Transurethral Resection Procedures Research Articles

Metastasis development in non-muscle-invasive bladder cancer.

Non-muscle-invasive bladder cancer (NMIBC) is the most common type of bladder cancer presentation and is characterized by a varying probability of recurrence and progression. Sporadically, patients with NMIBC might also develop tumour metastases without any pathological evidence of muscle-invasive disease within the bladder, a condition known as metastatic NMIBC. In the published literature, this phenomenon is limited to several case reports and small reviews, with few data regarding the possible aetiologies. Several possible factors can be potentially associated with metastatic NMIBC, including tumour understaging, the number of transurethral resection procedures received by the patient, the presence of circulating tumour cells, the modality used for diagnostic cystoscopy and possible gender-associated differences. In this Perspective, our aim was to integrate and report currently available data on this relatively rare entity and provide some potential aetiological explanations.

The relationship between heart failure and smoking, and development of urethral stricture.

To evaluate the relationship between heart failure (HF), chronic obstructive pulmonary disease (COPD), and smoking with the development of urethral stricture (US) by examining the patients who underwent transurethral prostate resection procedure, with and without the development of US in their follow-ups. Among the patients who underwent transurethral resection of the prostate, 50 patients who developed US during their follow-ups formed group 1, while a total of 50 patients who did not develop US and were selected by lot formed group 2. The relationship between the patients' data on HF, COPD and smoking status and the development of US was investigated. The mean number of cigarettes smoked was statistically significantly high in the group with stricture (p = 0.007). Furthermore, pulmonary function test parameters of patients such as forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and FEV1/FVC were found to be statistically significantly higher in Group 2 (p < 0.001, p < 0.001, and p = 0.008, respectively). In the logistic regression analysis, being a smoker was found to be the strongest predictor (p = 0.032). Our study concluded that smoking, HF, and COPD significantly increase the risk of developing stricture after transurethral resection of the prostate.

Adreno-Muscarinic Synergy of Contractile Responses From Human Hyperplastic Prostate.

Adreno-muscarinic synergy, a supra-additional contractile response to simultaneous application of α-adrenoreceptor and muscarinic receptor agonists, is a feature of several lower urinary tract regions that have dual sympathetic and parasympathetic innervation. We tested the hypothesis that synergy is also a feature of prostate tissue obtained from men with benign prostatic enlargement. Isolated tissue strips were dissected from prostate 'chips', collected after transurethral prostate resection procedures for in vitro experiments, to measure isometric tension at 36°C. Added separately to the superfusate, phenylephrine and carbachol generated contractions with mean pEC50 (-log10EC50) values of 5.36 and 5.58, respectively, although phenylephrine maximal responses were about six-fold greater. In the presence of carbachol, the mean phenylephrine pEC50 was significantly increased to 5.84 and maximal response increased by 28%; overall, a significant synergistic response was demonstrated. The synergistic response was reduced by muscarinic receptor antagonists, most potently by the M3-selective agent 4-DAMP (1,1-dimethyl-4-diphenylacetoxypiperidinium iodide), and less so by M2 and M1-selective inhibitors gallamine and pirenzepine, but with an overall profile indicating M3/M2 mediation of the synergistic response. The magnitude of the synergistic response was variable between prostate chips that provided isolated preparations suggesting regional heterogenicity, although their zonal origin could not be determined. These experiments show that adreno-muscarinic contractile synergy is a feature of human hyperplastic prostate tissue. This has implications for the use of a combination therapy of α-blockers and anti-muscarinic agent to relieve secondary symptoms associated with benign prostatic hyperplasia, at least in men who can tolerate antimuscarinics without a risk of retention.

A Study on Bipolar Transurethral Resection of Prostate (TURP) versus Transurethral Resection and Electrovaporization (TURP-TUVP) Sandwich Procedure

Background: TURP is the gold standard for the endoscopic treatment of BPH. Nonetheless, it remains associated with significant morbidity, especially in terms of hemorrhage leading to possible blood transfusion and delayed hospital discharge. TUVP is associated with reported improvements in subjective and objective measures but a high rate of postoperative irritative symptoms and lack of tissue for histologic examination. The concept behind TURP and TUVP sandwich procedure is to overcome the drawbacks of the two procedures. Objective: To compare the outcome of bipolar transurethral resection of prostate (TURP) and bipolar transurethral resection and electrovaporization of prostate (TURP-TUVP) sandwich procedure in patient with benign prostatic hyperplasia. Methods: This quasi experimental study was conducted in the Department of Urology, National Institute of Kidney Diseases and Urology (NIKDU), Dhaka, Bangladesh from July 2017 to June 2019 over a period of 2 years. Sixty patients with BOO caused by benign prostatic hyperplasia scheduled for transurethral resection of prostate were included in this study. Patients were selected first by purposive sampling and were grouped into A and B with randomization. Group A patients underwent bipolar TURP while group B patients underwent sandwich method. Perioperative findings as well as IPSS Qmax and PVR after 3 months of operation were compared. Results: Operative time was significantly longer in TURP-TUVP group than in TURP group (P value 0.036).Post operative hospital stay was significantly longer in TURP group (P value &lt;0.001). Catheterization time was significantly higher in TURP group (P value &lt;0.001).Intra-operative irrigation was significantly higher in TURP-TUVP group (P value 0.001). Post operative irrigation time was significantly longer in TURP group (P value &lt;0.001). Hemoglobin decrease was significantly higher in TURP group (P value &lt;0.001). Similarly, sodium decrease was higher in TURP group than that of TURP-TUVP group but not statistically significant (P value 0.81).Clot retention was 2 (6.7%) in TURP group. Short-term follow up at 3 month showed no significant difference in IPSS in TURP and TURP-TUVP groups (P value 0.349), significantly higher Qmax in TURP-TUVP group (P value 0.022) and significantly higher PVR in TURP group (P value0.005) Conclusion:. TURP-TUVP procedure has higher operative time and intraoperative irrigation, but has significantly lower catheterization time, postoperative irrigation time, hemoglobin change and hospital stay. Bangladesh J. Urol. 2021; 24(2): 161-165

Bladder Explosion during Transurethral Resection Surgery-Case Series

The explosion of the bladder or intravesical explosion is a rare but possible complication in Transurethral Resection (TUR) procedures. The chances of a bladder rupture occurring during TUR are approximately 0.02%. In all types of transurethral surgeries which involve diathermy, the possibility of bladder explosion remains. It can be in the form of a mucosal tear which is a simple or a deep rupture in the bladder. Immediate and quick intervention is important for repairing the bladder when this complication occurs. The initial cases of this complication were reported in 1926. Since then, there have only been thirty reports of such complications.

Multi-Institutional Study of Dorsal Onlay Urethroplasty of the Membranous Urethra after Endoscopic Prostate Procedures: Operative Results, Continence, Erectile Function and Patient Reported Outcomes

(1) Background: To critically evaluate dorsal onlay buccal mucosal graft urethroplasty (DOBMGU) for posterior urethral stenosis repair following transurethral resection and other endoscopic prostate procedures. (2) Methods: A retrospective multi-institutional review of patients with membranous or bulbomembranous urethral stenosis for whom treatment with DOBMGU was conducted after receipt of prostate endoscopic procedures. Baseline data, peri-operative care, post-operative care and patient-reported outcomes were analyzed. The primary outcomes were procedural failure and development of de novo stress urinary incontinence (SUI). The secondary outcomes were changes in voiding, sexual function and patient satisfaction. (3) Results: A total of 107 men with a mean age of 69 ± 9.5 years and stenosis length of 3.5 ± 1.8 cm were included. Prior endoscopic procedures among participants were 47 patients (44%) with monopolar TURP, 33 (30.8%) with bipolar TURP, 16 (15%) with Greenlight laser, 9 (8.4%) with Holmium laser enucleation and 2 (1.9%) with bladder neck incision. At a mean follow-up time of 59.3 ± 45.1 months, stenosis recurred in 10 patients (9.35%). Multivariate analysis confirmed that postoperative complications (OR 12.5; p = 0.009), history of radiation (OR 8.3; p = 0.016) and ≥2 dilatations before urethroplasty (OR 8.3; p = 0.032) were independent predictors of recurrence. Only one patient (0.9%) developed de novo SUI. Patients experienced significant improvement in PVR (128 to 60 cc; p = 0.001), Uroflow (6.2 to 16.8 cc/s; p = 0.001), SHIM (11.5 to 11.7; p = 0.028), IPSS (20 to 7.7; p < 0.001) and QoL (4.4 to 1.7; p < 0.001), and 87 cases (81.3%) reported a GRA of + 2 or better. (4) Conclusions: DOBMGU is an effective and safe option for patients with posterior urethral stenosis following TURP and other prostate endoscopic procedures. This non-transecting approach minimizes external urinary sphincter manipulation, thus limiting postoperative risk of SUI or erectile dysfunction.

Irrigation fluid absorption during transurethral bipolar and laser prostate surgery: a systematic review.

Transurethral endoscopic procedures using bipolar current, or laser energy are nowadays widely accepted and have replaced the traditional monopolar resection. A major advantage of these techniques is the utilization of isotonic saline as irrigation solution, which minimizes side effects such as symptoms associated to classical transurethral resection syndrome (TUR-syndrome). Nonetheless, clinically significant IFA also occurs with saline and is determined by pressure gradients, systemic resistance and by the amount of irrigation fluid. We aimed to investigate the extend of IFA and symptoms due to volume overload during bipolar transurethral resection (bTUR) and laser procedures of the prostate. We performed a systematic literature search using PubMed, restricted to original English-written articles, including animal, artificial model, and human studies. Search terms were TUR, transurethral, laser, HoLEP, ThuLEP, greenlight, enucleation, fluid absorption, fluid uptake, and TUR-syndrome. Mean and maximum IFA during bTURP ranges between 133 and 915ml and 1019ml and 2166ml, respectively. Absorption during laser procedures can be significant with maximum values up to 4579ml and mainly occurs during prostate vaporization techniques. Incidence of moderate to severe symptoms from iso-osmolar volume overload reaches 9%. Irrigation fluid absorption during bTUR and laser surgery of the prostate is not negligible. Iso-osmolar overhydration with development of non-classical TUR-syndrome should be identified peri- and postoperatively and surgical teams should be aware of complications. Breath ethanol, venous pH, serum chloride, and bicarbonate could be markers for detecting dangerous events of IFA with saline.

Evidence-Based Recommendations for Opioid Prescribing After Endourological and Minimally Invasive Urological Surgery.

Introduction: Procedure-specific guidelines for postsurgical opioid use can decrease overprescribing and facilitate opioid stewardship. Initial recommendations were based on feasibility data from limited pilot studies. This study aims to refine opioid prescribing recommendations for endourological and minimally invasive urological procedures by integrating emerging clinical evidence with a panel consensus. Materials and Methods: A multistakeholder panel was convened with broad subspecialty expertise. Primary literature on opioid prescribing after 16 urological procedures was systematically assessed. Using a modified Delphi technique, the panel reviewed and revised procedure-specific recommendations and opioid stewardship strategies based on additional evidence. All recommendations were developed for opioid-naive adult patients after uncomplicated procedures. Results: Seven relevant studies on postsurgical opioid prescribing were identified: four studies on ureteroscopy, two studies on robotic prostatectomy including a combined study on robotic nephrectomy, and one study on transurethral prostate surgery. The panel affirmed prescribing ranges to allow tailoring quantities to anticipated need. The panel noted that zero opioid tablets would be potentially appropriate for all procedures. Following evidence review, the panel reduced the maximum recommended quantities for 11 of the 16 procedures; the other 5 procedures were unchanged. Opioids were no longer recommended following diagnostic endoscopy and transurethral resection procedures. Finally, data on prescribing decisions supported expanded stewardship strategies for first-time prescribing and ongoing quality improvement. Conclusion: Reductions in initial opioid prescribing recommendations are supported by evidence for most endourological and minimally invasive urological procedures. Shared decision-making before prescribing and periodic reevaluation of individual prescribing patterns are strongly recommended to strengthen opioid stewardship.

Endoscopic surgical simulation using low-fidelity and virtual reality transurethral resection simulators in urology simulation boot camp course: trainees feedback assessment study.

The objective of our study was to study trainees' feedback and rating of models for training transurethral resection of bladder lesions (TURBT) and prostate (TURP) during simulation. The study was performed during the ''Transurethral resection (TUR) module" at the boot camp held in 2019. Prior to the course, all trainees were required to evaluate their experience in performing TURBT and TURP procedures. Trainees simulated resection on two different models; low-fidelity tissue model (Samed, GmBH, Dresden, Germany) and virtual reality simulator (TURPMentor, 3D Systems, Littleton, US). Following the completion of the module, trainees completed a questionnaire using a 5-point Likert scale to evaluate their assessment of the models for surgical training. In total, 174 simulation assessments were performed by 56 trainees (Samed Bladder-40, Prostate-45, TURPMentor Bladder-51, Prostate-37). All trainees reported that they had performed < 50 TUR procedures. The Samed model median scores were for appearance (4/5), texture (5/5), feel (5/5) and conductibility (5/5). The TURPMentor median score was for appearance (4/5), texture and feel (4/5) and conductibility (4/5). The most common criticism of the Samed model was that it failed to mimic bleeding. In contrast, trainees felt that the TURPMentor haptic feedback was inadequate to allow for close resection and did not calibrate movements accurately. Our results demonstrate that both forms of simulators (low-fidelity and virtual reality) were rated highly by urology trainees and improve their confidence in performing transurethral resection and in fact complement each other in providing lower tract endoscopic resection simulation.

Global Assessment of Urological Endoscopic Skills (GAUES): development and validation of a novel assessment tool to evaluate endourological skills

To develop and evaluate an assessment tool for endourological skills during simulation including cystoscopy, ureteroscopy (URS) and transurethral resection (TUR) procedures. We designed a Global Assessment of Urological Endoscopic Skills (GAUES) tool, comprised of nine endourology task-specific and two global-rating skills items. The tool was developed through two rounds of the Delphi process. The GAUES tool was used to assess acquisition of URS and TUR skills of novices (Year 2 core surgical trainees, CT2) and intermediate level trainees (residents at the start of the UK higher surgical training programme in Urology, Speciality Trainee Year 3, ST3) at the Urology Simulation Boot Camp (USBC) between 2016 and 2018. Validity was evaluated by comparing scores between trainees with different levels of urological experience. Inter-rater reliability was also assessed. We evaluated 130 residents, 52% of trainees were at an intermediate stage of training and 39% were novices. In all, 9% of the anonymous forms were missing demographics. The completion rate of the GAUES tool during the USBC for URS and TUR was 85% and 89%, respectively. Our analysis demonstrated a significant difference in all domains between intermediates and novices at assessment in URS, except for one domain more suited to clinical assessment (P=0.226). There was excellent intraclass correlation (ICC) overall between the two experts' judgements, ICC=0.841 (95% confidence interval 0.767-0.893; P<0.001, n=88). We have developed the novel GAUES tool for cystoscopic, URS and TUR skills. Overall, we demonstrated good face, content and construct validity and excellent reliability, suggesting that the GAUES tool can be useful for endourological skills assessment.

Impact of second transurethral resection on recurrence in patients with high-grade Ta bladder cancer.

To clarify the potential therapeutic benefit of a second transurethral resection for high-grade Ta bladder cancer. From January 2009 to August 2019, 521 patients with bladder tumors underwent initial transurethral resection procedures at Kagawa University Hospital. Patients diagnosed with high-grade Ta bladder cancer considered to have been resected completely were included in this study. Recurrence and progression rates were compared between patients who received a second transurethral resection and those who did not. We identified 97 eligible patients, including 22 patients who received a second transurethral resection. In terms of clinical characteristics, the proportion of patients with bladder cancer and upper urinary tract tumor history was lower in the second transurethral resection group than in the no second transurethral resection group (P<0.01 and P=0.03, respectively). The histopathological findings of 22 transurethral resection procedures were no cancer in 13 (59.2%), Ta in six (27.2%) and carcinoma insitu in three patients (13.6%). After the second transurethral resection, one patient (4.6%) had recurrent high-grade T1 bladder cancer. The no second transurethral resection group showed a 44% recurrence rate (33 patients), including five patients (6.7%) with progression, and consequently, had a higher rate of recurrence than in the second transurethral resection group (P<0.01). Multivariate analysis showed that no second transurethral resection was the independent predictive factor influencing recurrence (hazard ratio 8.662, P=0.04). The Kaplan-Meier curve showed that a second transurethral resection significantly decreased the recurrence rate than that of patients without a second transurethral resection (P<0.01). A second transurethral resection can reduce the recurrence rate in high-grade Ta bladder cancer, showing a possible therapeutic benefit of this procedure.

Cardiovascular Collapse During Transurethral Resection of Bladder Tumor: A Case Report

Despite innovative modalities, transurethral resection (TUR) procedures are the primary surgical intervention for bladder tumor and enlarged prostate. TUR syndrome, a major complication of TUR procedures, leads to derangement in electrolytes, hemodynamic compromise, and possible cardiac arrest. This case report describes cardiovascular collapse in a 60-year-old male during TUR of a bladder tumor under general anesthesia. The patient developed hypoxia, which progressed to cardiovascular collapse. Electrolyte analysis revealed acute hyponatremia. The patient was resuscitated successfully, transferred to intensive care unit, and discharged from the hospital without any complications. This case report of a cardiovascular collapse during transurethral resection of bladder tumor offers insight of the risks in urologic procedures and highlights the importance of clear communication as well as early recognition and successful management of complications.

Giant prostatic hyperplasia and its causes.

We present a case of a 59-year-old male who was admitted to theemergency department with urinary retention, with ahistory of lower urinary tract symptoms, with thevalue of serum prostate specific antigen level of 100ng/mL and an estimated prostate size of 800mL, according to magnetic resonance imaging. Aprostate biopsy showed benign prostatic hyperplasia. Transvesical prostatectomy was performed, following additional procedure of transurethral resection of theprostate. To thebest of our knowledge, this is thefourth highest prostate volume reported in medical literature. In this paper, we examine thefactors that may have influenced thedevelopment of giant prostate hyperplasia.

Efficacy of Laparoscopic Partial Cystectomy with a Transurethral Resectoscope in Patients with Bladder Endometriosis: See-Through Technique

Purpose: Bladder endometriosis (BE) is rare. Deep invasive endometriosis is difficult to control with medications alone; such cases need surgical treatment. Good results of laparoscopic partial cystectomy with a transurethral (TU) resectoscope by the see-through technique for patients with BE are reported. Materials and Methods: From January 2008 to February 2016, 12 cases of symptomatic BE were seen in our institution. The chief complaints of 9 cases were micturition pain during menstruation. Preoperative cystoscopy showed a bladder mass with blueberry spots. All surgeries were performed under general anesthesia. Laparoscopic surgery was performed with a fan of 4 ports in the lower abdomen. First, the uterus and bilateral ovaries were checked. Then, the TU resectoscope was inserted. When the affected bladder wall was identified, it was again observed with the laparoscopic light source off, which made it possible to observe the twilight leaking inside from the bladder. This twilight came from the light source of the TU resectoscope via the unaffected bladder wall. In contrast, the thickness of the affected wall prevented the light from inside the bladder from passing through it. We call this the “see-through technique.” The tumor was then safely dissected with both laparoscopic and TU resection procedures. Finally, the bladder was sutured by laparoscopic procedures using absorbable sterile surgical suture. The urethral catheter was removed after cystography 7 days after the operation. Results: The surgical margins of all cases were negative. There has been no recurrence of BE so far in any patients. There were no major adverse events perioperatively and the urinary symptoms improved in all cases. Conclusions: By laparoscopic partial cystectomy assisted with a TU resectoscope and see-through technique, the edge of BE could be easily and precisely identified. These procedures are effective and safe for BE surgical treatment.

The impact of histological variants on bladder cancer outcomes

: Pure urothelial carcinoma is the most common histology of bladder cancer, consisting of about 75% of all cases. The remaining cases are represented by histological variants (HVs). Despite an apparent and recent rise in the incidence of variant histology (VH) in pathological reports, the real epidemiology, presentation and prognostic value on oncological outcomes are still not well established. Pathological identification of HVs indeed is challenging and at risk of under-recognition and misclassification, both at transurethral resection (TUR), due to the lack of a standardized technique, and at definitive histology after cystectomy because of the need for dedicated genitourinary pathologists. Genomic sequencing has led to identify molecular subtypes of bladder cancer eventually related to HVs and potentially implicated in the management of bladder cancer. The aim of this review is to present an overview of the literature regarding the impact of VH and molecular subtypes on bladder cancer outcomes. A narrative review of the literature was conducted applying several terms and combinations of them regarding HVs and molecular subtypes. The main findings are that HVs are indicative of a more aggressive disease, often advanced at presentation. When matched for stage and grade, the oncological outcomes are similar with pure urothelial carcinoma, except for pure squamous cell and signet ring cell carcinoma variants that invariably portend a poor prognosis. Radical cystectomy (RC) remains the treatment of choice and should be considered even in non-muscle-invasive cases if some forms of VH are present. Neoadjuvant chemotherapy is recommended in chemo-sensitive variants. Molecular composition could be related to the expression of specific VH and new subtypes could be identified with further investigations. Future developments in TUR procedures, genomic techniques and dedicated genitourinary pathologists will lead to a better definition of each HV, along with related prognosis and response to treatments.

Impact of Bladder Neck Involvement on Recurrence in Patients With Non-muscle-invasive Bladder Cancer: An Analysis Based on a Time-dependent Model.

Tumor location in bladder neck has reported to be a prognostic factor for non-muscle-invasive bladder cancer (NMIBC). We investigated the impact of bladder neck involvement (BNI) on recurrence in NMIBC using time-dependent covariate analysis. We enrolled 585 Japanese patients who underwent transurethral resection for bladder tumors at a single center from 2000 to 2016 and were pathologically diagnosed with Ta and T1 NMIBC. Each patient at each recurrence was assigned to a separate time-dependent stratum with its own baseline hazard function according to the Prentice-Williams-Peterson gap time model for analyzing recurrent events. Over a median follow-up period of 41.3 months (interquartile range, 18.0-82.3 months), 253 (43.2%) patients experienced a total of 475 recurrences. Among the 1001 total transurethral resection procedures, BNI was observed in 122 (12.2%) cases. The 3-year cumulative recurrence rates of patients with and without BNI were 62.5% and 46.3%, respectively. Multivariable analysis revealed that number of tumors≥ 4 (sub-hazard ratio [SHR], 1.48; P= .004), intravesical bacillus Calmette-Guérin therapy (SHR, 0.44; P< .001), and BNI (SHR, 1.59; P= .004) were all independent predictors of recurrence. Assigning 1 point for each of these 3 predictive factors, the resulting scores enabled us to classify patients into 3 prognostic groups that were clearly stratified according to recurrence. Our time-dependent covariate analysis shows that BNI is a significant risk factor for recurrence in NMIBC. Our prognostic model incorporating BNI is an easy means of estimating recurrence risk and determining optimal management for individual patients.

Hexaminolevulinate in the Management of Nonmuscle Invasive Bladder Cancer: A Meta-Analysis.

Objective: The objective of this study was to assess the effect of photodynamic diagnosis (PDD) using hexaminolevulinate on the diagnostic and therapeutic outcomes in nonmuscle invasive bladder cancer (NMIBC) patients. Methods: PubMed, Embase, and the Cochrane Library databases together with conference proceedings were searched. Results: Recurrence-free survival was significantly higher at 3, 6, 9, and 12 months in the PDD groups than in the white light cystoscopy (WLC) groups with the cumulative values of differences in recurrence rates at different follow-up intervals ranging from 8% to 11%. PDD identified additional tumors in 25% of all NMIBC patients and in 35% of carcinoma in situ (CIS) patients. In a patient-based analysis mean sensitivity of PDD versus WLC for all tumor detection was 94% and 84%, respectively. The assessed patient-based specificity was comparable for PDD and WLC in all types of tumors (55-56%); however, in CIS it was higher for PDD (82% vs. 72%). Conclusions: The meta-analysis confirms that PDD in conjunction with WLC detects significantly more tumors than WLC alone. Better diagnostic abilities of PDD transpose to significantly lower short-term recurrence rates after transurethral resection procedure and may improve treatment of NMIBC patients.

The Effects of Instrumentation on Urine Cytology and CK-20 Analysis for the Detection of Bladder Cancer

To evaluate the effects of cystoscopy on urine cytology and additional cytokeratin-20 (CK-20) staining in patients presenting with gross hematuria. For 83 patients presenting with gross hematuria, spontaneous and instrumented paired urine samples were analyzed. Three patients were excluded. Spontaneous samples were collected within 1 hour before cystoscopy, and the instrumented samples were tapped through the cystoscope. Subsequently, patients underwent cystoscopic evaluation and imaging of the urinary tract. If tumor suspicious lesions were found on cystoscopy or imaging, subjects underwent transurethral resection or ureterorenoscopy. Two blinded uropathological reviewers (DB, KK) evaluated 160 urine samples. Reference standards were results of cystoscopy, imaging, or histopathology. Thirty-seven patients (46.3%) underwent transurethral resection or ureterorenoscopy procedures. In 30 patients (37.5%) tumor presence was confirmed by histopathology. The specificity of urine analysis was significantly higher for spontaneous samples than instrumented samples for both cytology alone (94% vs 72%, P = .01) and for cytology combined with CK-20 analysis (98% vs 84%, P = .02). The difference in sensitivity between spontaneous and instrumented samples was not significant for both cytology alone (40% vs 53%) and combined with CK-20 analysis (67% vs 67%). The addition of CK-20 analysis to cytology significantly increases test sensitivity in spontaneous urine cytology (67% vs 40%, P = .03). Instrumentation significantly decreases specificity of urine cytology. This may lead to unnecessary diagnostic procedures. Additional CK-20 staining in spontaneous urine cytology significantly increases sensitivity but did not improve the already high specificity. We suggest performing urine cytology and CK-20 analysis on spontaneously voided urine.

Oncological outcomes of a single but extensive transurethral resection followed by appropriate intra-vesical instillation therapy for newly diagnosed non-muscle-invasive bladder cancer.

A second transurethral resection (TUR) has been recommended by guidelines for high-grade non-muscle-invasive bladder cancer (NMIBC). However, the impact of surgical quality and post-TUR intra-vesical instillation therapy on oncologic outcome still remains unclear for newly diagnosed NMIBC. We conducted a retrospective cohort study for the patients who underwent extensive TUR followed by appropriate intra-vesical therapy for newly diagnosed NMIBC to assess their oncological outcomes. We treated a cohort of 150 patients with NMIBC by our single but extensive TUR protocol at Hirosaki University Hospital between January 2005 and May 2012. The extensive TUR procedure comprised complete resection of all visible tumors including the muscle layer with a separate cold cup-biopsy of the marginal bottom. After visible tumors resection, additional resection for 5 mm wider area around the first surgical margin was performed. TUR was conducted by three expert urologists who had common agreement with the extensive TUR. All patients received 50 mg of epirubicin instillation immediately after TUR. Out of 150 patients, 74 patients who had multiple tumors or high-grade T1 disease received 40 mg of bacillus Calmette-Guérin Tokyo 172 strain once a week for six consecutive weeks. Patients who received second TUR were not included. The endpoints in this study were the recurrence-, progression-free, cancer-specific, and overall survivals. The 5-year recurrence- and progression-free survival rates were 77.2 and 98.0 %, respectively. The 5-year cancer-specific and overall survival rates were 98.0 and 92.6 %, respectively. The 5-year recurrence- and progression-free survival rates in high-grade T1 disease were 77.1 and 97.6 %, respectively, which were not significantly different from those in the cohort with Ta or low-grade BC. Cystoscopy revealed that 93 % of the patients were tumor-free, at the first cystoscopy, and four patients (3 %) showed progression to stage T2 or higher disease during the first year. While the present study has several limitations, including single-arm and retrospective nature, a single but extensive TUR combined with adjuvant intravesical treatment may have acceptable oncological outcomes in NMIBC patients.

The Effect of Resident Involvement on Perioperative Outcomes in Transurethral Urologic Surgeries

To conduct the first study of intra- and postoperative outcomes related to intraoperative resident involvement in transurethral resection procedures for benign prostatic hyperplasia and bladder cancer in a large, multi-institutional database. Relying on the American College of Surgeons National Surgical Quality Improvement Program Participant User Files (2005-2012), we abstracted all cases of endoscopic prostate surgery (EPS) for benign prostatic hyperplasia and transurethral resection of bladder tumors (TURBTs). Multivariable logistic regression models were constructed to assess the effect of trainee involvement (postgraduate year [PGY] 1-2: junior, PGY 3-4: senior, PGY ≥ 5: chief or fellow) vs attending only on operative time and length of hospital stay, as well as 30-day complication, reoperation, and readmission rates. In all, 5093 EPS and 3059 TURBTs for a total of 8152 transurethral resection procedures were performed during the study period for which data on resident involvement were available. In multivariable analyses, resident involvement in EPS or TURBT was associated with increased odds of prolonged operative times and hospital readmissions in 30 days independent of resident level of training. Resident involvement was not associated with overall complications or reoperation rates. Resident involvement in lower urinary tract surgeries is associated with increased readmissions. Strategies to optimize resident teaching of these common urologic procedures in order to minimize possible risks to patients should be explored.