Normal Cystoscopy Research Articles

Upper Urinary Tract Urothelial Carcinomas: Benefits of Diagnostic Ureteroscopy and Results of Conservative Treatment

Upper urinary tract urothelial carcinomas (UTUC) are rare and predominantly male. They may be multifocal in around 30% of cases. They are of particular interest because of the difficulties involved in their diagnosis. We report a series of 08 patients collected in the urology department of the Hôpital Nord Franche-Comte (HNFC) in Trevenans between 01/2019 and 03/2022. There were 05 men (62.5%) and 03 women (37.5%) with an average age of 70.85 years. Clinical symptoms were dominated by low back pain in 04 patients (50%), haematuria in 2 patients (25%), and a combination of low back pain and haematuria in 1 patient (12.5%). The finding was fortuitous in 1 patient (12.5%). The uroscanner performed in all our Patients revealed ureteral lesions in 7 patients (87.5%), a combination of ureteral lesion and ureteropyelocalic dilatation (UPD) in 4 patients (50%) and a normal uroscanner in 1 patient (12.5%). Ultrasound was not performed in any of our patients. Cystoscopy revealed an infracentimetric polyp at the level of the bladder dome in 3 patients (37%), including 1 patient undergoing surveillance for UTUC and who had no history of bladder tumour; the other 2 were already being monitored for bladder tumour; a trigonal polyp measuring approximately 3cm in 1 patient (12.5%) who had a history of bladder tumour, an infracentimetric floor polyp in 1 patient (12.5%) who had no history of bladder tumour, and normal cystoscopy in the other 3 (37.5%). Ureteroscopy revealed a papillary lesion measuring approximately 1cm in the middle calyx of the right kidney in 1 patient (12.5%), a lesion of the pelvic ureter in 4 patients (50%) measuring approximately 1.5cm, 2cm, 3cm in the first 3 patients and a lesion occupying the entire pelvic ureter in the 4th patient; a lesion of the iliac ureter in 3 patients (37.5%) whose sizes are approximately 1cm, 2cm, and 4cm. Urine cytology showed a strong suspicion of a high-grade urothelial lesion in 2 patients (25%), an appearance of a low-grade ..

Acquired childhood bladder melanosis

BackgroundBladder melanosis is rare. It has previously been described only in the fifth decade of life or beyond; it has not been described in childhood. Previous descriptions have generally been case reports, and so the natural history is poorly understood. Urinary symptoms present at the time of cystoscopy have frequently been attributed to bladder melanosis. A possible suggested aetiology is aberrant migration of melanocyte migration during embryogenesis.Case presentationWe present the first case of bladder melanosis in a child. He had been under our care since the age of 5 years with urinary incontinence and at that time, had undergone cystoscopy demonstrating normal bladder mucosa. A diagnosis of idiopathic detrusor overactivity with underactive voiding had been made. After other unsuccessful treatments, intravesical botulinum toxin was proposed. At the age of 13, repeat cystoscopy prior to botulinum toxin, demonstrated widespread pigmented areas in the bladder mucosa. Histology showed bladder melanosis. Our finding is important for several reasons. This is the first reported case of bladder melanosis to affect a child. The previous normal cystoscopy in our patient would refute the explanation that bladder melanosis is a congenital condition. Furthermore, the development of melanosis on the background of stable symptoms raises the possibility that the condition may be asymptomatic.ConclusionsThis unique finding of bladder melanosis in a child has provided further insight into this rare and poorly understood condition.

V07-10 SEMINAL VESICULOSCOPY FOR DIAGNOSIS AND MANAGEMENT OF HEMATOSPERMIA

You have accessJournal of UrologySexual Dysfunction & Transgender (V07)1 Sep 2021V07-10 SEMINAL VESICULOSCOPY FOR DIAGNOSIS AND MANAGEMENT OF HEMATOSPERMIA Aaron Brant, Nahid Punjani, Christopher Gaffney, Jonathan Fainberg, and James Kashanian Aaron BrantAaron Brant More articles by this author , Nahid PunjaniNahid Punjani More articles by this author , Christopher GaffneyChristopher Gaffney More articles by this author , Jonathan FainbergJonathan Fainberg More articles by this author , and James KashanianJames Kashanian More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002034.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Hematospermia is an uncommon urologic complaint but a cause of significant distress in affected patients. It is associated with bothersome symptoms such as dysorgasmia and chronic pelvic pain. First line treatment options include antibiotics, non-steroidal anti-inflammatory drugs (NSAIDS), alpha blockers, and 5-alpha reductase inhibitors. For patients with refractory symptoms, operative intervention with transurethral resection of ejaculatory ducts (TURED) and seminal vesiculoscopy has been described. METHODS: We provide a step-by-step description of seminal vesiculoscopy, TURED, and seminal vesicle (SV) balloon dilation in a 28-year old male presenting with five years of refractory hematospermia and dysorgasmia. He had failed treatment with antibiotics, NSAIDS, tamsulosin, and finasteride. His infectious and sexually-transmitted infection work-up was normal. His semen analysis was notable for 16% motility, 3.4 million WBC/mL, and cloudy brown color. Imaging with ultrasound and MRI revealed right SV dilation and clot in the left SV. RESULTS: After a normal cystoscopy, the verumontanum was identified, and the left ejaculatory duct was successfully cannulated with a 5-french open-ended catheter over a 0.014-inch micro-guidewire. Transrectal ultrasound was used to confirm correct placement. After dilation with a percutaneous transluminal angioplasty balloon dilator, the left seminal vesicle was entered under direct vision with a 4.5 french semi-rigid ureteroscope. Significant debris were noted and removed via irrigation through a luer-lock syringe. Both ejaculatory ducts were resected using a monopolar loop. The right SV was then cannulated, dilated, and entered under direct vision. Blood clot and debris were removed via irrigation. There were no post-operative complications. At six- and twelve-months follow-up, the patient reported significant improvement in dysorgasmia and complete resolution of hematospermia. CONCLUSIONS: Seminal vesiculoscopy with transurethral resection of ejaculatory ducts and balloon dilation is an effective procedure for hematospermia refractory to medical therapy in the appropriately selected patient. Source of Funding: N/A © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e553-e554 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Aaron Brant More articles by this author Nahid Punjani More articles by this author Christopher Gaffney More articles by this author Jonathan Fainberg More articles by this author James Kashanian More articles by this author Expand All Advertisement PDF downloadLoading ...

Evaluation of Spectra A and B Modes in Diagnosis of Suspicious Bladder Lesions.

Background: White light imaging (WLI) cystoscopy, a "gold standard" for diagnosis of nonmuscle invasive bladder cancer (NMIBC), can miss ∼25% of bladder cancers. Spectra A (SA) and Spectra B (SB) are virtual optical chromoendoscopy modes introduced by Storz. Objective: To evaluate whether SA and SB improve over WLI in diagnosis of NMIBC. Design, Setting, and Participants: Storz Professional Image Enhancement System (SPIES) modes allow side-by-side viewing of WLI and spectra images. Cystoscopy images of some patients with suspected NMIBC and some normal cystoscopy findings were cut in two parts: one WLI and the other SA or SB. Each individual image was sent to the 3721 members of Urological Society of India separately through online survey. Histologic diagnosis was considered final diagnosis. Intervention: The observers were asked whether they considered the image to be cancer; yes, no, or cannot say were the three response options. Outcome Measures and Statistical Analysis: Primary outcome measure was improved diagnosis of NMIBC. Diagnostic efficacy was analyzed through 2 × 2 tables, McNemar test, and Fleiss Kappa. Results and Limitations: A total of 273 observers participated in the study. The sensitivities of WLI, SA, and SB were 89.81, 91.15, and 88.81, respectively. The specificities were 73.18, 66.17, and 68.68, respectively. In patients with cancer, both SA and SB improved the diagnostic efficacy of WLI. SA added significantly to the diagnostic accuracy over WLI (χ2 = 12.23, p = 0.00046). SB also added significantly over WLI (χ2 = 11.76, p = 0.0006). With increasing cancer grade, the sensitivity and negative predictive value of all modes increased. The major limitation of this study is the online diagnosis based on still images. Conclusions: In patients with cancer, SA and SB significantly add to the diagnostic accuracy of WLI. As compared with the negative WLI, if SA and SB are negative, NMIBC would be less likely.

Video Atlas of Cystourethroscopy Findings

Study Objective The objectives of this video are to demonstrate normal findings at the time of cystourethroscopy, show examples of common benign findings within the bladder and urethra, and to show lesions that warrant additional investigation. We hope to provide examples of common benign and malignant findings to gynecologic surgeons to assist with recognition if they incidentally found. Design N/A Setting Tertiary academic hospital with a high-volume gynecologic surgery practice Patients or Participants The images shown in the video are taken from a variety of patients undergoing cystoscopy by two urogynecologists. Interventions Images were obtained at the time of surgery for educational purposes Measurements and Main Results This video demonstrates the equipment and steps of performing cystourethroscopy. We review examples of the following benign anatomic variants: shaggy urethral fronds, squamous metaplasia, cystitis cystica, bladder trabeculations, ureterocele, bladder diverticula, bladder wall cysts, ureteral orifice cysts, hypervascularity, duplicated collecting systems, foreign bodies, and fistulas. We also review two examples of neoplastic findings, including urothelial papilloma and papillary urothelial carcinoma. Conclusion Cystoscopy can be a useful procedure in the office and operating room. Gynecologic surgeons should be familiar with normal cystoscopy findings. If abnormalities are found, it is the surgeon's responsibility to document and refer the patient for additional testing if indicated.

Management of Patients with Normal Cystoscopy but Positive Cytology or Urine Markers

This presentation considers follow-up after successful transurethral resection of a high-grade non-muscle-invasive tumour, with normal cystoscopy, followed by bacillus-Calmette-Guérin (BCG) therapy. Focusing on two possible outcomes, a positive cytology but a negative urinary biomarker result, versus positive biomarkers but a negative cytology, we discuss what the evidence and guidelines recommend and which test is more robust. Patient summaryBladder cancer is usually assessed by examination of tissue taken from the bladder, either by surgery or by biopsy; however, trace elements in the urine, known as biomarkers, can also provide an assessment. The challenge arises when the two methods do not agree: the tissue sample is positive for cancer, but the biomarker is negative, or the reverse. For now, these authors conclude that the tissue examination is more reliable than the biomarker result.

Case Report about a Primary Bladder Lymphoma

Primary isolated bladder lymphoma represents around 0.2% of all extranodal Non-Hodgkin-Lymphoma and less than 1% of all bladder tumours. Clinical representation may be unspecific and correct diagnosis is essential for the appropriate treatment. We expose the case of a patient with a primary B-cell bladder lymphoma with normal cystoscopy.

The occult urothelial cancer.

Transitional cell carcinoma (TCC) is the tumor that most frequently affects the urinary tract. The most common location is in the bladder; the diagnosis, as the follow-up, is based on urine cytology, endoscopic, and radiological examinations. Urinary cytology is an important non invasive tool used in the diagnosis and follow-up of patients with TCC. A positive urine cytology result is highly predictive of the presence of TCC, even in the presence of normal cystoscopy, because malignant cells may appear in the urine long time before any cystoscopically visible lesion becomes apparent. The presence of a positive urinary cytology, in the absence of clinical or endoscopic evidence of a TCC, can identify an occult urothelial cancer, located in any site of the urinary tract (upper urinary tract, bladder, prostatic urethra). Most of the urothelial tumors of the renal pelvis and ureters are diagnosed by radiological examinations, but we can observe a high rate of false negatives. In order to improve the diagnostic role of urinary cytology and other conventional examinations, numerous molecular markers have been identified; however, the real clinical application remains unclear. Photodynamic diagnosis and narrow band imaging (NBI) cystoscopy increase the diagnostic accuracy of endoscopic examinations in the presence of lesions not easily detectable. The aim of this review is to analyze the current diagnostic standards in the presence of occult urothelial cancer.

The Additional Value of Cystoscopy with Urodynamic Study in the Assessment of Patients with Urinary Incontinence

Background: Urinary incontinence (UI) is generally defined as the involuntary loss of urine from the bladder through the urethral meatus. Filling cystometry is the method by which the pressure/ volume relationship of the bladder is measured during bladder filling. Purpose: To determine the value of diagnostic cystoscopy in addition to Urodynamic study (UDS) in patients with primary urinary incontinence. Material and Methods: 200 patients with primary incontinence studied prospectively from January 2013 to June 2014. Their age ranges from (14 - 93 years), 86.5% were female, and 13.5% of them were male. In addition to physical, neurological examination and bio-chemical investigations, urine analysis and urine culture with Ultra-sound and Post void residual volume (PVRV), all patients underwent diagnosticflexible cystoscopy under local anesthesia, and urodynamic study. Result: 43.5% of patients age were between (34 - 53 years), (39%) between (54 - 73 years), (9%) between (14 - 33 years) and (8.5%) were between (74 - 93 years). Atonic bladder on UDS were (40.5%), Detrusor over activity (29%), patients with normal UDS were (22%) and patients that had DSD (Detrusor Sphincter Dyssynergia) were (8.5%). Eighty-four cases (42%) were found to have normal cystoscopy, those with grade-I-II bladder wall trabeculations were (49%) and patients with grade-III were (8.5%). Sixty-one patients (30.5%) with normal diagnostic cystoscopy have abnormal UDS (Atonic bladder, over-active bladder and DSD) while twenty-one (10.5%) patients with normal UDS had bladder wall trabeculations (grade-I-III) on diagnostic cystoscopy. Conclusion: Diagnostic cystoscopy in addition to urodynamic study will put in further knowledge in the assessment of patients with urinary incontinence. To some extent, it can predict the diagnosis.

Multicenter evaluation of the role of UroVysion FISH assay in surveillance of patients with bladder cancer: does FISH positivity anticipate recurrence?

The significance of a positive UroVysion FISH assay is uncertain in patients with normal cystoscopy. This multicenter study evaluates the clinical significance of a positive FISH assay in patients with no visible tumor and excluding those with a positive cytology. A multi-institutional, retrospective study of patients with a history of urothelial carcinoma of the bladder identified 664 patients with a FISH assay after excluding those with cystoscopic evidence of a tumor and/or positive cytology. Our primary end point was cancer recurrence, defined by biopsy. Progression was defined as recurrence with a tumor stage ≥T2. Statistical analyses were performed using Fisher's exact test as a one-tailed test and Chi-square test with significance at 0.05, using SPSS(®) version 19.0 (SPSS Inc., Chicago, IL, USA). Of the 664 patients in this study, tumor stage was Ta (363, 55 %), T1 (183, 28 %), and CIS (109, 16 %) and most were high grade (440 pts, 66 %). The median follow-up was 26 months (3-104 months), and 277 (41.7 %) patients were recurred. In patients who were FISH positive, mean time to recurrence was 12.6 months, compared to 17.9 months if FISH negative (p = 0.03). In univariate analysis, atypical cytology, positive FISH, cystoscopic findings (atypical vs. normal), and previous intravesical therapy were associated with recurrence (p < 0.05). On multivariate analysis, pathologic stage, cystoscopic findings, and cytology were independently associated with recurrence (p < 0.05). Progression to ≥T2 disease occurred in 34 (5.1 %) patients in this cohort. On multivariate analysis, only initial T stage and FISH result were found to be independent predictors of progression (p < 0.05). Patients with a positive FISH and atypical cytology are more likely to recur even in the absence of visible tumor. FISH positivity may portend a higher risk for progression. These findings require prospective validation.

Bladder cancer: Normal cystoscopy, malignant cytology in NMIBC: why biopsy?

Bladder biopsy of normal-looking mucosa, as determined by cystoscopy, might not add clinical value in patients with positive voided-urine cytology after treatment of non-muscle-invasive bladder cancer. Methods to add value to bladder biopsies, such as characterization of molecular alterations, should be considered.

Bladder Biopsy of Normal-Appearing Mucosa is Not Helpful in Patients with Unexplained Positive Cytology after Nonmuscle Invasive Bladder Cancer

Malignant voided cytology with normal endoscopic evaluation represents a diagnostic and therapeutic challenge in many patients with a history of nonmuscle invasive bladder cancer. Bladder biopsy is often advised but its efficacy is unclear. We evaluated the usefulness of bladder biopsy in patients with unexplained positive cytology and describe recurrence patterns in this unique patient subset. From an institutional database we retrospectively identified patients with a history of nonmuscle invasive bladder cancer and surveillance cystoscopy from 2008 to 2012 who had malignant voided urine cytology but normal cystoscopy. Patients underwent systematic bladder biopsy or cystoscopic surveillance and were followed for recurrence and progression. Of 444 patients 343 were followed with surveillance only and 101 underwent a total of 118 biopsies of normal-appearing bladder mucosa. Three biopsies (2.5%) showed carcinoma in situ and none revealed invasive carcinoma. During the median 32-month followup recurrence developed in the bladder in 194 patients (44%), in the upper tract in 24 (5%) and in the prostatic urethra in 5 (1%) while 219 (49%) had no recurrence. A previous diagnosis of upper tract urothelial carcinoma and a history of bacillus Calmette-Guérin treatment were associated with an increased recurrence risk on multivariate analysis. Recurrence rates and patterns were similar in the biopsy and surveillance groups. Patients with malignant cytology despite normal cystoscopy have a high recurrence rate. Biopsy of normal-appearing bladder mucosa in this setting is rarely positive and does not alter the recurrence pattern.

V10-01 BLUE LIGHT CYSTOSCOPY: INITIAL USC EXPERIENCE

You have accessJournal of UrologyBladder Oncology/Robotics1 Apr 2014V10-01 BLUE LIGHT CYSTOSCOPY: INITIAL USC EXPERIENCE Mehrdad Alemozaffar, Hooman Djaladat, Anne Schuckman, and Siamak Daneshmand Mehrdad AlemozaffarMehrdad Alemozaffar More articles by this author , Hooman DjaladatHooman Djaladat More articles by this author , Anne SchuckmanAnne Schuckman More articles by this author , and Siamak DaneshmandSiamak Daneshmand More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2450AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Intravesical administration of hexaminolevulinic acid has been shown to improve the detection of non-muscle invasive bladder (NMIBC) during cystoscopy when viewed under blue light. The product has been available in Europe for several years (Hexvix) and has recently been approved in the US (Cysview) and is being used by select centers. In the video we demonstrate use of Cysview for detection of NMIBC. METHODS From August 2012 to August 2013, 96 patients scheduled for TURBT at our institution have undergone instillation of Cysview and cystoscopy under blue light. Several cases are highlighted in the video demonstrating cystosocpic view under normal and blue light with pathology results. RESULTS Use of Cysview to detect NIMBC is demonstrated in 2 select cases as seen in figure 1. The top images are under normal cystoscopy and the bottom images demonstrate the same view under blue light cystoscopy following administration of Cysview. The fluorescent areas were biopsied and revealed high-grade pT1 in the patient on the left and high grade pT1 and CIS in the patient on the right. CONCLUSIONS Use of Cysview can help with the detection of NMIBC as well as CIS in patients undergoing TURBT for bladder cancer. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e905-e906 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Mehrdad Alemozaffar More articles by this author Hooman Djaladat More articles by this author Anne Schuckman More articles by this author Siamak Daneshmand More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Commentary on “The value of transurethral bladder biopsy after intravesical bacillus Calmette-Guérin instillation therapy for nonmuscle invasive bladder cancer: a retrospective, single center study and cumulative analysis of the literature.” Swietek N, Waldert M, Rom M, Schatzl G, Wiener HG, Susani M, Klatte T. Department of Urology, Medical University of Vienna, Vienna, Austria: J Urol 2012;188(3):748-53 [Epub 2012 Jul 20

PurposeWe evaluated the need of routine transurethral biopsies after an induction course of intravesical bacillus Calmette-Guérin for high grade nonmuscle invasive bladder cancer. Materials and methodsThis retrospective study included 180 patients with high grade nonmuscle invasive bladder cancer who underwent a 6-week induction course of bacillus Calmette-Guérin. Cystoscopic findings, urinary cytology and pathological results of transurethral biopsy were evaluated. For cumulative meta-analysis we systematically reviewed studies indexed in MEDLINE®, EMBASE® and Web of Science®. The records of 740 patients from a total of 7 studies were finally analyzed. ResultsBiopsy was positive in 58 patients (32%). Cystoscopy appeared normal in 75 patients (42%) and showed only erythema in 51 (28%) and tumor in 54 (30%), of whom 6 (8%), 11 (22%) and 41 (76%), respectively, showed positive findings at biopsy. The positive predictive value of erythema was 15% with negative cytology and 56% with positive cytology. The positive predictive value of a tumor with negative and positive cytology was 63% and 89%, respectively. A combination of negative cytology and normal cystoscopy was associated with a negative biopsy in 94% of cases. A total of 970 bladder biopsies were taken, of which 137 (14%) were positive, including 20 of 125 erythematous lesions (16%), 73 of 107 tumors (68%) and 44 of 738 normal-appearing areas (6%). Cumulative analysis findings were comparable. ConclusionsRoutine transurethral bladder biopsies after a bacillus Calmette-Guérin induction course are not necessary. An individually approach is recommended, tailored from cystoscopic findings and cytology.

Hunner’s lesions

The article in this issue of CUAJ on endoscopic ablation of Hunner’s ulcers1 raises several issues related to interstitial cystitis/painful bladder syndrome (IC/PBS) that are noteworthy: IC/PBS is common, Hunner’s ulcers are rare, but their presence should prompt biopsy and fulguration. Interstitial cystitis is common.2 Payne and colleagues1 cite 10-year-old data showing that the prevalence of IC/PBS approaches 1 million people in the United States.3,4 Even this number underestimates its true prevalence.5,6,7 A recent, exhaustive study with over 100 000 American households with follow-up interviews for possible IC/PBS subjects shows a prevalence estimate of 3% to 6% of American women over the age of 18 meet symptom criteria for IC/PBS.8 Urologists undoubtedly encounter IC/PBS patients frequently in their practices.6 Hunner’s ulcers represent the minority of IC/PBS cases, typically less than 7% of patients. Moreover, this study mirrors others in that Hunner’s ulcers generally occur in older patients, with median ages of 53 to 65.9–11 Historically, Hunner’s ulcers were considered the hallmark of IC/PBS. Yet, they are rare and seen primarily in advanced phases of IC/PBS. Hunner’s ulcer patients tend to be more symptomatic (more pain, more nocturia, smaller voided volumes) and may have increased mast cell counts below the denuded epithelium.12,13 Importantly, the absence of Hunner’s ulcers on cystoscopy does not exclude IC/PBS as a diagnosis. In the younger patient whose symptoms suggest IC/PBS, cystoscopy may show a normal-appearing bladder.2,14 A normal cystoscopy does not exclude IC/PBS. In the current study, the authors describe a non-validated test, whereby “touching” the patch of denuded epithelium with the cystoscope tip produced pain, and their control was to “touch” similarly non-affected areas. In my experience of outpatient flexible cystoscopy with IC/PBS patients with Hunner’s ulcers, small volumes of bladder filling reproduce their pain. I am not convinced that “touching” the lesion to reproduce pain is a valid test. More importantly, the image of the Hunner’s ulcer is difficult to distinguish from carcinoma in situ. Any patient with these cystoscopy findings should undergo bladder biopsy, at which time the lesion can be fulgurated or ablated. The excellent results reported in this study1 mirror my own experience, in that I find older IC/PBS patients frequently have Hunner’s ulcers, and they obtain symptom relief from fulguration of the ulcer.11 In my follow-up of these patients, if they have flare-ups, I am quick to repeat the cystoscopy. If I find a recurrent ulcer, and it is re-fulgurated, these patients tend to obtain symptom relief.

The Value of Transurethral Bladder Biopsy after Intravesical Bacillus Calmette-Guérin Instillation Therapy for Nonmuscle Invasive Bladder Cancer: A Retrospective, Single Center Study and Cumulative Analysis of the Literature

We evaluated the need of routine transurethral biopsies after an induction course of intravesical bacillus Calmette-Guérin for high grade nonmuscle invasive bladder cancer. This retrospective study included 180 patients with high grade nonmuscle invasive bladder cancer who underwent a 6-week induction course of bacillus Calmette-Guérin. Cystoscopic findings, urinary cytology and pathological results of transurethral biopsy were evaluated. For cumulative meta-analysis we systematically reviewed studies indexed in MEDLINE®, EMBASE® and Web of Science®. The records of 740 patients from a total of 7 studies were finally analyzed. Biopsy was positive in 58 patients (32%). Cystoscopy appeared normal in 75 patients (42%) and showed only erythema in 51 (28%) and tumor in 54 (30%), of whom 6 (8%), 11 (22%) and 41 (76%), respectively, showed positive findings at biopsy. The positive predictive value of erythema was 15% with negative cytology and 56% with positive cytology. The positive predictive value of a tumor with negative and positive cytology was 63% and 89%, respectively. A combination of negative cytology and normal cystoscopy was associated with a negative biopsy in 94% of cases. A total of 970 bladder biopsies were taken, of which 137 (14%) were positive, including 20 of 125 erythematous lesions (16%), 73 of 107 tumors (68%) and 44 of 738 normal-appearing areas (6%). Cumulative analysis findings were comparable. Routine transurethral bladder biopsies after a bacillus Calmette-Guérin induction course are not necessary. An individually approach is recommended, tailored from cystoscopic findings and cytology.

'Stop going off on a tangent': a novel method for discriminating pathological from tangential fluorescence during photodynamic diagnosis cystoscopy

BACKGROUND Fluorescence photodynamic diagnosis (PDD) cystoscopy is gaining credence in the diagnosis and surveillance of bladder cancer. It combines normal white light cystoscopy with periodic blue light examination of the bladder pre-instilled with a tumour selective porphyrin, hexa-aminolevulinic acid (hexa-ALA). 1 This method detects areas of fluorescent tissue suggestive of tumour or carcinoma in situ, and has been shown to decrease recurrence rates and improve outcomes when compared with white light cystoscopy. 2 The mucosa of the bladder neck and lateral bladder wall is viewed at an angle on blue light cystoscopy and displays tangential fluorescence following hexa-ALA instillation. Although a useful observation, by acting as a positive control, 3 a common conundrum remains the discrimination between pathological and tangential fluorescence. We describe a simple technique to aid in discriminating between the two.

Reported use of intravesical therapy for non‐muscle‐invasive bladder cancer (NMIBC): results from the Bladder Cancer Advocacy Network (BCAN) survey

Study Type - Therapy (patterns of practice) Level of Evidence 2b. What's known on the subject? and What does the study add? Claims-based analyses suggest unexplained and potentially problematic variation in treatment intensity adherence to guidelines-recommended care in NMIBC. Previous physician surveys prior to the contemporary Clinical Practice Guidelines (CPGs) reported associations between variation in NMIBC care and practice type, years in practice, and other physician-related factors. In the largest physician survey addressing the management of NMIBC, and the first to examine these questions after the promulgation of contemporary CPGs, US urologists report grade-specific utilization consistent with CPG recommendations, at rates higher than suggested by recent claims-based analyses. As with prior studies, practice type and years in practice were significantly associated with variation in practices. Further research is needed to reconcile these findings with administrative claims data. To determine self-reported practices of use of intravesical chemo- and immunotherapy for patients with non-muscle-invasive bladder cancer (NMIBC) • To evaluate the extent to which respondent characteristics were associated with any observed variation. Guidelines recommend intravesical therapy (IVT) in the management of NMIBC, but recent claims-based analyses suggest exceedingly low rates of use of some of these therapies. An electronic survey was developed by members of the Bladder Cancer Advocacy Network (BCAN) to elicit self-reported use of management strategies for NMIBC. • The survey was circulated to urologists via the American Urological Association, Society for Urologic Oncology and Large Urology Group Practice Association distribution lists. • In all, 512 respondents completed the survey. In all, 63% reported routine perioperative mitomycin-c (MMC) after transurethral resection of bladder tumour (80% academic vs 54% private practice, P < 0.001). • Whereas 5% of respondents reported routine induction therapy with all new low-grade (LG) diagnoses, 99% reported routinely doing so in new high-grade (HG) cases; most commonly with single-agent bacille Calmette-Guérin (BCG) (94% vs 9% BCG/interferon and 5% MMC). • Reported induction therapy was higher in the setting of high-volume (77%) or frequently recurrent (44%) LG disease. • In all, 89% reported routinely using maintenance therapy for HG vs 29% for LG disease. • Routine biopsy after BCG, even with normal cystoscopy, was endorsed by 28% (39% academic vs 22% private practice, P < 0.001). Urologists report grade-specific use of IVT for NMIBC, at rates higher than suggested in some claims-based analyses. • Further study is needed to corroborate these self-reported patterns of care with lower rates of use suggested by claims-based analyses.

Does 3D Ultrasound Enhance the Diagnosis of Bladder Tumours in Patients with Haematuria?

Purpose. Bladder cancer is a frequent cause of haematuria in elderly patients, and bladder ultrasound (US) is a valuable tool in diagnosing these malignancies. We examined the accuracy of 3D bladder US in diagnosing bladder tumors in patients with haematuria. Patients and Methods. Twenty-one patients observed in the emergency department for haematuria underwent a kidney and bladder US. Patients with normal or uncertain bladder US findings underwent a 3D US and a cystoscopy. Results. In 5 (23.8%) patients, the 3D US detected bladder tumours not seen in 2D US. All these patients were found to have bladder tumours on cystoscopy. Another 5 (23.8%) patients with uncertain findings on 2D US had normal 3D US and cystoscopy. 3D US showed a sensitivity of 83.3% and a specificity of 100% with a positive predicted value and negative predictive values of 100% and 93.8%, respectively. Conclusion. 3D US was more sensitive than 2D US in diagnosing bladder tumours in patients with haematuria.

Ability of urovysion FISH analysis to select patients with low- or intermediate-risk non-muscle-invasive bladder cancer (LI-NMIBC) for decreased surveillance.

283 Background: Recurrent LI-NMIBC is difficult to detect cytologically, requiring frequent cystoscopies. Urovysion's (Abbot Laboratories, Downers Grove, IL) fluorescent in situ hybridization assay (FISH) detects genetic changes associated with LI-NMIBC and may be useful in identifying patients for extended screening intervals. Methods: Charts of 54 consecutive patients with LI-NMIBC who underwent cystoscopy, cytology, and FISH analysis every 3 months for the first year after resection since 2004 were retrospectively identified and reviewed. We analyzed the number of tumors or high-grade cytologies that would have been missed if surveillance cystoscopy, cytology, and FISH analysis had not been done between 3 and 12 months post-resection for patients with a normal cystoscopy, cytology, and FISH analysis at 3 months after initial resection and compared those results to patients with normal cystoscopy, cytology, and abnormal FISH analysis. Results: Mean age of the 54 patients was 67 (range 25–89) and 41 were males. Thirty-nine patients had normal cystoscopy, cytology, and FISH analysis at 3-months follow-up. If no further surveillance was done until 1 year post-resection, 2 low-grade tumors (3 and 7 mm at 7 months post-resection) and 2 incidents of high-grade cytology would have been missed (4 of 39, 10%). Fifteen patients had normal cystoscopy and cytology but abnormal FISH analysis results at 3 months. If no further surveillance had been done until 1 year after resection, 6 tumors (6 of 15, 40%) (5, 8, 3, 3, 9, 2 mm at 5, 6, 6, 7, 9, 10 months post-resection) and no high-grade cytology would have been missed. Overall, statistically fewer patients with normal compared to abnormal FISH analysis at first follow-up developed tumors before 1 year (4 of 39 vs. 6 of 15, p=0.033). Conclusions: FISH analysis can be used to significantly increase our ability to select patients suitable for extended screening intervals. It may be prudent to include FISH analysis at the first post-resection follow-up before selecting patients with LI-NMIBC for an extended screening interval. [Table: see text]