Optimal timing for the first cystoscopic follow-up using time-to-treatment initiation analysis of oncologic outcomes in primary non-muscle invasive bladder cancer

Various guidelines recommend the first follow-up cystoscopy at 3 months; however, no data exist on the optimal timing for initial follow-up cystoscopy. We tried to provide evidence on the timing of the first cystoscopy after the initial transurethral resection of bladder tumor (TUR-BT) for patients with non-muscle invasive bladder cancer (NMIBC) using big data. This was a retrospective National Health Insurance Service database analysis. The following outcomes were considered: recurrence, progression, cancer-specific mortality, and all-cause mortality. Exposure was the time-to-treatment initiation (TTI), a continuous variable representing the time to the first cystoscopy from the first TUR-BT within 1 year. Additionally, we categorized TTI (TTIc) into five levels: < 2, 2-4, 4-6, 6-8, and 8-12 months. A landmark time of 1 year after the initial TUR-BT was described to address immortal-time bias. We identified the optimal time for the first cystoscopy using Cox regression models with and without restricted cubic splines (RCS) for TTI and TTIc, respectively. Among 26,660 patients, 16,880 (63.3%) underwent cystoscopy within 2-4 months. A U-shaped trend of the lowest risks at TTI was observed in the 2-4 months group for progression, cancer-specific mortality, and all-cause mortality. TTI within 0-2 months had a higher risk of progression (aHR 1.36; 95% confidence intervals [CI] 1.15-1.60; p < 0.001) and cancer-specific mortality (aHR 1.29; 95% CI 1.05-1.58; p = 0.010). Similarly, TTI within 8-12 months had a higher risk of progression (aHR 2.09; 95% CI 1.67-2.63; p < 0.001) and cancer-specific mortality (aHR 1.96; 95% CI 1.48-2.60; p < 0.001). Based on the RCS models, the risks of progression, cancer-specific mortality, and all-cause mortality were lowest at TTI of 4 months. The timing of the first cystoscopy follow-up was associated with oncologic prognosis. In our model, undergoing cystoscopy at 4 months has shown the best outcomes in clinical course. Therefore, patients who do not receive cystoscopy at approximately 4 months for any reason need more careful follow-up to predict a poor clinical course.

Diagnosis and Treatment of Non-Muscle Invasive Bladder Cancer: AUA/SUO Guideline: 2024 Amendment

PURPOSE

The purpose of this American Urological Association (AUA)/Society of Urologic Oncology (SUO) guideline amendment is to provide a useful reference on the effective evidence-based treatment strategies for non-muscle invasive bladder cancer (NMIBC).

MATERIALS AND METHODS

In 2023, the NMIBC guideline was updated through the AUA amendment process in which newly published literature is reviewed and integrated into previously published guidelines in an effort to maintain currency. The amendment allowed for the incorporation of additional literature released since the previous 2020 amendment. The updated search gathered literature from July 2019 to May 2023. This review identified 1918 abstracts, of which 75 met inclusion criteria.When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) in support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions.

RESULTS

Updates were made to statements on variant histologies, urine markers after diagnosis of bladder cancer, intravesical therapy, BCG maintenance, enhanced cystoscopy, and future directions. Further revisions were made to the methodology and reference sections as appropriate.

CONCLUSIONS

This guideline seeks to improve clinicians' ability to evaluate and treat patients with NMIBC based on currently available evidence. Future studies will be essential to further support or refine these statements to improve patient care.

Routine Imaging After Bulbar Urethral Reconstruction Does Not Impact Surgical Outcomes and May Not Be Necessary

OBJECTIVE

To assess whether omitting routine post-operative imaging adversely impacts clinical outcomes after bulbar urethroplasty. Contrast imaging is commonly performed prior to catheter removal after urethroplasty but the clinical need for this is unclear.

METHODS

This was a matched, case-control analysis comparing patients undergoing routine voiding cystourethrogram (VCUG) prior to catheter removal after bulbar urethroplasty to patients without imaging. Patients were matched with respect to age, stricture etiology, length, and urethroplasty technique. Follow-up consisted of clinical assessment 3 weeks post-operatively for VCUG/catheter removal, cystoscopy at 3-4 months with clinical assessment annually. Outcome measures were 90-day complications (Clavien ≥2) and stricture recurrence (failure to pass a 16-Fr flexible cystoscope on follow-up). Chi-square and Kaplan-Meier analysis were conducted where appropriate.

RESULTS

Hundred patients undergoing bulbar urethroplasty with VCUG prior to catheter removal were compared to 100 matched case controls without imaging. Groups did not differ with respect to failed endoscopic treatment (P = .82), prior urethroplasty (P = .09), comorbidities (P = .54), smoking (P = .42), or pre-operative bacteriuria (P = 1.00). The incidence of extravasation in the VCUG group was 2%. Overall 90-day complications were 9.5% and 15 patients developed recurrence with a median follow-up of 174 months. On chi-square analysis, 90-day complications did not differ between patients undergoing VCUG and those without (12% vs 7.0%; P = .34). On log-rank analysis, stricture recurrence did not differ between groups (P = .44).

CONCLUSION

Routine imaging with VCUG after bulbar urethroplasty does not influence the risk of post-operative complications or stricture recurrence. Surgeons should consider avoiding this potentially unnecessary examination in routine clinical practice.

Fish: A Promising Screening Tool for Malignancy After Augmentation Cystoplasty?

INTRODUCTION

Malignancy after augmentation cystoplasty (AC) is reported up to 5.5 %. We assessed the use of urine fluorescence in situ hybridization (FISH) screening for bladder malignancy after AC.

PATIENTS AND METHODS

In this study, 36/98 patients under follow-up who have completed tenth year after ileal AC were included prospectively. Twenty-four (66.7 %) patients were tested with FISH initially and overall 28 (77.8 %) patients with conventional cytology (CC). Twenty-four (66.7 %) patients with FISH analysis also had cytology analysis. Blinded from the cytology results, 32 (88.9 %) patients who were consented underwent cystoscopy with random biopsy (native bladder, ileal segment, ileovesical junction). Two patients those were tested with FISH did not consented cystoscopy. This study was registred to the government registry (No: 71146310).

RESULTS

Mean follow-up time after AC was 15.4 ± 4.8 years. 2/32 (5.6 %) patients were diagnosed with adenocarcinoma in cyctoscopic biopsy. FISH analysis of 3/24 (12.5 %) patients demonstrated abnormal findings consistent with malignancy. Two FISH malignant patients were patients who had adenocarcinoma. The third patient's biopsy was benign and the third year control cystoscopy was normal. 2/4 patients with malignant CC had adenocarcinoma and 2/4 patients had benign biopsy. The sensitivity and specificity of FISH in our series were 100 % and 95 % respectively. Whereas the sensitivity and specificity of CC was 100 % and 91.6 % respectively.

CONCLUSION

Despite limited number of patients in this study, FISH showed higher specificity than CC in this series. FISH is a promising tool for malignancy screening after AC.

TYPE OF STUDY

Diagnostic Studies.

LEVEL OF EVIDENCE

II.

Laser excision of urethral mesh erosion: a 10-year experience

PURPOSE

To review our 10-year experience with laser excision for urethral mesh erosion (UME) of mid-urethral slings (MUS).

METHODS

Following Institutional Review Board approval, the charts of female patients with endoscopic laser excision of UME were retrospectively reviewed. Demographics, clinical presentation, surgical history, pre- and post-operative Urinary Distress Inventory-6 scores and quality of life ratings, operative reports, and outcomes were obtained from electronic medical records. UME cure was defined as no residual mesh on office cystourethroscopy 5-6 months after the final laser excision procedure.

RESULTS

From 2011 to 2021, 23 patients met study criteria; median age was 56 (range 44-79) years. Twenty (87%) had multiple prior urogynecologic procedures. Median time from MUS placement to presentation with UME-related complaints was 5.3 [interquartile range (IQR) 2.3-7.6] years. The most common presenting symptom was recurrent urinary tract infection (rUTI) (n = 10). Median operating time was 49 (IQR 37-80) minutes. Median duration of follow-up was 24 (IQR 12-84) months. Fourteen (61%) required more than 1 laser excision procedure for UME. Although 5 were asymptomatic (22%), new (n = 5) or persistent (n = 8) urinary incontinence was the most common symptom on follow-up (57%).

CONCLUSION

UME presenting symptoms are highly variable, necessitating a high index of suspicion in patients with a history of MUS, especially in the case of rUTI. Endoscopic laser excision is a minimally invasive, brief, safe, outpatient procedure with a high UME cure rate.

Workflow efficiencies for flexible cystoscopy: comparing single-use vs reusable cystoscopes

BACKGROUND

Flexible cystoscopy is a common procedure to diagnose and treat lower urinary tract conditions. Single-use cystoscopes have been introduced to eliminate time-consuming reprocessing and costly repairs. We compared the hands-on labor time differences between flexible reusable cystoscopes versus Ambu's aScope™ 4 Cysto (aS4C) at a large urology Ambulatory Surgery Center (ASC).

METHODS

Reusable and single-use cystoscopy procedures were shadowed for timestamp collection for setup and breakdown. A subset of reusable cystoscopes were followed through the reprocessing cycle. T-tests were calculated to measure the significance between groups.

RESULTS

The average hands-on time necessary for reusable cystoscope preparation, breakdown, and pre-cleaning was 4'53″. Of this, 2'53″ were required for preparation, while 2'0″ were required for breakdown and pre-cleaning. The average hands-on time for reprocessing for reusable was 7'1" per cycle. The total time for single-use scopes was 2'22″. Of this, 1'36″ was needed for single-use preparation, and 45 s for breakdown. Compared to reusable cystoscopes, single-use cystoscopes significantly reduced pre and post-procedure hands-on labor time by 2'31", or 48%. When including reprocessing, total hands-on time was 80% greater for reusable than single-use cystoscopes.

CONCLUSION

Single-use cystoscopes significantly reduced hands-on labor time compared to reusable cystoscopes. On average, the facility saw a reduction of 2'31″ per cystoscope for each procedure. This translates to 20 additional minutes gained per day, based on an 8 procedures per day. Utilizing single-use cystoscopes enabled the facility to reduce patient wait times, decrease turnaround times, and free up staff time.

Urinary markers for bladder cancer diagnosis: A review of current status and future challenges

Bladder cancer is a common urological cancer with a high recurrence rate that requires long-term follow-up, and early detection positively affects prognosis. To date, the initial diagnosis and follow-up for bladder cancer rely on cystoscopy, which is an invasive and expensive procedure. Therefore, urinary markers for the detection of bladder cancer have attracted research attention for decades to reduce unnecessary cystoscopies. Urine, which is in continuous contact with bladder cancer, is considered a suitable fluid for providing tumor information. Urinary cytology is the only widely used urinary marker in clinical practice; however, it has poor sensitivity for low-grade tumors; indicating the need for novel urinary markers. Considerable research has been conducted on this topic over the years, resulting in a complex landscape with a wide range of urinary markers, including protein-, exfoliated cell-, RNA-, DNA-, and extracellular vesicle-based markers. Although some of these markers have been approved by the U.S. Food and Drug Administration and are commercially available, their use in clinical practice is limited. To facilitate clinical application, potential urinary markers must withstand prospective clinical trials and be easy for patients and clinicians to understand and utilize in a clinical context. This review provides a comprehensive overview of currently available and recently reported promising urinary markers for bladder cancer. Additionally, the challenges and the prospects of these urinary markers for clinical implementation in bladder cancer treatment were discussed.

Patients' Emotional Talk During Surveillance Cystoscopy for Non-muscle Invasive Bladder Cancer: Opportunities for Improving Communication

OBJECTIVE

To examine the emotional communication that takes place between patients and health care providers during surveillance cystoscopy for non-muscle invasive bladder cancer (NMIBC).

METHODS

Participants were 57 patients with a diagnosis of NMIBC attending for surveillance cystoscopy and 10 health care professionals (HCPs). Cystoscopy procedures were audio-recorded and transcribed verbatim. Two approaches to analysis of transcriptions were undertaken: (1) a template analysis and (2) Verona Coding Definitions of Emotional Sequences.

RESULTS

Communication during cystoscopy generally comprised of "social/small talk," "results of the cystoscopy," and "providing instructions to the patient." Emotional talk was present in 41/57 consultations, with 129 emotional cues and concerns expressed by patients. Typically patients used hints to their emotions rather than stating explicit concerns. The majority (86%) of HCPs responses to the patient did not explicitly mention the patient's emotional concern or cue. Urology trainees were less likely than other HCPs to provide space for patients to explore their emotional concerns (t = -1.78, P <.05).

CONCLUSION

Emotional communication was expressed by the majority of patients during cystoscopy. While all HCPs responded to patients' emotional communication, there were a number of missed opportunities to "pick-up" on patients' emotional cues and improve communication. Urologists need to be aware of the nuances of patients' emotional communication. Learning to identify and respond appropriately to emotional cues may improve communication with patients.

Autonomic dysreflexia in urological practice: pathophysiology, prevention and treatment considerations

PURPOSE

Spinal cord injury (SCI) leads to sensorimotor impairments; however, it can also be complicated by significant autonomic dysfunction, including cardiovascular and lower urinary tract (LUT) dysfunctions. Autonomic dysreflexia (AD) is a dangerous cardiovascular complication of SCI often overlooked by healthcare professionals. AD is characterized by a sudden increase in blood pressure (BP) that can result in severe cardiovascular and cerebrovascular complications. In this review, we provide an overview on the clinical manifestations, risk factors, underlying mechanisms, and current approaches in prevention and management of AD.

METHODS

After conducting a literature research, we summarized relevant information regarding the clinical and pathophysiological aspects in the context of urological clinical practice CONCLUSIONS: The most common triggers of AD are those arising from LUT, such as bladder distention and urinary tract infections. Furthermore, AD is commonly observed in individuals with SCI during urological procedures, including catheterization, cystoscopy and urodynamics. Although significant progress in the clinical assessment of AD has been made in recent decades, effective approaches for its prevention and treatment are currently lacking.

The role of URO17® in diagnosis and follow up of bladder cancer patients

OBJECTIVE

to evaluate the role of urinary URO17® biomarker in the detection of urothelial tumors in haematuria patients and the detection of recurrence in non-muscle invasive bladder urothelial tumors.

MATERIALS AND METHODS

Our study was formed of two cohorts of patients, group I represents patients presenting with haematuria (n = 98), while group II represents patients with known non-muscle invasive bladder cancers on their scheduled follow up cystoscopic investigation (n = 51). For both groups, patients were asked to provide urine samples before cystoscopy, either primary as part of the haematuria investigation or as a scheduled follow-up. Urine samples were sent anonymously for standard urine cytology and URO17® biomarker immunostaining. Results were compared to cystoscopic findings using Chi-square analysis and Fisher's exact test (P < 0.05).

RESULTS

Group I was formed of 98 patients, with an average age of 60 years. URO17® showed 100% sensitivity and 96.15% specificity with a negative predictive value (NPV) of 100 and a positive predictive value (PPV) of 95.83. The results showed statistical significance with P value < 0.001. Group II was formed of 51 patients, with an average age of 75 years. URO17® was shown to have a sensitivity of 85.71% and NPV of 95.45. Eleven patients of group II were on scheduled BacillusCalmette-Guerin (BCG) and another 5 received Mitomycin C (MMC). The overall results of both groups combined (n = 149) showed statistical significance between flexible cystoscopy results and the results of urinary URO17® and urine cytology.

CONCLUSION

URO17® has a potential to be a reliable test for diagnosis and follow up of urothelial cancer patients and a screening tool adjunct to flexible cystoscopy.

TRIAL REGISTRATION

Not applicable as the current study is not a clinical trial, as per according to the National Institutes of Health, "studies that involve a comparison of methods and that do not evaluate the effect of the interventions on the participant do not meet the NIH clinical trial definition."

Endoscopic treatment of primary obstructive megaureter with high pressure balloon dilation in infants

INTRODUCTION AND OBJECTIVE

Ureteral reimplantation of the dilated ureter in infants is challenging; however, some patients with primary obstructive megaureter (POM) in this age group require intervention due to clinical or radiological progression. We sought to determine if high pressure balloon dilation (HPBD) can serve as a definitive treatment for POM in children under one year of age, or as a temporizing measure until later reimplantation.

MATERIALS AND METHODS

All patients from a single institution who underwent HPBD between October 2009 and May 2022 were retrospectively reviewed. Patients were excluded if older than 12 months or diagnosed with neurogenic bladder, posterior urethral valves, or obstructed refluxing megaureter. Patients with prior surgical intervention at the ureterovesical junction were excluded. Indications for surgery included progressive hydroureteronephrosis or urinary tract infection (UTI). Balloon dilation was performed via cystoscopy with fluoroscopic guidance, followed by placement of two temporary ureteral stents. Primary outcomes were improvement or resolution of megaureter and rates of subsequent reimplantation. Secondary outcomes included total number of anesthetics and postoperative UTIs.

RESULTS

Fifteen infants with median age of 7.6 months (IQR 3.8-9.7) underwent HPBD. Twelve (80%) patients were detected prenatally and 3 (20%) after a UTI. Indication for surgery was progressive hydroureteronephrosis in 10 patients (67%) and UTI in five (33%). All had SFU grade 3 or 4 hydronephrosis on preoperative ultrasound and median distal ureteral diameter was 13 mm. Median follow up was 2.9 years. Twelve (80%) succeeded with endoscopic treatment: 7 patients had an undetectable distal ureter on ultrasound at last follow-up, 5 were improved with median distal ureteral diameter of 7 mm. Three patients (20%) required ureteral reimplantation due to progressive dilation, all with grade 4 hydronephrosis and distal ureteral diameters were 11, 15, and 21 mm. Six patients (40%) required two anesthetics to complete endoscopic treatment. Among those, 4 patients required initial stent placement for passive dilation followed by a second anesthetic for HPBD weeks later. Two patients underwent repeat HPBD following postoperative proximal migration of the ureteral stents. All 15 patients had an additional anesthetic for removal of stents. Five patients (33%) were treated for a symptomatic UTI (4 febrile, 1 afebrile) with the stents indwelling but there were no UTIs in the group following stent removal.

CONCLUSION

Balloon dilation is a practical option for treatment of POM in infants, and in most cases (80%) avoids subsequent open surgery (over median 2.9 years of follow-up).

Mullerianosis of the urinary bladder: a case report

Mullerianosis is a rare, complex, benign tumor most commonly found in the bladder and often mistaken for a neoplastic lesion.  Herein, we report a case of mullerianosis in a 65-year-old woman who presented with an incidental 2 cm bladder mass found on cross-sectional imaging.  A mixed cystic and solid tumor was identified on cystoscopy and a transurethral resection of the suspected tumor was performed with histopathology confirming a final diagnosis of mullerianosis.  While an unusual diagnosis, mullerianosis of the urinary bladder needs to be correctly identified to provide appropriate treatment and avoid misdiagnosis.

Urinary Bladder "Melanosis": A Case Report and Review of the Literature

Melanosis of the urinary bladder, so-called melanosis vesicae, is a rare condition characterized by dark, velvety bladder mucosa observed by cystoscopy examination. Up to 20 examples have been reported in the English literature, and the etiology of this disease still needs to be discovered. We present an 82-year-old woman with a history of pelvic organ prolapse-associated urinary symptoms. The patient was found to have pigmented urinary bladder mucosa on cystoscopy and underwent a total hysterectomy and bladder mucosal biopsy. Histologically, pigmented granules were evident in the bladder stroma and epithelium, highlighted by Periodic Acid-Schiff (PAS) stain, suggestive of lipofuscin in nature. We outline the diagnostic features of bladder melanosis, discuss the diagnostic mimickers, and thoroughly review the literature on the subject.

[Bladder Cancer Detected Incidentally by Cystoscopy before Radical Prostatectomy]

Radical prostatectomy is the treatment of choice for localized prostate cancer. In our institution, preoperative cystoscopy is performed routinely to clarify the prostate anatomy, including the median lobe and position of ureteral orifices. We conducted a retrospective analysis of 721 patients, from January 2008 to December 2022, our aim being to assess the clinical course of bladder cancer discovered incidentally through cystoscopy prior to radical prostatectomy. We found that bladder cancer was detected in eight of these patients (1.1%), seven of whom had low-grade, non-invasive, papillary urothelial carcinomas ; the remaining patient had a high-grade lesion. Notably, the pathological stage was Ta in all cases. The median duration of follow-up of patients with bladder cancer was initially set at 21 months (12-24 months). During the follow-up period, bladder cancer recurrence was identified in three patients. Patients who remained recurrence-free beyond the follow-up period underwent radical therapy. Importantly, no evidence of prostate cancer progression was detected throughout the follow-up period. Thus, incidental bladder cancer detected prior to radical prostatectomy is predominantly non-invasive, ensuring safe treatment of both the bladder and prostate cancers. Our findings suggest that cystoscopy could be omitted.

JJ stent dislodgement in the distal ureter: how to recover it in preschool children?

Double-J ureteral stents are usually placed after various urological procedures. The dislodgement of their distal ringlet is a rare complication, whose retrieval is arduous in younger children, due to the small ureteral caliber. We propose our innovative endoscopic approach to recover the dislodged JJ stent. Under 8-9.8 Ch cystoscopy, the ureteral meatus is gently cannulated with a 00.18″ guidewire, then a balloon catheter Passeo 18 3-4 mm (Biotronik, Lake Oswego, OR, USA) is coaxially inserted. A pneumatic dilatation of the vesical-ureteral junction is performed up to 8 atmospheres for 5 minutes under direct vision. Consequently, the ureteral meatus allows the cystoscope passage, and the JJ-stent can be recovered thanks to endoscopic grasping forceps. A mono-J stent is then left in place for 24 hours. Four patients aged 8 months - 4 years have been successfully treated with this approach after that JJ migration was found intraoperatively or during ultrasonography. No intra- or postoperative complications occurred. Postoperative hospital stay was prolonged for one day. During 29.5 medium follow-up no clinical or ultrasonographic signs of vesical-ureteral reflux ensued. Our cystoscopic approach is effective and safe to ensure a prompt endoscopic JJ retrieval without changing neither surgical approach nor the anesthesiological support. We believe that all the pediatric urology centers should know the procedure and have small size balloon catheter available.

Indirect signs of infravesical obstruction on voiding cystourethrography improve post-neonatal posterior urethral valves detection rate

OBJECTIVES

To identify the diagnostic performance of clinical and radiological signs (on voiding cystourethrography [VCUG]) to detect posterior urethral valves (PUV) in the post-neonatal period.

MATERIALS AND METHODS

One hundred eighteen males (median age = 0.8 years, range = 1 month-14 years, 48 toilet-trained) undergoing VCUG in a 2-year period were prospectively enrolled. Direct (dilated posterior urethra) and indirect (hypertrophied bladder neck, musculus interuretericus hypertrophy, and trabeculated appearance of the bladder wall) PUV signs on VCUG were assessed. Uroflowmetry was defined pathological by patterns suggesting infravesical obstruction.

RESULTS

Twenty-two patients with direct, 28 with indirect PUV signs on VCUG, and one with normal VCUG but persisting micturition symptoms with pathological uroflowmetry underwent urethrocystoscopy and in 43/51 a PUV diagnosis was made (n = 22, 51.2%, with direct PUV signs). In 8/28 patients with indirect signs, PUV were not confirmed. Among non-toilet-trained patients, none of the clinical signs/symptoms was associated with PUV while among toilet-trained patients only pathological uroflowmetry (odds ratio, OR = 4.0 [95% confidence interval:1.2-13.2; p = 0.02]) and pathological uroflowmetry with history of urinary tract infection (OR = infinity) were significantly associated with PUV. Significant associations with PUV of direct and indirect signs on VCUG were found both in toilet-trained and non-toilet trained patients. Direct PUV sign had 100% specificity and sensitivity while indirect PUV signs showed sensitivity = 58.1% and specificity = 89.3%. The absence of any radiological sign had a negative predictive value = 98.5%.

CONCLUSION

Only half of patients with endoscopy-confirmed PUV presents with direct sign of PUV on VCUG. Accounting for indirect PUV signs on VCUG and pathological uroflowmetry (in toilet-trained children) could improve the PUV detection rate.

CLINICAL RELEVANCE STATEMENT

Indirect radiological PUV signs should be valorized when interpreting VCUG to improve the PUV detection rate. The absence of any radiological PUV (direct and indirect) sign on VCUG excludes PUV with a very high negative predictive value.

KEY POINTS

• Worldwide agreement is that a non-dilated urethra on voiding cystourethrography excludes obstruction. • Half of patients with posterior urethral valves have non-dilated urethra on voiding cystourethrography. • Accounting for indirect signs of posterior urethral valves on voiding cystourethrography improves the diagnostic performance.

Hemangioma of the Urinary Bladder: A Brief Narrative Review of Their Diagnosis, Histology, and Treatment Options

BACKGROUND

Hemangioma of the urinary bladder is a rare benign tumor. Although benign, their presenting symptoms are alarming for both patients and doctors, and their rarity makes them challenging to correctly diagnosis and treat. This review paper summarizes current knowledge about hemangioma of the urinary bladder, treatment options, and follow-up modalities.

SUMMARY

After the kidney, the bladder is the second most common location of hemangiomas in the urinary tract. There is painless gross hematuria on clinical presentation once the lesion has eroded the urothelium. Magnetic resonance imaging (MRI) has been reported to be valuable in diagnosing soft-tissue hemangiomas. Cystoscopic findings of a sessile, blue, multilocular mass suggest hemangioma. Most tumors are solitary, smaller than 3 cm, and have smooth or irregular surfaces. Histologically, lesions comprise numerous proliferative capillaries with thin-walled, dilated, blood-filled vessels lined with flattened endothelium. The treatment of patients with hemangioma has been controversial. It depends on the tumor size and the degree of penetration. The prognosis of these tumors is excellent.

KEY MESSAGES

Despite the widespread use of MRI, CT, and endoscopy in evaluating hematuria, hemangioma remains one of the rarest bladder tumors. Moreover, only a histological examination can confirm the diagnosis. Transurethral resection, fulguration, and YAG laser ablation are standard treatments for small tumors. In terms of follow-up, cystoscopy after 6 months of treatment helps assess recurrence. In addition, MRI is a practical, noninvasive technique for follow-up of small hemangiomas.

Budgetary Impact of Including the Urinary Genomic Marker Cxbladder Detect in the Evaluation of Microhematuria Patients

INTRODUCTION

Current AUA guidelines mandate a risk-stratified approach for the evaluation of microhematuria. Urine genomic tests with high negative predictive value could further reduce unnecessary diagnostic testing and morbidity, but the economic impact is unknown. This study modeled the financial impact of Cxbladder Detect on microhematuria evaluations.

METHODS

A decision tree analysis was constructed by Coreva Scientific comparing 1-year costs of the standard microhematuria evaluation using the AUA guidelines vs an algorithm incorporating Cxbladder Detect. Cxbladder Detect-positive patients had cystoscopy and imaging, whereas patients with negative tests were reevaluated in 6 months. Patients with positive diagnostic testing underwent cystoscopy, and positive cystoscopies led to transurethral resection of bladder tumor. Test performance was based on published literature, and costs were based on Medicare allowable fees.

RESULTS

Using the decision tree model, the average savings of using Cxbladder Detect was $559 compared with the standard of care, with an average reduction of 0.38 procedures per patient. Probabilistic analysis showed statistical significance with a median reduction in the total cost of $498 per patient (95% CrI [-1356, -2]) and a significant median reduction in diagnostic procedures per patient of 0.36 (95% CrI [-0.52, -0.16]) without impact on the number of cancers diagnosed.

CONCLUSIONS

This model-based study demonstrates the potential economic value of using a Cxbladder-driven protocol for microhematuria evaluations.

Recurrence of non-muscle invasive bladder carcinoma after transurethral resection with hexaminolevulinate photodynamic diagnosis or regular cystoscopy

OBJECTIVES

To compare the recurrence of non-muscle invasive bladder carcinoma (NMIBC) after transurethral resection employing cystoscopy with hexaminolevulinate-based photodynamic diagnosis (PDD) or with standard white light.

PATIENTS AND METHODS

We included patients with newly suspected NMIBC in this retrospective cohort study and compared those undergoing transurethral resection by white light cystoscopy (WLC) (2008-2010) and PDD (2010-2012). All patients were treated following established criteria for good quality resection. The primary outcome was the difference in the recurrence rate after 60 months' follow-up, but we also stratified recurrence by risk groups, as set by the European Organization for Research and Treatment of Cancer. The mean recurrence-free survival was compared between the cohorts. Odds ratios or hazard ratios are reported with their 95% confidence intervals.

RESULTS

The WLC and PDD cohorts comprised 124 and 91 subjects, respectively. There were no significant differences in recurrence rates between the cohorts at 6 months (recurrence rate 9/123; 7.3%), 12 months (17/118; 14.4%) or 60 months (39/102; 38.2%), with odds ratios of 1.23 (CI 0.48-3.25), 1.32 (CI 0.67-2.62) and 1.12 (CI 0.70-1.79), in favour of WLC, respectively. Further analysis showed no significant effect of PDD on either recurrence by risk group or on mean recurrence-free survival (hazard ratio, 1.12 [CI 0.70-1.79]).

CONCLUSION

We found no relevant differences in the recurrence of NMIBC after the introduction of PDD with hexaminolevulinate compared to standard WLC when used for transurethral resection in our single institution.

Recurring cystitis cystica and cystitis glandularis masquerading as urothelial carcinoma

We report a rare case of cystitis cystica and glandularis mimicking low-grade urothelial carcinoma that was found incidentally and treated with resection and fulguration via transurethral resection of bladder tumor (TURBT). When early recurrence was found on surveillance cystoscopy 3 months later, the patient was treated with repeat TURBT and intravesical gemcitabine. Surveillance cystoscopy 4 months later revealed cystitis cystica and cystitis glandularis yet again. We highlight the diagnosis and management of multiple early recurrences of cystitis cystica in this patient, particularly our treatment with gemcitabine and close surveillance.

In-utero Diagnosis of Prostatic Embryonal Rhabdomyosarcoma

Though rhabdomyosarcoma is the most common soft-tissue tumor diagnosed in children there are no reported cases of prenatally detected prostatic embryonal rhabdomyosarcoma. This report demonstrates the first reported case of this phenomenon and its subsequent workup, diagnosis, and treatment.

Optimal endoscopic treatment and partial cystectomy with or without bladder augmentation for Hunner-type interstitial cystitis

Interstitial cystitis/bladder pain syndrome (IC/BPS) presents a significant challenge for urologists in terms of management, owing to its chronic nature and adverse impact on patient quality of life. Given the potential distinction between two disease entities within IC/BPS, namely Hunner-type IC and BPS without Hunner lesion, there is a need for an optimal therapeutic approach that focuses on the bladder lesions in Hunner-type IC. In cases where Hunner lesions are observed, complete transurethral ablation of these lesions should be prioritized as the initial intervention, as it has demonstrated effectiveness in symptom control. However, recurrence remains a limitation of this intervention. The techniques of resection and coagulation are equally effective in terms of symptom relief and recurrence prevention. Reconstructive surgery becomes necessary in cases of end-stage IC/BPS where various therapeutic approaches have failed. Patient selection is crucial in reconstructive surgery, particularly for patients with clear Hunner lesions and small bladder capacity who have not responded to previous treatments. Furthermore, it is vital to consider the patients' expectations and preferences adequately. Based on a comprehensive review of the literature and our own clinical experiences, subtotal cystectomy followed by bladder augmentation is considered a safe and effective surgical option. This stepwise and tailored therapeutic approach aims to optimize patients' quality of life by specifically targeting Hunner-type IC.

[Melanosis of the bladder-a rare diagnosis]

Melanosis of the urinary bladder is an extremely rare benign condition in which melanin deposits occur in the urothelial and stromal cells. We report such a case in which melanosis of the urinary bladder was detected in a 55-year-old woman with known multiple sclerosis during an extended workup due to urinary urgency complaints. The findings were confirmed by biopsy.

Utility of preoperative urine cultures and cystoscopies before ureteral reimplantation in pediatrics

BACKGROUND

Ureteral reimplantation remains the primary surgical method used for patients with vesicoureteral reflux (VUR). Cystoscopy is commonly performed first to visualize anatomy and rule out possible abnormalities. Urine cultures may also be obtained. The objective of this study is to evaluate the prudency of preoperative urine cultures and cystoscopies in pediatric patients undergoing ureteral reimplantation.

METHODS

Pediatric urologists were surveyed regarding collecting urine cultures in asymptomatic patients and cystoscopies before reimplantation. A retrospective review was also conducted of patients who underwent ureteral reimplantation for VUR between March 2018 and April 2021 at Cook Children's Medical Center.

RESULTS

When physicians were asked the frequency they obtain urine cultures before reimplantation on asymptomatic patients, 36% said "never" and 38% said "always." Regarding cystoscopy, 53% said "never" and 32% said "always." Inclusion criteria were met by 101 patients. Cystoscopies were performed in 46 patients and never altered the reimplantation. There were 20 preoperative, 90 intraoperative, and 61 postoperative urine cultures. Complications were associated with positive cultures of urine collected intraoperatively and postoperatively only.

CONCLUSION

Cystoscopies and asymptomatic urine cultures obtained before ureteral reimplantation provide no additional benefit while increasing cost for patients' families. Further research is needed to thoroughly identify the prudency of such practices in ureteral reimplantation for VUR.

Differences in clinical features between focal and extensive types of cystitis glandularis in patients without a previous history of urinary tract malignancy

PURPOSE

To understand the clinical differences of cystitis glandularis (CG), a proliferative disorder of urinary bladder epithelium, based on the extent of cystoscopic findings in patients without a history of urinary tract malignancy.

MATERIALS AND METHODS

We conducted a review of patients diagnosed with CG in two tertiary hospitals from 2005 to 2021. Patients with previous or concurrent history of urinary tract malignancy were excluded. Medical records, including demographics, endoscopic and all available imaging studies, and managements, were reviewed. Patients were divided into two types according to extent of the lesion, and their clinical features were compared.

RESULTS

In total, 110 patients were enrolled in the final analysis, with 36 (32.7%) classified as extensive type and 74 (67.3%) as focal type. Patients with extensive type were predominantly males and relatively younger than those with focal type (p=0.025). Voiding problems were more strongly associated and hydronephrosis caused by CG was significantly more common in the extensive type (p=0.005 and p=0.003, respectively). Multiple transurethral resection procedures were more frequently performed in the extensive type (p=0.017). Subsequent urinary tract malignancy was observed in four patients, all of whom had focal-type CG.

CONCLUSIONS

There were significant differences in clinical features between the extensive- and focal-types CG. The extensive type was more often associated with urologic complications. Meanwhile, in the focal type, subsequent urinary tract malignancy might develop during the follow-up period. Thus, thorough initial work-up and careful follow-up is necessary despite the benign nature of CG. Annual surveillance cystoscopy may be appropriate.

Endoscopic Urethroplasty Using Buccal Graft for Male Membranous Urethral Stricture

OBJECTIVE

To demonstrate a new minimally invasive endoscopic approach to urethroplasty.

METHODS

The procedure was performed in a male patient with prior history of prostate cancer managed by radiation who subsequently developed an 8 mm flow-limiting membranous urethral stricture. After stricture dilation a 1 cm wide strip of superficial mucosa was resected from the bladder neck past the area of stricture, creating a bed for the graft to lay. Buccal mucosa graft was harvested in standard fashion. With the graft outside the urethra and using the RD 180 endoscopic suturing device, a suture is placed in the proximal end of the graft, then through the bladder neck, and back through the graft. As the suture is pulled, the pulley phenomenon advances the graft into place on the bladder neck. The graft is then anchored to the posterior urethra with secure straps. A catheter is placed to hold the graft flat during the healing process.

RESULTS

The procedure lasted 2.5 hours without any complications. Estimated blood loss was 50cc, and the patient was discharged after the procedure. Catheter was removed at 4weeks. Cystoscopy at 10weeks post-op showed good graft viability, with peak flow improving to 20 mL/s compared to 4 mL/s preoperatively. At 6months, he continues to do well without evidence of recurrent urethral stricture.

CONCLUSION

Endoscopic urethroplasty using buccal graft appears to offer a safe and effective repair option for management of ureteral strictures.

Single-use digital flexible cystoscope for double J removal versus reusable instruments: a prospective, comparative study of functionality, risk of infection, and costs

BACKGROUND

The removal of ureteral stent can be performed with disposable or reusable flexible cystoscopes, but limited comparative data are available on functionality, risk of infections, and costs.

METHODS

We performed a multicentric, prospective, observational study on patients undergoing in-office ureteral stent removal with Isiris-α® or a reusable Storz™ flexible cystoscope. Study endpoints were the functionality and effectiveness of the devices, the rate of postoperative bacteriuria and UTIs, and the costs of the procedure.

RESULTS

A total of 135 patients were included, 80 (59.2%) treated with reusable cystoscopes and 55 (40.8%) with Isiris-α®. No significant baseline differences between groups were detected. Isiris-α® outperformed the reusable device in terms of quality of vision (p 0.001), manoeuvrability (p 0.001), grasper functionality (p < 0.001), and quality of the procedure (p 0.01). Mean procedure time was shorter with Isiris-α® (p < 0.001) due to a shorter instrument preparation time (p < 0.001). No differences were found in terms of perceived patient pain (p 0.34), nor postoperative bacteriuria or symptomatic UTIs. According to our cost analysis, the in-office procedure performed with Isiris-α® was more expensive (+ 137.8€) but was independent from instrument turnover or disinfection. Among limitations of study we acknowledge the lack of randomization, the use of antibiotic prophylaxis in several patients, and the high rate of missing preoperative urine cultures.

CONCLUSIONS

Isiris-α® outperforms reusable cystoscopes for in-office ureteral stent removal in terms of total operative time and quality of the procedure, at the cost of being more expensive. No significant differences in postoperative bacteriuria or symptomatic UTIs were found.

Potential benefits of routine cystoscopy and vaginoscopy prior to reconstructive surgery in patients with an anorectal malformation

PURPOSE

First, to assess the number of patients with anorectal malformations (ARM) in whom additional urological and/or gynecological anomalies were identified through routine screening with cysto- or vaginoscopy prior to reconstructive surgery. Second, to assess potential procedure-related complications.

METHODS

Retrospective mono-center cohort study, including all ARM patients born between January 2019 and December 2022. Routine screening consisted of cystoscopy for male patients, with the addition of vaginoscopy for female patients. Chi-square was used to compare the screening percentages over time.

RESULTS

In total, 38 patients were included, of whom 27 (71.1%) underwent cystoscopy ± vaginoscopy, without the occurrence of complications. Nine of 13 females (69.2%) underwent cysto- and vaginoscopy and 18 of 25 males (72.0%) underwent a cystoscopy. The percentage of patients that underwent these procedures improved over the 2 time periods (50.0% in 2019-2020 vs 90.0% in 2021-2022, p = 0.011). In 15 of 27 patients (55.6%) that underwent cystoscopy ± vaginoscopy, additional anomalies were found that were not identified through physical examination or US-kidney.

CONCLUSIONS

In 56% of the patients that underwent cysto- ± vaginoscopy, additional anomalies were identified that were not with imaging studies or physical examination. This study emphasizes the potential benefit of routine cysto- and vaginoscopy in the diagnostic work-up of children with ARM.

LEVEL OF EVIDENCE

III.

Can we predict urethral length of boys? - An observational study

INTRODUCTION

An additional knowledge about normal anatomy of urethra in boys can improve clinical outcome of any urological interventions. This will also reduce catheter related complications like intra vesical knotting and urethral injuries. At present there is no systematic data available which has studied the urethral length of boys. We have done this study to analyse the length of urethra in boys.

AIM

The aim of the study is to measure the urethral length in Indian children from the age of 1 year till 15 years and plot a nomogram. Furthermore to analyse the influence of anthropometry on urethral length and derived a formula to predict the urethral length in boys.

STUDY DESIGN

This is a single institution prospective observational study. After obtaining clearance from the institutional review board, a total of 180 children from the age of 1-15 were recruited for the study. The urethral length was measured during Foley's catheter removal. Other data like age, weight, and height of the patient are collected and the obtained values were analysed with SPSS software. The acquired figures were further used to derive formulae to predict urethral length.

RESULTS

A nomogram of urethral length based on age was plotted. With collected figures, five separate formulae were derived to calculate the urethral length based on the age, height and weight. Furthermore for day-to-day use we have deduced a formulas to calculate urethral length which are simplified forms of original formulae.

DISCUSSION

The length of urethra of a new-born male is 5 cm, which attains 8 cm by three years of age and to 17 cm by adulthood. There were attempts to measure the urethral length in adults using cystoscopy, Foley's catheter and different imaging techniques like Magnetic Resonance Imaging and dynamic retrograde urethrography. Simplified formulae which has been derived from this study for clinical use is Urethral length = 8.7 + Age (in year) × 0.55 CONCLUSION: Our results will complement the current anatomical understanding of the urethra. This evades some rare complications of catheterisation and facilitate reconstructive procedures.

Xpert bladder cancer monitor to predict the need for a second TURB (MoniTURB trial)

To determine whether Xpert bladder cancer monitor, a noninvasive PCR-based biomarker test, can predict the need for 2nd transurethral resection of the bladder (TURB) better than clinical assessment. Patients scheduled for TURB were prospectively screened. After initial TURB, patients were assigned to 2nd TURB or follow-up cystoscopy at 3 months (FU) by clinicians' discretion. Central urine cytology and Xpert monitor tests were performed prior to the 1st TURB and 2nd TURB or FU, respectively. Statistical analysis to compare clinical assessment and Xpert monitor comprised sensitivity (SENS), specificity (SPEC), NPV and PPV. Of 756 screened patients, 171 were included (114 with 2nd TURB, 57 with FU). Residual tumors were detected in 34 patients who underwent 2nd TURB, and recurrent tumors were detected in 2 patients with FU. SENS and SPEC of Xpert monitor were 83.3% and 53.0%, respectively, PPV was 32.6% and NPV was 92.1%. Clinical risk assessment outperformed Xpert monitor. In patients with pTa disease at initial TURB, Xpert monitor revealed a NPV of 96%. Xpert monitor was not superior than clinical assessment in predicting the need for 2nd TURB. It might be an option to omit 2nd TURB for selected patients with pTa disease.

[Carboxycryobiopsy and carboxycryoextraction of bladder tumor. Experimental study]

AIM

To evaluate the possibility of performing transurethral carboxycryobiopsy (CCB) and carboxycryoextraction (CCE) of a bladder tumor for pathomorphological examination, as well as to perform a comparative analysis of the safety (quality) of biopsy material (tumor tissue) during standard transurethral biopsy and carboxycryobiopsy.

MATERIALS AND METHODS

In the first experiment in vitro, CCE of bladder tumor fragments obtained after transurethral resection was performed. In the second pilot study, cystoscopy followed by CCB and CCE in a patient with multiple bladder tumors was done. The procedure was performed by transurethral access. During cryopreservation of the bladder tumor, a biopsy was performed. After freezing, the tumor was removed from the bladder and sent for histological examination.

RESULTS

The first experiment showed that cryoextraction of the fragments of a bladder tumor using carbon dioxide (CCE) in vitro is a feasible procedure and allows the evacuation of tumor tissues of various sizes. According to the second experiment, CCB and CCE of the bladder tumor using carbon dioxide allows to obtain a biopsy of a bladder tumor of sufficient size without compression or coagulation artifacts, which contributes to a more accurate histological evaluation.

CONCLUSION

Our experiments showed that CCB and CCE of a bladder tumor using carbon dioxide are feasible procedures that contribute to obtaining better biopsy material for pathomorphological examination, and also allows to evaluate the effect of low temperatures of carbon dioxide on the biopsy material (tumor tissue).

Efficient Augmented Intelligence Framework for Bladder Lesion Detection

PURPOSE

Development of intelligence systems for bladder lesion detection is cost intensive. An efficient strategy to develop such intelligence solutions is needed.

MATERIALS AND METHODS

We used four deep learning models (ConvNeXt, PlexusNet, MobileNet, and SwinTransformer) covering a variety of model complexity and efficacy. We trained these models on a previously published educational cystoscopy atlas (n = 312 images) to estimate the ratio between normal and cancer scores and externally validated on cystoscopy videos from 68 cases, with region of interest (ROI) pathologically confirmed to be benign and cancerous bladder lesions (ie, ROI). The performance measurement included specificity and sensitivity at frame level, frame sequence (block) level, and ROI level for each case.

RESULTS

Specificity was comparable between four models at frame (range, 30.0%-44.8%) and block levels (56%-67%). Although sensitivity at the frame level (range, 81.4%-88.1%) differed between the models, sensitivity at the block level (100%) and ROI level (100%) was comparable between these models. MobileNet and PlexusNet were computationally more efficient for real-time ROI detection than ConvNeXt and SwinTransformer.

CONCLUSION

Educational cystoscopy atlas and efficient models facilitate the development of real-time intelligence system for bladder lesion detection.

Mucinous appendiceal adenocarcinoma invading the bladder: not always an easy diagnosis. A case report

Appendiceal neoplasms account for less than 1% of intestinal cancers and their clinical manifestation is typically, nonspecific and ambiguous. Appendiceal tumor infiltrating the urinary tract is extremely rare and few cases are mentioned in literature. A 72-year-old woman presented gross hematuria and right colic pain. No prior urologic disease was reported. Cystoscopic examination showed a large lesion on the right side of posterior bladder wall, with multiple ulcerated areas and microscopical examination of the specimen revealed a mucinous adenocarcinoma infiltrating urinary bladder. Contrast-enhanced computed tomography (CT) scan identified focal thickening of bladder dome 21 × 7 cm with a possible origin from the appendix and with an unclear relationship with the uterus and the right fallopian tube. These findings were discussed with the local gastrointestinal multidisciplinary team, where a decision to perform upfront surgery was made. Explorative laparotomy confirmed a tumor of the appendix invading the urinary bladder. We performed an en-bloc resection including right colon, 40 cm of terminal ileum with a partial cystectomy removing the infiltrated area of the right bladder wall, and an omentectomy. Reconstruction was made first with a full-thickness suture of the bladder, then with an ileo-colon stapled anastomosis. The postoperative course was uneventful and the CT scan at 9 months from surgery did not show any recurrence. Right hemicolectomy is considered the gold standard for all lesions with invasion beyond the mucosa, and, appendicectomy alone seems to be the ideal treatment for in situ and localized cases.

Cystoscopy, an indispensable tool for the diagnosis and prognosis of bladder pain syndrome, takes nomograms for predicting recurrence

PURPOSE

We aimed to illustrate the importance of cystoscopy for the diagnosis and prognosis of bladder pain syndrome (BPS) or interstitial cystitis (IC).

METHODS AND MATERIALS

We designed a 4-year prospective follow-up study. Patients who underwent cystoscopy between May 2011 and July 2021 with a diagnosis of BPS/IC before surgery or positive cystoscopic findings during initial surgery at Peking University People's Hospital were enrolled. Data related to symptom recurrence were obtained through clinic visits and telephone follow-up. We compared the differences in clinical features of BPS/IC subtypes differentiated by cystoscopy and first created clinical predictive nomograms for BPS/IC.

RESULTS

A total of 141 patients were included. There was an 8.51% chance of BPS/IC being misdiagnosed as other diseases or other diseases being misdiagnosed as BPS/IC without cystoscopy. Patients with HIC had higher pain scores and ICPI, higher residual urine volume, lower first-sense-to-void, and maximum cystometric bladder capacities than NHIC. Nomogram Models showed that patients who with higher ICPI, ICSI and lower AMBC have a greater recurrence probability, and lesions in the trigone may indicate a greater likelihood of recurrence than lesions in other bladder walls.

CONCLUSIONS

Timely detection of bladder cancer and other diseases using cystoscopy can avoid poor treatment effects. BPS/IC subtypes can be classified according to mucosal changes under cystoscopy. Lesions in the bladder triangle can indicate a higher recurrence risk, which is important in follow-up treatment. We strongly recommend that cystoscopy should be included in the international BPS/IC diagnostic criteria.

Diagnostic value of the combination of DAPK methylation in urinary sediment and B ultrasound for recurrent urinary bladder cancer

BACKGROUND

Urinary bladder cancer (UBC) is the most common malignancy affecting the urinary system. This study aimed to investigate the diagnostic value of combining DAPK methylation in urinary sediment and B ultrasound in the detection of recurrent UBC.

METHODS

A total of 1021 cases with primary UBC who underwent electrocision of bladder tumor through urethra were included in this study and followed up. Various parameters including B ultrasound, DAPK methylation in urinary sediment, examination of exfoliated cells in the urine, and cystoscopy were performed. The data collected was analyzed using the Kappa test, and receiver operating characteristic (ROC) curve was constructed to assess the diagnostic role in recurrent UBC.

RESULTS

Among the 1021 patients, 115 patients experienced recurrence confirmed by cystoscopy and biopsy within two years and were excluded from the study, resulting in an effective sample size of 906 primary UBC cases. The results of cystoscopy showed agreement with B ultrasound (Kappa = 0.785, P < 0.05), as well as with DAPK methylation in urinary sediment, and the combination of B ultrasound and DAPK methylation (Kappa = 0.517, P < 0.05, Kappa = 0.593, P < 0.05). The combination of B ultrasound with DAPK methylation yielded an area under the curve of 0.922, with a sensitivity of 92.86%, specificity of 91.63%, and a negative predictive value of 99.4%, suggesting that a negative result indicates a low risk of recurrence.

CONCLUSION

The combination of DAPK methylation in urinary sediment with B ultrasound demonstrates high diagnostic performance for recurrent UBC.

Bladder Epicheck Test: A Novel Tool to Support Urothelial Carcinoma Diagnosis in Urine Samples

Bladder cancer and upper urothelial tract carcinoma are common diseases with a high risk of recurrence, thus necessitating follow-up after initial treatment. The management of non-muscle invasive bladder carcinoma (NMIBC) after transurethral resection involves surveillance, intravesical therapy, and cytology with cystoscopy. Urinary cytology, cystoscopy, and radiological evaluation of the upper urinary tract are recommended during follow-up in the international urological guidelines. Cystoscopy is the standard examination for the first assessment and follow-up of NMIBC, and urine cytology is a widely used urinary test with high sensitivity for high-grade urothelial carcinoma (HGUC) and carcinoma in situ (CIS). In recent years, various urinary assays, including DNA methylation markers, have been used to detect bladder tumors. Among these, the Bladder EpiCheck test is one of the most widely used and is based on analysis of the methylation profile of urothelial cells to detect bladder neoplasms. This review assesses the importance of methylation analysis and the Bladder EpiCheck test as urinary biomarkers for diagnosing urothelial carcinomas in patients in follow-up for NMIBC, helping cytology and cystoscopy in doubtful cases. A combined approach of cytology and methylation analysis is suggested not only to diagnose HGUC, but also to predict clinical and histological recurrences.

Comet-FISH analysis of urothelial cells. A screening opportunity for bladder cancer?

INTRODUCTION

Bladder cancer (BCa) is the most frequent cancer of the urinary tract, with more than 500,000 reported cases and nearly 200,000 related deaths yearly. Cystoscopy is the standard examination used for the initial diagnosis and follow-up of BCa in the noninvasive stage. However, the American Cancer Society does not include BCa screening in its list of recommended cancer screenings.

AREAS COVERED

Recently, several urine-based bladder tumor markers (UBBTMs) that identify genomic, transcriptomic, epigenetic, or protein alterations have been introduced, some of which have been approved by the Food and Drug Administration (FDA) to improve its diagnosis and surveillance. Several biomarkers have been found in the tissues and blood of individuals with BCa or predisposed to develop the disease, further enriching our information.

EXPERT OPINION

From a prevention perspective, alkaline Comet-FISH could be a valuable tool with broad potential for clinical application. Furthermore, a comet assay could be more beneficial for diagnosing and monitoring bladder cancer and determining individual susceptibility. Thus, we recommend further studies to understand the potential of this combined assay in the general population as a potential screening test and in patients initiated into the diagnostic process.

An Enhanced Synthetic Cystoscopic Environment for Use in Monocular Depth Estimation

As technology advances and sensing devices improve, it is becoming more and more pertinent to ensure accurate positioning of these devices, especially within the human body. This task remains particularly difficult during manual, minimally invasive surgeries such as cystoscopies where only a monocular, endoscopic camera image is available and driven by hand. Tracking relies on optical localization methods, however, existing classical options do not function well in such a dynamic, non-rigid environment. This work builds on recent works using neural networks to learn a supervised depth estimation from synthetically generated images and, in a second training step, use adversarial training to then apply the network on real images. The improvements made to a synthetic cystoscopic environment are done in such a way to reduce the domain gap between the synthetic images and the real ones. Training with the proposed enhanced environment shows distinct improvements over previously published work when applied to real test images.

Cxbladder Monitor testing to reduce cystoscopy frequency in patients with bladder cancer

PURPOSE

Bladder cancer surveillance is associated with high costs and patient burden. CxMonitor (CxM), a home urine test, allows patients to skip their scheduled surveillance cystoscopy if CxM-negative indicating a low probability of cancer presence. We present outcomes from a prospective multi-institutional study of CxM to reduce surveillance frequency during the coronavirus pandemic.

MATERIALS AND METHODS

Eligible patients due for cystoscopy from March-June 2020 were offered CxM and skipped their scheduled cystoscopy if CxM-negative. CxM-positive patients came for immediate cystoscopy. The primary outcome was safety of CxM-based management, assessed by frequency of skipped cystoscopies and detection of cancer at immediate or next cystoscopy. Patients were surveyed on satisfaction and costs.

RESULTS

During the study period, 92 patients received CxM and did not differ in demographics nor history of smoking/radiation between sites. 9 of 24 (37.5%) CxM-positive patients had 1 T0, 2 Ta, 2 Tis, 2 T2, and 1 Upper tract urothelial carcinoma (UTUC) on immediate cystoscopy and subsequent evaluation. 66 CxM-negative patients skipped cystoscopy, and none had findings on follow-up cystoscopy requiring biopsy. Six of these patients did not attend follow-up, 4 elected to undergo additional CxM instead of cystoscopy, 2 stopped surveillance, and 2 died of unrelated causes. CxM-negative and positive patients did not differ in demographics, cancer history, initial tumor grade/stage, AUA risk group, or number of prior recurrences. Median satisfaction (5/5, IQR 4-5) and costs (26/33, 78.8% no out-of-pocket costs) were favorable.

CONCLUSIONS

CxM safely reduces frequency of surveillance cystoscopy in real-world settings and appears acceptable to patients as an at-home test.

[A Case of Inflammatory Myofibroblastic Tumor of The Bladder Treated with Partial Cystectomy]

A 60-year-old woman with extensive hematuria visited our hospital. Cystoscopy revealed a tumor with an edematous surface on the left lateral wall of the urinary bladder. To diagnose the tumor, we performed a transurethral resection of the bladder tumor. Pathological examination suggested leiomyoma. Four weeks after the transurethral resection, magnetic resonance imaging revealed an increase in the bladder tumor. She received partial cystectomy. Pathological analysis revealed an inflammatory myofibroblastic tumor. No recurrence was observed 9 months after the initial operation.

Feasibility of Novel Technique of Flexible Cystoscopic En Bloc Snare Resection of Bladder Tumor: f-ESRBT

Background: En bloc resection of bladder tumors (ERBT) has been used as a treatment option to improve pathologic diagnostic accuracy in non-muscle invasive bladder cancer. We report on the feasibility of a novel ERBT technique using an electrosurgical snare with flexible cystoscope: flexible cystoscopic En bloc Snare Resection of Bladder Tumor (f-ESRBT). Methods: We used the electrosurgical snare to resect a superficial bladder tumor after injection of 50% glucose in the submucosa at the tumor base. We collected each resected tumor with a basket catheter and coagulated the resected area with a coagulation electrode. A flexible cystoscope was used for all procedures. Results/Discussion: We performed 10 operations. Mean tumor size was 10.2 ± 7.3 mm and mean surgery time was 13.8 ± 6.8 minutes. All procedures were performed without complications. Results showed f-ESRBT to be simple and minimally invasive and to enable accurate pathologic diagnoses. Conclusion: f-ESRBT is a feasible treatment option for small and non-muscle invasive bladder cancer.

Sequential Application and Post-Test Probability for Screening of Bladder Cancer Using Urinary Proteomic Biomarkers: A Review based Probabilistic Analysis

BACKGROUND

Bladder cancer is one of the most common cancers in the world, with men being affected more than women. Diagnosis by cystoscopy, cytology and biopsy is invasive. Urine cytology, a non-invasive modality is not sensitive. This study is undertaken to evaluate whether non- invasive urinary proteomic profiling is more sensitive, specific for bladder cancer.

OBJECTIVE

To evaluate the sensitivity and specificity of various urinary proteomic biomarkers as a screening tool for bladder cancer.

METHODS

PubMed database was searched from 4th December 2011 to 30th November 2021 using Mesh terms and n = 10,364 articles were found. PRISMA guidelines were followed and Review articles, animal studies, Urinary tract infections, non-bladder cancer and other irrelevant articles were excluded. All studies who have reported mean/median (SD/IQR), sensitivity, specificity, cut off values (ROC analysis) were included (n=5). Post-test probability of various biomarkers was calculated using sequential approach. Pooled analysis was depicted using Forest plot.

RESULTS

Analysis of diagnostic studies of bladder cancer showed the post-test probability of CYFRA21-1 was 36.6%. Using sequential approach, the panel of biomarkers CYFRA 21-1, CA-9, APE-1, COL13A1 has post-test probability of 95.10% to diagnose bladder cancer. Analysis of two observational studies with APOE (n= 447) showed non-significant increase of APO-E levels in bladder cancer cases (WMD: 66.41with 95% CI 52.70-185.51; p=0.27, I2 92.4%).

CONCLUSION

In patients presenting with hematuria, a panel of CYFRA 21-1, CA-9, APE-1, COL13A1 markers can be considered for screening of bladder cancer.

Vaginoscopy With Laser Treatment of Symptomatic Upper Vaginal Mesh Exposure After Prior Mesh Sacrocolpopexy

OBJECTIVE

To describe the technique of vaginoscopy with Holmium:YAG and Thulium laser treatment of upper vaginal mesh exposure after mesh sacrocolpopexy (MSC) as well as evaluate treatment efficacy.

METHODS

Following IRB approval, a chart review of all patients who underwent laser treatment of upper vaginal mesh exposure during vaginoscopy at a single institution between 2013 and 2022 was performed. Demographic information, previous mesh placement history, presenting symptoms, physical examination and vaginoscopy findings, imaging, laser type and settings, operating time, complications, and follow-up including examination and office vaginoscopy findings were extracted from electronic medical records.

RESULTS

Five patients and 6 surgical encounters were identified. All patients had a history of MSC and symptomatic mesh exposure at the vaginal apex, which was tented up and difficult to access by traditional transvaginal mesh excision. Five patients underwent vaginal mesh treatment with laser with no further vaginal mesh exposure on follow-up exam or vaginoscopy. One patient was found to have a small recurrence at 4 months and underwent a second treatment with negative findings on vaginoscopy 7.9 months post-operatively. There were no complications.

CONCLUSION

Vaginoscopy using a rigid cystoscope and laser treatment of upper vaginal mesh exposure using a Holmium:YAG or Thulium laser is a safe and quick method which led to definitive symptom resolution.