This study aimed to investigate the effects of pre-procedural video education and intra-procedural distraction using virtual reality (VR) nature videos on patient anxiety and pain perception during office-based flexible cystoscopy. In this single-center, four-arm, parallel-group randomized controlled trial, 240 adult patients scheduled for flexible cystoscopy were enrolled. Participants were randomized into four groups: Video + VR- (n = 60), Video + VR + (n = 60), Video- VR + (n = 60), and Video- VR- (control, n = 60). Anxiety was assessed using the Spielberger State-Trait Anxiety Inventory (STAI), and pain was measured with a visual analog scale (VAS). Intergroup comparisons were performed using nonparametric tests, and outcome assessors were blinded to group allocation. Pain scores differed significantly among groups (H = 44.604, p < 0.001). The lowest pain scores were observed in the Video + VR + group (4.3 ± 1.1), while the highest were in the control group (5.7 ± 1.1). Reductions in STAI-S (state anxiety) scores also showed significant group differences (H = 28.311, p < 0.001). Compared with the control group, the Video + VR + group demonstrated significant improvements in both VAS (p < 0.001, r = 0.610) and STAI-S reduction (p < 0.001, r = -0.493), with large effect sizes. Analyses based on baseline STAI-T (trait anxiety) scores indicated that the interventions were effective regardless of initial anxiety levels, with the combined Video + VR + approach consistently providing the greatest benefit. The combination of pre-procedural video education and intra-procedural VR distraction was associated with the greatest reduction in pain and anxiety during flexible cystoscopy. These findings support the potential value of multimodal approaches for improving patient comfort during urologic procedures. Registered on 05 September 2025 in the ISRCTN registry (ISRCTN22513446).

(007) Mini-Jupette Sling for Climacturia Without Penile Prosthesis

We report a rare case of a urethral phyllodes tumour. A 58‐year‐old male presented with urinary retention requiring catheterisation, preceded by a gradual onset of poor urinary flow. He had a prior history of poor urinary flow in 2022, when a urethral fibroepithelial polyp was identified and excised. Histopathology at the time confirmed a fibroepithelial polyp. On recurrence, flexible cystoscopy showed a polyp arising from the prostatic urethra and extending into the bladder neck, while MRI prostate revealed a 63 cc gland with a small median lobe and a PI‐RADS 1, Likert 1 lesion. The patient underwent redo transurethral resection of the lesion, and histology revealed a low‐grade phyllodes tumour. This case underscores the importance of recognising rare urological tumours in order to guide appropriate management.

ObjectivesTo investigate the potential of the Haematuria Cancer Risk Score (HCRS) to improve the real‐world investigation pathway for suspected bladder cancer.Materials and methodsData were retrospectively analysed for all consecutive patients referred with suspected urinary tract cancer on a faster diagnostic pathway to five UK institutions between January and April 2025. The HCRS cut‐off score of ≥82 was used to define a ‘HCRS high risk’ population. The co‐primary outcomes were the ability to calculate HCRS in the referred population from the information provided by primary care and the cancer detection rate.ResultsIn total, 1944 referrals were received, median age of 71 years (IQR 61–78), 1186/1944 (61%) were male, and 1586/1944 (82%) had sufficient information to calculate the HCRS. Of the cohort with HCRS scores, overall 165/1586 (10%) had bladder cancer. The HCRS was ≥82 in 176/437 (40%) of those with non‐visible haematuria (NVH); in total, 6/176 (3%) had bladder cancer; and using HCRS in the NVH group alone, no case of muscle‐invasive bladder cancer (MIBC) would have been missed. The HCRS was ≥82 in 1062/1149 (92%) with visible haematuria (VH), of whom 150/1062 (14%) had bladder cancer. Adopting a strategy of using HCRS and upper tract imaging in combination for the whole cohort would have resulted in two cases of NMIBC being missed for the NVH cohort and one case of NMIBC being missed for the VH cohort. No cases of MIBC or upper tract urothelial cancer would have been missed.ConclusionHCRS is a simple innovation, which demonstrates clear potential when combined with upper tract imaging to improve current UK risk stratification to determine which patients referred with haematuria need flexible cystoscopy.

Haemorrhagic radiation cystitis (HRC) is a challenging complication of pelvic radiotherapy, often resistant to conventional treatments. To evaluate the clinical efficacy and safety of RADA16, a self-assembling peptide, in managing severe HRC. A preliminary feasibility case series of five consecutive patients treated at two UK hospitals. All patients had persistent haematuria despite standard interventions and received RADA16 via flexible or rigid cystoscopy. The findings from the cases suggest that all patients have experienced at least a partial or early resolution of haematuria and no adverse effects were reported. In most cases, two applications of RADA16 were sufficient. The longest patient followed up was still symptom free at 3years. This preliminary feasibility case series has demonstrated early efficacy for RADA16 in the management of HRC. RADA16 is a potentially promising minimally invasive treatment for refractory HRC. Further trials are warranted to confirm these findings.

Reconstructing the reconstructed: Outcomes of redo-urethroplasty for recurrent urethral strictures.

Prospective randomized evaluation of patient- and physician-reported pain concordance in flexible cystoscopy: impact of experience and anxiety.

Bladder cancer remains one of the most common urological malignancies and demands timely diagnosis and streamlined pathways to achieve optimal patient outcomes. This article provides an overview of bladder cancer, including grading and staging, and outlines the 2023 Getting It Right First Time (GIRFT) bladder cancer pathway. It highlights the nurse's pivotal role from early detection and diagnosis through treatment, surveillance, and holistic care. Emphasis is placed on nurse-led flexible cystoscopy, intravesical therapy, and how clear communication, education and compassionate support can reduce patient anxiety at each stage. Practical considerations are set out for advanced practice, training and service improvement to ensure delivery of safe, high-quality, evidence-based care. By examining real examples, it demonstrates how nurses build trust, facilitate shared decision-making and support patients' psychosocial wellbeing. This review provides generalist and specialist nurses with essential knowledge and recommendations to enhance bladder cancer care, aligned with the GIRFT principles.

Introduction: Flexible cystoscopy is a common urological procedure with a low infectious risk. Current guidelines recommend selective rather than routine antibiotic prophylaxis (AP), reserving its use for patients with well-defined risk factors. However, real-world adherence to these recommendations remains uncertain. The objective was to assess adherence of urologists to guideline-directed AP use before flexible cystoscopy and to identify physician-related predictors of non-compliance. Methods: A nationwide anonymous questionnaire was distributed to all urology specialists practicing in Israel. The survey consisted of 18 structured items examining demographic, academic, and clinical characteristics, as well as AP prescribing patterns and risk-factor considerations. Descriptive statistics, chi-square tests, and multivariate logistic regression were used to evaluate associations between physician characteristics and prophylactic antibiotic use. Results: Of 300 urologists, 75 responded (25%). Overall, 20% routinely prescribed AP for all patients undergoing cystoscopy, regardless of risk stratification. Academic rank was significantly associated with non-compliance; 41% of associate and full professors prescribed AP routinely (p = 0.012), and academic rank remained the only independent predictor on multivariate analysis (p = 0.009). Older age showed a trend toward increased non-adherence (p = 0.07), while gender, subspecialty, fellowship status, workplace, and procedure volume were not associated with prescribing practices. Guideline-based risk factors most frequently prompting AP use included immunosuppression (51%), chronic catheterization (48%), and recurrent urinary tract infections (37%). Conclusion: A significant number of urologists continue to prescribe AP prior to flexible cystoscopy, contrary to guideline recommendations. Academic rank was the strongest predictor of non-adherence, potentially reflecting workflow pressures and habitual practice patterns. Improved awareness, stewardship initiatives, and standardized protocols may enhance evidence-based AP utilization and reduce unnecessary antibiotic exposure.

Drug-coated balloon (DCB) urethral dilatation which offers an alternative to standard endoscopic treatments of male anterior urethral stricture disease (AUSD). Its ease of delivery has facilitated its use by urologists with various subspecialty interests. The objective of this study was to characterise real-world practice patterns of a DCB device. An exploratory cross-sectional online survey was distributed to Optilume® users via national and international urological societies and device distributor mailing lists. Descriptive and inferential statistics were performed using SPSS software. N = 102 urologists responded to the survey of whom n = 47 (46%) were reconstructive subspecialists. DCB dilatation was predominantly performed under general anaesthesia (n = 59, 58%). Significant variation was seen with catheter duration, perioperative antibiotic use and post-procedure contraception advice. Off-label use was common with respondents offering DCB for penile urethral strictures (65%), primary treatment (64%) and bladder neck stenoses (65%). Higher-volume users (≥ 10/year) were more likely to perform DCB under flexible cystoscopy (OR 5.14, 95% 1.57-16.79, p = 0.007), bladder neck stricture (OR 4.66, 95% CI 1.55-14.03, p = 0.006), and for recurrences (OR 6.92, 95% CI 2.22-21.6, p = 0.001). Limited practitioner experience, an evidence gap, and the importance of shared decision making were highlighted on thematic analysis. This study provides an insight into the early experience a novel DCB among practicing urologists. Further research is required to optimize patient selection, procedural protocols and the understanding of long-term outcomes.

In this case report, a 77-year-old female attended a department of urology for a flexible cystoscopy in local anaesthesia with injection of botulinum toxin A in the bladder wall. One day later, she presented with suprapubic pain and hypotension which stabilized spontaneously. She was discharged but presented twice within the following week with severe bladder pain that was treated with mild analgesics. Eight days after the procedure she was readmitted with a haematoma of the abdomen and right flank and continuous bladder pain. CT revealed a large retroperitoneal haematoma, which was managed conservatively.

ABSTRACT Cystoscopy is a cornerstone diagnostic procedure in urology, especially for diagnosing and monitoring various bladder pathologies, including urothelial tumours and haematuria of unknown origin. Recently, advancements in endoscopic technology have introduced single‐use flexible cystoscopies (SU‐FC) as an alternative to traditional reusable flexible cystoscopies (R‐FC), potentially simplifying workflow and reducing infection risk compared with reusable scopes. This prospective study aims to compare patient‐ and operator‐reported outcomes, including comfort, pain levels, image quality and overall satisfaction when employing single‐use versus reusable flexible cystoscopes. From October to December 2023, a single‐centre study was conducted, enrolling 200 patients undergoing diagnostic flexible cystoscopy, 10 urologists and 10 urologic scrub nurses. Standardized questionnaires, adapted from validated instruments, were used to collect data on perceived pain (Visual Analogue Scale), device performance, image quality and operator satisfaction. Statistical analyses (Wilcoxon rank‐sum, Fisher's exact) tested for significant differences between SU‐FC and R‐FC. Of the 200 patients, 100 underwent cystoscopy using SU‐FC and 100 with R‐FC. Patients in the single‐use group reported significantly lower or milder pain ( p = 0.0112) and higher satisfaction distributions ( p &lt; 0.0001). Operator assessments (physicians and nurses) indicated higher satisfaction with single‐use devices in terms of image clarity, navigation and instrument performance ( p &lt; 0.0001). SU‐FC confer notable benefits for both patients and healthcare professionals, including reduced pain, superior image quality and enhanced workflow. These findings support the broader investigation of disposable cystoscopy in routine practice while urging cost‐effectiveness and sustainability evaluations.

To conduct a randomised controlled trial (RCT) to assess the efficacy of the Urethrotech urethral catheterisation device (UCD®; Urethrotech Ltd., Kingston Upon Thames, Surrey, UK) catheter compared to a standard Foley catheter for catheterisation in post-phalloplasty transgender and gender diverse (TGD) individuals following urethral lengthening. In a prospective, single-blind RCT (Safe Access for Bladder Entry in Transgender Men Following Penile Reconstruction [SAFE]; ClinicalTrials.gov identifier NCT04454970), patients were allocated to catheterisation using either the UCD or a standard Foley catheter. Participants underwent insertion or revision of an inflatable penile prosthesis, with catheterisation as part of the planned surgery. The primary endpoint was successful catheterisation with the allocated catheter. If catheterisation failed, flexible cystoscopy with guidewire-assisted insertion of a standard Foley catheter was performed. Secondary endpoints included time to successful catheterisation, requirement for flexible cystoscopy or suprapubic catheter insertion, and 30-day complications. A total of 20 patients were randomised into two groups. The UCD was successfully inserted six of 10 patients, compared to three of 10 patients for the Foley catheter. The UCD is a promising device for catheterising tortuous urethras and addressing the unique challenges faced by clinicians managing patients after phalloplasty.

Flexible cystoscopy is well tolerated by women. Reprocessing of cystoscopes requires sterilization or, at least, high-level disinfection (HLD). This study aims to assess the incidence of bacteriuria after flexible cystoscopy using ortho-phthalaldehyde HLD. This is a prospective study. Seventy-eight women undergoing diagnostic outpatient flexible cystoscopy were included. Exclusion criteria were microbiologically confirmed or acute urinary tract infection, significant urethral stricture, and bleeding disorders. Cystoscopes were reprocessed using ortho-phthalaldehyde. Pre-cystoscopic urine cultures were obtained via catheterization 3-5days prior. Post-cystoscopic urine cultures were obtained immediately after the procedure. No antibiotics prophylaxis. One woman (1.3%) developed post-cystoscopy bacteriuria. The overall mean age was 58.7 ± 11.2years; the mean BMI was 23.4 ± 3.3kg/m2. In the non-bacteriuric cohort, the mean age was 58.87 ± 11.3years, 40 (51.9%) were in the older age group (> 60years), 60 (77.9%) were postmenopausal, 69 (89.6%) were non-diabetic, 20 (26%) had a prior hysterectomy, 13 (16.9%) had previous pelvic reconstructive surgery, 10 (13%) had undergone anti-stress urinary incontinence surgery, and no woman had current pelvic organ prolapse. The most common indication for flexible cystoscopy was hematuria (n = 45, 58.4%). Seventy-three (94.8%) women had unremarkable cystoscopic findings. The single bacteriuric woman was 53years old, postmenopausal, non-diabetic, with a BMI of 22.3kg/m2, and an intact uterus; cystoscopy was performed for interstitial cystitis. The incidence of bacteriuria following flexible cystoscopy was 1.3%. Ortho-phthalaldehyde is effective for HLD in flexible cystoscopy, provided robust rinsing, drying, and exposure-tracking protocols are maintained.

Non-visible haematuria (NVH) is a common reason for referral to urology services1. There is contrasting guidelines internationally regarding its investigation1,2. The aim of this study is to investigate the rate of detection and resource burden of NVH on a tertiary urology service. A retrospective chart review was performed which identified patients who were investigated for NVH from July 2023 to July 2024. Data was collected on patient demographics, indication, findings, and radiological imaging. Information regarding cost of investigations were also obtained. A total of 1,868 flexible cystoscopies were reviewed, with 175 (9.4%) indicated for NVH. One clinical diagnosis of bladder tumour was identified, and two cystoscopies identified an erythematous area warranting biopsy, both of which were benign. Imaging identified three patients with findings requiring follow-up imaging. Cost of flexible cystoscopy is estimated at €609, ultrasound imaging €102, CT imaging €170, and outpatient clinic appointment €150. This equates to minimum cost of €861 for investigation of NVH. Non-visible haematuria has a detection rate of 6% for urological malignancy in recent large volume studies2,3. Investigation contributes to a significant resource burden. Additionally, the risk to patients of these investigations must be considered. We welcome universal terminology and guidelines to be established.

Background/Objectives: Non-muscle invasive bladder cancer (NMIBC) is characterized by high recurrence rates, requiring frequent diagnostic and therapeutic interventions. This study evaluates the feasibility, safety, oncological outcomes, and economic impact of implementing an in-office laser bladder tumor fulguration protocol. Methods: A descriptive, longitudinal study was conducted between 2020 and 2025 on 65 patients with recurrent NMIBC. Procedures were performed in an outpatient setting under local anesthesia using a flexible cystoscope and a Holmium:YAG (Ho:YAG) laser. The primary endpoint was recurrence-free survival. Secondary endpoints included complication rates (Clavien-Dindo) and a cost-analysis comparison with conventional transurethral resection of the bladder (TURBT). Results: The mean age was 69.4 years, with 89.2% of patients classified as ASA ≥ 2. After a median follow-up of 20.3 months, the recurrence rate was 33.8%, with 0% progression. Most procedures (95.4%) had no complications; only 4.6% presented Clavien-Dindo grade 1 events. Adjuvant mitomycin C was administered in 93.8% of cases. The cost analysis demonstrated substantial economic advantages, with costs reduced by 89.7% versus the 24 h admission model and 82.1% versus the day-surgery model according to regional health-system tariffs. Conclusions: In-office laser fulguration is a safe, effective, and economically sustainable alternative to traditional TURBT for selected low-risk recurrences. It optimizes hospital resources, minimizes anesthetic risk in comorbid patients, and maintains favorable oncological control.

We aimed to compare patient pain perceptions and bladder cancer detection rates following cystoscopy performed by physician associates/physician assistants (PAs) versus staff urologists (SUs). We performed a secondary analysis of our earlier single-center, prospective, double-blind, randomized controlled trial that originally investigated irrigation "bag squeeze" versus standard cystoscopy. In this analysis, 98 men who underwent flexible cystoscopy by either a SU or a PA were included. Patients completed a pain questionnaire following the procedure. The mean pain score for SU-performed cystoscopy was 2.67 compared with 2.62 for PA-performed cystoscopy ( p = .92). A total of 23 cystoscopies (SU-performed, 11 [23%]; PA-performed, 12 [24%]; p > .05) resulted in positive or suspicious findings. Pathologic sampling was performed for 15 (SU-performed, 6; PA-performed, 9), out of which 8 total (SU-performed, 3 [6.25%]; PA-performed 5 [10%]) were positive for urothelial cancer. PA-performed cystoscopies demonstrate similar outcomes to those performed by physicians in terms of patient-reported pain scores and malignancy detection rates.

Introduction: Flexible cystoscopy is a common diagnostic procedure used to evaluate the urethra, bladder, and prostate by inserting a camera-equipped flexible tube through the urethra. Similarly, urinary catheterization involves the passage of a tube into the bladder for drainage or treatment. Both procedures are known to cause discomfort due to urethral sensitivity and share similar pre-procedural preparation steps. This quality improvement project (QIP) aimed to reduce patient discomfort during flexible cystoscopy by improving urethral preparation techniques, with potential applicability to urinary catheterization to minimize traumatic insertions and false passages.Methods: A mixed-methods approach was used. Observations were made of healthcare professionals performing pre-procedural urethral preparation to identify variations in lubrication techniques. Patient feedback was collected using the Numeric Pain Rating Scale (NPS) and the Visual Analog Scale (VAS) following flexible cystoscopy. After analyzing the findings, the staff was educated on appropriate lubrication techniques, emphasizing adequate gel application prior to instrumentation.Results: Initial observations revealed that inadequate lubrication was commonly practiced, contributing to increased discomfort during flexible cystoscopy. Questionnaire data confirmed higher reported pain scores among patients who received suboptimal lubrication. Following implementation of proper lubrication techniques, patients reported lower pain and discomfort levels, indicating improved procedural tolerance and patient satisfaction.Discussion and conclusion: Optimizing the urethral lubrication technique significantly reduces pain during flexible cystoscopy and may prevent traumatic catheterizations. Based on these findings, an instructional video will be developed for the National Health Service (NHS) Greater Glasgow and Clyde (GGC) to demonstrate correct versus incorrect lubrication methods. This initiative is expected to standardize best practices, enhance patient comfort, and reduce complications during urological procedures.

Background/Objectives: Transurethral Laser Ablation (TULA) is fast evolving as a surgical procedure, especially for small or recurrent bladder tumours. It offers a safe alternative for patients who are unsuitable for general anaesthetic (GA) or who cannot obtain timely pre-operative assessments for Transurethral Resection of Bladder Tumour (TURBT). Patients are identified for TULA in ‘Bladder Cancer Surgery Planning Meetings’ (BSPMs) and this significantly reduces their cancer waiting time (CWT). Its effectiveness as a diagnostic and therapeutic tool, including its complications and costs, has been assessed. Methods: All TULA procedures performed at the Trust were studied in two cycles. The first between August 2023 and November 2024, prior to initial audit, and then up to September 2025. Case notes, operation notes, and multidisciplinary team (MDT) outcomes were retrospectively reviewed. All procedures were performed with a flexible cystoscope and ‘cold cup’ biopsies with further ablation and haemostasis using a 1470 nm diode laser at 4 watts and 400 µm laser fibre. Patients were identified for TULA based on tumour size, location, and fitness for general anaesthetic. Results: During the study period, 95 TULA procedures were performed with a follow-up period between 4 weeks and 1 year. A total of 86 patients (90.5%) had local anaesthetic (LA) ± intravenous (IV) sedation, with 50% having LA alone in the second phase of the study; of the remaining patients, 8 had GA (8.4%) and 1 (1.1%) had spinal anaesthetic. None of the cases were considered to have missed a significant finding. One case (1.1%) was complicated, with ongoing bleeding requiring bladder washout under GA. BSPMs were introduced in July 2024 and audited in the first phase of this study. A total of 24 (39%) of patients were identified for TULA. Of those, 7 (29%) were originally scheduled for TURBT and were having difficulties obtaining pre-operative assessment (POA) clearance. Cost figures were provided by the hospital’s accountants. Conclusions: TULA has been implemented with a low complication rate and appropriate sampling. In the next phase, TULA will be rolled out to an outpatient setting, performed exclusively under LA. This will lead to a significant cost reduction.

Objective: Non-muscle invasive bladder cancer (NMIBC) is traditionally managed with transurethral resection of bladder tumour (TURBT) and intravesical therapy. Although effective, TURBT carries morbidity, particularly in frail or comorbid patients. Outpatient transurethral laser ablation (TULA) is an emerging alternative with fewer complications. However, national data on patient selection and practice patterns are limited. This survey provides a contemporary overview of TULA use in the United Kingdom. Materials and methods: A structured questionnaire was distributed to UK urologists, assessing current TULA practice, selection criteria, and barriers to service delivery. Results: Responses were received from 105 urologists. Of these, 60 (57%) reported performing TULA, averaging 348 procedures annually. Indications included low-grade, small (&lt;1 cm) superficial recurrences, and primary treatment in patients unsuitable for TURBT due to comorbidities. Additional considerations were anticoagulated patients and challenging lesion sites, such as the bladder dome. Reported limitations included technical challenges with lesion visibility during flexible cystoscopy, difficulties at the bladder neck, and service constraints related to funding and laser equipment availability. Conclusion: TULA is a promising treatment for carefully selected NMIBC cases, particularly in frail populations. Standardised selection criteria, prospective monitoring of outcomes, and establishment of a national registry are required to guide safe practice, inform clinical guidelines, and support equitable service provision. Level of evidence: Level 4 cohort study