Disposable grasper-integrated flexible cystoscope for ureteral stent removal in transplanted patients; focus on feasibility, safety, and patient experience. Results and micro-cost analysis from a tertiary referral center.

INTRODUCTION & OBJECTIVES: To evaluate ureteral stent removal (SR) using a grasper-integrated disposable flexible cystoscope (giFC-Isiris ®, Coloplast ®) after kidney transplantation (KT), with a focus on feasibility, safety, patient experience, and costs. MATERIAL AND METHODS: All consecutive KT undergoing SR through giFC were prospectively enrolled from January 2020 to June 2023. Patient characteristics, KT and SR details, urine culture results, antimicrobial prescriptions, and the incidence of urinary tract infections (UTI) within 1 month were recorded. A micro-cost analysis was conducted, making a comparison with the costs of SR with a reusable FC and grasper. RESULTS: A total of 136 KT patients were enrolled, including both single and double KT, with 148 stents removed in total. The median indwelling time was 34 days [26, 47]. SR was successfully performed in all cases. The median preparation and procedure times were 4 min [3,5]. and 45 s[30, 60], respectively. The median Visual Analog Scale (VAS) score was 3 [1, 5], and 98.2% of patients expressed willingness to undergo the procedure again. Only one episode of UTI involving the graft (0.7%) was recorded. Overall, the estimated cost per SR procedure with Isiris ® and the reusable FC was 289.2€ and 151,4€, respectively. CONCLUSIONS: This prospective series evaluated the use of Isiris ® for SR in a cohort of KT patients, demonstrating feasibility and high tolerance. The UTI incidence was 0.7% within 1 month. Based on the micro-cost analysis, estimated cost per procedure favored the reusable FC.

Feasibility of injected indocyanine green for ureteral identification during robotic left-sided colorectal resections.

BACKGROUND: Ureteral identification is essential to performing safe colorectal surgery. Injected immunofluorescence may aid with ureteral identification, but feasibility without ureteral catheterization is not well described. METHODS: Case series of robotic colorectal resections where indocyanine green (ICG) injection with or without ureteral catheter placement was performed. Imaging protocol, time to ureteral identification, and factors impacting visualization are reported. RESULTS: From 2019 to 2020, 83 patients underwent ureteral ICG injection, 20 with catheterization and 63 with injection only. Main indications were diverticulitis (52%) and cancer (36%). Median time to instill ICG was faster with injection alone than with catheter placement (4min vs 13.5min, p < 0.001). Median time [IQR] to right ureter (0.3 [0.01-1.2] min after robot docking) and left ureter (5.5 [3.1-8.8] min after beginning dissection) visualization was not different between injection alone and catheterization. CONCLUSION: ICG injection alone is faster than with indwelling catheter placement and equally reliable at intraoperative ureteral identification.

Deep learning-based classification of blue light cystoscopy imaging during transurethral resection of bladder tumors.

Bladder cancer is one of the top 10 frequently occurring cancers and leads to most cancer deaths worldwide. Recently, blue light (BL) cystoscopy-based photodynamic diagnosis was introduced as a unique technology to enhance the detection of bladder cancer, particularly for the detection of flat and small lesions. Here, we aim to demonstrate a BL image-based artificial intelligence (AI) diagnostic platform using 216 BL images, that were acquired in four different urological departments and pathologically identified with respect to cancer malignancy, invasiveness, and grading. Thereafter, four pre-trained convolution neural networks were utilized to predict image malignancy, invasiveness, and grading. The results indicated that the classification sensitivity and specificity of malignant lesions are 95.77% and 87.84%, while the mean sensitivity and mean specificity of tumor invasiveness are 88% and 96.56%, respectively. This small multicenter clinical study clearly shows the potential of AI based classification of BL images allowing for better treatment decisions and potentially higher detection rates.

A micro-costing analysis of outpatient flexible cystoscopy: implications for adoption of single-use flexible cystoscopes.

PURPOSE: To evaluate the total cost of outpatient flexible cystoscopy associated with reusable device purchase, maintenance, and reprocessing, and to assess potential cost benefits of single-use flexible cystoscopes. METHODS: Cost data regarding the purchasing, maintaining, and reprocessing of reusable flexible cystoscopes were collected using a micro-costing approach at a high-volume outpatient urology clinic. We estimated the costs to facilities with a range of annual procedure volumes (1000-3000) performed with a fleet of cystoscopes ranging from 10 to 25. We also compared the total cost per double-J ureteral stent removal procedure performed using single-use flexible cystoscopes versus reusable devices. RESULTS: The cost associated with reusable flexible cystoscopes ranged from $105 to $224 per procedure depending on the annual procedure volume and cystoscopes available. As a practice became more efficient by increasing the ratio of procedures performed to cystoscopes in the fleet, the proportion of the total cost due to cystoscope reprocessing increased from 22 to 46%. For ureteral stent removal procedures, the total cost per procedure using reusable cystoscopes (range $165-$1469) was higher than that using single-use devices ($244-$420), unless the annual procedure volume was sufficiently high relative to the number of reusable cystoscopes in the fleet (≥ 350 for a practice with ten reusable cystoscopes, ≥ 700 for one with 20 devices). CONCLUSION: The cost of reprocessing reusable cystoscopes represents a large fraction of the total cost per procedure, especially for high-volume facilities. It may be economical to adopt single-use cystoscopes specifically for stent removal procedures, especially for lower-volume facilities.

Biopsy at flexible cystoscopy: is it worthwhile?

INTRODUCTION: Flexible cystoscopy is the gold standard for diagnosis and surveillance of bladder carcinoma. Most flexible cystoscopes feature a working channel allowing for bladder biopsy and diathermy if a suspicious lesion is observed. However, the working channel permits only small instruments which limit the volume of material retrieved for histological analysis. There are no published standards for quality control of biopsy specimens taken at flexible cystoscopy. We reviewed the diagnostic yield of biopsies taken at flexible cystoscopy at our institution. METHODS: Theatre log books were retrospectively examined to identify cases of flexible cystoscopy where bladder biopsy was performed. Histopathology reports were reviewed. All biopsies were taken using single-use biopsy forceps, diameter 1.8 mm, open cup width 4.5 mm. RESULTS: From January 2014 to December 2017, a total of 143 biopsies were performed. All biopsies were taken for suspicious lesions where the differential diagnosis included malignancy. Of the 143 samples taken, 27 biopsies showed evidence of malignancy, and 9 cases were high-grade urothelial cancer. A total of 16 samples were inadequate for any histological diagnosis. All remaining samples excluded malignancy within the sample provided. A histopathological diagnosis was provided for almost 89% of cases. CONCLUSION: Approximately 18% of biopsies detected malignancy. While only small volumes of tissue are collected at flexible cystoscopy, these can help to distinguish malignancy from benign pathology. Our institution reports a non-diagnostic rate of approximately 11%, and in these cases, when there is still a suspicion of malignancy, a rigid cystoscopy and biopsy should be performed.

Expert and Crowdsourced Evaluation of Image Quality From a Novel Endoscopy Phone Light Adapter.

OBJECTIVE: To evaluate the image quality of cystourethroscopy using a novel 3D printed phone light adapter with subject expert and crowdsourced evaluators. METHODS: A simple 3D printed light adaptor for a flexible cystoscopy was developed and made open source. Two videos were then recorded of a simulated cystourethroscopy, one using the novel adapter and the other using a traditional endoscopy light source. Expert evaluators (urology trainees and attendings) were then asked to evaluate the video quality using a double stimulus impairment scale. They were also asked to rate their level of confidence in using the novel adapter in clinical scenarios. Using Amazon's Mechanical Turk marketplace, 100 crowdsourced evaluators viewed the same videos and completed the same rating scale. The Mann-Whitney U test was then used to compare the expert and crowdsourced ratings. RESULTS: Expert and crowdsourced evaluators saw minimal degradation of video quality for the simulated urethroscopy (P= .66). However, while expert evaluators did identify degradation in the cystoscopy video, the crowdsourced evaluators did not (P = .012). 96% of the expert evaluators would either "often" or "always" use the novel adapter for difficult Foley placements and removal of ureteric stents. CONCLUSION: The novel light adapter caused minimal degradation in image quality for urethroscopy as compared to a traditional endoscopy light source, with vast majority of raters believing it would be adequate to perform common bedside cystoscopy procedures.

Is Meatal Analgesia Necessary for Pain Reduction During Cystoscopy in Females? A Prospective Randomized Study.

OBJECTIVE: To evaluate whether anesthesia of the meatal orifice reduces pain during cystoscopy in women, known to cause significant pain, discomfort and anxiety in women. Secondary end-point was to compare pain between rigid and flexible cystoscopy. METHODS: A total of 120 women, median age 66 (interquartile range 57-69), referred for office cystoscopy were prospectively randomized into 2 groups according to meatal orifice exposure: (1) 5-minute meatus exposure with 2% lidocaine gel; (2) 5-minute meatal exposure with water soluble gel. In each group a pad soaked by the gel was externally placed on the meatal orifice. Each group was further divided to flexible or rigid cystoscopy. Exclusion criteria included urethral stricture, urinary tract infection, chronic pain disease (e.g., IC/PBS), neurogenic disorder, allergy to lubricant, and concurrent pain medication. In all patients, a water-based lubricant applied on the cystoscope, was used for lubrication. A 0-10 visual analogue scale was performed at 4 checkpoints: before examination, immediately following urethral penetration, immediately at end of procedure and 15 minutes after completion RESULTS: Study groups did not significantly differ in clinical or demographic parameters. Pain level prior to procedure was 0 in all patients. Mean visual analogue scale immediately after urethral penetration was 4.2 ± 2.3 in both groups 1 and 2 (P= 1). No significant differences in other checkpoints was reported. Further subanalysis by cystoscope type did not demonstrate significance. CONCLUSION: Meatal analgesia does not increase tolerance to cystoscopy in females. Pain level is not reduced by the use of flexible cystoscope in the female population.

The grasper-integrated disposable flexible cystoscope is comparable to the reusable, flexible cystoscope for the detection of bladder cancer.

Flexible cystoscopy under local anaesthesia is standard for the surveillance of bladder cancer. Frequently, several reusable cystoscopes fail to reprocess. With the new grasper incorporated single-use cystoscope for retrieval of ureteric stents, we explored the feasibility of using it off-label for diagnosis and the detection of bladder cancer. Consecutive diagnostic flexible cystoscopies between Mar 2016 and Nov 2018 were reviewed comparing the reusable versus the disposable cystoscopes. A total of 390 patients underwent 1211 cystoscopies. Median age was 61.5 years (SD 14.2, 18.8-91.4), males 331 (84.9%) and females 59 (15.1%). Indication for cystoscopy was prior malignancy in 1183 procedures (97.7%), haematuria 19 (1.6%) or bladder mass 7 (0.6%). There were 608 reusable and 603 disposable cystoscopies. There was no significant difference between groups at baseline in age, sex, BMI, smoking status, or prior tumor risk category. There was no significant difference in positive findings (123/608, 20.2% vs 111/603, 18.4%, p = 0.425) or cancer detection rates (95/608, 15.6% vs 88/603, 14.4%, p 0.574) among the two groups, respectively. We conclude that the disposable grasper integrated cystoscope is comparable to reusable cystoscope in the detection of bladder cancer.

Preclinical and Clinical Evaluation of a Novel, Variable-View, Rigid Endoscope for Female Cystoscopy.

OBJECTIVE: To evaluate the preclinical and clinical performance of the pivoting lens rigid Endocameleon (ECAM) endoscope in white light cystoscopy (WLC). MATERIALS AND METHODS: Preclinical evaluation was performed ex vivo in CT-based, anatomically accurate and validated bladder phantoms. Six defined tasks with objective endpoints were compared between ECAM-WLC and rigid WLC (30° view angle, rWLC) in 30 interventions. Subsequently, the comparison was transferred to in vivo n = 21 interventions. A validated usability score (System Usability Scale, SUS) as well as physician and patient-related outcomes were assessed using Likert-scale-based questionnaires. Intra- and postinterventional complications were recorded according to the Clavien-Dindo classification. RESULTS: The ex vivo evaluation showed a significant superiority of ECAM-WLC in 4 of 6 endoscopic tasks. Noteworthy is the lower pressure on the bladder neck due to the endoscopesalteration of the endoscope (4/60 vs 17/60, P <.0001) and a more precise imaging of all bladder regions (22/30 vs 30/30, P = .046), including the anterior wall (0/30 vs 28/30, P <.0001). In vivo, surgeons rated the ECAM-WLC with an "excellent" SUS of 86.79%, also expressing that ECAM-WLC would enhance bladder surface visualization (4.52/5.0 ± 0.51), with a preferred use for ECAM-WLC during their next cystoscopy (4.62 ± 0.50). Patients reported ECAM-WLC to be less painful (4.5/5.0 ± 0.84) compared to rWLC. No intervention-related complications were observed. CONCLUSION: ECAM-WLC is a safe and accessible procedure that could improve conventional diagnostic WLC by combination of the advantages of fWLC and rWLC.

Use of a shaving technique for surgical management of partial ureteral obstruction due to endometriosis.

OBJECTIVE: To illustrate the surgical management of advanced endometriosis causing extrinsic ureteral compression. DESIGN: Video description of the case, demonstration of the surgical technique, reevaluation at 14-year follow-up, and review of urogenital endometriosis. Patient provided consent for the video recording and publication. This surgical report with no identifying patient data was exempt from Institutional Review Board approval. SETTING: Tertiary referral center. PATIENT(S): A 42-year-old nulligravida with a known history of endometriosis presented with persistent pelvic pain and no other specific symptoms. She had previously undergone a diagnostic laparoscopy demonstrating advanced endometriosis involving multiple organs, including the urinary tract. She was referred to us for further surgical management. Preoperative intravenous pyelogram showed partial obstruction and constriction of a long portion of the midpelvic and distal left ureter with proximal hydroureter, consistent with extrinsic ureteral compression. INTERVENTION(S): The patient underwent operative video laparoscopy using a multipuncture technique, with enterolysis, extensive left ureterolysis, shaving of periureteral constrictive fibrosis and endometriosis, cystoscopy, and placement of left ureteral stent. MAIN OUTCOME MEASURE(S): There was extensive endometriosis and fibrotic adhesions involving the left pelvic sidewall. Proximal hydroureter was noted to the pelvic inlet secondary to severe periureteral fibrosis from the pelvic brim to the bladder meatus, with significant narrowing of the pelvic ureter. The endometriosis was resected using hydrodissection and shaving with a carbon dioxide laser. Histopathologic evaluation of the resection specimens confirmed endometriosis. RESULT(S): An intravenous pyelogram performed 4 weeks postoperatively revealed ureteral patency and resolving hydroureter, and her ureteral stent was removed. Annual renal ultrasounds for the subsequent 2 years were normal. Fourteen years later, she remained asymptomatic on no suppressive treatment. A follow-up intravenous pyelogram was performed and showed a normal urinary tract with bilateral ureteral patency and no recurrent strictures or hydroureter. CONCLUSION(S): In selected cases, conservative shaving of periureteral fibrotic endometriosis avoids ureteral resection and has acceptable outcomes.

Bipolar en Bloc Resection - Is it the Future in Non-Muscle Invasive Bladder Cancer?

Bladder cancer is among the most common urological malignancies. In this context, despite of all the technological advancements, transurethral resection of bladder tumour (TURBT) continues to represent the gold-standard diagnostic and treatment in non-muscle invasive bladder tumours (NMIBTs). The surgical technique of en bloc bipolar tumour resection could be performed using the hemispherical shape plasma-button electrode and saline irrigation fluid or using the laser fiber. The malignant formation is gradually pushed up and separated from the bladder wall. The final aspect of the bladder wall reveals the clean muscular fibers of the detrusor layer, free of malignant tissue, irregularities or debris. Concerning the outcomes, the operative parameters are heterogenous in the literature, because of the different resection devices utilized. However, there are few main points where all the studies agreed, concerning the lower recurrence rates comparing with classical resection and also the good quality resection samples. In conclusion, even if the general outcomes are favourable for the en bloc resection, there is still a lack of large multicentric comparative trials which establish the right place of the method in the urological armamentarium.

Overactive bladder symptoms in patients undergoing rigid and flexible cystoscopy.

PURPOSE: To evaluate overactive bladder (OAB) symptoms in patients undergoing diagnostic cystoscopy. Overall changes in the entire study population were assessed, as well as broken down by various subgroups. METHODS: A prospective multi-center study among consecutive 450 adults undergoing diagnostic cystoscopy was conducted. OAB-symptoms were evaluated with the validated eight-item OAB Screening Awareness Tool (OAB-V8) immediately before and on days 1, 4, and 7 after cystoscopy. Patients were distinguished between being OAB-negative and OAB-positive (< 8 and ≥ 8 sum-score, respectively). Average sum-scores and subdomains were evaluated. RESULTS: Before cystoscopy, 44.7% of patients were screened OAB-positive and 55.3% OAB-negative. Out of those being screened negative, development of de-novo OAB was noticed in 16.8%, declining to 8.1% on day 7 (p < 0.001). In patients being OAB-positive before cystoscopy, a decline of OAB-positivity was noted during follow-up (p < 0.001). No statistically significant differences were noted when broken down by gender (p = 0.92), age (p = 0.82) and type cystoscope (rigid vs. flexible, p = 0.38). Average sum-scores declined from 8.68 before cystoscopy to 6.9 during follow-up. Flexible cystoscopy was superior over rigid in four subdomains: uncomfortable urge to urinate (p = 0.04), sudden urge to urinate with little or no warning (p = 0.02), uncontrollable urge to urinate (p = 0.03), and urine loss associated with a strong desire to void (p = 0.009). CONCLUSION: OAB-symptoms are common in patients undergoing cystoscopy. Cystoscopy itself can cause de-novo OAB-symptoms. Controversially, a decline of OAB-symptoms was noted after cystoscopy when patients were screened OAB-positive before cystoscopy. Flexible scopes were superior in some subdomains.

DaBlaCa-11: Photodynamic Diagnosis in Flexible Cystoscopy-A Randomized Study With Focus on Recurrence.

OBJECTIVE: To examine whether photodynamic diagnosis (PDD) in addition to flexible cystoscopy in the outpatient clinic can reduce risk of tumor recurrence in patients with previous nonmuscle invasive bladder cancer. PDD is an optical technique that enhances the visibility of pathologic tissue and helps guidance tumor resection. METHODS: From February 2016 to December 2017, 699 patients from 3 urologic departments in Denmark were enrolled in a randomized controlled trial. Four months after transurethral resection of bladder tumor patients were randomized 1:1 to either an intervention group (hexaminolevulinate was instilled in the bladder before flexible cystoscopy with PDD video cystoscope) or a control group (white light flexible cystoscope), only. Primary endpoint was tumor recurrence within 8 months from the randomization. Secondary outcomes were numbers of procedures in general anesthesia, time to the first recurrence, differences in tumor size, risk of tumor progression, and identification of carcinoma in situ. RESULTS: A total of 351 patients were allocated to the intervention group (flexible PDD), and 348 to the control group (flexible white light). Throughout the following 8 months after randomization, only 117 patients in the intervention group had at least 1 tumor recurrence compared to 143 patients in the control group (P = .049). Odds ratio of 0.67 (P = .02, 95% CI: 0.48-0.95) correlates with a tumor reduction of 33% in favor of the intervention group. CONCLUSION: Use of PDD in a routine surveillance cystoscopy first time after transurethral resection of bladder tumor for nonmuscle invasive bladder cancer reduces subsequent risk of tumor recurrence compared to WL cystoscopy alone.

Ureteral stent placement and percutaneous nephrostomy in the management of hydronephrosis secondary to cervical cancer.

OBJECTIVE: This study aimed to evaluate the efficacy of ureteral stent placement for the treatment of hydronephrosis secondary to cervical cancer and analyze factors that may predict failure of ureteral stent placement and the differences between ureteral stent placement and percutaneous nephrostomy. STUDY DESIGN: Clinical data of patients with cervical cancer complicated with hydronephrosis admitted to our hospital from July 2008 to August 2018 were retrospectively analyzed. To evaluate the efficacy of ureteral stent placement and percutaneous nephrostomy in the management of hydronephrosis secondary to cervical cancer. RESULTS: A total of 89 patients were analyzed. A ureteral stent was successfully placed in 60 patients. Indwelling stent failed in 29 patients, and then percutaneous nephrostomy was performed. Both surgical procedures were safe and effective. There was a significant correlation between the success rate of ureteral stent placement and the degree of hydronephrosis and the length of the ureteral obstruction. There was no significant difference in the incidence of complications following ureteral stent placement and percutaneous nephrostomy, while there were significant differences between the two treatment modalities in terms of surgical time, hospitalization time, and surgical cost. CONCLUSION: Ureteral stent placement is the preferred method for the treatment of hydronephrosis secondary to cervical cancer. However, in patients with more severe hydronephrosis and ureteral obstruction >3 cm in length, percutaneous nephrostomy may be more appropriate.

Endockscope: A Disruptive Endoscopic Technology.

Objective: To assess optical performance and diagnostic capability of the Endockscope system (ES) vs the standard endoscopic system (SES) using four rigid/semi-rigid endoscopes. The ES combines a smartphone, lens system, and a rechargeable light-emitting diode (LED) light source to provide a low-cost alternative ($45) to the standard camera and high-powered light source ($45,000) used in endoscopic procedures. Materials and Methods: Video clips (<20 seconds) of standard rigid nephroscopy, semi-rigid ureteroscopy, rigid cystoscopy, and laparoscopy in two adult male cadavers were recorded using the ES combined with either the Apple iPhone X or Samsung Galaxy S9+ and also with the high-definition SES (Karl Storz). Sixteen urologists blinded to the camera modality assessed the image resolution, brightness, color, sharpness, and overall quality using a Likert-type scale; acceptability for diagnostic purposes was judged on a binary scale (yes/no). Results: For rigid cystoscopy, there was no statistical difference between both ES systems and the SES. For semi-rigid ureteroscopy the two ES systems performed equal to or better than the SES. For rigid nephroscopy, the ES plus Galaxy was comparable to the SES, except in brightness (p < 0.05), whereas the ES plus iPhone was inferior in various parameters. For laparoscopy, the ES plus Galaxy was inferior to the SES in brightness and overall quality (p < 0.05); the ES plus iPhone was inferior for all laparoscopic image parameters compared with the SES. For diagnostic purposes, the ES plus Galaxy was equivalent to the SES for all endoscopes; the ES plus iPhone was equivalent to the SES for cystoscopy, ureteroscopy, and nephroscopy. Conclusion: The ES plus the Apple iPhone X or Samsung Galaxy S9+ offers comparable imaging and provides diagnostic information equivalent to the standard system for rigid endoscopy of the kidney, ureter, and bladder; the Galaxy S9+ provides comparable imaging and diagnostic capabilities for evaluation of the abdomen.

[Surgical treatment of bladder cancer: advances made in the past 50 years]. / Operative Therapie des Harnblasenkarzinoms: Fortschritte der letzten 50 Jahre.

The past 5 decades have seen major advances in the surgical treatment of bladder cancer, which have significantly reduced the morbidity and mortality of the disease. Enhanced understanding of tumour biology as well as a large number of newly developed endoscopic instruments and techniques have contributed to making treatment more successful. Moreover, modified and improved surgical techniques of radical cystectomy have been implemented and the clinical and pathological risk stratification of patients has been improved. Hence, patients are treated differently according to risk groups. Treatment algorithms range from repeated transurethral resections to adjuvant intravesical therapy to radical cystectomy, which may be part of a multimodal approach with curative intent. Celebrating the 50th anniversary of "Aktuelle Urologie", we summarise the most important advances in the treatment of BC since 1969 and report some current trends. Modern endoscopic imaging techniques ("enhanced cystoscopy") and molecular subtyping of BC may further improve risk stratification. Moreover, some initial experience has been made with robot-assisted radical cystectomy, and there are new trends for the standardisation of techniques, concepts of enhanced recovery after surgery, as well as initiatives for the measurement of surgical quality and patient-reported outcomes. We believe that all these current developments may help to further improve the quality of life and therapeutic outcome of patients with BC.

Efficacy and Safety of COX-2 Inhibitor Parecoxib for Rigid Cystoscopy-related Pain Management in Male Patients: A Prospective, Randomized and Controlled Study.

Using anesthetic gel may not sufficiently exclude pain perception during and after cystoscopy in male patients. To evaluate the analgesic efficacy and safety of intramuscular parecoxib (40 mg) for outpatient-based rigid cystoscopy, we performed a prospective, randomized and controlled study. Consecutive male patients requiring diagnostic cystoscopy in our hospital were divided into group A (1% tetracaine gel, n=50) and group B (parecoxib, n=51) at random. Patients received intramuscular injections of either 2 mL sterile saline in group A or 40 mg parecoxib in group B 30 min before the procedure. Tetracaine gel was injected into the urethra 3 min before the procedure in group A, with patients receiving plain lubricant gel in group B at the same time. Cystoscopy-associated pain levels were evaluated using the Visual Analog Score (VAS) during the procedure. Post-procedure urethral pain and complications were recorded and analyzed. The results showed that male patients experienced significantly less pain in group B than in group A (2.70±1.36 vs. 3.56±1.74, P=0.008). The percentage of patients with dysuria pain was not significantly different between the two groups. In addition, 24 h after cystoscopy, the patients with no previous experience of cystoscopy were more likely to declare urethral pain (59.2% vs. 33.3%, P=0.012, relative risk=1.78). No difference was observed in analgesic-related complications between the two groups. We conclude that intramuscular injection of 40 mg parecoxib may improve comfort for male patients undergoing rigid cystoscopy.

[Enhanced endoscopic imaging for urothelial cancer]. / Enhanced imaging ­ Neue diagnostische Methoden beim Urothelkarzinom.

The precise identification and detection of bladder tumours is a prerequisite for complete transurethral resection and, thus, the reduction of recurrence. White-light cystoscopy remains the gold standard and has been further improved by the introduction of digital HD techniques. New digital techniques such as narrow-band imaging (NBI) or the IMAGE 1 S-System have been introduced to better visualise suspicious areas. They are particularly valuable in the outpatient setting. However, fluorescence or photodynamic diagnostics (PDD) after instillation of hexaminolevulinic acid into the bladder is the only approach supported by good evidence. It is recommended by most guidelines in high-grade tumours or carcinoma in situ, while the value of NBI and the Image 1 S-System is under evaluation. Newer approaches include microscopic techniques such as optical coherence tomography, confocal laser endomicroscopy or molecular imaging. The combination of these methods with macroscopic imaging could be very promising.