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Differential diagnosis of intra-uterine device migrating to bladder using radiographic image of calculus formation and review of literature.

A 28-year-old woman in whom a copper-T 280-A intra-uterine device (IUD) had been placed 6 months previously, presented complaining of urinary system infection and lower abdominal pain. Intra-vesical migration of IUD was confirmed by radiography and cystoscopy. Since 1966, 17 other cases of calculus formation among 41 cases of intra-vesical migration have been reported.

Abdominal Pain↗

Prolonged hydrodistention of the bladder for symptomatic treatment of interstitial cystitis: efficacy at 6 months and 1 year.

OBJECTIVE: To determine the efficacy of hydrodistention of the bladder for symptomatic treatment of interstitial cystitis after 6 months and 1 year of follow-up and to identify a predictive factor. METHODS: The study included 65 consecutive patients (a first retrospective series of 33 and a second prospective series of 32) treated by hydrodistention of the bladder for urinary symptoms attributed to interstitial cystitis. All experienced pain on bladder filling, which was relieved by micturition or bladder voiding, and had more than two nocturias. Glomerulations were detected at short hydrodistention during cystoscopy. No patients were subject to NIH exclusion criteria. Hydrodistention was performed continuously for 3 h without rest intervals under epidural anesthesia using a balloon with a pressure equal to the patient's mean arterial pressure. Efficacy was defined as the disappearance of pain on bladder filling or the persistence of moderate, non-disabling pain for which the patient did not request treatment, and a low frequency of nocturia (zero to two times). The efficacy period was estimated according to Kaplan-Meier methods for survival curves. The second series was used to verify the analytic results of the first series. RESULTS: Treatment efficacy was 12/32 (37.7% CI: 20.7-54.3) at 6 months and 7/32 (21.9% CI: 7.6-36.2) at 1 year for the first series, and 18/30 (60.0% CI: 45.0-75.0) at 6 months and 13/30 (43.3% CI: 25.6-61.1) at 1 year for the second series. In both series, results were better for the subgroup of patients with a bladder capacity > or = 150 ml during cystometry before distention. CONCLUSIONS: This study showed good but transient efficacy in the least developed or least severe forms of the disease.

Adult↗

Lignocaine gel: does it cause urethral pain rather than prevent it?

OBJECTIVES: To test the hypothesis that the chemical content of lignocaine gel is the cause of urethral pain during its instillation into the urethra. METHODS: A prospective, double blind study was designed to test whether plain aqueous gel caused less delivery discomfort in the male urethra than 2% lignocaine hydrochloride gel (Instillagel). 100 consecutive, consenting male patients attending for flexible cystoscopy were recruited and randomised to receive 11 ml of 2% lignocaine hydrochloride gel or 11 ml of plain aqueous gel. Upon receiving the gel into the urethra, the patient was asked to score any associated discomfort by using a horizontal, 100mm, non-graphical, visual analogue scale. Statistical comparison between the groups was made using the non-parametric Mann-Whitney U-test. RESULTS: Statistical analysis by Mann-Whitney U-test showed a significant reduction in urethral delivery discomfort in those patients receiving plain gel compared to those receiving 2% lignocaine hydrochloride gel (p=0.039). CONCLUSIONS: This current study has shown that plain aqueous gel causes significantly less delivery discomfort in the male urethra than 2% lignocaine hydrochloride gel (Instillagel).

Anesthetics, Local↗

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↗

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↗

[Tumorlike form of bladder schistosomiasis in children].

Two tumorlike forms of urinary schistosomiasis are reported. Diagnosis was suspected as the patients exerted haematuria while they originated from a geographic area where schistosomiasis is endemic. Terminal urine samples were positive for Schistosoma haematobium. Cystoscopy revealed an hemorrhagic granulomatous polyp in one case and villous polyps in the other case, associated with suggestive lesions of schistosomiasis. Schistosoma haematobium infection in children is uncommon in Europe and rarely considered in the diagnosis of haematuria.

Animals↗

Squamous metaplasia of the bladder: findings in 14 patients and review of the literature.

We have documented the data of squamous metaplasia of the bladder in 14 patients who had undergone cystoscopies for different reasons. In two biopsies, there were marked keratinization and cellular atypia. One of these two subjects was diagnosed as squamous carcinoma of the prostate and transitional cell carcinoma of the bladder. The lesions of 8 female patients were on the trigone and evaluated as normal anatomical variants due to hormonal changes. Three of them were remarkable because of recurrent urinary infections. Apart from the two male patients with squamous cell carcinoma of the prostate the two male patients with current squamous metaplasia have been following up. In this study, we have also reviewed the relationship between squamous metaplasia, infection and malignancy.

Adult↗

Prognostic value of cystocopically pseudotumoral lesions (inflammation/granuloma) in primary stage T1 grade 3 bladder tumors treated with BCG.

OBJECTIVE: The aim of this study is to find out whether the pseudotumoral lesions (inflammation/granuloma) seen at the follow-up cystoscopy performed three to six months after transurethral resection of primary stage T1 grade 3 bladder tumor and instillations of BCG therapy might have some prognostic value as far as recurrence and/or long term progression are concerned. MATERIAL AND METHODS: From the first group of one hundred and thirteen patients with primary stage of T1 grade 3 bladder tumor treated with 81 mg of BCG Connaught (weekly/during six weeks), those with recurrent tumor at the 3rd and 6th month were excluded, so we evaluated 99 patients. We identified 13 patients with cystoscopically pseudotumoral lesions. RESULTS: of the 13 cystoscopically pseudotumoral lesions, we observed recurrence in two cases (15%), while among the rest of the 86 patients, we observed 22 recurrences (26%) (p = 0.9; not significant). Concerning progression, eight cases were reported out of 86 patients (9%) within the cistocopically normal group. No cases of progression were reported among the 13 patients with cystoscopically pseudotumoral lesions. This difference was not statistically significant (p = 0.5). CONCLUSIONS: The patients with cystoscopically pseudotumoral lesions (inflammation/granuloma) are a reduced group (13%) with less tendency to recurrence and without progression, even though this relationship is not significant.

Adjuvants, Immunologic↗

Delayed suture intravesical migration as a complication of a Stamey endoscopic bladder neck suspension.

We report our experience with two cases of late migration of the suture and bolster occurring 2 years after a modified Stamey endoscopic bladder neck suspension. Delayed migration of the suture and bolster after an endoscopic bladder neck suspension across tissue planes, with subsequent erosion into the bladder, is uncommon. Recurrent urinary tract infection and mild suprapubic discomfort were the only symptoms. Cystoscopy was the only helpful diagnostic tool and should be considered early in the evaluation of this kind of patients. The mechanism of migration of the cuff and the operative technique are discussed.

Cystoscopy↗

Ectopic prostate: an unusual bladder tumor.

A 25-year-old man presented with gross painless hematuria. Cystoscopy revealed a smooth surfaced mass in the supratrigonal region. Complete transurethral resection of the mass was done. Histopathological examination revealed benign prostatic tissue situated ectopically.

Adult↗

Cooled lignocaine gel: does it reduce urethral discomfort during instillation?

INTRODUCTION: Topical urethral analgesia with 2% lignocaine gel for office procedures is an accepted practice in contemporary urology. However, instillation of 2% lignocaine gel into the urethra is associated with discomfort in some patients. MATERIAL AND METHODS: Forty consenting men reporting for cystoscopy under local anesthesia were randomized to receive 10 ml of 2% lignocaine hydrochloride gel at 4 degrees C and 22 degrees C. After instillation of the gel the patients were immediately asked to score the pain using a nongraphical visual analogue scale. RESULTS: The pain scores were analyzed using the paired Student's t-test. There was significant reduction in pain scores in the group receiving gel at 4 degrees C compared with the group at 22 degrees C (P < 0.05). CONCLUSION: Refrigerating the gel to 4 degrees C can significantly reduce the initial discomfort associated with instillation of 2% lignocaine hydrochloride into the male urethra.

Administration, Topical↗

A prospective randomised trial of radiation with or without oral and intravesical misonidazole for bladder cancer.

Patients with T2 grade 3 and T3 bladder cancer were randomised to be treated with radiation alone (NO MISO) or with radiation and misonidazole (PLUS MISO). Patients in both groups initially received 40 Gy in 2 Gy fractions (5/week). Patients in the NO MISO arm received a further 20 Gy in 2 Gy fractions (5/week). Patients in the PLUS MISO arm received a further 12 Gy in 6 Gy fractions (1/week). MISO was administered orally (3.0 g m-2) and intravesically (1.0 g in 35 ml of solvent) 4 h and 2 h respectively prior to each fraction of 6 Gy. Fifty-eight patients were randomized of whom 53 are evaluable. There is a minimum follow-up of 5 years in the surviving patients. In the NO MISO and PLUS MISO arms, the complete response rate at cystoscopy at 6 months was 63% and 69%, the 5-year survival rate was 41% and 48% and the 5-year local control rate with bladder preservation was 46% and 36% respectively (censored for death from metastases while locally clear). These differences are not statistically significant. Two patients had grade 3 RTOG late bowel complications. Both patients were in the PLUS MISO arm, had undergone salvage cystectomy and subsequently required colostomies for bowel obstruction for a 5-year late complication rate (RTOG grade 3) of 9%. In addition, two patients in the PLUS MISO arm developed wound sepsis post cystectomy. We were not able to demonstrate improved results from the use of oral and intravesical MISO in this study. The number of patients entered are relatively low and large differences would have been required to be detected with a power of 0.80. The use of an unconventional radiation fractionation schedule may have resulted in increased bowel morbidity in patients in the PLUS MISO arm who subsequently underwent cystectomy.

Administration, Intravesical↗

Effect of nifedipine on cystometry-induced elevation of blood pressure in patients with a reflex urinary bladder after a high level spinal cord injury.

In 10 patients with a reflex urinary bladder after a cervical or high thoracic spinal cord injury, the effect of nifedipine on the cystometry-induced elevation of blood pressure was studied. The blood pressure was measured every 30 s in four consecutive cystometries before and after administration of 10 mg nifedipine sublingually. In each patient there was a decrease in the maximum systolic and diastolic blood pressure after the administration of nifedipine. In the whole group the mean maximum systolic pressure decreased significantly from 147 mmHg (range 119-165, SD 14) to 118 mmHg (range 99-145, SD 14). The mean maximum diastolic pressure decreased from 110 mmHg (range 96-124, SD 10) to 83 mmHg (range 71-99, SD 10). The effect of nifedipine was significant in each of the four cystometries that were performed. The decrease in blood pressure was due to both a significant decrease of the baseline pressure and a significant decrease of the blood pressure reaction during cystometry. Nifedipine may be useful in order to prevent dangerous blood pressure reactions, e.g. during cystoscopy and other diagnostic or therapeutic procedures in spinal cord injured patients with autonomic dysreflexia.

Adolescent↗

Endoscopic management of urethral trauma in male spinal cord injury patients.

Spinal cord injury (SCI) patients with a neuropathic bladder are more prone to develop catheter-induced urethral trauma than occurs in the general population because many of the SCI patients are on indwelling urethral catheter drainage, or intermittent urethral catheterisation is performed either by them or by their carers. The presenting symptoms of improperly positioned Foley catheter in SCI patients may be at times, peculiar to the SCI patients and these include profuse sweating, bypassing of the catheter, increased spasms, or rarely, full fledged features of autonomic dysreflexia. With the availability of the flexible cystoscope, cystourethroscopy has been performed safely on SCI patients who had sustained catheter-induced urethral trauma, on the bedside, with an immediate, and accurate diagnosis of the extent of urethral trauma, and the presence of urethral false passage(s). Further, flexible cystoscopy has helped to treat the patients with urethral trauma by introducing a flexible tip guide wire under vision into the urinary bladder via the normal urethral channel and subsequently, passing a 12 Fr. Foley catheter over the guide wire, thus avoiding the false passage(s) in the urethra. With this technique, it was possible to avert the need for suprapubic urinary diversion in those SCI patients who had sustained acute urethral trauma. Such endoscopic management of acute urethral trauma in SCI patients is described with illustrative case reports of eight patients seen during a 15 month period.

Cystoscopy↗

Future research needs for the definition/diagnosis of interstitial cystitis.

In Workshop 8 at the International Conference on Interstitial Cystitis (Kyoto March 2003, future research needs for the definition/diagnosis of interstitial cystitis (IC) were discussed by the participants. To structure discussions a study proposal was used. This workshop decided that research should focus on identifying and validating classification criteria for the diagnosis of IC. This might well be done in a (multi-centre) study with a control group of urge-frequency patients without pain (OAB?). However, before doing so standards should be defined as on how to perform and interpret vaginal examination, urodynamic investigation, cystoscopy under anesthesia, potassium sensitivity test, and histopathology in these patients.

Biomedical Research↗

Hamartoma of the urinary bladder.

BACKGROUND: Hamartomas of the urinary bladder are extremely rare. We report on a case in a 58-year-old female who presented with the chief complaint of pain on urination. METHODS/RESULTS: Cystoscopy revealed a solid tumor on the left posterior wall of the bladder. Transurethral resection of the tumor failed to provide a definitive pathological diagnosis of the tumor. Thus, we performed partial cystectomy. The pathological diagnosis was hamartoma arising from the urinary bladder. CONCLUSION: This is the ninth case diagnosed as urinary bladder hamartoma to be reported in the literature.

Cystoscopy↗

Extraperitoneal bladder rupture secondary to rectal impalement.

Impalement injury to both the urinary bladder and the rectum is a rare occurrence. A 45-year-old man was referred to our hospital because he had been stabbed through the internal femoral skin by a steel bar. Retrograde cystography and computed tomography failed to demonstrate bladder rupture. We carried out cystoscopy (CS) because of the existence of gross hematuria and found a penetrating wound in the posterior wall. Colon fiberscopy revealed two wounds in the rectum, one of which communicated with the bladder. A diagnostic laparoscopy revealed no associated injuries in the peritoneal cavity. Vesicorectal injury was diagnosed and treatment included transanal closure of fistulas and indwelling ureteral and urethral catheters. Postoperative CS revealed complete closure of the injury.

Cystoscopy↗

Pheochromocytoma of the urinary bladder without typical symptoms.

Pheochromocytoma of the urinary bladder is an unusual tumor that typically presents with hypertensive crises related to micturition. We report, herein, the case of a 62-year-old woman with bladder pheochromocytoma. The patient presented with a bladder tumor that was incidentally found by computed tomography (CT) without the triad of sustained hypertension, hematuria and postmicturitional syncope. Cystoscopy revealed a yellowish submucosal tumor in the right lateral wall of the bladder. Treatment consisted of transurethral resection in the initial diagnosis of bladder tumor. A definitive diagnosis was made postoperatively upon pathological examination. The patient has been followed up for 12 months and has shown no recurrence.

Abdominal Pain↗