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PubMed2003

Practice pattern of urologists in the Rocky Mountains region with regard to use of urodynamic studies.

OBJECTIVES: To evaluate the patterns of urodynamic studies (UDS) use among community urologists. Much controversy exists with regard to the need and indications for UDS in the clinical evaluation of urinary incontinence (UI) and voiding dysfunction (VD). METHODS: A one-page questionnaire containing 11 questions was mailed to urologists practicing in the Rocky Mountains region. Physicians were asked about (a) their type of practice; (b) the number of patients with UI and VD they see per week; (c) the number of office procedures they perform on these patients; (d) the percentage of patients with UI and VD for whom they use UDS for diagnostic clarification; and (e) the limiting factors to more frequent use of UDS. RESULTS: Of the 127 questionnaires mailed, 51 (40%) were returned, and 49 (39%) of these were returned "completely filled out." No follow-up letter was sent nor was a telephone interview done. Most urologists (n = 38; 76%) indicated they are in private practice, 5 (10%) are in academics, 3 (6%) are in multispeciality groups, 2 (4%) are affiliated with a health maintenance organization (HMO), and 1 is in a hospital-based practice. Twelve (24%) see fewer than 5 UI patients per week, 21 (43%) see 5 to 10 UI patients per week, and 16 (32%) see more than 10 UI patients per week. The respective numbers for VD patients seen per week are 4 (8%), 12 (24%), and 33 (67%). Thirty (61%) and 32 (65%) of respondents use UDS in fewer than 5% of patients seen with UI or VD, respectively. Thirty-seven (76%) use cystoscopy in more than 5% of patients seen with UI or VD. Regarding limiting factors for more frequent use of UDS (of those 35 urologists giving single answers), 60% believed there was a lack of indication and 40% noted that UDS are too time-consuming or not cost-effective (20%), difficult to interpret (5.7%), or that they had no access to such equipment (14%). CONCLUSIONS: This study shows that the majority of urologists perform cystoscopy more frequently than UDS for diagnostic clarification of patients with UI and VD, and 40% of urologists do not perform UDS for reasons other than lack of indication. These results may indicate a need for more access to, and additional training in, UDS among urologists for management of UI and VD.

Diagnostic Techniques, Urological↗
PubMed2003

Modified "tubeless" percutaneous nephrolithotomy using a tail-stent.

INTRODUCTION: "Tubeless" percutaneous renal surgery has previously been described at our institution. Avoiding external nephrostomy tube drainage significantly decreases the pain and morbidity of percutaneous renal surgery. However, internal drainage with a double-J ureteral stent still results in bothersome bladder symptoms, especially in younger male patients. In addition, removal of the stent requires uncomfortable office cystoscopy. We report a technical enhancement of our "tubeless" technique that uses a novel tail-stent for internal drainage. TECHNICAL CONSIDERATIONS: A tubeless approach to any renal surgery should only be attempted in select uncomplicated cases. The exclusion criteria should include operative times longer than 2 hours, three or more percutaneous accesses, significant perforations or disruptions of the collecting system, significant residual stone burden, and significant bleeding. In these instances, and when second-look nephroscopy is desired, traditional external nephrostomy tube drainage should be used. In our select cases, in lieu of the standard double-J stent, we place a 7F/3F tail-stent with the string attached exiting the urethral meatus. Care is taken in correct placement to avoid having the tail of the stent exiting the meatus. CONCLUSIONS: In our initial 4 patients, tail-stents were successfully placed. The pain scores were low and stent symptoms appeared minimal. All stents were easily removed without the use of cystoscopy. Fluoroscopic visualization of the 3F tail is poor, and positioning of the tail can be difficult. Nevertheless, this modification appears feasible and safe with excellent patient satisfaction.

Adult↗
PubMed2003

Laparoscopy for the diagnosis and treatment of radiologically occult but symptomatic hypoplastic kidneys.

OBJECTIVES: To evaluate the efficacy of different imaging modalities for visualization of small poorly functioning hypoplastic and dysplastic kidneys and to assess the role of laparoscopy in localization and treatment. METHODS: Between 1998 and 2002, 10 female patients who presented with urinary incontinence, flank pain, or hypertension secondary to small, poorly functioning hypoplastic or dysplastic kidneys were treated at our institute. We reviewed the results of the imaging studies, cystoscopy, and evaluation under anesthesia for these patients. After the diagnosis, all patients were treated with laparoscopic retroperitoneal or transperitoneal nephroureterectomy or nephrectomy. RESULTS: Intravenous urography and ultrasonography failed to visualize the affected renal units in all 10 cases. Computed tomography could locate small dysplastic renal units in only 5 patients (50%). Dimercaptosuccinic acid renal scintigraphy was diagnostic in all 10 cases (100%). Magnetic resonance urography was done in 2 cases only, and the affected renal units were identified in both. Cystoscopy and vaginoscopy were inconclusive in all but 2 cases. Laparoscopy efficiently located the offending renal units in all 10 cases. In 9 cases, the affected renal units were located in the lumbar region, and in 1 case it was situated ectopically in the pelvis. All 10 patients underwent laparoscopic retroperitoneal or transperitoneal nephroureterectomy or nephrectomy and were asymptomatic after surgery. CONCLUSIONS: Dimercaptosuccinic acid scintigraphy is an accurate and specific imaging modality for visualization of small hypoplastic renal units that are not visualized by conventional radiologic imaging techniques. Laparoscopy can be recommended as the ideal method of management, because it provides a minimally invasive technique for detecting the kidney and simultaneously correcting the problem.

Adolescent↗
PubMed1998

Unusual complications of the vacuum erection device.

OBJECTIVES: The vacuum erection device (VED) is usually well tolerated and very effective for patients with erectile dysfunction. When used correctly, VEDs carry low morbidity and few recognized complications. We report on 5 patients who developed unusual complications associated with VED use, including two previously unreported complications of urethral bleeding and capture of scrotal tunica within the penile shaft. METHODS: Patient 1: a 38-year-old diabetic man with significant peripheral neuropathy and an 8-year history of erectile dysfunction developed penile skin necrosis at the ring site after leaving the penile ring on for an excessive length of time (6 hours). Patient 2: a 76-year-old diabetic man who used a VED correctly for 3 months developed severe urethral bleeding. Patient 3: a 75-year-old diabetic man who enjoyed satisfactory erections with a VED for 14 months developed a 3 x 3-cm penile cystic mass located on the proximal right side of the penile shaft. This mass was not present in the flaccid state and was seen only with VED use. Patient 4: a 65-year-old man developed Peyronie's disease after 4 years of correct VED use. Patient 5: a 62-year-old man with neurogenic impotence following a radical prostatectomy developed penile ecchymoses acutely following placement of a smaller constriction ring. He subsequently developed a dorsal penile plaque with mild dorsal curvature. RESULTS: Patient 1 did well with local skin care and no longer uses a VED. Patient 2 underwent cystoscopy and was found to have prominent urethral vessels (varicosities) in the midurethra, compared with a normal cystoscopy 9 months previously. This patient no longer uses a VED and now denies any urethral bleeding at 15-month follow-up. Patient 3 underwent corpora cavernosography and contrast injection of the cystic mass. These radiographic studies showed that the mass did not communicate with either corpora cavernosa or the corpus spongiosum. A retrograde urethrogram failed to show a urethral diverticulum. The patient was surgically explored, and the penile cystic mass was found to be scrotal tunica vaginalis. Subsequently, a hydrocele repair was performed, yet postoperatively the patient developed testicular migration into the ipsilateral penile shaft. Testicular fixation was not feasible secondary to a childhood herniorrhaphy, and an orchiectomy was performed. Patient 4 underwent implantation of a penile prosthesis and is doing well at 3-year follow-up. Patient 5 experiences mild dorsal penile curvature with erections induced by transurethral prostaglandin E1. The penile curvature does not interfere with intercourse and will be managed conservatively. CONCLUSIONS: We describe unusual side effects associated with VEDs. Although thousands of men use VEDs successfully and without morbidity, the urologist must be aware of unusual complications associated with VED use.

Adult↗
PubMed1998

Altered expression of bladder mast cell growth factor receptor (c-kit) in interstitial cystitis.

OBJECTIVES: To investigate the presence of mast cell growth factor receptors (c-kit) on bladder mast cells in interstitial cystitis (IC), a bladder condition occurring primarily in women. IC is characterized by pain, urgency, frequency, and mucosal microhemorrhages discernible with cystoscopy under general anesthesia. One of the prevailing theories to explain IC pathophysiology is the increased number of bladder mast cells, many of which are activated in at least a subgroup of IC patients. Stem cell factor (SCF), also known as c-kit ligand, is now recognized as the key molecule responsible for mast cell proliferation and is known to exert its action through specific surface receptors. METHODS: Bladder specimens from patients with IC, identified by the criteria established by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), and control patients were obtained during diagnostic cystoscopy and were immediately fixed in 4% paraformaldehyde. They were then examined by immunohistochemistry for the unique proteolytic mast cell enzyme tryptase or the presence of c-kit, or both. RESULTS: Bladders of IC patients contained a higher number of mast cells than control patients. However, mast cells in IC patients expressed fewer c-kit on their surface than those in control patients. These results could be explained if the c-kit were occupied by endogenous SCF or were downregulated, possibly by internalization after ligand-receptor interactions, making them inaccessible to immunocytochemical detection. CONCLUSIONS: Bladder mastocytosis and/or activation of mast cells, in at least a subpopulation of IC patients, may be explained by increased stimulation of mast cells by SCF. These results could be explained either by a mutation leading to constitutive activation of c-kit or overproduction of c-kit ligand leading to bladder mast cell proliferation in IC.

Adolescent↗
PubMed1998

Urinary NMP22 for the detection of recurrence after transurethral resection of transitional cell carcinoma of the bladder: experience on 137 patients.

OBJECTIVES: To evaluate the nuclear matrix protein 22 (NMP22) test in the management of patients after transurethral resection (TUR) of recurrent transitional cell carcinoma of the bladder. METHODS: The NMP22 test was performed in 137 patients: in 42 patients, a bladder recurrence was detected by cystoscopy and histologically confirmed; 95 patients were recurrence-free at cytology and cystoscopy performed at least 3 months after TUR. RESULTS: In patients with tumoral recurrence, the mean NMP22 value was 54.8 U/mL. The false-negative rate was 28.5%. In recurrence-free patients, the mean NMP22 value was 22.8 U/mL. The specificity of the NMP22 test was 61%. Higher NMP22 mean values (29.6 versus 15.8 U/mL) were found in patients who underwent intravesical chemotherapy or immunotherapy. CONCLUSIONS: Despite its good sensitivity, the NMP22 test cannot be adopted as a routine tool in the surveillance after TUR of patients with superficial bladder cancer because of its low specificity.

Adult↗
PubMed1998

Office evaluation and management of bladder neoplasms.

Transitional cell carcinoma is the predominant bladder neoplasm. These tumors are heterogeneous, and the risk of recurrence and progression should guide further management. When this approach is used, patients at lower risk avoid the morbidity and expense of unnecessary interventions and tests, whereas higher-risk patients are treated more aggressively. Cystoscopy and IVP remain the standard initial evaluation for patients suspected of having a bladder neoplasm. Intravesical chemotherapy and immunotherapy can be administered safely in the office to reduce disease recurrence when appropriate. The advent of lasers has permitted fulgaration of low-grade neoplasms in the office with local anesthesia. Surveillance of patients with superficial disease is still largely dependent on office-based cystoscopy. Tumor markers for the identification of recurrent disease are being investigated and may prove useful to reduce the number of negative cystoscopic evaluations performed for surveillance. Patients postcystectomy are followed up with attention to detection of recurrent disease in remnant urothelium, metastatic disease, and metabolic and nutritional disturbances, which may result from urinary diversion.

Disease Progression↗
PubMed1985

Value of ultrasonography in investigating morbidity due to Schistosoma haematobium infection.

In an area where urinary schistosomiasis was endemic 349 patients were examined by ultrasonography. To evaluate the sensitivity and specificity of this technique, intravenous pyelography and cystoscopies were also done on 29 and 31 patients, respectively. Ultrasonography compared favourably with pyelography and cystoscopy except in demonstrating bladder calcifications. It was a valuable tool for rapid mass detection of Schistosoma haematobium related morbidity. Major renal congestion and irregularity of the bladder wall as seen on ultrasonography correlated strongly with the prevalence and the intensity of S haematobium infection as well as with microhaematuria and proteinuria, thus indicating the usefulness of urine dip sticks for S haematobium case-finding, especially during attempts at morbidity control in endemic areas.

Adolescent↗
PubMed2003

[Use of flavonoids (hesperidin) in the treatment of bleeding bladder varices].

OBJECTIVE: To inform of the use of the Flavonoids in the treatment of bladder varicose veins, and their effectiveness. PATIENT: It is informed of 4 cases that went for haematuria, and that in the cystoscopy one observes bladder varicose veins, bleeding in 2 cases, in them you uses Hesperidina 150 mg bid or tid for 30 days. RESULTS: They were good, the 2 cases that bled the haematuria disappeared and in the 4 cases in the control cystoscopy the varicose veins had disappeared. CONCLUSIONS: The treatment antivaricose or antihemorrhoidal can be useful in the treatment of bladder varicose veins. It should be given as minimum by 30 days.

Adult↗
PubMed2000

Colour Doppler ultrasound in vesicovaginal fistulas.

The purpose was to evaluate the feasibility of diagnosing vesicovaginal fistulas by colour Doppler ultrasound with contrast media. Twelve consecutive patients were examined by vaginoscopy, methylene blue test, cystogram and cystoscopy. For ultrasound examination, the bladder was filled with saline. Then diluted contrast media (Levovist) was instilled. Colour Doppler ultrasound revealed a jet phenomenon through the bladder wall toward the vagina, proving the existence of the fistula. Eleven patients had vesicovaginal fistulas, one patient a vesicoureterovaginal fistula. Colour Doppler ultrasound had correct results in 11 of 12 patients (92%). In follow-up examinations of four patients during a prolonged drainage of the bladder, we could correctly demonstrate the closure of one fistula. Colour Doppler ultrasound with contrast media is a new useful diagnostic tool in the evaluation and follow-up of vesicovaginal fistulas. It is less invasive than cystoscopy and needs no radiation exposure. The examination is well tolerated by the patients.

Adult↗
PubMed2002

Intravesical meglumine gamma-linolenic acid in superficial bladder cancer: an efficacy study.

OBJECTIVES: Gamma-linolenic acid (GLA) is known to be cytotoxic to malignant cells. We assessed the efficacy of the novel intravesical formulation, meglumine gamma-linolenic acid (MeGLA), in a phase II trial, in patients with recurrent, superficial bladder cancer. PATIENTS AND METHODS: Thirty patients with recurrent, superficial transitional cell carcinoma (TCC) were recruited. The tumour pattern was recorded at flexible cystoscopy. Patients received a single intravesical instillation of 50ml of either 50mg (1mg/ml) (15 patients), or 125mg (2.5mg/ml) (15 patients) of MeGLA in water, retained for one hour. At subsequent cystoscopy, the tumour patterns were recorded, prior to undertaking routine cystodiathermy. Biopsies were obtained for histological assessment. Responses were divided into complete, partial or none. RESULTS: All 30 patients retained the drug for 1 hour without significant local or systemic side effects. There were 4 (13%) complete responses, 9 (30%) partial responses, and 17 (57%) non-responders. Histology showed no evidence of damage to surrounding urothelium. CONCLUSIONS: Our data confirms the safety and tolerability of MeGLA, which is consistent with findings from a previous phase I trial. A response rate of 43% also indicates that MeGLA has a significant cytotoxic effect against TCC and the results are similar to those obtained using standard, single-dose, intravesical regimens.

Administration, Intravesical↗
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↗
PubMed2004

Vesicouterine fistula in pregnancy: a case report.

BACKGROUND: Vesicouterine fistula is a rare complication of Caesarean delivery. This is the third known report of vesicouterine fistula diagnosed during pregnancy. CASE: Linda (pseudonym), a 28-year-old woman in her second pregnancy, having had a Caesarean delivery in her first pregnancy, was admitted to the delivery unit with possible preterm ruptured membranes at 23 weeks' gestation. She also complained of a fluid-filled sac bulging from her introitus during her admission assessment. Diagnosis of premature rupture of membranes was confirmed by a positive nitrazine paper test and appearance of ferning during microscopic evaluation of vaginal fluid. Cystoscopy, performed 3 days after admission, demonstrated ballooning of amnion into the bladder. At 24 weeks' gestation, the woman had a precipitous vaginal breech delivery. Two months later, the fistula was successfully repaired through a transabdominal route. CONCLUSION: Although uncommon in pregnancy, vesicouterine fistula should be considered in women who present with urinary incontinence or recurrent urinary tract infections after a lower transverse Caesarean section. Evaluation in pregnancy is usually limited to cystoscopy. Treatment is usually surgical and is often delayed until 2 to 3 months following delivery.

Adult↗
PubMed1980

Effect of electroconvulsive therapy (ECT) on plasma tryptophan.

The concentrations of total and free plasma tryptophan were measured in 12 unipolar depressed patients before and after a course of electroconvulsive therapy (ECT) and before and after single ECTs during the course of treatment. Eleven patients undergoing diagnostic cystoscopy served and controls to examine the acute effect of anaesthesia. Total and free plasma tryptophan concentrations in the depressed patients were not significantly different from control values and were not changed by course of ECT. Free plasma tryptophan varied considerably within individual patients. Total plasma tryptophan was reduced acutely by ECT/anaesthesia in the depressed patients (P less than 0.05) and by anaesthesia in the cystoscopy controls (P less than 0.01). Free plasma tryptophan was not significantly altered. This reduction in total plasma tryptophan could be secondary to an effect of thiopentone on albumin binding of tryptophan.

Adult↗
PubMed2002

Telomerase: its clinical relevance in the diagnosis of bladder cancer.

More than 50 years ago, Papanicolaou recognized the importance of a non-invasive technique for the diagnosis and follow-up of patients with carcinoma of the urinary bladder. Cystoscopy, however, has remained the 'gold standard' since no currently available non-invasive method can compete with cystoscopy's sensitivity and specificity. The detection of the ribonucleoprotein telomerase or the telomerase subunits human telomerase RNA (hTR) and human telomerase reverse transcriptase (hTERT) in urine samples offer new diagnostic perspectives. The present article presents a review of publications in the literature and evaluates their clinical relevance. The experimental studies reported to date are very promising and show that telomerase exactly fulfils the requirements for a good diagnostic marker for carcinoma of the urinary bladder. The diagnostic application remains in an experimental stage and telomerase is still several steps away for routine use as a clinical parameter. The remaining steps leading to its routine clinical application will be discussed.

Biomarkers, Tumor↗
PubMed2005

Practice patterns of Japanese physicians in urologic surveillance and management of spinal cord injury patients.

STUDY DESIGN: Analysis of answers to a new questionnaire. OBJECTIVE: To examine current practice patterns of physicians in the urological surveillance and management of spinal cord injury (SCI) patients in Japan. SETTING: Nationwide questionnaire survey to physicians in Japan. METHODS: A Japanese version of the 14-item questionnaire survey carried out in US was mailed to 770 members of the Japanese Neurogenic Bladder Society (JNBS). RESULTS: We received answers to our questionnaire from 333 (43.2%) members of JNBS. The responders were all urologists. For surveillance of the upper urinary tract (UUT), 239 (71.8%) respondents preferred abdominal ultrasound. Cystometry was performed routinely by 174 (52.3%) respondents for the evaluation of vesicourethral function. Cystoscopy was carried out in cases of hematuria (88.0%) and bladder stone (55.3%). Surveillance of the urinary tract was performed every year in 154 (46.2%). For detection of bladder cancer, which 119 (37.9%) respondents have experienced, 94.9% physicians perform cystoscopy, 76.3% urinary cytology, and 60.4% ultrasound. For initial treatment of detrusor-sphincter dyssynergia (DSD), 225 (69.2%) respondents chose alpha-blocker, and 94 (28.9%) chose clean intermittent catheterization (CIC) with/without anticholinergic agent(s). For initial treatment of overactive bladder, 245 (74.7%) chose anticholinergic agent(s) only and 63 (19.2%) chose anticholinergic agent(s) with CIC. For initial treatment of areflexic bladder, 233 (73.7%) chose CIC and 63 (19.9%) chose Credé maneuver or tapping. CONCLUSIONS: This survey shows that there are some differences in urological surveillance and management of SCI patients between Japan and the US. Reasons for the discrepancy should be examined.

Comorbidity↗
PubMed2002

Diagnostic lessons learnt from a series of enterovesical fistulae.

OBJECTIVE: An enterovesical fistula (EVF) is an uncommon condition requiring careful and sometimes extensive preoperative investigation. Our experience over a 10-year period has been reviewed with emphasis on the diagnostic investigations performed. PATIENTS AND METHOD: Forty-two patients (30 male) have been studied. Presenting symptoms, diagnostic investigations, and subsequent treatment have been reviewed. RESULTS: The site of the fistulae were; 37 colonic, 2 rectal, and 3 ileal. The commonest presenting symptoms were; pneumaturia 75%, faecaluria 63% and urinary tract infections 57%. The positivity rate of the investigations performed were; cystoscopy 89%, urine cytology 86%, barium enema 65%, computerized tomography (CT) scanning 55%, IVP 35%, and cystography 27.5%. The causes of the fistula were; diverticular disease 71%, carcinoma 20%, Crohn's disease 7%, and radiotherapy 2%. CONCLUSIONS: We recommend cystoscopy and urine cytology for faecal material as the first-line investigations in all patients with a suspected enterovesical fistulae. CT scanning and barium enema should not be first line investigations but may be performed subsequently to help determine the aetiology and planning of surgery.

Journal Article↗