. Cystoscopy was then performed, first using standard white light and then hexaminolevulinate fluorescence cystoscopy. Lesions or suspicious areas identified under the 2 illumination conditions were mapped and biopsied for histological examination. In addition, 1 directed biopsy was obtained from an area appearing to be normal. RESULTS: Of 196 evaluable patients 29.6% (58 of 196) had carcinoma in situ, including 18 with carcinoma in situ alone, and 35 with carcinoma in situ and concomitant papillary disease, which was only detected on random biopsy in 5. Of the 18 patients with no concomitant papillary disease carcinoma in situ was detected only by hexaminolevulinate fluorescence in 4 and only by white light in 4. In the group with concomitant papillary disease carcinoma in situ was found only by hexaminolevulinate fluorescence in 5 patients and only by white light in 3. The proportion of patients in whom 1 or more carcinoma in situ lesions were found only by hexaminolevulinate cystoscopy was greater than the hypothesized 5% (p=0.0022). Overall more carcinoma in situ lesions were found by hexaminolevulinate than by white light cystoscopy in 22 of 58 patients (41.5%), while the converse occurred in 8 of 58 (15.1%). Biopsy results confirmed cystoscopy findings. Of a total of 113 carcinoma in situ lesions in 58 patients 104 (92%) were detected by hexaminolevulinate cystoscopy and 77 (68%) were detected by white light cystoscopy, while 5 were detected only on directed visually normal mucosal biopsy. Hexaminolevulinate instillation was well tolerated with no local or systemic side effects. CONCLUSIONS: In patients with bladder cancer hexaminolevulinate fluorescence cystoscopy with blue light can diagnose carcinoma in situ that may be missed with white light cystoscopy. Hexaminolevulinate fluorescence cystoscopy can be used in conjunction with white light cystoscopy to aid in the diagnosis of this form of bladder cancer.     

Promises and challenges of fluorescence cystoscopy

IntroductionFluorescence based photodynamic diagnostic (PDD) techniques have been developed to improve detection and treatment of non-muscle invasive bladder cancer. The goal of this article is to evaluate the promises and challenges of blue light cystoscopy.MethodsThe literature was reviewed regarding articles pertaining to fluorescent cystoscopy and blue light cystoscopy (BLC).ResultsBlue light cystoscopy improves detection of bladder cancer tumors especially CIS. Randomized trials have demonstrated a reduction of recurrences. BLC has been demonstrated to be safe and effective in treatment of NMIBC of varying risk. The main obstacle to BLC will be adoption by urologists. Purchase cost of capital equipment may impact usage especially if adopted for outpatient clinics.ConclusionsBLC has been demonstrated to be safe and effective in treatment of NMIBC of varying risk. The reduction of recurrences and yet unproven but potential reduction in progression should be viewed favorably by urologists and patients. The main obstacle to BLC will be adoption by urologists who can put pressure on hospitals to acquire the capital equipment and who will seek the training to become proficient in using the technology. Patient demand for the technology may also help increase availability. Finally, the companies involved with BLC need to support trials that will demonstrate reduction in progression and that will answer the practical issues regarding usage in proximity to BCG and repeated usage.     

Stage Ta-T1 bladder cancer: the relationship between findings at first followup cystoscopy and subsequent recurrence and progression

PURPOSE: We studied the relationship of first cystoscopy findings with recurrence and progression rates in a large, population based series of patients with bladder cancer. MATERIALS AND METHODS: All 463 patients with an initial diagnosis of stage Ta-T1 bladder cancer in western Sweden in 1987 to 1988 were followed at least 5 years. The 355 patients who were treated with transurethral resection only until repeat cystoscopy or longer were selected for this report. RESULTS: Negative first cystoscopy findings were associated with significantly decreased recurrence and progression rates for all grades, and for stage Ta and T1 tumors. However, some patients with initial high grade carcinoma (WHO 2 to 3) had stage progression despite negative first cystoscopy. On multivariate analyses first cystoscopy findings and papillary urothelial neoplasm of low malignant potential versus grades 1 to 3 but not stage and the number of tumors had prognostic significance for time to recurrence. Only first cystoscopy findings and grade had prognostic significance for time to stage progression. CONCLUSIONS: Our data support other groups who recommend a less intense cystoscopy followup schedule in patients with negative cystoscopy findings 3 months after initial transurethral bladder resection. We recommend that patients with initial papillary urothelial neoplasm of low malignant potential and low grade carcinoma (WHO 1) with negative first cystoscopy findings undergo repeat cystoscopy at month 12. In our opinion followup should not be less intense in patients with high grade carcinoma (WHO 2-3), even in those with stage pTa disease.     

Correlation of cystoscopy with histology of recurrent papillary tumors of the bladder

PURPOSE: We correlated individual urologist impressions of tumor stage and grade of recurrent papillary bladder tumors at cystoscopy with histological findings after transurethral resection to determine whether cystoscopy can reliably identify low grade, noninvasive papillary tumor for outpatient fulguration. MATERIALS AND METHODS: A total of 144 recurrent papillary bladder tumors identified on outpatient flexible cystoscopy were classified as low grade and noninvasive (stage Ta grade 1), high grade and noninvasive (stage Ta grade 3) or invasive (stage T1). Voided urine cytology was also performed. The cystoscopic impression of each tumor was correlated with the final histological findings of tumor stage and grade after transurethral resection. RESULTS: Cystoscopy classified 97 tumors as stage Ta grade 1 and 47 as stage Ta grade 3 or stage T1. Cystoscopy correctly predicted the tumor stage and grade of 93% of stage Ta grade 1 and 99% of stage Ta grade 1 lesions associated with negative urine cytology. CONCLUSIONS: Urologists can usually identify noninvasive, low grade recurrent papillary tumors on followup cystoscopy that may be treated safely with outpatient fulguration.     

Improved detection of urothelial carcinoma in situ with hexaminolevulinate fluorescence cystoscopy

PURPOSE: In this European multicenter study we compared hexaminolevulinate (HAL) fluorescence cystoscopy and standard white light cystoscopy for the detection of carcinoma in situ (CIS) in patients suspected of having high risk bladder cancer. MATERIALS AND METHODS: This study was a prospective controlled, within-patient comparison of standard and HAL fluorescence cystoscopy. Eligible patients received an intravesical instillation of 50 ml HAL 8 mM solution. Cystoscopy was performed using a D light system, which provided white and blue light at 375 to 440 nm. The bladder wall was inspected and mapped, first under white light, followed by blue light. All tumors and suspicious areas identified under white light and by red fluorescence were resected or biopsied. Histological findings were assessed by an independent central pathologist blinded to the identity of the biopsies. RESULTS: Of 211 evaluable patients 83 (39%) had CIS, of whom 18 (22%) were detected by HAL cystoscopy only, 62 (75%) were detected by standard and HAL cystoscopy, 2 (2%) were detected by standard cystoscopy only and 1 (1%) was detected by nonguided biopsy. Therefore, HAL cystoscopy identified 28% more patients with CIS than standard cystoscopy. The side effects of HAL instillation were negligible and no unexpected events were reported. CONCLUSIONS: HAL fluorescence cystoscopy improves the detection of bladder CIS significantly, which has consequences for clinical management and may improve the patient prognosis. The procedure is easily implemented as an adjunct to standard cystoscopy and it adds no significant risk of complications.     

多层面螺旋CT仿真膀胱镜对膀胱肿瘤的诊断价值

目的：探讨多层面螺旋CT仿真膀胱镜(multi—slice spiral CT virtual cystoscopy，MSCTVC)对膀胱肿瘤的诊断价值。方法：对以血尿为主诉，经B超发现膀胱内占位性病变的20例患者行MSCTVC和传统膀胱镜检查。通过导尿管将4．8％泛影葡胺注入膀胱，行盆腔CT扫描，将资料传至工作站，采用Voyager。软件angios—copy模式行仿真膀胱镜影像重建。结果：传统膀胱镜证实的25处膀胱内病变MSCTVC显示23处，准确率92％。输尿管口和尿道内口均清晰显示。结论：MSCTVC具有重建图像清晰逼真、大视野、无盲区等特点，能较准确地发现膀胱内占位性病变，可作为尿道狭窄、严重血尿或拒绝行传统膀胱镜检等特定条件下替代常规膀胱镜的检查方法之一。     

Virtual cystoscopy: the evaluation of bladder lesions with computed tomographic virtual cystoscopy

Purpose

Our objective was to assess the accuracy of computed tomographic virtual cystoscopy (CTVC) in the detection of urinary bladder lesions.

Methods

Twenty-five patients were examined using CTVC. Bladder scanned using multislice CT at a slice thickness of 1 mm. The data were transferred to a workstation for interactive navigation using surface rendering. Findings obtained from CTVC were compared with results from conventional cystoscopy and with pathological findings.

Results

Thirty-eight lesions were identified. The smallest was 0.2 × 0.3 cm; the largest was 7 × 4.5 cm. Both CTVC and conventional cystoscopy were used. Conventional cystoscopy detected the same number of lesions that were detected by CTVC. On morphological examination, 26 of the lesions were polypoid, 7 were sessile and 5 were bladder wall-thickening. While one of the polypoid lesions was reported as an inverted papilloma, 2 of the 5 lesions that were identified as wall-thickening were malignant and 3 were benign. The sensitivity of using CTVC to identify neoplasias was 100%; the accuracy was 89%.

Conclusion

Although the definitive diagnosis of some suspected urinary bladder tumours is only possible with conventional cystoscopy and biopsy, CTVC is a minimally invasive technique which provides beneficial information about urinary bladder lesions.     

Thulium laser resection via a flexible cystoscope for recurrent non‐muscle‐invasive bladder cancer: initial clinical experience

OBJECTIVE

To present our initial experience of thulium laser resection via a flexible cystoscope for recurrent non‐muscle‐invasive bladder cancer (ThuRBT), as transurethral resection for bladder tumour (TURBT) is regarded as the reference standard for treating this disease, but alternative laser resection or ablation is suitable especially for recurrent tumours.

PATIENTS AND METHODS

From January 2005 to October 2005, 32 patients with early recurrent bladder tumour (recurrent within a year after TURBT) were treated with ThuRBT via a flexible cystoscope. The follow‐up included urine analysis, ultrasonography and cystoscopy every 3 months.

RESULTS

All patients were treated successfully with ThuRBT in one session, with no bladder haemorrhage, obturator nerve reflex or vesicle perforation. Randomized biopsies taken after surgery on and adjacent to the resection surface revealed no residual tumours. The mean (range) tumour diameter was 1.5 (0.5–3) cm and the mean operative duration was 25 (15–35) min. During the first year of follow‐up, local and heterotopic recurrences were found in three and six patients, respectively. The accumulated recurrence rates at 3, 6 and 12 months were 9%, 22% and 28%, respectively.

CONCLUSIONS

ThuRBT is a reliable therapy with minimal morbidity and invasiveness for selected patients with bladder cancer.