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PubMed1977

Non-obstructive vesicoureteral reflux in adults: value of conservative treatment.

Chronic or recurrent non-obstructive urinary tract infection was investigated in 158 adult patients, 39 of whom had vesicoureteral reflux. Conservative, long-term chemotherapy did not eradicate the reflux in these patients. The characteristics of reflux in adults were studied with cystograms, excretory urograms, cystoscopic findings of the ureteral orifices or trigones and the clinical histories of the patients. These data were evaluated and compared to data obtained from adults with chronic or recurrent uncomplicated urinary tract infection and from children with vesicoureteral reflux who were referred to us during the same period. Non-obstructive vesicoureteral reflux in adults may be considered to be congenital in most cases, since the proportion of trigonal anomalies in adults with reflux is equal to that in children and the frequency of abnormalities at the ureteral orifice and trigonal region is significantly more than the frequency noted in control patients with uncomplicated pyelonephritis. Characteristically, excretory urography revealed caliceal scarring in adults with reflux in contrast to children, in whom a normal or dilated pattern of the upper tract was prominent. Recurring renal infection, for which this congenital defect of the ureterovesical valve must be responsible, produces progressive renal damage. Prolonged conservative treatment is of little use and is often destructive in adults with reflux.

Adult↗

PubMed1976

Silver nitrate irrigation to control bladder hemorrhage in children receiving cancer therapy.

Silver nitrate irrigations after cystoscopic evacuation of clots stopped intractable hemorrhage from the bladder in 8 of 9 children who had received cyclophosphamide and/or pelvic irradiation for various malignant diseases. This method of management produces fewer adverse side effects yet appears to be as effective as the more drastic measures of control, such as cystectomy or colocystoplasty.

Cautery↗

PubMed1976

Analgesic cystitis: an unusual microangiopathy of the bladder.

A brownish discoloration of the bladder mucosa around the ureteral orifices has been observed on cystoscopic examination in 3 patients taking excessive quantities of analgesics. Biopsy revealed an unusual degree of hyalinization of the capillary walls in the submucosa.

Adult↗

PubMed1976

Cytogenetic analysis: a potential index for recurrence of early carcinoma of the bladder.

In 15 cancer patients cystoscopic resection or biopsy coupled with cytogenetic analysis at intervals of 3 to 69 months showed persistence of chromosomal patterns with markers (abnormal chromosomes) in 4 of 7 non-invasive and in 6 of 8 submucosal invasive carcinomas. Recurrence was limited to but constant in those carcinomas containing markers. Marker chromosomes have potential value as a prognostic aid. Further, the triad of tetraploidy, markers and submucusal invasive moderately well differentiated carcinoma appears to carry such a lethal prognosis as to militate for early radical resection.

Carcinoma, Transitional Cell↗

PubMed1976

Prognosis for resolution of moderate, primary reflux in girls.

Detailed cystoscopic grading of ureteral orifices has proved unnecessary in our experience for determining the prognosis of moderate, primary reflux in girls. Medially placed orifices strongly predict spontaneous resolution with preventive medication, while radiographic pyelonephritic scarring and/or grade III reflux strongly predict failure to resolve. While laterally placed ureteral orifices and low volume reflux suggest a need for operation, they are prognostically less useful, particularly when those with grade III reflux are excluded. Cystitis cystica and unrelated anomalies seem to be associated with the ultimate need for operation but are of uncertain significance.

Child↗

PubMed1975

Carcinoma of the bladder in children.

Apparently, epithelial bladder tumors in children differ markedly from their more malignant counterparts in adults. The childhood bladder epithelial tumors morphologically are of a lower grade malignancy, show no evidence of invasion and no tendency to recur. Therefore, all cases thus far reported have resulted in a benign clinical course with a 100 per cent survival rate. These childhood epithelial bladder tumors apparently do not recur, which is in sharp contrast to their adult counterparts. However, this should not lessen the urologist's obligation to provide routine cystoscopic re-evaluation.

Adolescent↗

PubMed1991

Spontaneous renal rupture during pregnancy.

Spontaneous rupture of the renal parenchyma or renal pelvis during pregnancy has been previously reported in 16 cases. In the case we describe in this report, the patient initially had right flank pain and nausea for 48 hours, which progressed to severe abdominal symptoms that necessitated exploratory laparotomy. Cystoscopic placement of a ureteral stent relieved the obstruction and allowed spontaneous healing of the renal pelvis. Dilatation of the urinary collecting system commonly occurs during pregnancy. Spontaneous rupture of the renal parenchyma or renal pelvis, however, is unusual and often associated with diseased kidneys. Our case is the 8th one of spontaneous rupture of the renal collecting system with no identifiable underlying pathologic condition and the 17th case of spontaneous renal rupture overall.

Acute Disease↗

PubMed1986

Laser photodynamic therapy for bladder cancer.

The lack of a tumor-localization aid for transitional cell carcinoma of the bladder and the known cytotoxic effect of light-activated intracellular hematoporphyrin derivative (HpD) prompted the initiation of a trial of HpD photodynamic therapy in patients with focal and diffuse bladder cancer. An argon-ion, pumped-dye laser was used as a source of red light. In 15 patients with focal disease and circumscribed treatment, 3-month follow-up cystoscopic examination showed disappearance of the lesions, but the subsequent recurrence rate seemed high. Therefore, whole-bladder HpD photodynamic therapy was administered to 14 patients with diffuse resistant carcinoma in situ. Three of these patients had focal recurrent disease. The only adverse effects of therapy were cutaneous photosensitivity and bladder irritability. HpD seems to be a good tumor-localizing aid for transitional cell carcinoma of the bladder, and HpD photodynamic therapy effectively destroys this type of carcinoma.

Antineoplastic Agents↗

PubMed1988

Neoadjuvant chemotherapy for locally advanced transitional cell carcinoma of the bladder: do local findings suggest a potential for salvage of the bladder?

Sixteen patients with locally advanced transitional cell carcinoma of the bladder were given two to four cycles of combination chemotherapy with methotrexate, vinblastine, doxorubicin hydrochloride (Adriamycin), and cisplatin (M-VAC) in an effort to reduce tumor size and enhance the potential for surgical resection. All patients had initial clinical staging (based on cystoscopy and cystoscopic biopsy, urine cytology, computed tomographic scanning, and excretory urography). Before each cycle, all patients had repeat clinical staging tests. Ten patients underwent postchemotherapy bilateral pelvic lymphadenectomy and radical cystoprostatectomy, and their bladders were examined histopathologically by step-sectioning techniques. One patient underwent abdominal exploration, bilateral pelvic lymphadenectomy, and ipsilateral partial cystectomy. Five patients had repeat clinical staging only without removal of their bladders. Of the 16 patients, 5 (31%) had residual invasive tumor and no tumor response. Three patients (19%) had a partial response, two of whom had only carcinoma in situ (one with prostatic duct involvement) and one of whom had stage pT1, NO, MO disease. Five patients (31%) had normal findings on computed tomographic scans, cystoscopy, biopsy, and urine cytology and thus had complete responses. In addition, 3 of 11 patients who underwent pathologic staging had no residual tumor on clinical and surgical staging and were complete responders. The overall (partial + complete) response rate was 69%, and the overall complete remission rate (pathologic + clinical staging) was 50%. These results suggest that the concept of possible salvage of the bladder with the current treatment program might be premature and must be applied selectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗

PubMed2002

Recognition of occult bladder injury during the tension-free vaginal tape procedure.

OBJECTIVE: To identify signs and the etiology of occult bladder injury during the tension-free vaginal tape sling procedure. METHOD: The charts of 140 women who underwent a tension-free vaginal tape procedure were reviewed, and complications were tabulated and analyzed. The tension-free vaginal tape procedure was performed in six fresh-frozen pelves to demonstrate the mechanism of the occult bladder injury. RESULTS: Occult bladder injury was suspected when cystoscopy instillation fluid flowed from the plastic sheath that covers the prolene tape after the extraction of the tension-free vaginal tape trocar. Three of six cases of intraoperative bladder injury had occult bladder injury identified on repeat cystoscopic inspection. The bladder injury caused by the rough edge at the point of attachment of the tension-free vaginal tape to the trocar was reproducible in three of 12 tension-free vaginal tape applications in fresh-frozen pelves. Traction on the tension-free vaginal tape reapproximates the injured bladder edges and potentially promotes spontaneous healing. CONCLUSION: Bladder injuries may go unrecognized during a tension-free vaginal tape procedure. Continuous seepage of water through the prolene plastic sleeve is suggestive of occult bladder injury and requires repeat cystoscopy to identify the potential site of injury.

Female↗

PubMed2002

Diagnosing interstitial cystitis in women with chronic pelvic pain.

OBJECTIVE: To evaluate the Interstitial Cystitis Symptom Index and Problem Index as a screening tool for interstitial cystitis, and to estimate the prevalence and risk factors for interstitial cystitis in women with chronic pelvic pain. METHODS: Forty-five women scheduled to undergo laparoscopy for chronic pelvic pain were recruited. Women were questioned about lower urinary tract symptoms, administered the Interstitial Cystitis Symptom Index and Problem Index, and rated pain symptoms on a 0-10 visual analogue scale. Cystoscopy with hydrodistension and bladder biopsy was performed at the time of laparoscopy. Interstitial cystitis was diagnosed if women had a combination of: 1) urgency, 2) frequency or nocturia, and 3) positive cystoscopic findings. RESULTS: Seventeen women (38%) were diagnosed with interstitial cystitis. A score of 5 or more on the Symptom Index had 94% sensitivity (95% confidence interval [CI] 71%, 99.8%) and 93% negative predictive value (95% CI 68%, 99.8%) in diagnosing interstitial cystitis. On multivariable analysis, an elevated Symptom Index score of 5 or more (odds ratio [OR] 9.4; 95% CI 1.01, 88.1) and an elevated dyspareunia score of 7 or more (OR 5.5; 95% CI 1.10, 27.1) were risk factors for interstitial cystitis. CONCLUSION: In our sample of women with chronic pelvic pain, the prevalence of interstitial cystitis was 38%. The Interstitial Cystitis Symptom Index was a useful screening tool. Independent risk factors for the diagnosis of interstitial cystitis were an elevated Symptom Index score and an elevated dyspareunia pain score. For women with chronic pelvic pain, screening for interstitial cystitis should be performed.

Adult↗

PubMed1987

Reflux uropathy.

Although much remains to be learned, most pediatric nephrologists and urologists are now in comfortable agreement with the following assumptions: (1) Most reflux (primary reflux) is due to a congenital anatomic abnormality of the bladder trigone. (2) In many instances this anomaly improves with growth and development of the child so that the reflux may cease spontaneously. In low-grade (I-II) reflux with undilated ureters, approximately 75 to 85 per cent will stop refluxing. In higher grades (III-V) with dilated ureters, the cessation rate is in the range of only 25-30 per cent. (3) Although radiologic grading is helpful in predicting the likelihood of spontaneous cessation, it is possible to improve that predictability by cystoscopic evaluation of the size, configuration, and position of the ureteral orifice plus the length of the submucosal tunnel. (4) Reflux in combination with bacteriuria can and does lead to renal scarring. (5) Renal scarring probably does not occur in patients with primary reflux and normal voiding pressures in the absence of bacteriuria. (6) Renal growth may proceed normally despite sterile reflux. (7) A few refluxing patients, perhaps 10 per cent, will have bacteriuria despite continuous antimicrobials, and these "breakthrough" infections may cause renal scars. (8) Other patients prove either unwilling or unable to comply with continuous medications and are also vulnerable to scars. (9) A successful antireflux operation may not change the recurrence rate of urinary tract infections per se, but it almost eliminates the likelihood of pyelonephritic episodes and the necessity for further continuous antibiotics. Unfortunately, in patients with intermediate grades of reflux, it is not presently known whether an early surgical correction might be more effective in allowing normal renal growth, in avoiding renal scars, and in preventing eventual hypertension, which is present as a late complication in almost 20 per cent of the patients. The data to answer this important question should ultimately be forthcoming from the current International Collaborative Reflux Study.

Child↗

PubMed2000

Percutaneous sacral third nerve root neurostimulation improves symptoms and normalizes urinary HB-EGF levels and antiproliferative activity in patients with interstitial cystitis.

OBJECTIVES: A highly effective treatment for interstitial cystitis (IC) remains elusive. We determined whether sacral third nerve root (S3) percutaneous neurostimulation (PNS) might be effective in relieving symptoms of IC, as well as in normalizing urinary factors that are specifically altered in IC. METHODS: Six consecutive patients with symptoms and cystoscopic findings compatible with IC underwent 5 days of continuous S3 neurostimulation by way of leads placed percutaneously into the S3 foramen. Patients filled out voiding frequency diaries and pain and urgency questionnaires before PNS and at the end of PNS when the leads were removed. Urine specimens were collected at these two time points and measured for heparin-binding epidermal growth factor-like growth factor (HB-EGF) by enzyme-linked immunosorbent assay and for antiproliferative factor (APF) activity by (3)H-thymidine uptake by normal human bladder urothelial cells. RESULTS: S3 PNS significantly improved all measured parameters toward normal values. Voiding frequency decreased twofold from 23.1 +/- 4.6 to 10.6 +/- 4.0 voids daily during PNS (P = 0.0001). Pelvic pain on a scale of 1 to 10 decreased from 7.0 +/- 1.6 to 2.3 +/- 3.2 (P = 0.05). Urinary urgency on a scale of 1 to 10 decreased from 6.0 +/- 2.2 to 1.8 +/- 1.7 (P = 0. 02). Urinary HB-EGF concentration increased sevenfold from 1.5 +/- 2. 1 to 11.0 +/- 1.7 ng/mL (P <0.0001), and urinary APF activity decreased from -76.1% +/- 31% to -4.5% +/- 8.8% (P = 0.005). CONCLUSIONS: S3 PNS significantly decreased symptoms and normalized urinary HB-EGF and APF activity in patients with IC. These results suggest that permanent S3 PNS may be beneficial in treating IC.

Cell Division↗

PubMed2000

Comparison of two qualitative assays, the UBC rapid test and the BTA stat test, in the diagnosis of urothelial cell carcinoma of the bladder.

OBJECTIVES: To compare the diagnostic value of two rapid tests, the bladder tumor antigen (BTA stat) test and the newly developed urinary bladder cancer (UBC) Rapid test, in patients having symptoms suggestive of urothelial cell carcinoma (UCC) and patients being followed up after transurethral resection. METHODS: One hundred eighty patients with a mean age of 65.8 years (range 22 to 92) were included in the present study. The tests were performed on voided urine samples. Fifty-seven patients had symptoms suggestive of UCC and 123 patients were being followed up after complete transurethral resection of UCC. The voided urine was evaluated by the BTA stat and UBC Rapid test, which detects cytokeratins 8 and 18. All patients underwent subsequent cystoscopic evaluation and biopsy of any suspicious lesion. RESULTS: In 53 patients with histologically proved UCC, the BTA stat had a sensitivity of 52.8% and the UBC Rapid test of 66%. According to the histologic stage, the sensitivity of the BTA stat was 42.8% in pTa tumors, 61.5% in pT1, and 70% in pT2 or higher tumors. The sensitivity of the UBC test was 60.7% in pTa, 69. 2% in pT1, and 80% in pT2 or higher tumors. For histologic grades 1 to 3, the sensitivity was 38.8%, 52.6%, and 68.7% for the BTA stat and 44.4%, 78.9%, and 75% for the UBC Rapid test, respectively. The specificity was 70% and 90% for the BTA stat and UBC Rapid test, respectively. CONCLUSIONS: The UBC Rapid test was superior to the BTA stat in both sensitivity and specificity. Both assays are simple office procedures and require no special knowledge. However, they cannot replace, but only lower, the number of cystoscopies during the follow-up of patients with previous UCC of the bladder.

Adult↗

PubMed2001

Role of 5-aminolevulinic acid in the diagnosis and treatment of superficial bladder cancer: improvement in diagnostic sensitivity.

OBJECTIVES: To use 5-aminolevulinic acid (5-ALA) in diagnostic cystoscopy and during transurethral resection of the bladder (TURB) to treat transitional cell carcinoma. The efficacy of this new technique was compared with standard cystoscopy. METHODS: The 5-ALA, instilled in the bladder 2 hours before cystoscopy, makes the pathologic tissue fluorescent when illuminated with blue light (375 to 400 nm). This allows a better recognition of the neoplastic forms for both diagnostic and therapeutic purposes during TURB. This method has been used since May 1997 on 49 patients in whom bladder tumor was diagnosed either immediately or during postchemotherapy follow-up. RESULTS: One hundred seventy-nine biopsies were taken of fluorescent and nonfluorescent areas (3.5 per patient) to check the effectiveness of the new method compared with standard cystoscopy. A good correlation was found between 5-ALA cystoscopy and the histopathologic diagnosis, with a good sensitivity (87%). The 5-ALA cystoscopy allowed the diagnosis of a tumor in 24 patients with negative standard cystoscopic findings. Furthermore, 5-ALA cystoscopy detected 7 cases of carcinoma in situ. Neither local nor systemic (because of endovesical instillation) side effects were noted. CONCLUSIONS: We believe that 5-ALA could be routinely used in the diagnosis of superficial bladder tumors, as it was shown to improve the diagnostic sensitivity for carcinoma in situ and to reduce the risk of recurrence related to missed cancerous lesions or incomplete TURB.

Adult↗

PubMed2001

Cystoscopy at the time of ureteral reimplantation for primary vesicoureteral reflux: is it necessary? Incidence of undetected anomalies and cost.

OBJECTIVES: To evaluate the impact on the planned procedure and associated cost of cystoscopy performed immediately before the surgical repair of vesicoureteral reflux. Cystoscopy is commonly performed at the time of ureteroneocystostomy to rule out a previously unsuspected anomaly such as ureterocele or ureteral duplication. METHODS: We retrospectively reviewed the results of preoperative voiding cystourethrograms and ultrasound studies performed on 128 patients who underwent ureteral reimplantation for primary vesicoureteral reflux between 1994 and 2000. Radiographic findings were compared with observations made at cystoscopy and reimplantation to determine the rate of unsuspected ureterocele or duplication in the presence of a radiologic evaluation considered adequate by the operating surgeon and/or radiologist. We then performed an itemized analysis to determine the cost cystoscopy contributed to the procedure. RESULTS: Of the 128 patients, 1 (0.7%) was found to have a small, undiagnosed ureterocele at cystoscopy. A review of this patient's preoperative evaluation revealed that her ultrasound examination was incomplete, lacking views of the bladder. At our institution, cystoscopy increased the total direct and indirect operating room costs of this procedure by 16.2%, adding $123.77 to the original cost of $762.97. CONCLUSIONS: Routine cystoscopic examination before ureteral reimplantation in the setting of an adequate preoperative radiologic evaluation yields little diagnostic information. In this series, it did not have an impact on the surgical procedure to be performed but did add significantly to the cost. Cystoscopy before ureteral reimplantation for primary reflux should only be considered in those children with suspicious or inadequate radiologic studies.

Cystoscopy↗

PubMed2001

Risk of continued intravesical therapy and delayed cystectomy in BCG-refractory superficial bladder cancer: an investigational approach.

OBJECTIVES: To assess the risk of continued intravesical therapy and delayed cystectomy in the management of superficial bladder cancer refractory to bacillus Calmette-Guérin (BCG) therapy. METHODS: We retrospectively reviewed the medical records of 24 patients who underwent an experimental intravesical treatment with BCG plus interferon alpha-2b or valrubicin for transitional cell carcinoma of the bladder. All patients had Stage Tis and/or T1 transitional cell carcinoma and had failed multiple prior courses of intravesical therapy, including at least one course of BCG. RESULTS: Patients were followed up for a median of 28.5 months (range 6 to 48). One patient died of unrelated disease. All other patients were alive at last follow-up. Fourteen patients with preserved bladder were continuing cystoscopic surveillance: four had no recurrence, five had recurrence limited to the mucosa (Ta or Tis) and became free of disease after an additional course of intravesical therapy, and five had recurrent Ta or Tis or positive cytologic findings. The remaining 9 patients underwent radical cystectomy. All pathologic specimens showed no evidence of progression to muscle-invasive disease. Tis of the resected ureters in 6 and involvement of the prostate in 4 of the 9 patients (three in the urethral ducts and glands and one in the prostatic stroma) were noted. CONCLUSIONS: A select group of patients with BCG-refractory transitional cell carcinoma and a poor surgical risk for cystectomy may benefit from continued intravesical therapy without a significant risk of progression. However, a cautious approach to this treatment modality is recommended, and very close follow-up is necessary to detect bladder recurrences and involvement of the upper tract and prostatic urethra.

Administration, Intravesical↗

PubMed2001

Diagnostic efficacy of the ImmunoCyt test to detect superficial bladder cancer recurrence.

OBJECTIVES: To study the diagnostic performance of the ImmunoCyt test in patients in follow-up for superficial urothelial cell carcinoma (UCC) of the bladder. METHODS: Voided urine samples were collected from all included patients. Samples were processed with the ImmunoCyt test. The ImmunoCyt slides were scored under a fluorescence microscope by 3 observers. The ImmunoCyt test was considered positive if one or more observers scored the test positive. Urethrocystoscopy (and additional histologic examination in the case of suspicious cystoscopic findings) was used as the reference standard. To investigate the validity of ImmunoCyt, sensitivity, specificity, positive predictive value, negative predictive value, area under the receiver operating characteristic curve, and diagnostic odds ratios were determined. To investigate the reproducibility of ImmunoCyt, kappa values (measure of agreement) were computed. The observers' findings were analyzed in pairs. RESULTS: One hundred four patients in follow-up after primary superficial UCC of the bladder were included. Samples of 18 patients had to be excluded because of low cellularity (ie, insufficient assessable urothelial cells). Tumor recurrence was found in 22 of the remaining 86 patients (17 pTa, 3 pT1, 1 carcinoma in situ, 1 pT2 or higher). The test had a sensitivity of 50%, specificity of 73%, positive predictive value of 39%, and negative predictive value of 81%. The diagnostic odds ratio was 2.8 (95% confidence interval 1.0 to 7.5). The area under the curve for the different observers varied between 0.54 and 0.60. The kappa values were low (0.05 to 0.45), representing high interobserver variability. CONCLUSIONS: The promising results from other studies could not be confirmed in this specific group of patients in follow-up for superficial UCC of the bladder. The validity of ImmunoCyt was insufficient to justify the omission of cystoscopy in patients in follow-up for superficial UCC.

Adult↗