Cancer detection and complications of transperineal prostate biopsy with antibiotics when indicated.

OBJECTIVES: To describe the prostate cancer (PCa) detection rate, including clinically significant prostate cancer (csPCa), in a large cohort of patients who underwent transperineal ultrasonography-guided systematic prostate biopsy (TPB-US) using a probe-mounted transperineal access system, with magnetic resonance imaging (MRI) cognitive fusion in case of a Prostate Imaging-Reporting and Data System grade 3-5 lesion, under local anaesthesia in an outpatient setting. Additionally, to compare the incidence of procedure-related complications with a cohort of patients undergoing transrectal ultrasonography-guided (TRB-US) and transrectal MRI-guided biopsies (TRB-MRI). PATIENTS AND METHODS: This was an observational cohort study in men who underwent TPB-US prostate biopsy in a large teaching hospital. For each participant, prostate-specific antigen level, clinical tumour stage, prostate volume, MRI parameters, number of (targeted) prostate biopsies, biopsy International Society of Uropathology (ISUP) grade and procedure-related complications were assessed. csPCa was defined as ISUP grade ≥2. Antibiotic prophylaxis was only given in those with an increased risk of urinary tract infection. RESULTS: A total of 1288 TPB-US procedures were evaluated. The overall detection rate for PCa in biopsy-naive patients was 73%, and for csPCa it was 63%. The incidence of hospitalization was 1% in TPB-US (13/1288), compared to 4% in TRB-US (8/214) and 3% in TRB-MRI (7/219; P = 0.002). CONCLUSIONS: Contemporary combined systematic and target TPB-US with MRI cognitive fusion is easy to perform in an outpatient setting, with a high detection rate of csPCa and a low incidence of procedure-related complications.

Large primary vaginal stone in a woman with multiple sclerosis.

Vaginal stones are rare and therefore a delay in accurate diagnosis often occurs. We present a 54-year old woman with multiple sclerosis who was diagnosed with a primary vaginal stone. Initially, she presented with recurring urinary tract infections (UTI) and macroscopic haematuria to the urologist. A cystoscopy showed no abnormalities. Because of persistent bleeding, she was referred to the gynaecologist, and on gynaecological examination, a vaginal stone was revealed. Stone formation was likely to be the result of urinary pooling due to incontinence, which was caused by a neurogenic bladder. Other contributing factors were prolonged recumbency, threads of an intrauterine device and a UTI. The presence of a vesicovaginal fistula was excluded by testing with methylene blue. The stone was surgically removed and composed of 70% struvite and 30% apatite. The patient was treated for decubitus ulcerations of the vaginal wall with estriol (Synapause-E3). Follow-up was uneventful.

The Feasibility and Utility of Cystoscopy-Guided Hydrogel Marker Placement in Patients With Muscle-Invasive Bladder Cancer.

PURPOSE: Fiducial markers at the borders of bladder tumors are useful to facilitate target delineation radiation therapy (RT) and offer the possibility of image guided RT for a focal boost. Our purpose was to evaluate the feasibility and technical performance of cystoscopy-guided placement of hydrogel markers in patients with bladder cancer referred for RT. METHODS AND MATERIALS: Ours was a prospective, multicenter, feasibility, and utility study. Thirty-two consecutive patients with muscle-invasive bladder cancer, referred for RT, underwent cystoscopy-guided implantation of hydrogel markers. Feasibility, clinical performance of the markers, and adverse events were registered. Computer tomography (CT) scans and cone beam CT (CBCT) scans acquired during RT were analyzed to evaluate the visibility and stability of the markers during the radiation period. RESULTS: A total of 107 hydrogel spots were implanted in 32 patients with bladder cancer. There were no procedure-related adverse events. On the simulation CT scan 76.6% of the implanted markers were sufficient for tumor delineation. At start of treatment 52.3% were visible on the CBCT and adequate for positional verification on a routine basis. The washout rate during treatment was 9.3%. At the end of treatment 46.7% of implanted spots were visible on CBCT scan and adequate for routine positional verification. At patient level, in 31.2% of cases, use of hydrogel fiducials showed adequate performance throughout the whole course. CONCLUSIONS: Cystoscopy-guided placement of hydrogel markers is both safe and feasible for muscle-invasive bladder tumors. Adequate performance for radiation purposes throughout the whole course (implantation, delineation, and positional verification) was 46.7% of all implanted markers, leaving room for improvement.

Value of urodynamics before stress urinary incontinence surgery: a randomized controlled trial.

OBJECTIVE: To estimate whether a strategy of immediate surgery was noninferior to a strategy based on discordant urodynamic findings followed by individually tailored therapy in women with stress urinary incontinence (SUI). METHODS: A multicenter diagnostic cohort study with an embedded noninferiority randomized controlled trial was conducted in six academic and 24 nonacademic Dutch hospitals. Women with predominant SUI eligible for surgical treatment based on clinical assessment were included between January 2009 and November 2010. All patients underwent urodynamics. In patients in whom urodynamics were discordant with clinical assessment, participants were randomly allocated to receive either immediate surgery or individually tailored therapy based on urodynamics. The primary outcome was clinical improvement assessed by the Urogenital Distress Inventory 12 months after baseline. Analysis was by intention to treat; a difference in mean improvement of 5 points or less was considered noninferior. RESULTS: Five hundred seventy-eight women with SUI were studied, of whom 268 (46%) had discordant findings. One hundred twenty-six patients gave informed consent for randomization and were allocated to receive immediate surgery (n=64) or individually tailored therapy (n=62). The mean improvement measured with the Urogenital Distress Inventory after 1 year was 44 points (±24) in the group receiving immediate surgery and 39 (±25) points in the group receiving individually tailored treatment. The difference in mean improvement was 5 points in favor of the group receiving immediate surgery (95% confidence interval -∞ to 5). There were no differences with respect to cure or complication rate. CONCLUSION: In women with uncomplicated SUI, an immediate midurethral sling operation is not inferior to individually tailored treatment based on urodynamic findings. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00814749. LEVEL OF EVIDENCE: I.

Hematuria: a problem-based imaging algorithm illustrating the recent Dutch guidelines on hematuria.

OBJECTIVE: To present a problem-based algorithm in the work-up of patients with Hematuria. Since the 2010 Dutch Guideline on Hematuria was problem-based, this served as an illustration for such an approach.. CONCLUSION: The work-up of hematuria should be individualized and risk-based. Given the a priori low likelihood of cancer in hematuria, risk categories should be established and imaging algorithms should be tailored to populations at low-risk, medium-risk and high-risk for developing urothelial cancer.