Active Surveillance in Non-Muscle Invasive Bladder Cancer, the Potential Role of Biomarkers: A Systematic Review.

Bladder cancer (BC) is the tenth most common cause of cancer worldwide and is the thirteenth leading cause of cancer mortality. The non-muscle invasive (NMI) variant represents 75% of cases and has a mortality rate of less than 1%; however, it has a high recurrence rate. The gold standard of management is transurethral resection in the case of new lesions. However, this is associated with significant morbidity and costs, so the reduction of these procedures would contribute to reducing complications, morbidity, and the burden to the health system associated with therapy. In this clinical scenario, strategies such as active surveillance have emerged that propose to manage low-risk BC with follow-up; however, due to the low evidence available, this is a strategy that is underutilized by clinicians. On the other hand, in the era of biomarkers, it is increasingly known how to use them as a tool in BC. Therefore, the aim of this review is to provide to clinical practitioners the evidence available to date on AS and the potential role of biomarkers in this therapeutic strategy in patients with low-grade/risk NMIBC. This is the first review linking use of biomarkers and active surveillance, including 29 articles.

Persistencia de uraco en paciente joven. Reporte de caso / Persistence of urachus in a young patient. Case report

Introducción. Durante el desarrollo embrionario normal, se espera que el denominado uraco o ligamento umbilical mediano se oblitere a las 32 semanas de gestación. Ante una obliteración incompleta surgen las diferentes anomalías, siendo las más frecuentes el quiste y la fístula urinaria umbilical. El objetivo de este artículo fue presentar el caso de una paciente joven, sin comorbilidades, con quiste de uraco. Caso clínico. Mujer indígena de 19 años que consultó por dolor leve en hipogastrio, asociado a síntomas urinarios y distensión abdominal. Se sospechó en primera instancia cólico renal, pero ante hallazgos ecográficos de masa infraumbilical y reactantes de fase aguda elevados, la impresión diagnóstica cambió a sepsis secundaria a absceso intraabdominal. Posterior a tomografía y cistoscopía con calibración uretral se identificó pequeño divertículo en cúpula vesical, que sugirió el diagnóstico de uraco persistente, por lo que la paciente fue llevada a intervención quirúrgica para su resección, con evolución favorable. Discusión. El quiste de uraco es una anormalidad infrecuente, en su mayoría asintomática y generalmente de hallazgo incidental en la población anciana, por lo que se requiere de imágenes y manejo multidisciplinar para su correcto diagnóstico y abordaje. Conclusión. Son pocos los casos de uraco persistente reportados, y mucho menos en el sexo femenino. Dada la posibilidad de complicaciones tardías es importante el seguimiento para su manejo. Este caso se ha controlado de manera ambulatoria por 2 años

Introduction. During normal embryonic development, it is expected that the so-called urachus or median umbilical ligament will be obliterated at 32 weeks of gestation. In the face of incomplete obliteration, the different anomalies of the urachus arise. The most frequent anomaly of the urachus is the cyst followed by the umbilical urinary fistula. The objective of this article was to present the case of a young patient without comorbidities with urachal cyst. Clinical case. A 19-year-old indigenous woman consulted for mild hypogastric pain associated with urinary symptoms and abdominal distension. Renal colic was suspected at first, but due to ultrasound findings of an infraumbilical mass and high acute phase reactants, the diagnostic impression changed to sepsis secondary to an intra-abdominal abscess. After tomography and cystoscopy with urethral calibration, a small diverticulum was identified in the bladder dome, suggesting a diagnosis of persistent urachus, for which the patient was taken to surgery for its resection, with favorable evolution. Discussion. The urachal cyst is a rare abnormality, mostly asymptomatic and usually incidental finding in the elderly population. Imaging and multidisciplinary management are required for its correct diagnosis and approach. Conclusion. There are few reported cases of persistent urachus and much less in females. Given the possibility of late complications, follow-up is important for its management, in this case we have carried out control for 2 years

Dynamic cystoscopy to optimize preoperative assessment of bladder endometriosis

ABSTRACT Purpose Bladder endometriosis (BE) accounts for 84% of cases of urinary tract involvement. The use of cystoscopy for preoperative evaluation is limited. The aim of this study was to evaluate the accuracy of preoperative dynamic cystoscopy (DC) in patients undergoing surgery for deep endometriosis and to describe the main findings and their impact on surgical planning. Materials and Methods This cross-sectional observational study was conducted from January 2011 to March 2022. DC findings were divided into two groups according to the depth of involvement. To estimate sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), laparoscopic findings of bladder involvement and histopathological report were used as the gold standard. Results We included 157 patients in this study. 41 had abnormalities in DC. Of these, 39 had abnormalities that were confirmed intraoperatively. The sensitivity and specificity of the test were 58.21% and 97.78%, respectively. PPV was 95.12%, and NPV was 75.86%. The presence of any lesions in the DC had a diagnostic odds ratio (OR) of 61.28 for BE. Patients with BE type 2 had a higher rate of partial cystectomy than those with BE type 1 lesions (OR 9.72 CI 95% 1.9-49.1) Conclusion DC appears to be a highly specific test with lower sensitivity. DC abnormalities are associated with a higher ratio of bladder surgery for the treatment of deep endometriosis, and BE type 2 seems to be associated with a greater ratio (9.72) of partial cystectomy.

Dynamic cystoscopy to optimize preoperative assessment of bladder endometriosis.

PURPOSE: Bladder endometriosis (BE) accounts for 84% of cases of urinary tract involvement. The use of cystoscopy for preoperative evaluation is limited. The aim of this study was to evaluate the accuracy of preoperative dynamic cystoscopy (DC) in patients undergoing surgery for deep endometriosis and to describe the main findings and their impact on surgical planning. MATERIALS AND METHODS: This cross-sectional observational study was conducted from January 2011 to March 2022. DC findings were divided into two groups according to the depth of involvement. To estimate sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), laparoscopic findings of bladder involvement and histopathological report were used as the gold standard. RESULTS: We included 157 patients in this study. 41 had abnormalities in DC. Of these, 39 had abnormalities that were confirmed intraoperatively. The sensitivity and specificity of the test were 58.21% and 97.78%, respectively. PPV was 95.12%, and NPV was 75.86%. The presence of any lesions in the DC had a diagnostic odds ratio (OR) of 61.28 for BE. Patients with BE type 2 had a higher rate of partial cystectomy than those with BE type 1 lesions (OR 9.72 CI 95% 1.9-49.1) Conclusion: DC appears to be a highly specific test with lower sensitivity. DC abnormalities are associated with a higher ratio of bladder surgery for the treatment of deep endometriosis, and BE type 2 seems to be associated with a greater ratio (9.72) of partial cystectomy.

Open surgery for urethral foreign body.

The introduction of foreign bodies in the urethra are uncommon. Given its rarity, the approach to this condition is not standardized but it is highlighted that minimally invasive procedures should be prioritized depending on its feasibility. In the present study, we report a case of a 60-year-old male patient with bipolar disorder and a foreign body impacted in the bulbar urethra with open surgical resolution after a failed endoscopic treatment. We perform an analysis into the diagnostic and therapeutic methods used, with postoperative results.

La introducción de cuerpos extraños uretrales es poco frecuente, razón por la cual, la mayoría de las publicaciones disponibles en la literatura son reportes de casos aislados o pequeñas series con gran heterogeneidad. Existen distintas aproximaciones frente a esta afección, desde métodos menos invasivos hasta cirugías abiertas más complejas. Presentamos un caso de cuerpo extraño impactado en uretra bulbar con el objetivo de analizar métodos diagnósticos empleados y aproximaciones terapéuticas concluyendo en la resolución quirúrgica convencional. Se evaluaron resultados postoperatorios.

Open surgery for urethral foreign body / Tratamiento quirúrgico convencional de cuerpo extraño uretral

Abstract The introduction of foreign bodies in the urethra are uncommon. Given its rarity, the approach to this condition is not standardized but it is highlighted that minimally invasive procedures should be prioritized depending on its feasibility. In the present study, we report a case of a 60-year-old male patient with bipolar disorder and a foreign body impacted in the bulbar urethra with open surgical resolution after a failed endoscopic treatment. We perform an analysis into the diagnostic and therapeutic methods used, with postopera tive results.

Resumen La introducción de cuerpos extraños uretrales es poco frecuente, razón por la cual, la mayoría de las publicaciones disponibles en la literatura son reportes de casos aislados o pequeñas series con gran heteroge neidad. Existen distintas aproximaciones frente a esta afección, desde métodos menos invasivos hasta cirugías abiertas más complejas. Presentamos un caso de cuerpo extraño impactado en uretra bulbar con el objetivo de analizar métodos diagnósticos empleados y aproximaciones terapéuticas concluyendo en la resolución quirúrgica convencional. Se evaluaron resultados postoperatorios.

Excretory urographic, ultrasonographic, and cystoscopic characteristics of urinary bladder abscesses in a dog.

A 7-year-old male neutered, 6.5 kg, Maltese breed dog was referred with a history of dysuria after undergoing two cystotomies to remove calcium oxalate uroliths. Survey radiographs were inconclusive. Excretory urography allowed visualization of two filling defects in the cranioventral urinary bladder region. Ultrasonography showed urinary bladder sediments, a diffusely thickened wall, and two circumscribed intramural/intraluminal structures with an anechoic interior and a smooth and regular surface. The cystoscopic diagnosis was urinary bladder abscesses and urine cultures were positive for Escherichia coli. Antimicrobial/anti-inflammatory therapy was started with good clinical outcomes and negative culture after 21 days.

Discomfort and relieving factors among patients with bladder cancer undergoing office-based cystoscopy.

OBJECTIVE: To evaluate the degree of discomfort among patients with bladder cancer undergoing office-based cystoscopy and identify factors and interventions that influence discomfort and anxiety. METHODS: We conducted a survey of the Bladder Cancer Advocacy Network Patient Survey Network (BCAN PSN) to investigate the degree of discomfort associated with office-based cystoscopy and prevalence of interventions used to reduce discomfort. All patients had undergone at least one previous cystoscopy. Bivariable and multivariable logistic regression were used to identify factors associated with moderate-to-severe cystoscopy discomfort. RESULTS: Among 488 BCAN PSN respondents (50% response rate), 392 responded with demographic data and discomfort score. Cystoscopy was associated with moderate-to-severe discomfort in 52% of patients. Respondents who reported moderate-to-severe discomfort were more likely to describe their most recent cystoscopy discomfort as worse than prior (P<0.001) and to be interested in planning discomfort mitigation for cystoscopy (P<0.001). On multivariable analysis, gender was the only factor independently associated with discomfort, with women reporting less discomfort than men (OR 0.59, 95%CI 0.37-0.95,P=0.03). Patients reported a wide variety of cystoscopy-specific interventions with differing perceived effectiveness, the most common being intraurethral lidocaine. CONCLUSIONS: Over half of patients undergoing office-based cystoscopy for bladder cancer report moderate-to-severe discomfort, constituting a substantial problem among patients undergoing the procedure. Future large pragmatic comparative effectiveness trials are needed to better understand which interventions work most effectively to reduce discomfort associated with cystoscopy.

Virtual Reality as a distraction therapy during cystoscopy: a clinical trial / A Realidade Virtual como terapia de distração durante cistoscopias: um ensaio clínico

ABSTRACT Objectives: to investigate whether virtual reality (VR) experience is associated with decreased pain sensation among patients who undergo rigid cystoscopy under local anesthesia. Methods: we performed a prospective, randomized, controlled study of 159 patients who were aleatorily enrolled into two groups: VR and control. VR experience intervention consisted of using a headset with a smartphone adapted to a virtual reality glasses where an app-video was played during the procedure. Main outcomes analyzed were pain, discomfort, heart rate variability, difficulty and duration of the cystoscopy. Statistical analyses were performed using a Student's t test, Mann-Whitney test and Chi-square test. A P<0.05 was considered to be statistically significant. Results: among 159 patients studied (VR group=80 patients; control group=79 patients), the mean age was 63,6 years and 107 (67,3%) were male. There was no statistically significant difference in baseline characteristics between the 2 groups. VR was significantly associated to decreased heart rate variability (6,29 vs 11,09 bpm, P<0,001) and lower duration of the procedure (5,33 vs 8,65 min, P<0,001). Also, when cystoscopies due to double-J extraction were excluded, VR experience was associated with reduced pain on the visual analog score of pain (3,26 vs 4,33 cm, P=0,023). Conclusions: the use of VR as a distraction therapy while performing outpatient cystoscopies is safe, has no side effects, is associated with less pain and discomfort, and reduces length of procedure.

RESUMO Objetivos: investigar se a experiência de realidade virtual (RV) está associada à diminuição da dor em pacientes submetidos à cistoscopia rígida sob anestesia local. Métodos: foi realizado um estudo prospectivo, randomizado e controlado de 159 pacientes que foram alocados aleatoriamente em dois grupos: RV e controle. A intervenção da experiência de RV consistiu no uso de óculos de realidade virtual com smartphone adaptado e fones de ouvido, onde um vídeo foi reproduzido durante o procedimento. Os principais desfechos analisados foram dor, desconforto, variabilidade da frequência cardíaca, dificuldade e duração da cistoscopia. As análises estatísticas foram realizadas com o teste t de Student, o teste de Mann-Whitney e o teste do qui-quadrado. Um P<0,05 foi considerado como estatisticamente significativo. Resultados: entre os 159 pacientes estudados (grupo RV=80; grupo controle=79), a média de idade foi 63,6 anos e 107 (67,3%) eram do sexo masculino. Não houve diferença estatisticamente significativa nas características basais entre os grupos. A RV foi significativamente associada à menor variabilidade da frequência cardíaca (6,29 vs 11,09 bpm, P<0,001) e menor duração do procedimento (5,33 vs 8,65 min, P<0,001). Além disso, quando cistoscopias devido à extração de duplo J foram excluídas, a RV foi associada à redução da dor na escala visual analógica (3,26 vs 4,33cm, P=0,023). Conclusões: o uso da RV como terapia de distração durante a realização de cistoscopias ambulatoriais é seguro, não tem efeitos colaterais, está associado a menos dor e desconforto e reduz a duração do procedimento.

Long term outcomes of one-stage augmentation anterior urethroplasty: a systematic review and meta-analysis

ABSTRACT Objective: The objective is to summarize and characterize the long-term success of anterior augmentation urethroplasty in published series. The current literature on AU consists largely of retrospective series reporting intermediate follow-up and incompletely characterize the long term outcomes of AU. Materials and Methods: A systematic literature review was performed consistent with PRISMA guidelines to characterize long-term outcomes of AU with a minimum upper limit follow-up of 100 months. Penile/preputial skin flaps and graft and oral mucosal graft urethroplasties were included. The primary outcome was stricture-free survival for one-stage AU. Secondary analysis evaluated differences in outcomes based on two failure definitions: the need for intervention versus presence of recurrent stricture on cystoscopy or urethrography. Hazard rates were induced from the reported failure rates of one-stage AU and fixed and random effect models were fitted to the data. Additional subset analysis, removing potential confounders (lichen sclerosus, hypospadias and penile skin graft), was performed. Results: Ten studies met inclusion criteria, and two studies reported separate outcomes for grafts and flaps, and thus were included separately in the analysis. The mean hazard rate across all studies was 0.0044, the corresponding survival rates at 1 year 0.948, 5 years 0.766, 10 years 0.587, and 15 years 0.45. Subset analysis of the 4 select and homogeneous studies noted 1, 5, 10, and 15 years survival rates of 0.97, 0.96, 0.74, and 0.63, respectively. Conclusions: The long-term success rates of augmentation urethroplasty are appear to be worse than previously appreciated and patients should be counseled accordingly.

Long term outcomes of one-stage augmentation anterior urethroplasty: a systematic review and meta-analysis.

OBJECTIVE: The objective is to summarize and characterize the long-term success of anterior augmentation urethroplasty (AU) in published series. The current literature on AU consists largely of retrospective series reporting intermediate follow-up and incompletely characterize the long term outcomes of AU. MATERIALS AND METHODS: A systematic literature review was performed consistent with PRISMA guidelines to characterize long-term outcomes of AU with a minimum upper limit follow-up of 100 months. Penile/preputial skin flaps and graft and oral mucosal graft urethroplasties were included. The primary outcome was stricture-free survival for one-stage AU. Secondary analysis evaluated differences in outcomes based on two failure definitions: the need for intervention versus presence of recurrent stricture on cystoscopy or urethrography. Hazard rates were induced from the reported failure rates of one-stage AU and fixed and random effect models were fitted to the data. Additional subset analysis, removing potential confounders (lichen sclerosus, hypospadias and penile skin graft), was performed. RESULTS: Ten studies met inclusion criteria, and two studies reported separate outcomes for grafts and flaps, and thus were included separately in the analysis. The mean hazard rate across all studies was 0.0044, the corresponding survival rates at 1 year 0.948, 5 years 0.766, 10 years 0.587, and 15 years 0.45. Subset analysis of the 4 select and homogeneous studies noted 1, 5, 10, and 15 years survival rates of 0.97, 0.96, 0.74, and 0.63, respectively. CONCLUSIONS: The long-term success rates of augmentation urethroplasty are appear to be worse than previously appreciated and patients should be counseled accordingly. Available at. https://www.intbrazjurol.com.br/pdf/aop/2019-0242RW.pdf.

Fistulectomía vaginal exitosa en un caso de fístula vesicovaginal obstétrica por embolización de arterias uterinas / Successful vaginal fistulectomy in a case of obstetric vesicovaginal fistula due to uterine artery embolization

Resumen ANTECEDENTES: Las fístulas genitourinarias obstétricas se forman como consecuencia de una complicación de la embolización de las arterias uterinas debida a necrosis del útero o de la vejiga. El tratamiento quirúrgico vaginal es una opción menos invasiva, con tasas de éxito que alcanzan 84.12%. CASO CLÍNICO: Paciente de 40 años, con 35.7 semanas de embarazo y acretismo placentario, tratado con embolización de las arterias uterinas e histerectomía obstétrica posterior a la cesárea. A las 3 semanas tuvo pérdida vaginal de orina. En la exploración física, y con apoyo de la prueba de colorantes, cistoscopia y cistografía retrógrada se diagnosticó fístula vesicovaginal obstétrica. Posterior a la disminución del proceso inflamatorio se efectuó la fistulectomía vaginal, con modificación de la técnica de Latzko. La evolución posoperatoria fue satisfactoria, sin recurrencia de la fístula durante el seguimiento en la consulta externa. CONCLUSIÓN: Éste, es el quinto caso de fístula por necrosis vesical postembolización reportado en la bibliografía. La favorable atención del caso permitió concluir que la fistulectomía vaginal es una alternativa viable y segura de tratamiento quirúrgico de este tipo de fístulas obstétricas.

Abstract BACKGROUND: Obstetric genitourinary fistulas can cause as a complication of uterine artery embolization due to necrosis of the uterus and/or bladder. Vaginal surgical treatment is a less invasive option with success rates of up to 84.12%. CLINICAL CASE: A 40-year-old woman who came with a pregnancy of 35 5/7 weeks and placenta accreta, which was managed with uterine arteries embolization and obstetric hysterectomy after caesarean section. At 3 weeks she had vaginal urine loss; by physical examination and with support of dye test, cystoscopy and retrograde cystography, obstetric vesicovaginal fistula was diagnosed. After the improvement of the inflammatory process, vaginal fistulectomy was performed with modification of the Latzko technique. Its postoperative evolution was satisfactory and without recurrence of the fistula during the follow-up in the outpatient clinic. CONCLUSION: This is the fifth case of post-embolization bladder necrosis reported in the literature. The favorable resolution of this case allows us to conclude that vaginal fistulectomy is a viable and safe alternative in the surgical treatment of this type of obstetric fistulas.

Dehiscencia de cistorrafia en pacientes con embolización de arterias uterinas por acretismo placentario: reporte de dos casos / Cistorraphy dehiscence in patients with uterine arteries embolization due to placentary acretism: report of two cases

Resumen: ANTECEDENTES: La incidencia de percretismo varía de 5-7% y de ésta, 78% corresponde a complicaciones relacionadas con la cirugía. Hasta la fecha existen pocos casos reportados de dehiscencia de cistorrafia posterior a la embolización de arterias uterinas. CASOS CLÍNICOS: Caso 1. Paciente de 34 años, con embarazo de 36 semanas y diagnóstico de acretismo placentario. El tratamiento consistió en embolización de arterias uterinas e histerectomía subtotal, con lesión vesical reparada sin complicaciones. Dos semanas después del alta hospitalaria acudió a consulta por pérdida de orina y fiebre (pielonefritis aguda); se estableció el diagnóstico de dehiscencia de cistorrafia por tomografía y cistografía retrógrada. Se realizó cateterización ureteral bilateral, laparotomía exploradora con traquelectomía, resección de los bordes necróticos vesicales y cistorrafia. Caso 2. Paciente de 30 años, con embarazo de 37 semanas y acretismo placentario; se aplicó tratamiento similar al caso 1, del que devino una lesión vesical reparada sin complicaciones. Durante la hospitalización permaneció en vigilancia por hemorragia obstétrica e infección urinaria con mala evolución; dos semanas después tuvo pérdida de orina, por lo que se efectuaron: cistoscopia, tomografía y cistografía retrógrada. Se estableció el diagnóstico de dehiscencia de cistorrafia. Durante la cirugía se localizó el defecto por cistoscopia e histeroscopia, se cateterizaron los uréteres de ambos lados; posteriormente, mediante acceso laparoscópico, se resecaron los bordes vesicales necróticos y se complementó con cistorrafia. Ambas pacientes evolucionaron sin complicaciones. CONCLUSIÓN: La dehiscencia de cistorrafia en pacientes con embolización de arterias uterinas es una complicación excepcional. La sospecha diagnóstica y el tratamiento oportunos, con resección de los bordes necróticos y cistorrafia, se asocian con mayor tasa de éxito.

Abstract: BACKGROUND: The incidence of percretism is 5-7% with 78% of complications associated with surgical management. There are few reported cases of cystorraphy dehiscence after uterine arteries embolization. CLINICAL CASES: Case 1. A 34 years old patient with a pregnancy of 36 5/7 weeks and acretism; she was treated with uterine artery embolization plus subtotal hysterectomy with bladder injury repaired without complications. She was discharged, and in 2 weeks she consulted for vaginal urine loss and fever (acute pyelonephritis); cystorraphy dehiscence was diagnosed with support of tomography and retrograde cystography. Bilateral ureteral catheterization, laparotomy with trachelectomy plus resection of bladder necrotic edges and cystorraphy were performed. Case 2. A 30 years old patient with a pregnancy of 37 5/7 weeks and acretism; equal treatment of acretism was given with bladder injury repaired without complications. She was hospitalized in surveillance for obstetric haemorrhage and urinary infection with torpid evolution; she referred vaginal urine loss at 2 weeks, so cystoscopy, tomography and retrograde cystography were performed which diagnosed cystorraphy dehiscence. In surgery the bladder defect was located by cystoscopy and hysteroscopy and bilateral ureters were catheterized; subsequently, by laparoscopic approach necrotic bladder edges were resected and cystorraphy was performed. Both patients without complications and with successful postoperative evolution. CONCLUSION: Cystorraphy dehiscence in embolized patients is extremely rare; however, it should be considered as a possible complication. Diagnostic suspicion and timely management with resection of necrosis and new cystorraphy, achieve greater success.

Prognostic impact of non-adherence to follow-up cystoscopy in non-muscle-invasive bladder cancer (NMIBC).

PURPOSE: To evaluate the underexplored context of cystoscopy adherent versus non-adherent patients in the follow-up of urothelial high-risk non-muscle-invasive bladder cancer (NMIBC). METHODS: We performed a retrospective study (2005-2016) that evaluated patients´ demographical characteristics, histopathological data, recurrence, progression and cancer-specific mortality between adherent and non-adherents patients in the first 3 years of a proposed cystoscopy protocol. RESULTS: Among the 198 included patients, comparing cystoscopy non-adherent (n = 36, 18%) and adherent patients (n = 162, 82%), there was no demographic or histopathological differences; the rates of disease recurrence, progression and cancer-specific mortality were 15 (41.7%) versus 68 (42.2%), p = 0.58; 12 (33.3%) versus 28 (17.9%), p = 0.014 and 4 (11.1%) versus 19 (11.7%), p = 0.98, respectively. Cystoscopy non-adherence was associated with an inferior number of urinary cytology (p < 0.001) and 2.33 HR for cancer progression, p = 0.014, (95% CI 1.18-4.59). CONCLUSIONS: Non-adherence to follow-up cystoscopy in NMIBC is associated with more than twice progression risk. Future studies are needed to confirm our results and correlate cystoscopy non-adherence to other covariates.

Epidemiology, prevention, screening, diagnosis, and evaluation: update of the ICUD-SIU joint consultation on bladder cancer.

PURPOSE: To update current recommendations on prevention, screening, diagnosis, and evaluation of bladder cancer (BC) based on a thorough assessment of the most recent literature on these topics. METHODS: A non-systematic review was performed, including articles until June 2017. A variety of original articles, reviews, and editorials were selected according to their epidemiologic, demographic, and clinical relevance. Assessment of the level of evidence and grade of recommendations was performed according to the International Consultation on Urological Diseases grading system. RESULTS: BC is the ninth most common cancer worldwide with 430,000 new cases in 2012. Currently, approximately 165,000 people die from the disease annually. Absolute incidence and prevalence of BC are expected to rise significantly during the next decades because of population ageing. Tobacco smoking is still the main risk factor, accounting for about 50% of cases. Smoking cessation is, therefore, the most relevant recommendation in terms of prevention, as the risk of developing BC drops almost 40% within 5 years of cessation. BC screening is not recommended for the general population. BC diagnosis remains mainly based on cystoscopy, but development of new endoscopic and imaging technologies may rapidly change the diagnosis algorithm. The same applies for local, regional, and distant staging modalities. CONCLUSIONS: A thorough understanding of epidemiology, risk factors, early detection strategies, diagnosis, and evaluation is essential for correct, evidence-based management of BC patients. Recent developments in endoscopic techniques and imaging raise the hope for providing better risk-adopted approaches and thereby improving clinical outcomes.

A closer look at the health of cats showing urinary house-soiling (periuria): a case-control study.

OBJECTIVES: The aim of this study was to perform a case-control medical evaluation of cats from multi-cat households presenting with inappropriate latrining and spraying behavior. METHODS: Owners of 18 'spraying' and 23 'latrining' cats with normal control subjects available from the same households were recruited for a case-control study. Otherwise overtly healthy dyads (each dyad consisting of a case cat and a control cat) were brought together to the veterinary hospital of the University of São Paulo for a medical work-up (ie, physical examination, complete blood count, biochemical profile, urinalysis and urine culture, abdominal ultrasound of the urinary system and in females, where possible, cystoscopy). RESULTS: Medical problems were identified with similar frequency in the 'sprayers' (38.9%), 'latriners' (39.1%) and controls of the latrining group (26.1%), but not the controls of the spraying group (5.5%). The difference between 'cases' and 'controls' from spraying households was significant. Common potential health-related changes include renal insufficiency, cystitis and bladder lithiasis. Renal calculi, higher creatinine levels (within normal reference interval) and 'glomerulations' (detected during cystoscopy) were also found in the remaining sprayers and latriners that were considered clinically healthy. Post-cystoscopy, a new form of periuria occurred in two cats (one sprayer and one latriner). CONCLUSIONS AND RELEVANCE: These results indicate that spraying or latrining behavior in the home, as well as living with a cat that is not using the litter box as a latrine, are all associated with a higher level of urinary tract abnormalities; living with a cat that is spraying, however, does not have this association. The findings also suggest that both forms of periuria might be associated with interstitial cystitis. We therefore conclude that all cats with periuria need to be carefully evaluated medically and that treatment of latrine-related problems should consider all cats in the house, whereas spraying may be more focused on the individual displaying the problem.

Music to reduce pain and anxiety in cystoscopy: a systematic review and meta-analysis.

Background To assess the effectiveness and harms of music to reduce anxiety and pain in cystoscopy. Methods We searched MEDLINE (OVID), EMBASE, LILACS and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to nowadays. We included clinical trials, involving the assessment of the effect of music in cystoscopy. The primary outcomes were pain and anxiety measured by any scale and the secondary outcomes were length of stay, physiological parameters (blood pressure or heart rate) and adverse effects. Cochrane Collaboration tool was used to assess the risk of bias. We performed the statistical analysis in R and reported information about mean difference (MD) with 95% CI. Heterogeneity was evaluated using the I2 test. Results We included six studies in our qualitative and quantitative analysis. Five studies used a flexible cystoscope and the other one performed the procedure with a rigid cystoscope. Music was played during the procedure in five studies, while the other was before it. All studies compared music vs. no intervention. Almost all items were assessed as low risk of bias; however, the allocation concealment was unclear in all the studies. We found a MD of -1.33 (95% CI -2.45 to -0.21) (I2=97.2%) favoring music for pain and a MD of -8.42 (95% CI -15.02, -1.82) (I2=99.6%) was found, favoring music for anxiety. Conclusions Playing music might be an effective intervention that lowers pain and anxiety in patients who undergo cystoscopy.

Multiple bladder diverticula treated with robotic approach-assisted with cystoscopy.

A bladder diverticulum (BD) is a herniation of the bladder urothelium through the muscular bladder wall. As a result, BD presents as a thin walled bag, urine filled connected to bladder lumen through a neck or ostium. The clinical problem with bladder diverticula is their poorly empty during micturition which results in multiple lower urinary tract symptoms as well as recurrent urinary tract infections. Bladder diverticula can be grossly classified in two groups as follows: congenital or acquired with different age presentation and etiological factors in each one. Vast majority of BD occur in adults especially in men. Acquired BD, are commonly diagnosed in the setting of neurogenic dysfunction or bladder outlet obstruction, they use to be multiple, associated with trabeculated bladder and prostatic enlargement.

Urological approach for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in a clinical care center.

BACKGROUND: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is associated with significant manipulation of the urinary tract (UT). We aim to describe the urological events and their management in patients who underwent CRS-HIPEC. METHODS: Clinical records of patients who underwent treatment between 2007 and 2015 were reviewed. Urological events and their multidisciplinary management were analyzed. Descriptive statistics were calculated. RESULTS: A total of 103 patients were included. Mean age was 51 years (SD ± 11.8). Mean peritoneal cancer index (PCI) was 20.4 (SD ± 10.1). Primary tumors included appendicular (64%), gynecological (16%), colorectal (10%), and peritoneal mesotheliomas (9%). Ninety-three percent of patients had bilateral ureteral catheters inserted prior to surgery, without complications. Intraoperative UT injuries occurred in 7% of patients. In 5% of patients, tumor invasion of the bladder was evident at surgery and partial resection and primary repair of the bladder wall was performed. Urological complications included urinary tract infection (UTI) (21%) acute post-renal failure (4%), urinary fistulae (4%), and acute urinary retention (AUR) (1%). CONCLUSIONS: In our study, intraoperative UT events and postoperative complications, although not neglectable, were infrequent. Due to the high complexity of these cases, a multidisciplinary approach is mandatory. However, randomized clinical trials are necessary to clarify current data on the need and efficacy of prophylactic ureteral catheterization in patients undergoing CRS-HIPEC.

Cystoscopy-assisted laparoscopy for bladder endometriosis: modified light-to-light technique for bladder preservation

ABSTRACT Introduction Endometriosis is a disease with causes still unclear, affecting approximately 15% of women of reproductive age, and in 1%-2% of whom it may involve the urinary tract. The bladder is the organ most frequently affected by endometriosis, observed around 85% of the cases. In such cases, the most effective treatment is partial cystectomy, especially via videolaparoscopy. Study Objective, Design, Size and Duration In order to identify and delimit the extent of the intravesical endometriosis lesion, to determine the resection limits, as well as to perform an optimal reconstruction of the organ aiming for its maximum preservation, we performed a cystoscopy simultaneously with the surgery, employing a modified light-to-light technique in 25 consecutive patients, from September 2006 to May 2012. Setting Study performed at Campinas Medical Center – Campinas – Sao Paulo – Brazil.Participants/materials, setting and methods: Patients aged 27 to 47 (average age: 33.4 years) with deep endometriosis with total bladder involvement were selected for the study. The technique used was conventional laparoscopy with a transvaginal uterine manipulator and simultaneous cystoscopy (the light-to-light technique). A partial videolaparoscopic cystectomy was performed with cystoscopy-assisted vesical reconstruction throughout the entire surgical time. The lesions had an average size of 2.75cm (ranging from 1.5 to 5.5cm). The average surgical time was 137.7 minutes, ranging from 110 to 180 minutes. Main Results Postoperative follow-up time was 32.4 months (12-78 months), with clinical evaluation and a control cystoscopy performed every six months. No relapse was observed during the follow-up period. Conclusions A cystoscopy-assisted partial laparoscopic cystectomy with a modified light-to-light technique is a method that provides adequate identification of the lesion limits, intra or extravesically. It also allows a safe reconstruction of the organ aiming for its maximum preservation.