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PubMed2001

Polypropylene sling for treatment of stress urinary incontinence: an alternative to tension-free vaginal tape.

PURPOSE: Sling procedures have been used successfully to treat stress urinary incontinence (SUI). We report our initial experience with the use of a synthetic polypropylene mesh for treatment of SUI. Based on similar surgical principles of cadaveric fascia sling, we describe placement of a thinly woven polypropylene mesh under the distal urethra. We describe our technique and report our initial results. MATERIALS AND METHODS: There were 146 consecutive patients evaluated. All patients had clinical evidence of SUI. Patients underwent preoperative evaluation with video urodynamics, symptom questionnaire, and cystoscopy. Postoperatively the patients were evaluated at 3-month intervals by symptom questionnaire, physical examination, and postvoid residuals (PVR). One year after the procedure, all patients were asked to fill out a voiding dysfunction and incontinence symptom questionnaire and a validated quality-of-life questionnaire. A flow and PVR also were obtained. RESULTS: Average intraoperative time was 27 minutes for the sling procedure. There were no intraoperative complications and one major postoperative complication. There was no permanent retention and no erosions. Ninety-two percent of patients had either no or rare stress incontinence. Postoperatively, 7% of patients developed de novo urge incontinence. CONCLUSION: We describe excellent results with a new simple, quick, and inexpensive method to correct SUI by placing a polypropylene mesh under the distal urethra.

Cystoscopy↗
PubMed2001

The natural history of idiopathic urethrorrhagia in boys.

PURPOSE: We describe the presenting symptoms, evaluation and natural history of urethrorrhagia in boys. MATERIALS AND METHODS: The records of 27 consecutive toilet trained boys with idiopathic urethrorrhagia were retrospectively reviewed for information regarding age, symptoms, symptom duration, physical examination, and radiographic, endoscopic and laboratory data. Patient interviews were performed, and the resolution rate, symptom duration and associated urological abnormalities were evaluated. RESULTS: Mean age at presentation was 10.1 years. Symptoms included urethrorrhagia in 100% and dysuria in 29.6% of cases. Radiographic and laboratory evaluations were normal in all patients except for microscopic hematuria in 57%. Cystourethroscopy in 4 patients revealed bulbar urethral inflammation without stricture in 2. A total of 24 patients (89%) were followed an average of 37 months (range 10 to 106). Complete resolution developed in 46% of cases at 6 months, in 71% at 1 year and in 91.7% overall. The average duration of symptoms was 9.9 months (range 2 weeks to 38 months). In 2 boys (8.3%) urethrorrhagia persisted for 22 and 28 months, and in 1 cystoscopy revealed urethral stricture. Self-limiting urethrorrhagia recurred in 2 patients (8.3%) after initial resolution. Treatment consisted of watchful waiting in all patients except 1 with urethral stricture, who underwent urethral dilation. After urethrorrhagia resolved epididymo-orchitis recurred in 1 case. CONCLUSIONS: Routine radiographic, laboratory and endoscopic evaluation is unnecessary for evaluating urethrorrhagia. Watchful waiting is indicated because the condition resolves in 71% and 91.7% of patients at 1 and 2 years, respectively. Evaluation should be considered in patients with prolonged urethrorrhagia because urethral stricture may be identified.

Adolescent↗
PubMed2001

Quantification of 5-aminolevulinic acid induced fluorescence improves the specificity of bladder cancer detection.

PURPOSE: 5-Aminolevulinic acid induced fluorescence endoscopy has outstanding sensitivity for detecting early stage bladder cancer. Nevertheless, a third of the lesions that show specific fluorescence are histologically benign. We decreased the false-positive rate of 5-aminolevulinic acid induced fluorescence endoscopy by incorporating protoporphyrin IX fluorescence quantification into the standard cystoscopy procedure. MATERIALS AND METHODS: In 25 cases (53 biopsies) of a history of or suspicion for bladder cancer 5-aminolevulinic acid induced fluorescence endoscopy and fluorescence image quantification were performed. For fluorescence image quantification images obtained with a target integrating color charge-coupled device camera were digitized and stored in a personal computer. Red-to-blue ratios were calculated from fluorescence positive lesions and results were correlated with hematoxylin and eosin histology. RESULTS: Malignant fluorescence positive lesions showed significantly stronger fluorescence intensity than fluorescing lesions with benign histology. A threshold was established that decreased the false-positive rate by 30% without affecting sensitivity. CONCLUSIONS: Fluorescence image quantification is a new endoscopic method for objectively selecting multicolor fluorescence bladder lesion images for biopsy. It has the potential of eliminating human error by different surgeons with variable experience in fluorescence endoscopy.

Adult↗
PubMed2002

[Diagnosis of bladder tumors].

Prompt diagnosis of bladder cancer is essential to improve the management of this disease. Hematuria and lower urinary tract symptoms must draw attention to bladder difficulties. The diagnosis is based on cystoscopy and biopsy of any lesions. Once the diagnosis has been established, the tumour should be staged using the TNM system before treatment. Research efforts are continuing to identify biological markers sensitive and specific enough to predict the diagnosis and behavior of this disease accurately.

Aged↗
PubMed1975

Neurourologic evaluation after resection of the sacrum.

Five patients with bilateral, and four patients with unilateral, well defined sacral nerve lesions after sacral resection for tumor were examined with a clinical evaluation, cystometry, and cystoscopy including a test of vesical and urethal sensibility with different stimuli. In patients with bilateral division of the sacral nerves below the S 2 level, no active detrusor contractions were registered, indicating that the second sacral segment alone cannot subserve the micturition reflex. In patients with unilateral division of sacral nerves 1 to 5 or 2 to 5, a normal micturition reflex was registered. There was a complete loss of bladder mucosal pain when sacral nerves 3 to 5 had been cut bilaterally, while the sensibility was normal when sacral nerves 4 to 5 had been cut bilaterally. In patients with unilateral division of all sacral nerves below L 5 or S 1, mucosal pain tested by means of electrcoagulation of the bladder and pin-pricking of the urethra could not be felt on the denervated side. Stretching of the detrusor wall with a ureteral catheter, however, could be felt on the denervated side, indicating that this sensation was not mediated in sacral nerves but probably in the hypogastric nerves. Thermesthesia of the mucosa was demonstrated on the intact side of the bladder but not on the denervated side when the patients with unilateral sacral nerve lesions were tested with jet streams of cold or hot saline against the bladder wall.

Adult↗
PubMed2002

Clinically relevant improvement of recurrence-free survival with 5-aminolevulinic acid induced fluorescence diagnosis in patients with superficial bladder tumors.

PURPOSES: Fluorescence diagnosis induced by 5-aminolevulinic acid enables more thorough transurethral resection of superficial bladder carcinoma compared with conventional white light. We performed a prospective, single institution, randomized trial to investigate whether the residual tumor rate and long-term tumor recurrence can be decreased by fluorescence diagnosis. MATERIALS AND METHODS: A total of 301 patients underwent transurethral resection of bladder tumors with white light or fluorescence diagnosis. Transurethral resection was repeated 5 to 6 weeks later to evaluate the residual tumor rate. To determine recurrence-free survival patient followup was performed every 3 months by white light cystoscopy and urine cytology. Recurrence-free survival was analyzed via Kaplan-Meier methods and multivariable Cox regression analysis. RESULTS: A total of 191 patients with superficial bladder carcinoma were available for efficacy analysis. The residual tumor rate was 25.2% in the white light arm versus 4.5% in the fluorescence diagnosis arm (p <0.0001). Median followup in the white light arm in 103 cases was 21.2 months (range 4 to 40) compared with 20.5 (range 3 to 40) in the 88 in the fluorescence diagnosis arm. Recurrence-free survival in the fluorescence diagnosis group was 89.6% after 12 and 24 months compared with 73.8% and 65.9%, respectively, in the white light group (p = 0.004). This superiority proved to be independent of risk group. The adjusted hazard ratio of fluorescence diagnosis versus white light transurethral resection was 0.33 (95% confidence interval 0.16 to 0.67). CONCLUSIONS: Fluorescence diagnosis is significantly superior to conventional white light transurethral resection with respect to the residual tumor rate and recurrence-free survival. The differences in recurrence-free survival imply that fluorescence diagnosis is a clinically relevant procedure for decreasing the number of tumor recurrences.

Administration, Intravesical↗
PubMed2002

Blood flow, pressure and compliance in the male human bladder.

PURPOSE: The regulation of human bladder blood flow during filling is poorly understood. We characterized changes in bladder blood flow with filling and examined the relationship of bladder compliance and blood flow. MATERIALS AND METHODS: A total of 17 awake male patients underwent saline cystometry followed by cystoscopy while under local anesthesia, during which a laser Doppler flow probe was placed into the posterior bladder wall detrusor. Systemic blood pressure, bladder blood flow and intravesical pressure were measured with the bladder empty and filled to 25%, 50%, 75% and 100% of awake maximum cystometric capacity as well as immediately after bladder drainage. RESULTS: Mean bladder blood flow was lowest in the empty bladder and increased with bladder filling. A mean peak flow plus or minus standard error of 7.6 +/- 1.1 ml. per minute per 100 gm. tissue was observed at volumes greater than 75% but less than 100% of maximum cystometric capacity. At 100% maximum cystometric capacity mean intravesical pressure increased by 73% from 25.2 to 43.5 cm. water and bladder blood flow decreased by 36%. Rapid bladder drainage was associated with a rebound in mean bladder blood flow to approximately 1.6 times baseline. Bladder compliance calculated for the whole filling curve positively correlated with bladder blood flow (p = 0.025), that is low compliance was associated with low blood flow. CONCLUSIONS: Human bladder blood flow tends to increase with increasing volume and pressure, and depends largely on local regulation. At capacity bladder blood flow is significantly decreased. Immediately after bladder drainage there is a rebound in blood flow, allowing reperfusion to occur. Decreased bladder blood flow and decreased bladder wall compliance correlated strongly, suggesting that ischemia may lead to structural changes in the bladder wall.

Adult↗
PubMed2002

Polypropylene mesh tape for stress urinary incontinence: complications of urethral erosion and outlet obstruction.

PURPOSE: Gynecare tension-free vaginal tape (Ethicon, Inc., New Brunswick, New Jersey) is a propylene mesh tape recently introduced in the United States as minimally invasive treatment for stress urinary incontinence. We report the combined experience at 3 tertiary care institutions with graft erosion and bladder outlet obstruction after procedures performed elsewhere. MATERIALS AND METHODS: We reviewed the records of 5 patients with complications who presented to 1 of 3 institutions after polypropylene mesh tape placement. All pertinent information was obtained from the medical records and the operating surgeon at the referring institution. RESULTS: Treatment was required in 2 patients with urethral erosion, 1 with vaginal and bladder erosion, and 2 with bladder outlet obstruction. Common presenting symptoms included urge, urge incontinence and gross hematuria. Cystoscopy showed polypropylene graft erosion at the urethra or through the bladder wall. Each patient required explantation of the polypropylene mesh tape and further surgery to restore continence. The graft was divided transvaginally in the 2 patients presenting with outlet obstruction. Urge incontinence resolved and they returned to complete spontaneous voiding. CONCLUSIONS: High clinical suspicion is necessary when evaluating patients presenting with urinary symptoms after polypropylene mesh tape placement. Bladder outlet obstruction and possible graft erosion should be considered.

Adult↗
PubMedDate not supplied

BTA TRAK urine test increases the efficacy of cytology in the diagnosis of low-grade transitional cell carcinoma of the bladder.

BACKGROUND: Among urinary tumor markers we studied the utility of the BTA TRAK assay to diagnose transitional cell carcinoma of the bladder in highly suspiscious patients, in comparison to urine cytology. MATERIALS AND METHODS: A preliminary study of 65 patients was made (21 transitional cell carcinoma (TCC), 36 without TCC and 8 excluded patients who received BCG therapy, endocavitary mytomicin or radiotherapy), using the BTA TRAK, cytology and cystoscopy. RESULTS: 12 out of the 21 selected patients were pTa (9 G1and 3 G2), 2 carcinoma in situ (CIS), 2pT1 (1 G2 and 1 G3) and 5 muscle invasive tumors (all of them G3). Setting our cut-off at 18 U/ml, a sensitivity of 52.3% and a specificity of 88.9% was reached. BTA TRAK detected 11 out of 21 of the tumors as well as urine cytology. However, BTA TRAK was more sensitive in the detection of low grade tumors (p<0.05). When considering both tests as complementary, a combined sensitivity of 80.9% and specificity of 88.5% were obtained. CONCLUSION: BTA TRAK is a valid test for the diagnosis of TCC of the bladder, which is not superior to urine cytology but complementary. More extensive prospective studies are required to validate this application and others of the BTA TRAK assay used either alone or in combination with urinary cytology in the management of bladder cancerpatients.

Antigens, Neoplasm↗
PubMed2002

[Imaging and pathology of bladder tumors].

Epithelial bladder tumors are very common. Multiple lesions are possible with variable degrees of malignant potential. Benign and mesenchymal tumors are much less frequent. The role of imaging is to first raise the possibility of such a tumor and then to provide pretreatment staging. Cystoscopy with tumoral resection and histological diagnosis remains essential for adequate treatment selection. Ultrafast MR imaging may be very valuable for evaluation of these tumors. Posttreatment follow-up is needed to detect recurrent tumors. Intravenous urography remains valuable for evaluation of the upper tracts.

Aftercare↗
PubMed2002

[Evaluation of diagnostic methods and characteristics of patients operated on for cervical cancer in Lithuania, 1998-2000].

The total number of new cases of cervical cancer for the three-year period was 1392 patients. The number of cases was fairly evenly distributed among the years of the study period 1998-2000. The total number of new cases of Stages I and II of cervical cancer was 713 (51.2%) cases, and that of Stages III and IV was 623 (44.8%) cases. The number of the new cases with an unknown stage of the disease was found to be 56 (4.0%) cases. The number of patients with Stage IIIB disease was the highest (69 cases) among all the stages of cervical cancer for the study period 1998-2000. The second most common stage was Stage IB disease with 52 patients belonging to this category. One-half (50.0%) of all operated patients because of cervical cancer during the study period 1998-2000 were women of 44 years of age and younger. Therefore, major considerations are to be given for women of reproductive age where effective screening and early detection of cervical pathology could help to avoid a lot of invasive cases of the disease and thus decrease mortality due to it. Generally, the diagnostic work-up and examinations of cervical cancer patients were insufficient, especially in cases of advanced stage disease. Stages III and IV were diagnosed in 44.8% of all cases. Overall, cystoscopy was performed in 39.4% (42 cases) of the total number of cases in Stages IIB through IVA of cervical cancer. Overall, rectosigmoidoscopy was performed in 6.4% (7 cases) of the total number of cases in Stages IIB through IVA of the disease. Finally, the proportion of CT that was performed in cases of Stages IIB through IVB of cervical cancer was 8.4% only. Clinical staging correlates well with pathologic staging in Stage I, particularly Stage IA (88.91%). The data also indicates that parametrial involvement would seem to be the most difficult problem, as 28.59% of Stage IIB and 32.3% of Stage IIIB were down-staged on the basis of pathological findings. This would suggest that in some cases the basic clinical staging rules are not being followed, or clearly understood. Kappa statistics (p = 0.05), diagnostic agreement 86.9% +/- 8%.

Adenocarcinoma↗
PubMed2002

[Inflammatory pseudotumor of the urinary bladder: a case report].

A 52-year-old man presented with gross hematuria. He had neither history of urinary tract infection nor trauma. Cystoscopy revealed a bladder tumor with ulcer on a left lateral wall. Computed tomography confirmed a round solid mass 3 cm in diameter invading deeply into the muscle layer of the urinary bladder. Transurethral biopsy revealed an inflammatory pseudotumor of the urinary bladder. Partial cystectomy was performed. This is the 38th reported case of inflammatory pseudotumor of the urinary bladder in Japan. No local recurrence was seen 3 months after surgery.

Cystectomy↗
PubMedDate not supplied

The evil twins of chronic pelvic pain syndrome: endometriosis and interstitial cystitis.

OBJECTIVE: To determine the value in the initial laparoscopic and cystoscopic evaluation of avoiding the unnecessary delay in diagnosing the "evil twins" of chronic pelvic pain syndrome, endometriosis and interstitial cystitis. METHODS: We performed a retrospective review of 60 women ranging in age from 19 to 62. They underwent concurrent laparoscopy, cystoscopy, and hydrodistentions from January 1999 to October 2000. A gynecology and urology team performed these procedures in these 60 patients at a regional pelvic pain center in Northwest Ohio. RESULTS: Fifty-eight patients (96.6%) were diagnosed with interstitial cystitis by the presence of glomerulation and terminal hematuria according to National Institutes of Health criteria. A diagnosis of (active and inactive) endometriosis was found in 56 patients (93.3%). Biopsy-confirmed active endometriosis was found in 48 patients (80%). In the interstitial cystitis patient group (58), 54 patients had a diagnosis of (active and inactive) endometriosis (93.1%), and 47 patients had biopsy-confirmed active endometriosis (81%). In the group of 56 patients with a diagnosis of (active and inactive) endometriosis, 54 patients were found to have interstitial cystitis (96.4%). In the group of 48 patients with active biopsy-confirmed endometriosis, 47 have interstitial cystitis (97.7%). CONCLUSION: Patients with chronic pelvic pain syndrome are very difficult to manage. Eighty percent were found to have endometriosis and had numerous previous operations. Many patients failed to respond to multiple therapies. In many cases, pain persists even after a hysterectomy. Through our study, we showed the high prevalence and association of interstitial cystitis and endometriosis, the evil twins of chronic pelvic pain syndrome. It is absolutely necessary to perform both laparoscopic and cystoscopic examinations concurrently with the patient anesthetized in the initial evaluation and treatment of chronic pelvic pain syndrome to avoid unnecessary delay in making the diagnosis of the evil twins, because chronic pelvic pain syndrome can be caused by either or both of these entities. It is very important to have the gynecologists and urologists working as a team in making an early diagnosis to resolve these chronic debilitating diseases.

Adult↗
PubMed2003

[Your patient with carcinoma of the urinary bladder. Options for organ preservation].

Every year, some 18,000 persons develop cancer of the bladder, making it one of the most common of the malignant diseases. Major underlying causal factors are exposure to aromatic amines, nicotine abuse, chronic infections and various medications. On the basis of the TMN system, a differentiation is made between superficial, invasive and metastasizing (lymphogeneous, hematogenous) carcinomas. A classical symptom is painless hematuria. The diagnosis is established primarily by white-light cystoscopy. Superficial urothelial lesions, which are often overlooked with this method, may be detected with the aid of the more sensitive method of fluorescence endoscopy. Depending upon local tumor spread and degree of differentiation, treatment includes transurethral electrocoagulation, laser coagulation, instillation of cytostatics and immunotherapeutic agents, as well as--in the case of muscle invasion--radical cystectomy.

Adenocarcinoma↗
PubMed2003

Preoperative work-up of early cervical cancer (stages Ib-IIa).

OBJECTIVE: To determine the effectiveness of preoperative investigations in early cervical cancer. MATERIALS: We retrospectively reviewed the medical records of 309 patients with previously untreated early cervical carcinoma who completed pretreatment evaluation at "St. Savas" Cancer Hospital of Athens and "Metaxas" Memorial Hospital of Peireas between January 1986 and September 1, 2000. Ages ranged from 18-77 years old with a mean age of 48 and S.D. of 12.25. FIGO staging was Ib (200 pts.), IIa (105 pts.), IV (4 pts.). Histologic type was squamous (267 pts.), adenoid (35 pts.), adenosquamous (7 pts.). The patients were clinically examined and routinely evaluated with blood work-up, chest X-ray, IVP, abdominal CT scan, barium enema, sigmoidoscopy, cystoscopy, and/or urine cytology. Patients with early stage cervical carcinoma were treated with Wertheim-Meigs radical hysterectomy and pelvic lymphadenectomy, while those with advanced stage cervical carcinoma were treated with radiotherapy and chemotherapy. RESULTS: In urinary tract investigation, CT showed a sensitivity of 100% and a specificity of 99.67%. In gastrointestinal tract investigation CT showed a sensitivity of 50% and a specificity of 99.67%. When we compared the histologic findings of the pelvic lymph nodes that were extracted in surgically treated patients with the preoperative CT findings, we found that CT had a sensitivity of 63.33% and a specificity of 88.57%. CONCLUSION: In our series of patients with early stage cervical carcinoma, imaging and endoscopic tests added limited information over pelvic examination and altered in four cases (1.29%) the choice of the appropriate treatment modality. CT scans proved adequate in this series of patients in the evaluation of the bladder and colon. All other tests could have been performed only when CT was suspicious of invasion. Moreover, CT served as a baseline examination for future comparative studies in the follow-up of patients.

Adolescent↗
PubMed2002

Rigid retrograde endoscopy under regional aneasthesia: a novel technique for the early realignment of traumatic posterior urethral disruption.

Traumatic disruption of the posterior urethra usually occurs in association with pelvic fractures and may result in significant morbidity. The management of this injury remains difficult and controversial. Recently, early restoration of urethral continuity in these patients using either both antegrade and retrograde cystoscopy (with or without fluoroscopy), or flexible retrograde urethroscopy alone under general aneasthesia, has been reported with good results. These procedures have been proposed as an improvement over the traditional teaching of placement of a suprapubic catheter followed by delayed open repair (urethroplasty). We now describe a novel method of restoration of urethral continuity by rigid retrograde endoscopy alone under caudal aneasthesia in the early post-trauma phase. This procedure can be carried out in an outpatient endoscopic suite with standard (endoscopic)optical urethrotomy equipment and is suitable for most patients with prostatomembranous urethral disruptions. A 'high-riding' prostate is however a relative contraindication for this procedure. To date, we have carried out this procedure successfully in 4 of 5 patients with traumatic prostato-membranous disruption (a success rate of 80%). We recommend that early retrograde rigid endoscopic realignment under regional analgesia should be considered as a management option in patients with traumatic disruption of the posterior urethra.

Accidents, Traffic↗
PubMed1992

[Pseudo-tumoral form of urinary bilharziasis in a child].

A tumor-like form of urinary schistosomiasis is reported. Diagnosis was established intraoperatively. The finding of hematuria and of a stay in an area where schistosomiasis is endemic suggested the diagnosis but specific investigations were negative. Cystoscopy revealed a budding, hemorrhagic tumor lying against the posterior aspect of the bladder with no other lesions suggestive of schistosomiasis. The true prevalence of these tumor-like forms of urinary schistosomiasis is analyzed. Emphasis is put on the need for using several investigations to reach the correct diagnosis.

Child↗
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↗