Monitoring the coupling of the lithotripter therapy head with skin during routine shock wave lithotripsy with a surveillance camera.

PURPOSE: With lithotripters today the shock waves are typically transmitted into the body via water filled bellows using coupling gel to make contact with the skin. Usually the coupling zone is not visible to the operator. We investigated coupling quality during routine clinical shock wave lithotripsy and the associated effect on shock wave disintegration efficiency. MATERIALS AND METHODS: During 30 routine shock wave lithotripsy treatments the coupling zone was continuously monitored by a video camera integrated into a DoLi SII lithotripter (Dornier MedTech, Wessling, Germany). However, it was not shown to the blinded operator to resemble the standard clinical situation. We used 3 coupling gels, including LithoClear®, Sonogel® and a custom-made gel of low viscosity. The ratio of air in the relevant coupling area was measured. Lithotripter disintegration efficiency was evaluated by in vitro model stone tests at an air ratio of 0%, 5%, 10% and 20%. RESULTS: Only in 10 of 30 treatments was good coupling achieved with an air ratio of less than 5%. In 8 treatments the ratio was greater than 20%. The best coupling conditions were achieved with low viscosity gel. The mean ± SD number of shock waves needed for complete fragmentation in the model stone tests was 100 ± 4 for bubble-free coupling, and 126 ± 3 for 5%, 151 ± 8 for 10% and 287 ± 5 for 20% air bubbles. CONCLUSIONS: At 20 of 30 shock wave lithotripsy sessions there was imperfect coupling, accompanied by significant loss of disintegration capability. A surveillance camera is useful to monitor and improve coupling.

Real-time MRI of continent and stress incontinent male patients after orthotopic ileal neobladder.

INTRODUCTION: The aim of this study was to correlate anatomic differences with continence status in male patients after cystoprostatectomy and ileal neobladder using real-time magnetic resonance imaging. PATIENTS AND METHODS: Anatomic differences of 14 male patients (7 daytime continent and 7 stress incontinent) with ileal neobladder were determined by measuring the orthogonal distance of the bladder neck to the pubococcygeal line (PCL) to correlate anatomic differences with continence status. RESULTS: The median distance of the bladder neck to PCL was +5.4 mm in continent patients before voiding whereas in incontinent patients it was +2 mm (p = 0.012). During the Valsalva maneuver, the median distance in continent patients was +4 and in incontinent patients -3 mm (p = 0.003). At the end of micturition, the median distance was +2.3 mm in continent patients and -12 mm in incontinent patients (p = 0.002). CONCLUSIONS: The bladder neck in incontinent patients showed more pronounced mobility in relation to the PCL during micturition and the Valsalva maneuver as compared to continent patients. In addition, the ileal neobladder was positioned significantly lower in the pelvis of incontinent patients. These preliminary results suggest that a stable bladder neck may be an important factor to reach full continence in patients with ileal neobladder.

Patient-reported side effects of intradetrusor botulinum toxin type a for idiopathic overactive bladder syndrome.

OBJECTIVE: The aim of the study was a prospective assessment of patient-reported side effects in an open-label study after intradetrusor botulinum toxin injections for idiopathic overactive bladder (OAB). PATIENTS AND METHODS: Botulinum toxin A injection was performed in 56 patients with idiopathic OAB. Patients were followed up for 6 months concerning side effects and patients' satisfaction. RESULTS: Different types of side effects were assessed such as dry mouth (19.6%), arm weakness (8.9%), eyelid weakness (8.9%), leg weakness (7.1%), torso weakness (5.4%), impaired vision (5.4%) and dysphagia (5.4%). In all cases, symptoms were mild and transient. Urological complications such as gross hematuria (17.9%), acute urinary retention (8.9%) and acute urinary tract infection (7.1%) were noticed. In all cases, acute urinary retention was transient and treated with temporary intermittent self-catheterization. There was no statistically significant correlation between dosage and observed side effects. Patients' satisfaction rate was high (71.4%). CONCLUSION: Intradetrusor injection of botulinum toxin was associated with a high rate of neurourological side effects. In general, side effects were transient, mild and did not require special treatment.

Influence of clinical information on the interpretation of urinary cytology in bladder cancer: how suggestible is a cytologist?

OBJECTIVE: to determine the influence of the knowledge of the endoscopic findings and the influence of the patient's history on the cytologist's judgement, as urinary cytology is known to be subjective and has several limitations, in particular a high inter- and intra-observer variability. PATIENTS AND METHODS: we analysed the cytological and histological findings of patients who underwent transurethral resection of a bladder tumour, and determined whether the cytologist was aware of the endoscopic findings or not. The sensitivity and specificity of cytology were calculated with or without this knowledge, and that of the patients' bladder cancer history. RESULTS: the findings of 1705 patients were reviewed; in 641 the histological examination confirmed a malignant tumour and 1046 were classified as benign. The sensitivity of cytology was 66.0% and the specificity was 78.4%. The cytologist was aware of the endoscopic finding and patient history in 742 cases, and unaware of the endoscopic findings in 963. The specificity was higher in the latter group (80.2% vs 73.0%; P= 0.006). The specificity in patients with the endoscopic findings described as 'negative', 'inflammation', 'scar tissue', 'flat lesion', 'suspicious for tumour', and 'exophytic tumour' was 89.8%, 89.9%, 85.0%, 77.1%, 63.2% and 48.6%, respectively (P < 0.001). In 898 patients the history was negative for bladder tumours. Among these patients the sensitivity and specificity of cytology was 67.3% and 79.7%; the sensitivity and specificity was 65.4% and 74.8% for the 807 patients with a positive history of bladder cancer (P= 0.054). CONCLUSION: both being aware of the endoscopic findings and a positive patient history for bladder cancer lowers the specificity of cytology. Consequently, the cytologist should be unaware of the endoscopic findings.