Urethral steinstrasse--clinical experience and radiographic findings.
Urethral steinstrasse is rare and requires immediate intervention. The radiographic and cystoscopic findings in two patients with urethral steinstrasse are described.
Female↗
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Retrograde radiological retrieval and replacement of double-J ureteric stents.
Internal double-J stents are used to maintain ureteral patency and require replacement within 4-6 months. We present our experience with 15 consecutive patients who had 35 internal ureteral stents retrieved and in whom 27 were successfully replaced, retrogradely under fluoroscopic control. The double-J stents were retrieved using an Amplatz gooseneck snare. Replacement was more successful in female patients, and was technically more difficult via an ileal conduit or transplant ureter. We found this new technique to be straightforward and well tolerated by the patients. The procedure was performed on an outpatient basis, and no serious complications were reported. This technique is considerably cheaper than cystoscopic replacement under epidural or general anaesthesia, and is recommended for the retrieval and replacement of internal ureteral plastic stents in most patients.
Female↗
Laparoscopic management of 15 patients with infiltrating endometriosis of the bladder and a case of primary intravesical endometrioid adenosarcoma.
OBJECTIVE: To report laparoscopic management of 15 patients with infiltrative bladder wall endometriosis and to report a case of endometrioid adenosarcoma. DESIGN: Prospective chart review. SETTING: Referral center for endometriosis. PATIENT(S): Fifteen women with infiltrating endometriosis of the bladder. INTERVENTION(S): Laparoscopic segmental cystectomy and pathologic review of endometriotic bladder nodules in 15 patients. MAIN OUTCOME MEASURE(S): Location and characteristics of endometriotic bladder nodules. RESULT(S): Laparoscopic and cystoscopic evaluation confirmed that the endometriotic lesions were penetrating through the bladder wall. In 8 patients, the lesions were located in the dome of the bladder. In the remaining 7, the lesions were in the posterior wall, above the trigone. It was possible to treat all the lesions by performing a laparoscopic partial cystectomy. No intraoperative complications occurred. Deeply infiltrating endometriosis was confirmed on histologic evaluation in 14 cases. One patient was diagnosed with endometriosis on frozen section, but the final pathology revealed an adenosarcoma of the bladder. CONCLUSION(S): Surgical excision of deeply infiltrating endometriosis of the bladder wall can be performed laparoscopically and offers the benefit of a definitive pathologic diagnosis to rule out an occult malignancy.
Adenosarcoma↗
Vesicouterine fistula--an analysis of 24 cases from Poland.
OBJECTIVE: This study was undertaken to evaluate what clinical events or situations are currently associated with the occurrence of vesicouterine fistula. METHOD: A retrospective investigation was carried out on 24 patients treated in a tertiary referral center during a 12-year period. Clinical data were collected from the patients directly, the medical records, urographic and/or cystoscopic findings before repair and intraoperative findings at repair. RESULTS: All fistulas were iatrogenic, and 21 (87.5%) occurred following cesarean section or cesarean hysterectomy. Bladder injury occurred two times more often after repeat operations than after the primary. The proportion of repeat cesarean section resulting in a fistula was significantly increased (58.3% vs. 29.6%, P < 0.013) when compared to that previously reported. CONCLUSIONS: Cesarean sections are currently the single major risk factor associated with the occurrence of vesicouterine fistulas. Repeat procedures increase the risk of bladder injury and resultant fistulas.
Adult↗
Diagnostic flexible peritoneoscopy: assessment of the contralateral internal inguinal ring during unilateral herniorrhaphy.
BACKGROUND: Inguinal hernia is the most common pediatric surgical condition, with 75% of cases presenting unilaterally. No diagnostic study exists to determine preoperatively which children are at risk for subsequent contralateral hernia. The literature is not clear in advising whether surgeons should explore the contralateral side at the time of initial unilateral herniorrhaphy. METHODS: Twenty-four patients presenting clinically with a unilateral hernia underwent flexible peritoneoscopy by isolation of the ipsilateral hernia sac and placement of a flexible cystoscope into the peritoneal cavity. After establishing a CO2 pneumoperitoneum, the contralateral side is checked for patency of the internal inguinal ring. RESULTS: Our study found an open internal inguinal ring in 4 of 24 patients examined (16.7%). The other 20 patients were spared the usual routine contralateral exploration. An open contralateral internal inguinal ring was appreciated in two of nine (22.2%) left herniorrhaphy and 2 of 15 (13.3%) right herniorrhaphy patients. This technique requires an average of 4.5 minutes to perform. With 18-to 32-month follow-up, no hernias have developed on the contralateral side. CONCLUSION: Diagnostic flexible peritoneoscopy is safe, quick, simple, and could be used to evaluate the contralateral internal inguinal ring in unilateral pediatric herniorrhaphy patients.
Adolescent↗
Technique and complications of percutaneous nephroscopy: experience with 557 patients in the supine position.
PURPOSE: Percutaneous nephroscopy is usually performed with the patient prone, which is uncomfortable for the patient and does not prevent damage to the colon. We assess the possibility of performing percutaneous nephroscopy using local anesthesia with the patient supine, and evaluate the advantages and complications. MATERIALS AND METHODS: A total of 557 consecutive percutaneous nephroscopies were attempted in 221 men and 242 women in the supine position. Patient age ranged from 8 to 87 years (mean 55.1). Patients are supine with a 3 l. serum bag below the ipsilateral flank. We catheterize the affected uretheral meatus with a 5F catheter through a flexible cystoscope. The tract is infiltrated with local anesthesia. The skin is punctured in the posterior axillary line which corresponds to approximately 1 cm. above the bag. We use an Alken set to dilate the tract to 30F, which is the size of the Amplatz sheath we commonly use. RESULTS: Nephroscopy was performed in 519 cases (93.1%). Mean operation time was 85 minutes (range 15 to 240). Serious bleeding occurred in 3 cases. The colon was never damaged in patients treated in the supine position. CONCLUSIONS: Percutaneous nephroscopy using local anesthesia with the patient supine is safe and easy. According to our experience the advantages in comfort to the patient and feasibility to the surgeon justify its use.
Adolescent↗
Evaluation of NMP22 in the detection of transitional cell carcinoma of the bladder.
PURPOSE: Urinary nuclear matrix protein (NMP22) was evaluated for detection of new and recurrent bladder tumors in patients with a history of transitional cell carcinoma. Our objective was to determine sensitivity and specificity of this marker for tumors of various stages and grades, as well as its use as an adjunct to or substitute for urinary cytology. MATERIALS AND METHODS: A total of 231 patients with a history of transitional cell carcinoma provided 288 voided urine samples before cystoscopic examination at 1 of 3 institutions (53 patients were reevaluated at least once). Urine samples were assayed for NMP22 using the NMP22 Test Kit. Select patients underwent biopsy with appropriate additional therapy. Voided urinary cytology was obtained in 200 cases. End points for determination of the absence and presence of tumor were negative cystoscopy and positive biopsy, respectively. A receiver operating characteristics curve was constructed to determine the optimal NMP22 threshold for detection of transitional cell carcinoma. For positive biopsies NMP22 values were also correlated with tumor stage and grade. Comparison to cytology was limited to patients with complete data. RESULTS: There were 208 negative cystoscopies (158 with cytology) and 66 positive cystoscopies with biopsy (42 with cytology). Of the cases 14 were eliminated from statistical analysis due to incomplete data. Receiver operating characteristics curve interpretation determined that 6.4 units per ml. was an optimal reference value for detection of transitional cell carcinoma in this patient group. Sensitivity and specificity for all pathological groupings was 68 and 80%, respectively. When compared to cytology the sensitivities of NMP22 and cytology were 67 versus 31 or 40% (depending on the definition of positive cytology). CONCLUSIONS: NMP22 values represented significant improvement over urinary cytology for detection of transitional cell carcinoma. The sensitivity of NMP22 for detection of transitional cell carcinoma in bladder cancer patients was as much as twice that of cytology when a reference value of 6.4 units per ml. was used. NMP22 analysis was less costly than cytology and operator independent. While NMP22 has previously been shown to be a strong predictor of recurrence after tumor resection, it is an effective and sensitive screening test for detecting tumors in patients with transitional cell carcinoma.
Aged↗
Polymerase chain reaction amplification of bacterial 16S rRNA genes in interstitial cystitis and control patient bladder biopsies.
PURPOSE: Several characteristics of the chronic bladder disease called interstitial cystitis (IC) suggest an infectious etiology. However, a single causative organism has not been convincingly cultured in vitro, and DNA for a variety of microorganisms has been found inconsistently in bladder biopsies from IC patients. We therefore looked for a possible bacterial cause for IC by using a sensitive nested PCR assay on cystoscopic bladder biopsy specimens obtained from IC patients and controls. MATERIALS AND METHODS: Bladder biopsies were obtained at cystoscopy from 6 IC patients and 6 controls. DNA was extracted from these specimens and PCR with 2-round amplification performed using nested primers from a highly conserved region of the bacterial 16s rRNA gene. Amplified DNA was purified and sequenced using the Sequenase PCR Product Sequencing Kit, and the sequences obtained were compared with bacterial rRNA gene sequences recorded in GenBank. RESULTS: Biopsy specimens from all 6 patients and 6 controls were positive by PCR for DNA encoding bacterial 16s rRNA. Sequence data indicated a predominant microorganism in 10 of the 12 specimens, with > 95% homology to DNA from several different genera of bacteria including Acinetobacter, Propionobacterium, Salmonella, and Escherichia. None of the organisms identified by PCR had been cultured from tissue or urine obtained simultaneously from these persons, using sensitive culture techniques. CONCLUSIONS: These data indicate no difference between IC patients and controls in the proportion of bladder biopsies with PCR positivity or the type(s) of organism present, providing additional evidence that IC is not associated with infection by a particular type of bacterium.
Cystitis, Interstitial↗
Vesicovaginal and vesicocutaneous fistulas: transurethral suture cystorrhaphy as a new closure technique.
PURPOSE: We assessed the usefulness of endoscopic treatment of vesical fistulas. MATERIALS AND METHODS: Two bladder fistula patients underwent transurethral surgery in an attempt to close the fistula. RESULTS: Both patients were cured of the fistula, without undergoing an open procedure. CONCLUSIONS: Cystoscopically assisted suture closure of vesical fistulas can be a successful procedure in selected patients. Nontraditional instrumentation and technique allowed for transurethral closure of these fistulas.
Cutaneous Fistula↗
The rectal tube: an excellent catheter for severe clot retention.
PURPOSE: We describe the use of an alternative catheter for clot irrigation. MATERIALS AND METHODS: Six patients with severe clot retention that could not be treated successfully with irrigation using large bore urethral catheters were subsequently treated with a fenestrated 28 to 32F Rusch red rubber rectal catheter. RESULTS: All clots were successfully evacuated. Cystoscopic evaluation the following day in 4 patients with hematuria confirmed the absence of clots. The other 2 patients did not undergo cystoscopy but continuous bladder irrigation was completely clear for the next 24 hours and the catheters were removed without further sequelae. CONCLUSIONS: Irrigation through a rectal tube can provide immediate relief of clot retention and consequently avoid emergency endoscopic intervention in the operating room.
Humans↗
Trimming a tether: a simple way to prevent complications related to tethered ureteral stents.
PURPOSE: A method to prevent complications related to a tethered ureteral stent was assessed. MATERIALS AND METHODS: In 17 male patients tethers were trimmed just short of the meatus after insertion of a ureteral stent. At stent removal a rigid cystoscope was inserted into the anterior urethra, and the edge of the tether was grasped with foreign body forceps. RESULTS: Only 1 patient required removal of the tether due to severe urethral discomfort. Pain at cystoscopy for removal of the ureteral stent was minimal. CONCLUSIONS: This method is useful for improving the quality of life during the catheterization period without decreasing effectiveness of a conventional ureteral stent with a tether.
Adult↗
Fluorescein angiography of the bladder: technique and relevance to bladder cancer and interstitial cystitis patients.
PURPOSE: Fluorescein angiography has been used in the study of bleeding vessels, neovascularity, tumors and ischemic tissues in a variety of disorders. This pilot study was designed to evaluate the feasibility, safety and relevance of this interesting technology for the evaluation of bladder wall vessels in patients with interstitial cystitis and bladder cancer. MATERIALS AND METHODS: Five patients with National Institutes of Health defined interstitial cystitis symptoms and 10 with bladder cancer were studied during cytoscopy while they were under general anesthesia. A yellow-green barrier filter (520 nm.) was placed over the cystoscope eyepiece and a blue exciter filter (465 nm.) was attached to the light source. Patients received a 5 ml. bolus of 10% fluorescein intravenously. RESULTS: After hydrodistension, glomerulations in interstitial cystitis patients were more prominent with fluorescein angiography and occurred in the venule phase. Areas of papillary transitional cell tumor and carcinoma in situ developed a brilliant yellow-green fluorescence. Adjacent normal urothelium was nonfluorescent and provided a contrasting dark background facilitating the detection of all lesions. No allergic reaction or other adverse effect related to the fluorescein injection was observed. CONCLUSIONS: These unique observations in a limited number of patients suggest that fluorescein angiography of the bladder is a safe and simple procedure. This preliminary report underscores the relevance of fluorescein angiography in the detection of bladder tumor and offers a new approach to the evaluation of bladder wall vessels in interstitial cystitis patients.
Arterioles↗
Detection of eubacteria in interstitial cystitis by 16S rDNA amplification.
OBJECTIVE: To determine what role non-culturable microorganisms play in the etiology of interstitial cystitis (IC). MATERIALS AND METHODS: Thirty patients fulfilling NIH criteria for the diagnosis of interstitial cystitis and sixteen control patients with culture negative urine gave written informed consent and underwent bladder biopsy. Polymerase chain reaction (PCR) using two sets of universal primers for bacterial 16S rDNA was performed on urine from the cystoscope and on a cold cup bladder biopsy specimen. Of the PCR positive bladder biopsies, three patients with interstitial cystitis and three controls were randomly selected and cloned. Ten clones from each were sequenced and putative taxonomic assignments made. RESULTS: 12/26 (46%) IC and 5/12 (42%) control urine specimens and 16/30 (53%) and 9/15 (60%) bladder biopsies were PCR positive, respectively. The bacterial populations in the two patient groups tested appeared to be different based upon analysis of the 16S rRNA sequences. CONCLUSIONS: Both IC and control patients had non-culturable bacteria in their bladders. A random sampling of the two populations revealed that the bacterial populations are different, suggesting a possible link between one or more bacterial species and IC.
Bacteria↗
Intraoperative sentinel node detection improves nodal staging in invasive bladder cancer.
PURPOSE: We evaluated intraoperative SN detection in patients with invasive bladder cancer during radical cystectomy in conjunction with extended lymphadenectomy. MATERIALS AND METHODS: A total of 75 patients with invasive bladder cancer underwent radical cystectomy with extended lymphadenectomy. SNs were identified by preoperative lymphoscintigraphy, intraoperative dynamic lymphoscintigraphy and blue dye detection. An isotope (70 MBq (99m)Tc-nanocolloid) and Patent Blue(R) blue dye were injected peritumorally via a cystoscope. Excised lymph nodes were examined ex vivo using a handheld gamma probe. Identified SNs were evaluated by extended serial sectioning, hematoxylin and eosin staining, and immunohistochemistry. RESULTS: At lymphadenectomy an average of 40 nodes (range 8 to 67) were removed. Of 75 patients 32 (43%) were lymph node positive, of whom 13 (41%) had all lymph node metastases located only outside of the obturator spaces. An SN was identified in 65 of 75 patients (87%). In 7 patients an SN was recognized when the nodal basins were assessed with the gamma probe after lymphadenectomy and cystectomy. Of the 32 lymph node positive cases 26 (81%) had a positive (metastatic) SN. Thus, the false-negative rate was 6 of 32 cases (19%). Five false-negative cases had macrometastases and/or perivesical metastases. In 9 patients (14%) the SN contained micrometastases (less than 2 mm), in 5 of whom the micrometastasis was the only metastatic deposit. CONCLUSIONS: SN detection is feasible in invasive bladder cancer, although the false- negative rate was 19% in this study. Extended serial sectioning and immunohistochemistry revealed micrometastases in SNs in 9 patients and radio guided surgery after the completion of lymphadenectomy identified SNs in an additional 7. We believe that the technique that we used in this study improved nodal staging in these 16 of 65 patients (25%).
Aged↗
Minimally invasive ureteral stent retrieval.
PURPOSE: We developed a minimally invasive (noncystoscopic) method for retrieving ureteral stents. MATERIALS AND METHODS: A total of 30 consecutive patients underwent placement of a ureteral stent with a stainless steel bead attached to its distal end. The stent was later removed by a urethral catheter with a rare earth magnet attached to its proximal end. RESULTS: In 29 of the 30 patients the stent with the attached bead was removed without difficulty or patient discomfort. The single failure occurred in a patient with a large median prostate lobe. CONCLUSIONS: Minimally invasive, nonendoscopic ureteral stent retrieval was achieved in 97% of patients. The attractive force of the magnet for the bead was sufficient to attract and extract the stent. No adverse effects of the procedure or the stainless steel bead were noted. This magnet retrieval system is a feasible, simpler and less invasive alternative to cystoscopic retrieval of ureteral stents.
Adult↗
The ultrastructure of bladder lamina propria nerves in healthy subjects and patients with detrusor hyperreflexia.
PURPOSE: Detrusor hyperreflexia is a common finding in patients with neurological disease involving the spinal cord. In animal models it has been attributed to an emergent reflex mediated mostly by unmyelinated C-fibers. We describe and measure ultrastructural features of these nerves in the lamina propria in healthy subjects and patients with detrusor hyperreflexia. MATERIALS AND METHODS: Flexible cystoscopic bladder biopsies were obtained from 51 patients (8 controls, 8 with tropical spastic paraparesis, 23 with multiple sclerosis and 12 with spinal cord disease). Electron micrographs were obtained of every nerve profile seen in the midpoint of the biopsy specimen, and in each nerve profile a number of variables were measured and recorded. RESULTS: The mean nerve profile diameter was greater in patients with tropical spastic paraparesis (mean 2.19 microm.) compared to controls (1.59 microm.) and patients with multiple sclerosis (1.55 microm.) (p <0.001). We observed a sparse urothelial innervation by naked axonal varicosities but similar bare varicosities were more frequent in the superficial layer of the lamina propria. In deeper layers close membrane contacts between axonal varicosities and cells with cytological characteristics of myofibroblasts were seen. CONCLUSIONS: We described and measured ultrastructural characteristics of human bladder lamina propria nerves. The mean profile diameter is larger in patients with tropical spastic paraparesis compared to controls and patients with multiple sclerosis. This study provides a baseline to which other bladder disorders can be compared and may allow the effect of intravesical treatments on these nerves to be assessed. Some possible functional aspects of observed structural interrelationships are presented.
Adult↗
Correlation of cystoscopy with histology of recurrent papillary tumors of the bladder.
PURPOSE: We correlated individual urologist impressions of tumor stage and grade of recurrent papillary bladder tumors at cystoscopy with histological findings after transurethral resection to determine whether cystoscopy can reliably identify low grade, noninvasive papillary tumor for outpatient fulguration. MATERIALS AND METHODS: A total of 144 recurrent papillary bladder tumors identified on outpatient flexible cystoscopy were classified as low grade and noninvasive (stage Ta grade 1), high grade and noninvasive (stage Ta grade 3) or invasive (stage T1). Voided urine cytology was also performed. The cystoscopic impression of each tumor was correlated with the final histological findings of tumor stage and grade after transurethral resection. RESULTS: Cystoscopy classified 97 tumors as stage Ta grade 1 and 47 as stage Ta grade 3 or stage T1. Cystoscopy correctly predicted the tumor stage and grade of 93% of stage Ta grade 1 and 99% of stage Ta grade 1 lesions associated with negative urine cytology. CONCLUSIONS: Urologists can usually identify noninvasive, low grade recurrent papillary tumors on followup cystoscopy that may be treated safely with outpatient fulguration.
Carcinoma, Papillary↗
Primary localized amyloidosis of the bladder: experience with dimethyl sulfoxide therapy.
PURPOSE: We present our long-term experience with intravesical dimethyl sulfoxide (DMSO) for primary localized amyloidosis of the bladder. MATERIALS AND METHODS: The study included 4 males and 2 females 28 to 68 years old (mean age 54) at diagnosis of biopsy proven primary localized amyloidosis involving the bladder diffusely or extensively in 1 locale. All patients had normal upper urinary tracts. They continued to be symptomatic (hematuria in 3, irritative voiding symptoms in 1, and hematuria and irritative voiding symptoms in 2) despite conventional transurethral destructive therapy. Every 2 weeks they received 30-minute instillations of 50 ml. 50% DMSO intravesically for 3 months (patient 1), 6 months (1) and 1 year (4). RESULTS: Therapy failed at 3 and 6 months in 2 patients of whom 1 with a contracted bladder underwent cystectomy and another was stabilized for 1 year with laser therapy. In the remaining 4 patients who were followed for 6 years disease stabilized for 2 to 6 years (mean 3.5) but 3 later required additional therapy including repeat DMSO in 1 and laser therapy in 2. CONCLUSIONS: Diffuse or locally extensive bladder involvement by primary localized amyloidosis usually fails to respond to conventional transurethral destructive surgical procedures. Collectively, our experience and the literature suggest that intravesical DMSO can be a bladder saving measure and help resolve ureterovesical obstruction in some patients. High recurrence rate mandates lifelong cystoscopic surveillance.
Administration, Intravesical↗