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PubMed2000

Credentialing residents for intraoperative cystoscopy.

OBJECTIVE: To determine whether incorporation of routine intraoperative cystoscopy for evaluation of potential urinary tract injury into gynecologic residency training provides sufficient experience to justify hospital credentials after graduation. METHODS: We developed a curriculum to train residents in intraoperative cystoscopic evaluation of potential lower urinary tract injury. Cystoscopy was performed when indicated with hysterectomy and routinely in conjunction with pelvic reconstruction. Faculty members evaluated conceptual and technical proficiency by oral examination and direct observation in the operating room. Once the resident demonstrated a thorough understanding and proficiency in performing intraoperative cystoscopy, a competency certification document was issued by the Program Director. This certification was transmitted to the postresidency hospital credentials committee to justify granting privileges. RESULTS: Since 1994 over 400 transurethral cystoscopic evaluations have been done in conjunction with major gynecologic abdominal and vaginal surgeries, and since 1997 an additional 50 transvesical microcystoscopies have been done in selected abdominal cases. Twenty-five residency graduates have been certified as fully trained in intraoperative diagnostic cystoscopy. All these graduates have been granted intraoperative cystoscopy privileges at their subsequent hospital practice. CONCLUSION: Incorporation of cystoscopic urinary tract evaluation into routine gynecologic surgical training is good medical practice and provided a mechanism whereby obstetrics and gynecology residents could obtain intraoperative cystoscopy hospital privileges after graduation. (Obstet Gynecol 2000;96:1014-7.)

Credentialing↗
PubMed2001

Analysis of false-positive BTA STAT test results in patients followed up for bladder cancer.

OBJECTIVES: To evaluate the role of a positive BTA stat Test result in patients with negative cystoscopic findings. METHODS: Five hundred one consecutive patients in follow-up for bladder cancer were studied. A voided urine sample was obtained before cystoscopy and split for culture, cytology, and BTA stat testing. In the case of a positive BTA stat Test, but negative cystoscopic findings, patients underwent additional investigations. RESULTS: Of 501 patients, 133 (26.5%) had bladder cancer recurrence at cystoscopy, of which the BTA stat Test detected 71 (53.4%); only 21 of the cases (17.9%) were detected by cytologic examination. Of the remaining 368 patients with no visible tumor at cystoscopy, 96 (26.1%) had a positive BTA stat Test result. Fifty-five of those (57.3%) underwent intravenous urography or renal ultrasound and random biopsies, and an additional 9 recurrences (16.4%) were detected. Of those 46 patients who had a true false-positive BTA stat Test, 3 (3 of 43, 7.0%) had recurrence at the next follow-up cystoscopy, 4 (8.7%) had a urine infection, and 8 (17.4%) had ongoing intravesical instillations; the latter two percentages were significantly higher than among those with true-negative BTA stat Test results (0% and 6.8%, respectively). CONCLUSIONS: Patients with a positive BTA stat Test result but negative cystoscopic findings have about a 16% risk of an undetected recurrence. False-positive results may be due to present instillation treatment and urine infection, and the predictive value of a BTA stat Test for subsequent recurrence seems relatively low.

Adult↗
PubMed2002

Prediction of muscle invasion of bladder cancer by cystoscopy.

OBJECTIVES: Urologists make a decision on whether to indicate staging procedures for primary lesions of bladder cancer by findings of cystoscopy. However, cystoscopic findings for prediction of muscle-invasive bladder cancer have not been fully evaluated. METHODS: Two hundred seventy consecutive events of 165 patients with bladder cancer were included in this study. Multivariate analysis by a logistic regression model was applied to analyze cystoscopic findings for prediction of muscle invasion of bladder cancer. RESULTS: Logistic regression analysis revealed that the size, stalk and configuration of the cancer were independent and significant factors that predict muscle invasion of bladder cancer. CONCLUSIONS: Cystoscopic findings of bladder cancer may predict muscle invasion. When invasion is suggested by cystoscopy, imaging studies may be necessary before TUR of the cancer as well as deep resection of it.

Adult↗
PubMed1995

Video-assisted percutaneous cystoscopy of the bladder and prostatic urethra in the dog: new approach for visual laser ablation of the prostate.

A new minimally invasive approach for video laparoscopy was developed to access the bladder and prostatic urethra of the dog in order to perform laser ablation of the prostate without using either an open laparotomy or urethrostomy. During general anesthesia, a 10-mm laparoscope was introduced into the peritoneal cavity. Under direct vision, the bladder was distended, and trocars were placed percutaneously by two different methods. A 22F cystoscope was introduced through the transcystic trocar into the prostatic urethra for visual laser ablation of the prostate (VLAP). In all eight dogs, the video-assisted technique for percutaneous access to the prostatic urethra was successful. No complications were associated with placement of the Veress needle, creation of the pneumoperitoneum, or accessing of the bladder lumen and proximal urethra. The visibility in the peritoneal cavity was excellent, and hemorrhage was minimal in all cases. In two dogs, a laparotomy was performed after displacement of the cystoscope from the urinary bladder. Irrigation fluid for the cystoscope drained primarily around the trocar cuff surrounding the instrument. In one case, the irrigation fluid drained around the trocar in the bladder and filled the peritoneal cavity.

Animals↗
PubMed2006

Comparison of flexible grasping forceps and stone basket for removal of retracted ureteral stents.

BACKGROUND: Ureteral-stent dislocation can occur either during positioning or postoperatively. Grasping the distal end of the stent and removing it depends on the angulation between the extraction device and the stent, the size and length of the instrument, and the force of the branches and resistance of the dislocated stent. PATIENTS AND METHODS: Six cases of challenging stent removal are presented, and details of the surgical technique are described. By in-vitro testing, we investigated the deflection of flexible cystoscopes and ureteroscopes using forceps or a four-wire stone basket, the ability to grasp a stent depending on the angle between the stent axis and the extraction device, and the force that can be applied on the stent with the different devices. RESULTS: In all cases, it was possible to extract the stent with a stone basket. In an in-vitro setting, maximum extraction forces, measured with a macro scale, were 1.3 kg (cystoscopic forceps) and 0.4 kg (ureteroscopic forceps) until the forceps slipped off the stent. In the same setting, a rupture of the wires of the 1.9F stone basket occurred at 0.8 kg, whereas with a 2.4F basket, a force of 1.9 kg led to rupture of the stent, leaving the basket intact. CONCLUSIONS: Using a stone basket instead of grasping forceps in difficult cases of dislocated stents opens new possibilities for their cystoscopic and ureteroscopic removal. Because the superiority of the basket is counterbalanced by its higher costs, we suggest the basket extraction method only in difficult cases.

Adult↗
PubMed2005

Bladder perforation during tension-free vaginal tape procedures: analysis of learning curve and risk factors.

OBJECTIVE: To estimate whether rates of bladder perforation decrease with increasing surgical experience. METHODS: We performed a review of all patients undergoing a tension-free vaginal tape procedure performed by senior resident physicians under the guidance of a single surgeon. Physician experience was assessed by sequentially assigning case numbers to each procedure for each resident. For analysis of learning curve, cases were grouped in fives (ie, first five representing cases 1 to 5, second five cases 6 to 10). RESULTS: Twenty-three residents performed 278 procedures. The median number of cases performed was 13 (range 3 - 22); mean number was 12.1 (sd = +/- 5.6). The rate of perforation was 34.2% (95/278, 95% confidence interval 28.8-39.9%). Age and weight were significantly associated with perforation. The cystotomy group was, on average 4.5 years younger (P = .007) and 7.86 kg (17.3 lb) lighter (P < .001). Rate of injury in the first five series was 40.9%, 30.7% in second series of five, and 25.9% in the third series of five and was statistically significant (linear-by-linear association chi(2) = 4.286, df = 1, P = .038). The relationship between the incidence of cystotomy and the cumulative number of cases performed was inversely correlated. As the number of cases a resident completed increased, there was a slight tendency for cystotomy to decrease (P.033). On cystoscopic examination, residents missed 35 of the 95 injuries (37%, 95% confidence interval 27.8-46.9%). CONCLUSION: A learning curve exists for tension-free vaginal tape procedures. Many injuries are missed on initial resident cystoscopic inspection, highlighting the need for comprehensive cystoscopic training during residency. LEVEL OF EVIDENCE: II-3.

Adult↗
PubMed2004

Possible mechanisms inducing glomerulations in interstitial cystitis: relationship between endoscopic findings and expression of angiogenic growth factors.

PURPOSE: Glomerulation has been one of the requisite criteria for the diagnosis of interstitial cystitis (IC) but the mechanisms for glomerulation remain unclear. Therefore, we investigated the relationship between the cystoscopic findings of vascular events and the expression of angiogenic growth factors in IC bladders to identify the possible mechanisms inducing glomerulations in IC. MATERIALS AND METHODS: In 45 patients suspected of having IC continuous, fixed point cystoscopic observation was performed during hydrodistention using spinal anesthesia. Bladder biopsies were performed in these cases and in an additional 5 asymptomatic cases. Thereafter, the expression of platelet derived endothelial cell growth factor/thymidine phosphorylase (PDECGF/TP) was measured by enzyme-linked immunosorbent assay. Immunohistochemical staining for PDECGF/TP and vascular endothelial growth factor was also performed. RESULTS: Of 45 symptomatic patients 38 had glomerulations during cystoscopic examination. In these patients during hydrodistention the blood flow in bladder wall vessels was interrupted by whitish fibrous bundles. Thereafter petechial bleeding began from capillaries distal to obstructed vessels during bladder emptying. PDECGF/TP expression in patients with glomerulation was significantly higher than in symptomatic patients without glomerulation or asymptomatic patients (p < 0.001). In patients with glomerulations a high positive rate for PDECGF/TP (97.4%) and vascular endothelial growth factor (68.4%) staining was observed, while no positive staining was found in asymptomatic patients. CONCLUSIONS: Glomerulations during hydrodistention are highly associated with the over expression of angiogenic growth factors in the bladder. Thus, it seems likely that neovascularization promoted by angiogenic growth factors has an important role in the pathogenesis of IC, inducing glomerulations during hydrodistension.

Adult↗
PubMed2006

Diagnostic potential of three-dimensional ultrasound-based virtual cystoscopy: an experimental study using pig bladders.

OBJECTIVE: We sought to investigate the feasibility of 3-dimensional ultrasound (3D US)-based virtual cystoscopy in experimentally designed bladder phantoms using pig bladders. MATERIALS AND METHODS: Ten bladder phantoms with simulated polypoid tumors of different sizes were constructed to provide 3D US-based virtual cystoscopic images. The simulated polypoid tumors were divided by their location into 2 groups: group 1 included the polyps on the anterior and posterior walls, and group 2 included those on the remaining 4 walls. Two genitourinary radiologists independently interpreted the virtual cystoscopic images, with a consensus reached for cases with discrepant results. RESULTS: In a consensus reading, 3D US-based virtual cystoscopy detected 44 (91.7%) of 48 polypoid lesions. All lesions (n = 4) with false-negative results were 5 mm or smaller in diameter, and so the detection rate was 81.8% (18/22) for lesions 5 mm or smaller whereas it was 100% (26/26) for lesions larger than 5 mm. The detection rate for group 1 (93.8%) was not significantly different from that for group 2 (90.6%; P = 1.000). There were 7 false-positive lesions. Of these, 5 lesions were seen in group 1, and reverberation artifacts were the most common source of these errors (n = 4). Blind areas were present in 19 (31.7%) of 60 virtual cystoscopic images and were seen only in group 2. The differences in the false-positive rate and the incidence of blind area were statistically significant between both groups (P = 0.036, P = 0.00008, respectively). CONCLUSION: 3D US-based virtual cystoscopy may have diagnostic potential in the detection of polypoid bladder tumors.

Animals↗
PubMed1981

Percutaneous nephrolithotomy.

A new method of removing calculi from the renal collecting system, in which the large and traumatic incision in the loin currently used is unnecessary, was attempted in 31 patients. Small dilators were introduced over a guide wire through a nephrostomy tube into the renal pelvis and a catheter inserted. The track was dilated in stages and two days later the nephrostomy tube was removed and a cystoscope introduced into the interior of the kidney. A stone basket was introduced down the operating channel of the cystoscope and maneuvered to secure the stone; the cystoscope, stone basket, and stone were then removed. The procedure failed in 11 of the 31 patients, in five because the needle could not be placed accurately initially and in six because the stone could not be removed despite the establishment of a nephrostomy track. In the remaining 20 patients the procedure was successful. This procedure is far less traumatic than the conventional operation. With the development of a flexible nephroscope and an ultrasonic stone disintegrator it will be possible also to remove larger stones and stones in the peripheral calices using this method.

Cystoscopy↗
PubMed2003

Evaluation of transurethral cystoscopy and excretory urography for diagnosis of ectopic ureters in female dogs: 25 cases (1992-2000).

OBJECTIVE: To evaluate transurethral cystoscopy and excretory urography for diagnosis of ectopic ureter in female dogs and identify concurrent urogenital abnormalities. DESIGN: Retrospective study. ANIMALS: 25 female dogs. PROCEDURE: Medical records of female dogs that underwent transurethral cystoscopy, excretory urography, and ventral cystotomy were reviewed for signalment, history, physical examination findings, results of bacteriologic culture of urine, and surgical findings. Videotapes of transurethral cystoscopy and radiographic studies were reviewed systematically without knowledge of surgical findings. RESULTS: Ectopic ureters were diagnosed in 24 of 25 (96%) of the dogs, bilaterally in 22 of 24 (91.6%) dogs. Cystoscopic evaluation yielded a correct diagnosis in all dogs when results of ventral cystotomy were used as the diagnostic standard. Cystoscopic evaluation identified a terminal ureteral opening for all ureters. Urethral fenestrations, troughs, striping, and tenting were identified. Abnormalities of the vestibule were identified in all examinations available for review (24/25). The paramesonephric septal remnant and its association with ectopic ureters were identified and characterized by cystoscopy. Radiographic findings were discordant with surgical findings and correctly identified 36 of 46 (78.2%) ectopic ureters and 2 of 4 normal ureters. Hydroureter and renal abnormalities were associated with distal urethral ectopic ureters on radiographic evaluations. CONCLUSIONS AND CLINICAL RELEVANCE: Transurethral cystoscopy was accurate and minimally invasive for identification and classification of ectopic ureters in dogs. Contrast radiography had limitations in diagnosis of ectopic ureters. Cystoscopic findings and associated vaginal and vestibular abnormalities support abnormal embryologic development in the pathogenesis of ectopic ureters.

Animals↗
PubMed2005

[Uncertain analgetic efficacy of intraurethral instillation of anesthetic jelly in rigid cystoscopy for men].

PURPOSE: The analgetic efficacy of intraurethral instillation of anesthetic jelly in rigid cystoscopic examination for men is not clearly confirmed. This study evaluated the usefulness of intraurethral instillation of anesthetic jelly by questionnaires regarding the pain and uncomfortable feelings during and after the cystoscopic examination. MATERIALS AND METHODS: A total of 62 men were enrolled in the study. Sixteen patients had not received cystoscopy previously (first cases), and 46 had prior experiences of cystoscopy more than twice (repeat cases). These patients were sequentially divided into two groups; one group (jelly-group) received intraurethral instillation of oxybuprocaine hydrochroride jelly (Benoxil jelly) prior to cystoscopic examination, and the other group (no-jelly-group) did not receive the jelly instillation. Pain during the jelly instillation to examination, and uncomfortable feelings at micturition after the examination was evaluated by questionnaires. RESULTS: Instillation of the jelly itself caused considerable pain, which almost similar to that of scope insertion. There was no significant difference in pain score between jelly-group and no-jelly-group during the insertion of the scope to examination. The miction pain after examination was significantly severer in the jelly-group than in the no-jelly-group in repeat cases. In addition, 75% of repeat cases felt better comfortableness when jelly was not instilled, and 96% of repeat cases did not want jelly instillation for their future examination. CONCLUSIONS: Intraurethral instillation of anesthetic jelly had no efficacy for reducing the pain during cystoscopy. Instillation of the jelly itself caused considerable pain, and it made pain and uncomfortable feelings after the examination worse. These results suggested that the instillation of anesthetic jelly before rigid cystoscopy in men might not be useful enough for reducing the uncomfortable feeling during the examination.

Aged↗
PubMed2001

The value of cystoscopy, prostate biopsy and frozen-section urethral biopsy prior to orthotopic neobladder substitution.

INTRODUCTION: The traditional criteria for selecting suitability of male patients with bladder cancer for othtopic neobladder substitution includes: patient motivation, negative transurethral (TUR) prostate biopsy prior to cystectomy, and/or tumor-free biopsy of the urethral margin at the time of cystectomy. In this report we evaluate the value of these preoperative and intraoperative biopsies in the cystoscopically normal prostatic urethra. METHODS: During a 5-year period, cystectomies were performed on 54 men and 13 women with invasive bladder cancer. Prior to this procedure, all of the men had TUR biopsy of the prostate. Forty men with cystoscopically normal prostatic fossa had negative prostatic biopsies, and. had orthotopic neobladder substitution. RESULTS: Pathological examination showed that 3 out of these 40 men had transitional cell carcinoma (TCC) involving the prostate. In all 40 patients, the prostatic apical resection margin was negative. To date, none of the patients developed urethro-neobladder recurrence. CONCLUSION: TUR biopsy of the prostatic urethra prior to cystectomy, or biopsy of the prostatic urethral margin at the time of cystectomy in patients with cystoscopically normal, tumor free prostatic urethra has limited value in selecting candidates for orthotopic neobladder substitution.

Adult↗
PubMed2001

Simplified ureteral stent placement with the assistance of a ureteral access sheath.

PURPOSE: When using a ureteral access sheath following a ureteroscopic procedure, placement of an internal ureteral stent can be simplified by inserting the stent through the sheath without the need to reinsert the cystoscope. MATERIALS AND METHODS: An indwelling ureteral stent with the pull string attached is inserted over the guide wire into the access sheath followed by the pusher. The guide wire is partially withdrawn allowing the stent to form a coil in the renal pelvis, using the pull string to adjust the stent position. The fluoroscopy unit is then focused onto the bladder and the guide wire is slowly withdrawn until its tip is at the level of pubic symphysis. The pusher and guide wire are then removed and the pull string is cut at the urethral meatus. RESULTS: Among 71 cases studied 60 required ureteral stent placement. In 43 of the 60 cases (72%) the ureteral access sheath greatly facilitated ureteroscopy, and a stent was placed through the access sheath in 34 (79%). Stent placement through the access sheath was successful in all cases, with an average time saving of 2.3 minutes per case, compared to placing the stent by reinserting a cystoscope. CONCLUSIONS: If an access sheath has already been placed during a ureteroscopic procedure and stent insertion is deemed necessary, the stent can be easily placed through the access sheath under fluoroscopic guidance without the need to reinsert the cystoscope. Our experience suggests that all urologists who routinely perform ureteroscopic procedures can easily master this timesaving technique.

Equipment Safety↗
PubMed2001

[The significance of "atypical metaplasia" in the follow-up of patients operated for bladder cancer].

BACKGROUND: The aim of this study was to evaluate the clinical usefulness of urinary cytology in the follow-up of patients who under-went surgery for bladder cancer. Particularly, the positive predictive value of urinary cytology and time elapsed between a positive test and the diagnosis of a cystoscopically confirmed bladder tumor are analyzed. METHODS: This study was carried out at the Cytological Laboratory Department of Experimental Medicine and Pathology, University La Sapienza, Rome. Among 230 cases studied since 1996, 30 male patients over 50 were examined (25 with a previous bladder cancer and 5 with a previous prostate cancer) with long time follow-up, who underwent more than two cytological examinations on voided urine (2-12) at pre-fixed intervals. RESULTS: Nine (30%) of the patients suffered from recurrent disease. The cytological examinations was positive in 8 out of the 9 positive cases and negative in 17 out of the 21 negative cases. Absence of disease was confirmed in all the latter cases both by cystoscopic examination and clinical follow-up. One negative case showed clearly malignant cells in more than one specimen taken at different time intervals. This patient is actually under strict control. In 5 cases atypical metaplasia was present in the cytological specimen. In two of those cases cystoscopic examination 5 and 8 months later confirmed progressive disease. In the other three cases cystoscopy showed no evidence of disease. Two of the patients are well and alive after 2 and 14 months respectively. One is dead of prostatic cancer. CONCLUSIONS: Considering the cases of atypical metaplasi as positive the cytological examinations showed 100% sensibility, 81% specificity, a predictive negative value of 1 and a predictive positive value of 0.66.

Follow-Up Studies↗
PubMedDate not supplied

Multiple biopsies in bladder urothelial carcinomas. Correlation of atypical lesions with histological grade, clinical staging and number of tumors.

Twenty-eight cases of transitional cell carcinomas, (19 papillary cell carcinomas, 9 nonpapillary invasive carcinomas) with concomitant mucosal biopsies are reported. Multiple biopsies were obtained cystoscopically at diagnosis (during resection or biopsy of the main tumor) or afterwards, during post-operative evaluation. Fifteen patients (53.6%) were positive for dysplasia, carcinoma "in situ" or micro-invasive carcinoma in the biopsies. These lesions were correlated with the primary neoplasm in regard to: 1) histological grade. Atypical lesions were more frequent the higher the grade (0.01 < p < 0.05); 2) clinical staging. The possibility of finding atypical lesions was higher in cases with more advanced staging (0.01 < p < 0.05) and 3) presence of one or more tumors visible cystoscopically. The results were not statistically significant (0.10 < p < 0.50) but there was a trend toward a higher incidence of atypical lesions among patients with more than one tumor at cystoscopy. Performance of multiple mucosal biopsies is the only means of diagnosing for atypical lesions of the bladder because, due to their plane configuration, they are not detected cystoscopically. The presence of these lesions is very important because they influence the prognosis and the therapeutic measures.

Adult↗
PubMed1987

[Pediatric cystoscopy. Prospective study].

Like other European departments, we have been using since 1982 report form on cystoscopic studies, containing a total of 56 data. In this paper we present a model of our cystoscopic report and the results obtained from 185 cystoscopic explorations performed on 153 patients, of both sexes, between the ages of 4 days and 15 years. Cystoscopy which is not routinely performed in all patient suffering from uropathy or reflux, has facilitated the establishment or confirmation of diagnosis in 35% when combined with radiology. It has been useful in postoperative control as well (23%), it has to decide therapeutic policies (15%) and has resolved all ureteral valve cases as well as some ureteral stenosis cases. We explain the technic used in our department for the transfixation and tearing of the valves by electrocoagulation and the absence of any complications using this method. The actual nomenclature of ureteral meatus, based on their location, grade of opening and the frequently associated grade of renal dysplasia, as well as the criteria followed in the endoscopic control of previous ureteral reimplants and the rising pyelography indications, are also explained.

Adolescent↗
PubMed1994

Hyperbaric oxygen therapy in hemorrhagic radiation cystitis: a report of 20 cases.

Radiation cystitis with macroscopic hematuria has been a frustrating clinical problem for urologists. Since 1985 hyperbaric oxygen (HBO) has been used to treat this disease, showing favorable results. Between November 1989 and October 1992, 20 female patients with hemorrhagic radiation cystitis were treated with HBO at a pressure of 2.5 atm abs, breathing 100% O2 for 100 min in our multiplace hyperbaric chamber. After an average of 44 HBO sessions, macroscopic hematuria was completely halted in 16 patients (80%) and markedly decreased in 2 patients (10%). Comparison of the cystoscopic findings before and after HBO showed a significant decrease in hemorrhagic sites and telangiectasis of the bladder mucosa. One patient had urinary frequency and urgency without hematuria during her hospital stay. After 30 sessions of HBO therapy, her symptoms subsided, and the cystoscopic findings were much improved. Only one patient failed to respond to HBO and underwent ileal conduit diversion. The mean follow-up period was 14 mo. (5-41 mo.). From our clinical results and cystoscopic findings, we suggest that HBO is an effective and safe treatment for hemorrhagic radiation cystitis.

Adult↗
PubMed1997

Conventional bladder wash cytology performed by four experts versus quantitative image analysis.

Bladder wash cytology provides superior results for the detection of bladder malignancies than does voided urine analysis. Image analysis systems have been developed for quantification of cytologic features. In this study, routine bladder wash cytology is compared with an automated image analysis system (QUANTICYT). We studied a random set of 100 bladder wash samples from a population of 1614 patients in follow-up after bladder cancer. Four experienced pathologists interpreted the same 100 Papanicolaou-stained slides. Cytologic and image analysis results were compared for prediction of a cystoscopic lesion, histologic abnormalities, and tumor recurrence. After application of receiver operating characteristic curves, prediction of a cystoscopic lesion by cytology and image analysis was comparable. Both the image analysis system and the cytologic examination detected all of the high-grade lesions. Image analysis was superior to cytologic analysis for the prediction of tumor recurrence after normal findings at cystoscopic examination.

Cell Nucleus↗