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PubMed1985

Irradiation therapy with multiple small fractions per day in urinary bladder cancer.

In a clinical trial 168 patients with carcinoma of the bladder, T2-T4, were randomized to one of two treatments; 1 Gy 3 times a day to a total of 84 Gy or 2 Gy once a day to a total of 64 Gy. Local eradication of the tumour in the bladder cystoscopically and cytologically at 6 months after completion of treatment and patient survival were analyzed. The results favoured significantly the patients treated with 84 Gy. All patients were followed 5-9 years. The survival was significantly improved in patients with T3 lesions treated with 84 Gy (p less than 0.01). Complications in the bowel requiring surgical treatment were not significantly different between the two groups of patients. The results indicate a therapeutic gain by hyperfractionated radiotherapy in comparison to conventional fractionated radiotherapy.

Aged↗

PubMed1996

Urethroscopy, cystoscopy, and biopsy of the feline lower urinary tract.

This article discusses the utility and limitations of urethroscopy and cystoscopy in both male and female cats. The special equipment and techniques necessary to adequately visualize the urethra and bladder of female cats are described in some detail. The emerging ability to visualize the male urethra is introduced. Photographs taken through the cystoscope are used to illustrate both normal anatomy and lesions likely to be encountered with cats with lower urinary tract disease. Cystoscopy is an important diagnostic tool for an inclusionary and exclusionary diagnosis of interstitial cystitis (sterile idiopathic inflammation).

Anesthesia↗

PubMed1990

Emphysematous cystitis: a complication of urinary tract infection occurring predominantly in diabetic women.

The case of a patient with emphysematous cystitis who presented with complaints of lower abdominal pain, dysuria, and pneumaturia is presented. The presenting symptoms, differential diagnosis, and radiographic and cystoscopic appearances of emphysematous cystitis, a rare complication of lower urinary tract infection occurring almost exclusively in diabetics, are reviewed. Treatment consists of urinary drainage, prompt initiation of antibiotic therapy, and strict glucose control. The prognosis usually is excellent.

Combined Modality Therapy↗

PubMed1985

Diagnosis of intraperitoneal extravasation of urine by peritoneal lavage.

The diagnosis of intraperitoneal extravasation of urine in the multiple trauma patient is often delayed, resulting in increased morbidity and mortality. To determine if intraperitoneal extravasation of urine can be detected by peritoneal lavage, an animal study was designed to investigate whether urea nitrogen and creatinine levels in the urine, serum, and lavage fluid would be predictive of urinary extravasation. Seventeen adult mongrel dogs, weighing 21 to 30 kg, were divided into two groups. The six dogs in Group 1 were utilized as controls, and had peritoneal lavage (15 mL normal saline/kg) performed using the open technique (direct visualization of the peritoneum). Blood, urine and lavage urea nitrogen and creatinine and lavage red cell count were measured. Group 2 (11 dogs) had varying amounts of urine (5 mL to 330 mL) instilled into the peritoneal cavity. Diagnostic peritoneal lavage was performed 30 to 45 minutes after the instillation of urine in all Group 2 animals. Group 2A (nine dogs) had urine instilled under direct visualization through a peritoneal lavage catheter. As bladder dome rupture is the most common cause of intraperitoneal urine extravasation, Group 2B (two dogs) had bladder dome ruptures performed by cystoscopic approach using the resectoscope. Cystograms were obtained in the bladder-ruptured dogs after completion of the peritoneal lavage to confirm intraperitoneal extravasation of bladder contents. In these animals, urine was instilled back into the bladder following bladder rupture. Results demonstrate that urea nitrogen and creatinine can be measured in peritoneal lavage fluid when extravasation of urine is in amounts of 15 mL or greater, and not measurable in amounts of 5 mL or less.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

PubMed2000

[Bladder amyloidosis: report of 2 cases].

Two cases of amyloidosis of the bladder are reported: 1) a 45 year old man with haematuria. Cystoscopic examination reveals several tumours in the wall of the bladder. Transuretral resection was performed and histopathological examination revealed primary amyloidosis. Systemic amyloidosis was excluded. He was treated with oral colchicine with success. 2) a 71 year old male with diagnosis of rheumatoid arthritis and systemic amyloidosis visited our hospital with massive haematuria. Transuretral resection was unsuccessful and was necessary surgical ligation of hypogastric arteries.

Aged↗

PubMed2002

[Endoscopic surgery in urology].

At this moment in time, endourology is incorporating extraluminal endoscopic techniques (laparoscopy, lumboscopy, retziuscopy), which the urologist is expected to master. The current advanced stage of development of intraluminal endoscopic surgery is mainly due to the most recent technological achievements (miniaturization of the lens, the use of more versatile materials and new energy sources). In the current cystourethroscopic procedures, compact endoscopes and flexible cystoscopes play an important role. The most important of these new techniques include tissue vaporisation procedures, interstitial application of substances or energies, low-pressure transurethral resection and percutaneous vesical surgery. Upper endoluminal procedures have been the ones to most benefit from modern technological developments. The most important features of present day ureterorenoscopes and their clinical applications are studied and also those of percutaneous nephroscopy (lithiasis, neoformations and others). In a review on the current situation of extraluminal endoscopy, a wide range of laparoscopic techniques--applicable to adrenal regions, kidneys, ureters, retroperitoneal and lymphatic systems, testicles and sperm ducts, bladder and prostrate gland--are discussed as well as the indications, advantages and drawbacks involved and the preferential surgical approaches.

Endoscopy↗

PubMed2002

The use of biodegradable PGA stents to judge the risk of post-TURP incontinence in patients with combined bladder outlet obstruction and overactive bladder.

OBJECTIVE: For patients with the combination of severe bladder outlet obstruction (BOO) and severe overactive bladder (OB), no straightforward and safe treatment exists due to the risk of urge incontinence after TURP. In this study we have used a biodegradable polyglycolic stent to simulate the status after TURP and register the risk for urge incontinence. METHODS: A total of 37 patients with severe OB, combined with moderate to severe BOO, were asked if they wanted to participate. Under cystoscopic vision a polyglycolic biodegradable stent was inserted in the prostatic urethra. RESULTS: Twenty-five of the patients noticed no or only minor leakage and 19 of these have been subjected to TURP with good results. Three patients are on the waiting-list for TURP. Twelve of 37 patients were found to have major leakage after stent insertion. During the stent period, we noted five cases of complications, due to UTI, stent crash and irritation. All of these patients recovered within three weeks. CONCLUSIONS: A biodegradable PGA stent seems to be a new and unique tool to test the risk for post-TURP incontinence in patients with combined BOO and severe OB.

Absorbable Implants↗

PubMed2003

Long-term surveillance of bladder tumours: current practice in the United Kingdom and Ireland.

INTRODUCTION: Surveillance of transitional cell carcinoma of the bladder forms a major part of the workload of many urology units. Unfortunately, the policy for long-term surveillance of these cancers is neither clear nor agreed upon in the absence of evidence base. Our study was performed to provide current national practice data, and begin the debate on consensus guidelines. MATERIALS AND METHODS: A questionnaire was sent to Consultant Urologists (CUs) in the UK and Ireland (n=501) asking about their policy on the long-term surveillance of different bladder tumours once patients are free of recurrence. RESULTS: A 73% response rate was observed (365/501). Views varied considerably. They ranged from life long cystoscopic surveillance for low-stage low-grade tumours (pTaG1) to discharge after 5 years (or less) of a recurrence-free period for pT1G3 tumour. Once long-term surveillance with cystoscopy had been discontinued, 55% of CUs felt no role was indicated for urine cytology in further follow up, whereas 17% would use it for all tumour types and 28% are selective. CONCLUSION: Our study has shown the complete lack of consensus regarding the long-term surveillance of bladder cancer in the UK and Ireland. This has major implications for policy making, resources allocation and cancer survival. We highlight the need for national guidelines in this area for optimal surveillance of bladder cancer, as a good prospective evidence-based data will not be available for many years. We believe our study might form the basis for discussion on such guidelines.

Carcinoma, Transitional Cell↗

PubMed2000

Chemoradiotherapy for muscle invading bladder carcinoma. Final report of a single institutional organ-sparing program.

PURPOSE: Chemoradiotherapy is becoming an alternative to radical cystectomy among patients with muscle invading bladder cancer. We began a prospective study in 1988 to determine the possibilities of conservative treatment and aiming to improve the results obtained by cystectomy alone in invasive bladder cancer. A combination of methotrexate, vinblastine, adriamycin, and cisplatin (M-VAC), followed by radiotherapy and concomitant cisplatin was used. METHODS: Fifty patients with good performance status and with stages T2 to T4 operable untreated invasive bladder cancer were entered in the study. Treatment protocol was as follows: (i) cytoreductive transurethral resection; (ii) two cycles of M-VAC chemotherapy; (iii) radiotherapy, 45 Gy on pelvic volume and, at the same time, 20 mg/m(2) cisplatin on days 1 to 5. Cystoscopic evaluation: if there was a complete response, radiotherapy was completed up to 65 Gy; if there was not a complete response, a cystectomy was performed. Median follow-up of the series was 73 months (18-180 m). RESULTS: Tumor response was as follows: 34 complete responses (68%), 9 partial responses (18%), and 7 nonresponses (14%) were observed. The 5-year overall survival and local control were 48% and 47%, respectively. For the complete responder patient, 5-year survival and local control were 65% and 70%, respectively. Severe toxicity was uncommon. The most frequent were leucopenia and cystitis. No treatment-related deaths occurred with either treatment protocol. CONCLUSIONS: Conservative combination treatment may be an acceptable alternative to immediate cystectomy in selected patients with bladder cancer, although a randomized clinical trial would be required to produce definitive results.

Aged↗

PubMed2003

Feasibility of insertion/implantation of 2.0-mm-diameter gold internal fiducial markers for precise setup and real-time tumor tracking in radiotherapy.

PURPOSE: To examine the feasibility and reliability of insertion of internal fiducial markers into various organs for precise setup and real-time tumor tracking in radiotherapy (RT). MATERIALS AND METHODS: Equipment and techniques for the insertion of 2.0-mm-diameter gold markers into or near the tumor were developed for spinal/paraspinal lesions, prostate tumors, and liver and lung tumors. Three markers were used to adjust the center of the mass of the target volume to the planned position in spinal/paraspinal lesions and prostate tumors (the three-marker method). The feasibility of the marker insertion and the stability of the position of markers were tested using stopping rules in the clinical protocol (i.e., the procedure was abandoned if 2 of 3 or 3 of 6 patients experienced marker dropping or migration). After the evaluation of the feasibility, the stability of the marker positions was monitored in those patients who entered the dose-escalation study. RESULTS: Each of the following was shown to be feasible: bronchoscopic insertion for the peripheral lung; image-guided transcutaneous insertion for the liver; cystoscopic and image-guided percutaneous insertion for the prostate; and surgical implantation for spinal/paraspinal lesions. Transcutaneous insertion of markers for spinal/paraspinal lesions and bronchoscopic insertion for central lung lesions were abandoned. Overall, marker implantation was successful and was used for real-time tumor tracking in RT in 90 (90%) of 100 lesions. No serious complications related to the marker insertion were noted for any of the 100 lesions. Using three markers surgically implanted into the vertebral bone, the mean +/- standard deviation in distance among the three markers was within 0.2 +/- 0.6 mm (range -1.4 to 0.8) through the treatment period of 30 days. The distance between the three markers gradually decreased during RT in five of six prostate cancers, consistent with a mean rate of volume regression of 9.3% (range 0.015-13%) in 10 days. CONCLUSIONS: Internal 2.0-mm-diameter gold markers can be safely inserted into various organs for real-time tumor tracking in RT using the prescribed equipment and techniques. The three-marker method has been shown to be a useful technique for precise setup for spinal/paraspinal lesions and prostate tumors.

Adenocarcinoma↗

PubMed2003

RTOG 97-06: initial report of a phase I-II trial of selective bladder conservation using TURBT, twice-daily accelerated irradiation sensitized with cisplatin, and adjuvant MCV combination chemotherapy.

To examine combination cisplatin and twice-daily accelerated irradiation (RT) after aggressive transurethral resection of bladder tumor (TURBT) in an attempt to preserve the bladder and to determine the likelihood that patients who complete this regimen could then complete three cycles of methotrexate, cisplatin, vinblastine (MCV) chemotherapy. Between 1998 and 2000, 52 patients with Stage T2-T4aN0M0 disease, from 17 institutions, were entered into the trial. Forty-seven patients were deemed eligible; the planned accrual was 40. Of the 46 patients, 68% were >60 years old, 70% were men, and 96% had a Karnofsky score >/=90. The clinical T stage was T2 in 66%, T3a in 25%, and T3b in 9%. The median follow-up at the time of analysis was 26 months. The protocol required TURBT within 6 weeks of the initiation of induction therapy. Induction treatment involved 13 days of concomitant boost RT, 1.8 Gy to the pelvis in the morning followed by 1.6 Gy to the tumor 4-6 h later. For sensitization, cisplatin (20 mg/m(2)) was given on the first 3 days of each treatment week. Three to four weeks after induction, patients were evaluated cystoscopically for residual disease. Patients whose biopsies and cytologic evaluations showed no disease completed consolidation chemoirradiation. Patients with residual tumor went on to cystectomy. After either consolidation or cystectomy, patients were to complete three cycles of MCV chemotherapy. Of the 47 patients, 45% completed all phases of the protocol treatment with minor, or no, deviations. Five patients refused either the postinduction evaluation or cystectomy and 6 refused adjuvant chemotherapy. The CR rate after induction therapy was 74%. For 2 patients, residual disease after induction was limited to positive cytologic findings, and for 8 patients, biopsy of the primary site revealed persistence. Of the 8 cystectomy patients, 2 had no evidence of disease in the bladder at pathologic review of the surgery specimen. Grade 3 toxicity related to chemotherapy was observed in 11% of patients during both induction and consolidation, and in 41% during adjuvant chemotherapy. A total of 8 patients (36% of those receiving adjuvant chemotherapy) went on to develop Grade 4 neutropenia or thrombocytopenia during additional adjuvant chemotherapy. Grade 3 toxicity due to RT was seen in 4% and 0% of patients during induction and consolidation, respectively. One patient developed Grade 4 hydronephrosis during consolidation. The projected 36-month value for locoregional failure, distant metastasis, overall survival, and bladder-intact survival was 27%, 29%, 61%, and 48%, respectively. After aggressive TURBT, twice-daily accelerated RT initiated in concomitant-boost format is well tolerated and results in a rate of complete response (74%) similar to that in previous bladder-sparing trials. The projected 2-year values for locoregional control, bladder-intact survival, and overall survival were also consistent with previously reported trials of bladder-sparing treatment. With only 45% of patients completing three cycles of MCV, this form of adjuvant chemotherapy appears to be poorly tolerated by most patients.

Algorithms↗

PubMed1997

A feasibility study of high dose rate brachytherapy in solitary urinary bladder cancer.

PURPOSE: To determine the feasibility of high dose rate brachytherapy in the treatment of T1-T3 solitary bladder cancer and to compare results and side-effects to those obtained by others using conventional, i.e., low dose rate regimens. METHODS AND MATERIALS: Between July 1992 and 1995, 16 patients entered the study. Median age at diagnosis was 64 years (range: 45-79 years). Diagnostic transurethral resection showed four T1, five T2, and seven T3 lesions, all proven solitary by random biopsies. Radiotherapy consisted of low-dose preoperative external beam irradiation (3 x 3.5 Gy on the 3 consecutive days prior to implantation), followed by high dose rate brachytherapy (15 x 3 Gy during the 8 consecutive days thereafter). Median follow-up from the date of implantation was 23 months (range: 6-43 months). In 15 patients, cystoscopy was systematically performed during follow-up, whereas the 16th patient was followed on a clinical basis only. RESULTS: Recurrences have occurred in 2 of 15 evaluable patients (both stage T3): metastasis in 1 and combined local plus distant failure in the other patient. Cystoscopic evaluation showed persisting alterations of the implanted portion of the bladder mucosa in 11 of 15 evaluable patients (ulceration, calcifications, and/or punctiform bleedings). Symptomatic radiation cystitis was mild and transient in 14 but persisting and severe in 2 patients. CONCLUSION: This study documents the feasibility of high dose rate brachytherapy in a selected group of bladder cancer patients. Both patient outcome and side-effects are comparable to the best results obtained with low dose rate schedules. Additional follow-up is still needed to enforce the comparison.

Adenocarcinoma↗

PubMed2004

[Unexpected discovery of a bladder tumor during a TVT operation].

With the common use of the tension-free vaginal tape (TVT) procedure, we will probably be facing more and more pathologies that will require a transurethral treatment. We report an intra-operative discovery of a bladder tumor during a cystoscopic TVT procedure. The tumor was easily treated by several transurethral resections without any consequences on the result of the TVT procedure.

Cystoscopy↗

PubMed2005

[Urinary complications in sub-urethral sling procedures].

INTRODUCTION: Urinary complications following sub urethral sling procedures are common, and management of these complications continue to be discussed. METHODS: The literature available on Medline/PubMed, relating to urinary complications associated with suburethral sling procedures, was reviewed. RESULTS: Bladder perforation, which occurs with an incidence of 5.7% in tension-free vaginal tape procedure, requires repositioning of the sling, but does not cause any increase in postoperative morbidity. The trans-obturator approach appears to decrease this risk. Urethral perforation, which is uncommon (0.4-1%), is a contraindication to maintenance of the sling. Bladder erosion is rare, requiring resection of the mesh with a combined abdominal and cystoscopic approach. Urethral mesh erosion (0.07% to 1.5%) also requires surgical sling removal, but few patients remain continent because this removal requires a large urethrolysis (recurrence rate of incontinence is 66% following removal of the sling). Bladder outlet obstruction occurs frequently after sub-urethral procedures. When complete obstruction is clinically evident 2 days after a sub-urethral sling procedure, immediate reintervention is performed with a rapid return to normal voiding. Recurrence rate of stress incontinence is less than 30% following reintervention.

Equipment Failure↗

PubMed2006

Primary amyloidosis of the urinary bladder.

Amyloidosis is a systemic disease that usually occurs in the gastrointestinal tract or in muscular or adipose tissue. Primary amyloidosis of the urinary bladder is a rare disease that can mimic bladder cancer on cystoscopic examination as well as in its clinical presentation of painless gross hematuria. This report describes a 49-year-old male with repeated painless gross hematuria, who underwent transurethral resection of a suspected bladder tumor. Pathologic examination revealed papillary urothelial hyperplasia with vascular ectasia and no signs of malignancy. Massive gross hematuria occurred 2.5 years later. Cystoscopy showed multiple papillary lesions with yellowish-brown submucosal plaques on the posterior bladder wall. A second transurethral tumor resection was performed and histologic examination revealed plasma cell infiltration and eosinophilic amorphous deposits in the subepithelial stroma and vascular wall. The deposits were positive for Congo red and apple-green birefringence under polarized light examination but negative for Masson's trichrome stain, indicating that they were not fibrotic in nature. Hence, the diagnosis of amyloidosis of the urinary bladder was confirmed. Screening for amyloidosis was negative in other organ systems and the patient has remained disease-free up to the last follow-up 4 years after the second transurethral resection. Amyloidosis should be considered in the differential diagnosis of patients with recurrent hematuria who have symptoms characteristic of bladder cancer but negative pathologic study for malignancy. Correct diagnosis relies on clinical alertness and the use of a special staining technique during pathologic examination.

Amyloidosis↗

PubMed1996

Split course radical radiotherapy for bladder cancer in the elderly: nonsense or commonsense? A report of 76 patients.

The role of split course radical radiotherapy in bladder cancer is controversial. We have pursued such a policy in elderly patients in view of the unpredictable toxicity of radical radiotherapy in this group. Between 1987 and 1992, 76 patients were treated in this way, with 2 weeks' treatment followed by a 3-week gap. Patients were then reassessed and, if considered fit enough, a further 2 weeks of treatment was given. Fifty-three patients (mean age 78.4 years) completed treatment and 23 (mean age 78 years) received phase 1 alone. Thirty-seven of 53 patients completing treatment has a follow-up cystoscopy at 6 months. Twenty-five percent of all patients, 36% of those completing treatment, and 51% of those undergoing cystoscopy, achieved a complete response. The reasons for not completing treatment and not being followed up cystoscopically are examined. We feel that this policy has a role in selected patients whose fitness to tolerate a conventional radical course of radiotherapy is in doubt.

Aged↗

PubMed1996

Electromotive diffusion (EMD) and photodynamic therapy with delta-aminolaevulinic acid (delta-ALA) for superficial bladder cancer.

Recent reports have shown that topical application of delta-aminolaevulinic acid (delta-ALA) can be used for the photodynamic diagnosis and therapy of superficial bladder tumours. Electromotive diffusion (EMD) increases the cellular uptake of polar substances. In six patients with biopsy-proven recurrent carcinoma in situ of the bladder after Bacillus Calmette-Guérin (BCG) treatment, 100 cm3 of a 0.5% delta-ALA solution at pH approximately 6 was instilled into the bladder. With a special Foley catheter containing a stainless steel electrode, EMD, with a 15 mA, pulsed current, positive polarity at the catheter, was created for 20 min in the sedated patient. Thereafter a laser fibre with a spheric diffuser was inserted into the bladder over a cystoscope. The bladder surface was irradiated at a wavelength of 632 nm with 350 mW s-1 (total dose, 30-50 J cm-2). Follow-up consisted of a cystoscopy and biopsy after 6 weeks and cystoscopy and cytology every 3 months thereafter. The whole procedure was well tolerated. Currently, five patients are tumour free after a follow-up of 10-16 months. One patient has recurred after 10 months with a Ta G3 superficial tumour at the bladder neck which was resected. In a transwell cell culture model, we investigated the effect of delta-ALA treatment with and without application of EMD. In this in vitro system, application of an electric field showed only a small increase in delta-ALA uptake compared with uptake by passive diffusion.

Aged↗

PubMed2006

Anterior urethral valves.

We studied the clinical presentation and management of four patients with anterior urethral valves; a rare cause of urethral obstruction in male children. One patient presented antenatally with oligohydramnios, bilateral hydronephrosis and bladder thickening suggestive of an infravesical obstruction. Two other patients presented postnatally at 1 and 2 years of age, respectively, with poor stream of urine since birth. The fourth patient presented at 9 years with frequency and dysuria. Diagnosis was established on either micturating cystourethrogram (MCU) (in 2) or on cystoscopy (in 2). All patients had cystoscopic ablation of the valves. One patient developed a postablation stricture that was resected with an end-to-end urethroplasty. He had an associated bilateral vesicoureteric junction (VUJ) obstruction for which a bilateral ureteric reimplantation was done at the same time. On long-term follow-up, all patients demonstrated a good stream of urine. The renal function is normal. Patients are continent and free of urinary infections. Anterior urethral valves are rare obstructive lesions in male children. The degree of obstruction is variable, and so they may present with mild micturition difficulty or severe obstruction with hydroureteronephrosis and renal impairment. Hence, it is important to evaluate the anterior urethra in any male child with suspected infravesical obstruction. The diagnosis is established by MCU or cystoscopy and the treatment is always surgical, either a transurethral ablation or an open resection. The long-term prognosis is good.

Child↗