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PubMed2005

Correlation of office-based cystoscopy and cytology with histologic diagnosis: how good is the reference standard?

OBJECTIVES: To evaluate the accuracy of cystoscopy and cytology in predicting the histopathologic features of suspicious cystoscopic lesions. METHODS: We reviewed the bladder biopsy records at two institutions from July 2001 to July 2004. Intraoperative biopsies were performed for positive (papillary or sessile) (n = 155) and equivocal (n = 101) lesions found during office cystoscopy. The specimens were submitted for histopathologic analysis, and the results were correlated with the preceding office-based cystoscopy and cytology findings. RESULTS: Malignancy was found in 27 (26.7%) of 101 equivocal lesions and 128 (82.5%) of 155 sessile or papillary lesions. Of the 72 biopsies performed for equivocal lesions in patients with a history of transitional cell carcinoma (TCC), 24 (33%) had malignancy compared with 3 (10.3%) of 29 biopsies performed in patients without a history of TCC. For patients with no history of TCC and equivocal lesions, cytology was able to identify all neoplasms (100% sensitivity) and negative cytology always predicted a normal biopsy result (100% negative predictive value). However, for patients with a history of TCC and equivocal lesions, cytology had a sensitivity and negative predictive value of 81.8% and 88.2%, respectively. CONCLUSIONS: Our findings suggest that patients without a history of TCC who have an equivocal lesion at cystoscopy may avoid an unnecessary operation if they have normal cytology findings. A large number of patients with equivocal cystoscopic findings undergo unnecessary biopsies in the operating room, and future studies should be performed to assess the value of other bladder markers in predicting oncologic status in this setting.

Cystoscopy↗
PubMed2005

What is the value of cystoscopy with hydrodistension for interstitial cystitis?

OBJECTIVES: To determine the utility of cystoscopy with hydrodistension for the diagnosis and therapy of interstitial cystitis. Cystoscopy with hydrodistension is the most commonly performed diagnostic test and procedure in patients with interstitial cystitis. METHODS: Eighty-four consecutive patients with interstitial cystitis (68 women and 16 men) were studied retrospectively. The patients underwent history and physical examination, urinalysis, and urine culture and filled in a voiding diary and pain urgency frequency questionnaire. Cystoscopy with hydrodistension was performed in 47 patients. Patients who had and had not undergone hydrodistension were compared. Patients who underwent hydrodistension were characterized and followed up for response. RESULTS: The mean patient age was 41 years, mean daily voided volume was 98 mL, mean number of nocturnal episodes was 3, and pain urgency frequency score was 21. Comparing patients undergoing versus not undergoing hydrodistension, pain was reported in 61% versus 25% (P = 0.03), vaginal pain in 62% versus 32% (P = 0.02), and dyspareunia or ejaculatory pain in 67% versus 29% (P < 0.01), respectively. All other parameters were statistically similar. Of the patients undergoing hydrodistension, 43 had follow-up and 24 (56%) reported improvement (mean duration of 2 months). Of the patients with and without improvement, no difference was found in mean age (40 versus 46 years, P = 0.20), duration of symptoms (7 versus 7 years, P = 0.92), anesthetic capacity (722 versus 721 mL, P = 0.99), or glomerulation grade (P = 0.61), respectively. CONCLUSIONS: Cystoscopy with hydrodistension provided little useful information above and beyond the history and physical examination findings. As therapy, 56% of patients reported improvement, but the duration was short lived.

Adolescent↗
PubMed2006

Assessment of efficacy of transcutaneous electrical nerve stimulation for pain management during office-based flexible cystoscopy.

OBJECTIVES: To evaluate the efficacy of transcutaneous electrical nerve stimulation (TENS) for its effectiveness in eliminating or minimizing discomfort during office-based flexible cystoscopy. METHODS: A total of 148 patients were prospectively randomized into one of three groups: flexible cystoscopy with no analgesics, a placebo TENS, or an activated TENS. The patient data collected included patient parameters, number of previous flexible cystoscopies, visual analog pain scores during and after the procedure, surgeon's difficulty rating of procedure, and International Prostate Symptom Score before and 24 hours after the procedure. RESULTS: No statistically significant difference was found among the three groups regarding patient parameters. The visual analog pain scores were similar before and after the procedure. At 30 seconds, the mean visual analog scale score for the control group, placebo group, and TENS study group was 3.73, 3.65, and 3.52, respectively (control versus placebo, control versus active, and placebo versus active: P = 0.97, 0.29, and 0.53, respectively). At 1 and 5 minutes, the corresponding scores were 3.44, 4.37, and 3.50 (P = 0.88, P = 0.99, and P = 0.99) and 0.86, 1.23, and 0.88 (P = 0.97, P = 0.35, and P = 0.56), respectively. The surgeon's mean difficulty rating for the control procedures was 1.08 and for the placebo group was 2.30 (P = 0.02). CONCLUSIONS: All patients undergoing flexible cystoscopy in the office setting experienced discomfort. The TENS device provided no significant benefit for pain. The trend toward greater pain scores in the control group could be attributed to the greater degree of difficulty.

Ambulatory Surgical Procedures↗
PubMed1997

The value of intraoperative cystoscopy in urogynecologic and reconstructive pelvic surgery.

OBJECTIVE: Our goal was to evaluate the role of intraoperative cystoscopy during surgery for pelvic organ prolapse and urinary incontinence. STUDY DESIGN: Charts of 224 consecutive patients who had intraoperative cystoscopy performed after urogynecologic surgery were reviewed. RESULTS: Nine injuries occurred that were unsuspected before cystoscopy, for an incidence of 4%. Six ureteral ligations occurred, four after Burch cystourethropexy and two after vaginal culdoplasty. Intravesical sutures were noted after two Burch procedures, and another injury occurred with passage of fascia lata through the bladder during a pubovaginal sling procedure. Eight injuries were managed by removal and replacement of the suture or sling with only one requiring ureteroneocystotomy. When patients with injuries were compared with those without, there were no statistical differences in demographic or surgical parameters. CONCLUSIONS: The potential for damage to the lower urinary tract is significant with complex urogynecologic surgery. Because of the increased and delayed morbidity associated with unrecognized injury, intraoperative surveillance cystoscopy should be considered a part of all such procedures.

Adult↗
PubMed1994

The effects of intraurethral lidocaine anesthetic and patient anxiety on pain perception during cystoscopy.

Despite current practice there is no evidence to demonstrate the efficacy of intraurethral lidocaine gel as an anesthetic for rigid cystoscopy. To evaluate the usefulness of lidocaine in decreasing pain associated with cystoscopy, we performed a prospective, randomized, controlled, double-blind study comparing lidocaine gel with a water based lubricant. The effects of pre-procedure anxiety and prior experience with cystoscopy on pain perception were also evaluated. Physician perception of pain experienced by the patient was compared with the actual pain experienced. We found no decrease in pain perception in men or women following lidocaine gel instillation with a 5 or 10-minute dwell time compared to instillation of the plain lubricant. Increased preprocedure anxiety correlated with increased pain perception in women. Personal experience with prior cystoscopic procedures significantly decreased the current pain perception in men. Physicians underestimated the patient pain perception in all groups. Overall, we found the use of lidocaine gel to be of no benefit in routine rigid cystoscopy. Lowering pre-procedure anxiety may decrease the amount of pain perceived by women but not by men.

Adult↗
PubMed2005

[Comparative study between cystoscopy, urinary cytology, NMP-22 and a new method, bladder chek, in the follow-up of superficial bladder cell carcinoma].

OBJECTIVE: The goal of this work tries to evaluate the utility of the qualitative determination of NMP-22 in the evaluation of the superficial bladder carcinoma in asymptomatic patients, comparing it with its quantitative determination, the cytology and the cystoscopy. MATERIALS AND METHODS: A simple of urine just voided was taken in 88 asymptomatic patient follow-up for superficial bladder cell carcinoma. This dose was distributed in 3 parts, for performed cytology, for determination of NMP-22, and 4 drops of the third part are added to device bladder chek. Later, we performed cystoscopy and transurethral resection in patients with a suspicion of bladder cancer. RESULTS: 26 patients had tumor relapse and 62 patients were free of disease. The sensitivity for the bladder chek was of 28%, 34.62% for NMP-22, 34.62% for cytology and 100% for cystoscopy. The specificity was of 93.55%, 80.33%, 87.10% and 87.10% respectively. The sensitivity by degree was 25 in G1, 28.57 in G2 and 50 in G3 for Bladder chek; 29.41, 42.86 and 50 for NMP-22; 23.53, 71.43 and 0 for cytology. The sensitivity by stages was 27.7 in Ta-1 and 50 in T2 for Bladder chek; 34.78 and 50 for NMP-22; 39.13 and 0 for the cytology. CONCLUSIONS: The low sensitivity of bladder chek invalidates it like alternative method to the cystoscopy in the follow-up of the superficial asymptomatic bladder cell carcinoma.

Carcinoma, Transitional Cell↗
PubMed1996

[Virtual cystoscopy based on spiral CT data].

Simulation of three-dimensional cystoscopy based on helical CT scan data in real-time in patients with tumours of the urinary bladder. In three patients with histologically confirmed carcinoma of the urinary bladder, a helical CT scan with double detector technology was carried out preoperatively. A native scan was first performed, followed by an examination in the early contrast medium enhanced phase. After adequate contrasting of the urinary bladder (30 minutes latency), further images were acquired. These data were transferred to a separate graphic computer workstation and reconstructed. The results were then compared with the cystoscopic and pathohistological findings. All tumours of the urinary bladder identified at fiberoptic cystoscopy were also visualised by virtual cystoscopy. The best reconstruction results were obtained from data acquired after the 30-minute latency period. Virtual cystoscopy represents an interesting option in helical CT scanning, which is able to visualise polypoid tumours of the urinary bladder. Its clinical relevance, however, must be demonstrated in studies with a larger number of patients examined.

Aged↗
PubMed2001

Randomized trial of 10 mL and 20 mL of 2% intraurethral lidocaine gel and placebo in men undergoing flexible cystoscopy.

PURPOSE: To determine if 20 mL of 2% intraurethral lidocaine gel is superior to 10 mL of 2% lidocaine or sterile lubricant for flexible cystoscopy in men. PATIENTS AND METHODS: A randomized, double-blind, placebo-controlled trial was conducted. Sixty men scheduled to undergo diagnostic flexible cystoscopy were randomized to receive either 20 mL of placebo gel (Group I), 10 mL, of 2% lidocaine gel (Group II) or 20 mL of 2% lidocaine gel (Group III). A penile clamp was applied for 15 minutes to ensure consistent indwelling time in all patients. Patients recorded their pain on a 10-cm non-graphical visual analog scale prior to cystoscopy as a baseline, during the procedure, and immediately after the procedure. Patients also recorded their pain and willingness to have the same anesthetic on a 4-point descriptive scale. Heart rate and mean arterial blood pressure (MAP) were recorded at specific intervals throughout the procedure, and increases in mean arterial pressure were considered objective evidence of patient pain. RESULTS: Pain perception was not statistically different in the groups (Group I 4.65, Group II 3.93, Group III 3.57; P = 0.406). Pain assessment and willingness to have the same anesthetic also did not differ statistically among the groups. Similarly, differences in the increases in MAP were not statistically significant between groups. CONCLUSION: Instillation of 20 mL or 10 mL of 2% lidocaine gel has no advantage over plain lubricant in providing anesthesia for flexible cystoscopy in men.

Adult↗
PubMed2004

Fluorescence cystoscopy and bladder surveillance.

PURPOSE OF REVIEW: Update on new developments in the field of fluorescence cystoscopy. RECENT FINDINGS: New agents are being studied to improve the accuracy of fluorescence cystoscopy. Hexyl-5-aminolevulinic acid is an ester form of 5-aminolevulinic acid with improved uptake by tumor cells. It has been shown to have higher specificity than 5-aminolevulinic acid and can possibly play a complementary role to standard cystoscopy. Hypericin is a promising new agent that has excellent sensitivity and specificity. The use of confocal microscopy to examine fluorescent tissue may help improve the accuracy. SUMMARY: The addition of newer agents to the armamentarium of fluorescence cystoscopy has great potential with promising results in improving the diagnostic accuracy of bladder cancer and in particular carcinoma in situ. These agents need to be studied in large randomized trials to prove that using these agents can facilitate early diagnosis and improved prognosis in patients with bladder cancer.

Cystoscopy↗
PubMed1990

Screening workers exposed to 4,4'-methylenebis(2-chloroaniline) for bladder cancer by cystoscopy.

A bladder cancer incidence study was conducted among 540 workers exposed to the potential bladder carcinogen 4,4'-methylenebis(2-chloroaniline) from 1969 to 1979. Among the 385 workers who participated in a urine screening examination, none had suspicious or positive cytology. Twenty-one workers had at least one reading of atypia and 60 had either a positive dipstick for heme or greater than five red blood cells per low power field. The study protocol initially involved referral to private physicians for follow-up of any suspicious laboratory results. However, the diagnosis by cystoscopy of a bladder tumor in a nonsmoking man less than 30 years old with low-level hematuria prompted us to offer cystoscopy to all members of the cohort. A total of three tumors were identified in 200 persons who received cystoscopy. All were low-grade, papillary tumors and two occurred in men with completely normal urine screening results. These findings suggest that cystoscopy of asymptomatic persons should be considered in designing bladder cancer screening programs in high-risk cohorts.

Adult↗
PubMed2003

Successful diagnosis of orthotopic rat superficial bladder tumor model by ultrathin cystoscopy.

PURPOSE: In the orthotopic animal bladder tumor model noninvasive evaluation of the tumor establishment and the therapeutic effect has been difficult. To our knowledge we present the first diagnosis of orthotopic rat superficial bladder tumor model by ultrathin cystoscopy. MATERIALS AND METHODS: The established AY-27 rat bladder carcinoma cell line was transplanted orthotopically into 22 female Fischer F344 rats. A cell suspension containing 4 x 10 AY-27 cells was instilled into the bladder, which had been conditioned with mild acid washing. To evaluate tumor growth serial cystoscopy was performed via the urethra with an ultrathin endoscope (diameter 0.75 mm.) 5 to 14 days after tumor cell inoculation. At intervals after cystoscopic tumor detection the rats were sacrificed for autopsy and histological examination. RESULTS: In all 22 rats the orthotopic bladder tumor was established 7 to 10 days after tumor cell implantation and in most it was superficial. Cystoscopy permitted inspection of the urethra and whole bladder surface. We detected all tumors as broad based papillary mass (minimal lesion 1 mm. or less) and inspected its detailed appearance and accurate location. CONCLUSIONS: The orthotopic rat superficial bladder tumor model and the diagnostic procedure by ultrathin cystoscopy would be ideal system for preclinical evaluation of new potential intravesical therapies.

Animals↗
PubMed1994

Air insufflation versus water irrigation during flexible cystoscopy: a prospective randomized study.

OBJECTIVE: To compare air insufflation with water irrigation during routine diagnostic flexible cystoscopy. PATIENTS AND METHODS: A total of 200 consecutive patients scheduled for routine diagnostic flexible cystoscopy under topical anaesthesia were randomized prospectively to either air insufflation or water irrigation. Their tolerance to the procedure and post-operative symptoms were assessed from a questionnaire completed immediately after the procedure and then 1 week later. RESULTS: Air insufflation offered a better cystoscopic view than water irrigation. With regard to tolerance, in the air insufflation group, 72% reported the procedure to be comfortable, 22% uncomfortable and 6% painful compared to 44%, 45% and 11% respectively in the water irrigation group. This difference in favour of air insufflation was highly significant (Chi-square, P < 0.001). There was no statistical difference in either post-operative symptoms a week later or in the diagnostic yield between the two study groups. There were no complications in either group. CONCLUSION: Air insufflation cystoscopy is as safe and effective as water irrigation but better tolerated by patients. This, together with its more obvious advantages of the ease of administration and low cost, should prompt more routine use of air insufflation cystoscopy for day case procedures.

Carcinoma, Transitional Cell↗
PubMed2004

Virtual cystoscopy from computed tomography: a pilot study.

OBJECTIVE: To assess the feasibility of virtual cystoscopy reconstructed from helical computed tomography (CT) obtained using an intravenous contrast agent, and to correlate the findings with flexible (FC) and rigid cystoscopy (RC) in patients with bladder tumours. PATIENTS AND METHODS: Eighteen patients (16 men and two women, mean age 72 years, range 59-80) with haematuria and found to have a bladder tumour on FC were included in a pilot study. Contrast-enhanced helical CT scans were taken and based on these datasets, virtual cystoscopy (VC) images were reconstructed by a radiologist unaware of the findings at cystoscopy. All patients had RC and a biopsy taken. The VC images were compared with the findings from FC and RC. RESULTS: At FC, VC and RC, 32, 34 and 36 lesions were identified, respectively; 33 (92%) of the abnormal lesions at RC were correctly identified at VC. At VC, all lesions of >4 mm were identified but only one of three <4 mm was seen. There were two false-positive finding at VC; VC correctly identified 17 (94%) of 18 abnormal bladders. Only 25% of the ureteric orifices were seen. Carcinoma in situ and urethral tumours were not visualized. CONCLUSION: CT-based VC has a high sensitivity for detecting bladder lesions and is comparable with FC; it may have a potential role as a single imaging tool for haematuria. Further larger studies are required to assess its clinical role.

Aged↗
PubMed1999

An audit of positive findings in flexible and rigid check cystoscopy.

Both flexible and rigid cysto-urethroscopy are routinely used in the surveillance of transitional cell bladder tumours. This study addressed the issue of patient selection for either rigid or flexible cystoscopy. What proportion of positive findings at flexible cystoscopy and negative findings at rigid cystoscopy are acceptable? Standards were set of 10% for the former and 50% for the latter and our practice was then audited. A retrospective analysis of 800 patients undergoing check cystoscopy revealed a positive finding rate of 8.3% using the flexible instrument and 48.1% using the rigid instrument.

Carcinoma, Transitional Cell↗
PubMed2002

Effect of the rate of delivery of lignocaine gel on patient discomfort perception prior to performing flexible cystoscopy.

Flexible cystoscopy is commonly performed under local anaesthesia. Instillation of lignocaine gel is commonly associated with urethral discomfort, which in some cases results in fierce opposition to further flexible cystoscopy under local anaesthesia. Although studies have demonstrated that the temperature of lignocaine can influence the level of discomfort experienced, to date no study has investigated the influence of the rate of lignocaine delivery on perceived discomfort. We therefore performed a prospective, randomised study to investigate this in patients undergoing flexible cystoscopy. One hundred consenting men were randomised to receive 11 ml of 2% lignocaine hydrochloride gel over either 2 or 10 s. The groups were well matched for age. After instillation of the gel, the patients were immediately asked to score their discomfort using a visual analogue scale. The discomfort experienced by patients that received the gel over 10 s was significantly (p < 0.05; Student's t test) less than those that received it over 2 s. This was irrelevant of the age of the patient and the number of previous cystoscopies performed. We have demonstrated that slow administration results in decreased discomfort. This may, in turn, reduce the need to resort to general anaesthesia, which is associated with increased morbidity and cost.

Aged↗
PubMed2004

Do we need to perform cystoscopy on all adults attending urology centres as outpatients?

INTRODUCTION: There has been considerable expansion in the use of flexible cystoscopy (FC) and people who can perform the procedure. Hence, there is a criticism that this procedure is being overused with no management benefit. MATERIALS AND METHODS: We audited the use of FC in a district hospital for a period of 1 year. The results of FC for non-standard indications (other than haematuria and check cystoscopy) were analysed for their diagnostic yield. RESULTS: Of the 1,390 FCs performed, 295 were done for non-standard indications. 46.14% of these cystoscopies had positive findings. Cancer detection rate was 6.10%. Cystoscopy altered the management in 14.08% of patients and was supportive to diagnosis and management in 32.06%. CONCLUSION: This procedure is certainly not overused and the ever-increasing requirement of this simple procedure has serious resource implications for the National Health Service.

Adult↗
PubMedDate not supplied

Efficient scheduling of cystoscopies in monitoring for recurrent bladder cancer.

Proper timing for repeated evaluations is difficult to assess. The authors analyzed scheduling of cystoscopy to monitor patients for detection of recurrent bladder cancer assuming that 1) minimizing tumor detection delay helps prevent cancer morbidities; 2) only limited numbers of cystoscopies are available; 3) prediction of recurrence or progression to invasive cancer is uncertain; 4) future tumors recur according to a Poisson process. Assumptions 3 and 4 permit estimation of each patient's recurrence rate. Thus, patients may be compared according to their relative risks of future tumors. With these assumptions, nonlinear optimization theory was used to calculate monitoring schedules for a model practice. Given 5.4 available visits per week per 100 patients, cystoscopy was recommended in 9-11 weeks for high-risk patients and in 30-40 weeks for low-risk patients, depending on stages, grades, and numbers of previous tumors. In contrast, standard cystoscopy was recommended in 13, 26, or 52 weeks, depending only on time elapsed since last recurrence. The calculated schedule implied an average detection delay for potentially invasive tumors of eight weeks, while standard practice led to detection delays of 11 weeks (38% worse). These results suggest that inclusion of each patient's tumor history in an optimization approach may improve follow-up care for patients who have superficial bladder cancers. This approach is being evaluated in a larger clinical setting.

Appointments and Schedules↗
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↗