Combined percutaneous antegrade and cystoscopic retrograde approach in the treatment of distal ureteric fistulae

Purpose To determine the efficacy of a cystoscopic approach, as definitive treatment of ureteral fistulae, after failure of antegrade ureteral stent insertion.Methods Of 43 ureter fistulae encountered over 4 years, 10 postoperative and/or postradiotherapy fistulae could not be stented via an antegrade approach alone. A cystoscopic approach was used, with the antegrade approach available as back-up, if necessary.Results In two patients the ureteral orifice could not be visualized cystoscopically, thus precluding the retrograde approach. In the eight remaining patients, the retrograde approach alone never allowed successful stenting. In six patients, combined antegrade and retrograde approaches permitted stent insertions. In three of those six patients, a complex catheterization procedure was necessary. In two patients the combined approach failed altogether. Therefore, 6 of 10 patients underwent a successful stenting procedure with the combined approach; all ultimately closed the fistula.Conclusion Antegrade stent insertion remains the treatment of choice for ureteral leaks. If the antegrade approach fails, the retrograde approach alone is not likely to be successful. Instead, a combination of both approaches often does succeed.     

The value of intraoperative cystoscopy in urogynecologic and reconstructive pelvic surgery

OBJECTIVE: Our goal was to evaluate the role of intraoperative cystoscopy during surgery for pelvic organ prolapse and urinary incontinence. STUDY DESIGN: Charts of 224 consecutive patients who had intraoperative cystoscopy performed after urogynecologic surgery were reviewed. RESULTS: Nine injuries occurred that were unsuspected before cystoscopy, for an incidence of 4%. Six ureteral ligations occurred, four after Burch cystourethropexy and two after vaginal culdoplasty. Intravesical sutures were noted after two Burch procedures, and another injury occurred with passage of fascia lata through the bladder during a pubovaginal sling procedure. Eight injuries were managed by removal and replacement of the suture or sling with only one requiring ureteroneocystotomy. When patients with injuries were compared with those without, there were no statistical differences in demographic or surgical parameters. CONCLUSIONS: The potential for damage to the lower urinary tract is significant with complex urogynecologic surgery. Because of the increased and delayed morbidity associated with unrecognized injury, intraoperative surveillance cystoscopy should be considered a part of all such procedures.(Am J Obstet Gynecol 1997;177:71)     

Combined Cystoscopic and Laparoscopic Approach in Deep Endometriosis of the Bladder

Study ObjectiveTo report the combined cystoscopic and laparoscopic approach in deep endometriosis with full-thickness infiltration of the bladder.DesignVideo (Canadian Task Force classification III).SettingUniversity hospital.PatientA 34-year-old nulliparous woman with a large (35-mm) endometriosis nodule infiltrating the bladder and deep endometriosis of the rectum and sigmoid colon.InterventionThe urologic surgeon performed cystoscopy, identified the limits of mucosal involvement, and incised the muscular layer up to fat tissues surrounding the bladder. The gynecologic surgeon identified and followed the circular incision, and completed full-thickness resection of the bladder wall. Surgical technique reports in anonymous patients are exempt from ethical approval by the institutional review board.Measurements and Main ResultsThe patient's functional outcome was uneventful. Laparoscopic resection of large endometriotic nodules of the bladder per se may lead to inadvertent removal of healthy bladder muscle. Thus it increases the risk of postoperative complications and symptoms due to small bladder volume. Conversely, if resection of the nodule is performed only cystoscopically, it probably would not be completely removed. We routinely combine the 2 approaches because this enables complete resection of the endometriotic nodule. It not only averts the risk of excessive removal of healthy bladder muscle but also leaves no disease behind.ConclusionsOn the basis of our experience, we propose the combined cystoscopic and laparoscopic approach in managing large endometriotic nodules with full-thickness infiltration of the bladder.     

Cannon‐ball bladder stones: a complication of prolonged recumbence and benign prostate enlargement

Chronically bedridden patients are predisposed to various urological complications such as urinary infections, incomplete urinary bladder emptying after voiding and stone formation in the urinary tract, more so in the absence of good nursing care. Multiple giant bladder stones giving rise to ‘cannon ball’ appearance have rarely been reported. We present the case of an 85‐year‐old frail gentleman who was bedridden for the last 25 years and presented with haematuria. On evaluation he was found to have multiple large bladder stones and bladder diverticuli with enlarged prostate gland. This case highlights a relatively rare urological complication of prolonged recumbency, and emphasizes the importance of proper nursing care, early detection, management and prevention of such complications.     

Reflex ImmunoCyt Testing for the Diagnosis of Bladder Cancer in Patients with Atypical Urine Cytology

Background

ImmunoCyt/uCyt (Scimedx, Denville, NJ, USA) is a well-established urinary marker assay with high sensitivity for the diagnosis of urothelial carcinoma (UC) and can function as a second-level test to arbitrate atypical reads of urine cytology.

Objective

To determine the utility of uCyt as a reflex test for atypical cytology in patients undergoing a hematuria evaluation or surveillance with a history of UC.

Design, setting, and participants

The uCyt assay was performed as a second-level reflex test on all voided urine cytology tests read as atypical between January 2007 and June 2010 in an academic medical center. Records were retrospectively reviewed. Three hundred twenty-four patients underwent a total of 506 uCyt assays.

Intervention

Reflex uCyt assay on atypical urine cytology.

Outcome measurements and statistical analysis

The uCyt test characteristics include sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV).

Results and limitations

Reflex uCyt was performed on 506 atypical voided urine samples that were followed by cystoscopy within 90 d. Reflex uCyt with a history of UC showed a sensitivity of 73%, a specificity of 49%, and an NPV of 80%. In those with a history of low-grade UC, reflex uCyt had a sensitivity of 75%, a specificity of 50%, and an NPV of 82%, while in those with a history of high-grade UC, it had a sensitivity of 74%, a specificity of 44%, and an NPV of 79%. Without prior history of UC, reflex uCyt had a sensitivity of 85%, a specificity of 59%, and an NPV of 94%. This study's limitations include its retrospective design and interobserver variability inherent to cystoscopy, which was used as the reference test.

Conclusions

When used as a reflex test on atypical urine cytology, negative uCyt may predict a negative cystoscopy in select patients and modulate the urgency and further work-up in those with no prior history or low-grade disease.     

ICUD-EAU International Consultation on Bladder Cancer 2012: Non–Muscle-Invasive Urothelial Carcinoma of the Bladder

Context

Our aim was to present a summary of the Second International Consultation on Bladder Cancer recommendations on the diagnosis and treatment options for non–muscle-invasive urothelial cancer of the bladder (NMIBC) using an evidence-based approach.

Objective

To critically review the recent data on the management of NMIBC to arrive at a general consensus.

Evidence acquisition

A detailed Medline analysis was performed for original articles addressing the treatment of NMIBC with regard to diagnosis, surgery, intravesical chemotherapy, and follow-up. Proceedings from the last 5 yr of major conferences were also searched.

Evidence synthesis

The major findings are presented in an evidence-based fashion. We analyzed large retrospective and prospective studies.

Conclusions

Urothelial cancer of the bladder staged Ta, T1, and carcinoma in situ (CIS), also indicated as NMIBC, poses greatly varying but uniformly demanding challenges to urologic care. On the one hand, the high recurrence rate and low progression rate with Ta low-grade demand risk-adapted treatment and surveillance to provide thorough care while minimizing treatment-related burden. On the other hand, the propensity of Ta high-grade, T1, and CIS to progress demands intense care and timely consideration of radical cystectomy.     

Accuracy Of Bladder Stone Detection Using Abdominal X-Ray After Spinal Cord Injury

Abstract

Background: Bladder calculi are a common problern in those with spinal cord injury (SCI). Detection is important to prevent complications.

Objective: To determine the accuracy of bladder stone detection by abdominal x-rays.

Methods: X-ray reports from individuals with SCI with known bladder stones detected by cystoscopy were reviewed.

Main outcome measures: x-ray reports noted the presence or absence of bladder stones. The stone variables evaluated were stone composition (crystallographic analysis) , widest dimension of the largest stone (during cystoscopy) , and the total volume (cm3 ) of the stone mass removed.

Results: Sixty-two consecutive x-ray reports from individuals with bladder stones were reviewed. The majority of stones were calcium phosphate (46.8%) or struvite (26.7%). Regarding stone composition, the detection by x-ray was 28.6% for struvite stones and 41 .9% for calcium phosphate stones. Regarding diameter of largest stone, the detection by x-ray was 14% for stones < 0.5 cm, 0% for stones 0.5 cm to 0 .9 cm, 33% for stones 1.0 cm to 1.49 cm, 33% for stones 1.5 cm to 1.9 cm, and 54% for stones 2 2.0 cm. Regarding total volume of stones, the detection by x-ray was 0% forvolumes < 0.2 cm3 , 33% for volumes 0.2 cm3 to 0.39 cm3 , 60% for volumes 0.40 cm3 to 0.5 9 cm3 , 40% for volumes of 0.60 cm3 to 0.79 cm3 , 0% for stones from 0.8 cm3 to 0.99 cm3 , and 57% for volumes 2 1.0 cm3 . Overall, 13/ 62 (20.97%) of stones found during cystoscopy were detected by the x-ray.     

膀胱镜下膀胱肿瘤激光切除术与电切术的临床疗效对比研究

目的:探讨膀胱镜下膀胱肿瘤激光切除术与电切术的临床疗效及安全性。方法:选择2012年11月至2014年8月行膀胱肿瘤激光切除或电切术的163例患者,其中85例行激光切除术(激光组),电切组78例,对比分析两组手术时间、术中出血量、并发症发生率、术后导尿管留置时间、术后住院时间及随访情况。结果:163例均顺利完成手术,激光组与电切组手术时间[(24.2±2.4)min vs.(29.7±2.4)min]、术后留置导尿管时间[(2.83±0.96)d vs.(3.19±0.91)d]差异有统计学意义(P<0.001),激光组闭孔神经反射发生率低于电切组,术中出血量[(19.5±3.7)mL vs.(26.5±2.3)mL]低于电切组。两组患者术后均随访36个月,Kaplan-Meier生存曲线显示两组无瘤生存率差异无统计学意义(P=0.406),术后3年总体复发率差异无统计学意义。结论:与传统膀胱肿瘤电切术相比,激光切除的手术时间短,并发症发生率低,可作为膀胱镜下膀胱肿瘤切除术安全、可靠的替代术式,并且激光切除术可获取完整的术后病理组织,对于判断预后及后续治疗方案的制定具有重要作用。     

Predicción de resultados de cistoscopias en la práctica

ObjectiveOur objective was to elaborate a predictive model of bladder cancer, in an unselected clinical population submitted to cystoscopy.Materials and methodsWe recruited consecutive patients that underwent cystoscopy due to suspicion of bladder cancer or surveillance of a previously diagnosed bladder cancer. Urine cytology and a BTA-stat® (BTA) test were carried out for all patients. To avoid an assessment bias, the BTA-tests, cytologies and cystoscopies were conducted in a blinded fashion. We used logistic regression to predict cystoscopy results from cytology, BTA-test and clinical variables.ResultsFrom August 2011 to July 2012, we recruited 244 patients and 237 were valid for analysis. Newly diagnosed and surveillance cases were 13% and 87% respectively. Cytology and BTA-test sensitivities were 57.9% (CI 95: 42.2-72.1) and 63.2% (CI 95: 47.3-76.6) with specificities of 84.4% (CI 95: 78.7-88.8) and 82.9% (CI 95: 77.1-87.5). The predictive model included the BTA-test, cytology, time since previous tumour, and treatment with mitomicin or BGC during the last three months. The model predictive accuracy (AUC) was .85 (.78-.92), and dropped to 0.79 when excluding the BTA-test (P = .026). For the surveillance of bladder cancer, a 10% threshold on the model predicted probabilities resulted in an overall negative predictive value of 95.7%, and 95.0% in low grade tumours.ConclusionIn a cost containment environment, our prediction model could be used to space out cystoscopies in patients with previous, low grade tumours, resulting in a more efficient use of resources in the healthcare system.     

Computer-assisted cystoscopy diagnosis of bladder cancer

Objectives

One of the most reliable methods for diagnosing bladder cancer is cystoscopy. Depending on the findings, this may be followed by a referral to a more experienced urologist or a biopsy and histological analysis of suspicious lesion. In this work, we explore whether computer-assisted triage of cystoscopy findings can identify low-risk lesions and reduce the number of referrals or biopsies, associated complications, and costs, although reducing subjectivity of the procedure and indicating when the risk of a lesion being malignant is minimal.