Endoscopic management of upper tract urothelial carcinoma.

Nephroureterectomy is currently the gold standard for management of upper urinary tract urothelial carcinoma despite it results. This review article in the loss of a renal unit. The ultimate aim of endoscopic management of this condition is cancer control whilst preserving renal function and the integrity of the urinary tract. Endoscopic treatments of upper tract TCC include the antegrade percutaneous and retrograde ureteroscopic approaches. This review article summarizes the endoscopic management of upper tract urothelial carcinoma, surveillance of the disease after endoscopic management and adjuvant therapy. The main message regarding endoscopic management of upper tract urothelial cancer is that patients must be carefully selected. Patient selection is based on tumour size, grade, and multifocality. Single low-grade tumours, less than 1.5 cm in size, generally have a good outcome with endoscopic treatment provided that they have regular ureteroscopic surveillance. Ureteroscopic treatment of high-grade tumours is essentially palliative. It is essential that patients are motivated and compliant as lifetime follow-up is necessary. However, until large randomized trials with long-term follow-up are performed, endoscopic management cannot be considered a standard treatment and should be limited to poor performance status patients.

Intravesical explosions during transurethral endoscopic procedures.

Every Urologist, during the course of fulguration treatment of bladder tumours, has at some time or another experienced small intravesical explosions usually manifesting as a "pop". Major intravesical explosions are rare but potentially devastating complications of transurethral endoscopic resections. The damage to the bladder can range from small mucosal tears to bladder rupture, which can either be intraperitoneal (requiring laparotomy and open bladder repair) or extraperitoneal. We review the literature on intravesical explosions to determine the aetiology of these explosions and suggest strategies to prevent these. A comprehensive literature search was performed using Medline and Ovid to obtain information using search terms: intravesical explosions, transurethral procedures, endoscopic procedures, diathermyIntravesical explosions occur due to the production of explosive gases during use of diathermy on human tissues. The most dangerous combination is hydrogen and oxygen. Hydrogen alone is not explosive and it only becomes explosive when admixed with oxygen. Oxygen is not produced in sufficient quantity during diathermy to cause explosions but can enter into the bladder from the atmosphere during endoscopic procedures. Careful operative technique (correct use of the Ellick evacuator bulb and reducing the frequency of manual irrigations of the bladder) with minimisation of the operative time and using the coagulation current at moderate power as well as judicious coagulation of tissues can reduce the risk of this dangerous complication arising.

Autonomic side effects of Botulinum toxin Type B intravesical injections: report of 4 cases and review of the literature.

Recently, intravesical injections of Botulinum toxin type B (BT-B) have been trialled in an attempt to treat detrusor overactivity. Use of Botulinum toxin A (BT.-A), for the same in the past, has been quite successful without many reported side effects. Soon after commencing the clinical use of BT-B, a side effect profile was noticed not reported with BT-A. A total of 20 patients with refractory detrusor overactivity were included in this randomized, double blind, placebo controlled, cross over trial. As per protocol, 5000 MU (1 ml) BT-B diluted to a volume of 20 mls with normal saline were injected in 10 different sites into the detrusor, sparing the trigone. We report four cases of autonomic side effects after these injections which strongly suggest clinically relevant systemic spread of the toxin.

Case series data to encourage randomized trials of bladder retraining compared to antimuscarinic agents.

PURPOSE: This study was designed to test the power potential of a number of different clinical trial designs that could be deployed to test the efficacy of an antimuscarinic drug against bladder retraining. MATERIALS AND METHODS: This was an observational cohort study. Data were collected prospectively from patients treated for an overactive bladder by antimuscarinic agents with bladder retraining, or by bladder retraining alone. At initiation and at followup data on frequency, incontinence, urgency and urge incontinence were collected. Data from visits up to 16 weeks of treatment were analyzed using the parametric methods.708 patients were studied, 44 males and 664 females, and their mean age was 54 (sd 22). 52 patients used pure bladder retraining and 656 used bladder retraining and an antimuscarinic agent. The drug was oxybutynin, tolterodine or imipramine combined with oxybutynin or tolterodine as combination therapy. RESULTS: A between groups analysis demonstrated that bladder retraining was associated with a greater improvement in urinary frequency compared to antimuscarinic therapy (Z = -4.6, 95% CI of difference -3.3, -1.4, p <0.001) whereas antimuscarinic therapy was associated with a greater improvement in incontinence compared to bladder retraining (Z = -2.6, 95% CI of difference -0.93, -0.27, p = 0.024). The within group change in incontinence episodes in the bladder retraining group did not appear to show an effect (95% CI of change -0.19, 0.43). A subgroup showing greatest DeltaInc was sought. Boxplots of DeltaInc against age group, sex and the grading of symptoms were examined for maximum effect. Female sex, age group of 50 or greater and patients describing urge incontinence demonstrated the greatest DeltaInc. Their mean daily frequency was 11.45 (sd 6.1) and incontinence 1.6 (sd 2.1). A sample with such characteristics would be most sensitive to treatment effect. The bladder retraining group had a higher daily frequency (Z = -3.2, p = 0.001, 95% CI for bladder retraining 10 to 11, 95% CI for antimuscarinic group 10 to 12) and a lower daily incontinence compared to the antimuscarinic group (Z = -3.4, p <0.001, 95% CI of median for bladder retraining 0.75, 0.85, 95% CI of median for antimuscarinic group 0.75, 1.75). CONCLUSIONS: Change in frequency is a poor outcome measure, DeltaInc is significantly superior. An antimuscarinic tested against bladder retraining, using DeltaInc for outcome, would probably compare favorably.

Case report: angioleiomyoma of the spermatic cord: a rare scrotal mass.

We report a case of angioleiomyoma of the spermatic cord. Tumours arising from the spermatic cord are rare and most of them are benign. The commonest are lipomas with sarcomas being the predominant malignant variety. This is the first reported case of angioleiomyoma of the spermatic cord.

Effects of botulinum toxin B on refractory detrusor overactivity: a randomized, double-blind, placebo controlled, crossover trial.

PURPOSE: Open, observational studies of intradetrusor injections of botulinum toxin for detrusor overactivity have reported beneficial effects. We tested the efficacy and safety of botulinum toxin B for the treatment of the overactive bladder in a randomized, double-blind, placebo controlled crossover trial. MATERIALS AND METHODS: A total of 20 patients 18 to 80 years old with detrusor overactivity unresponsive to oral antimuscarinic agents participated in the study. They were injected with either placebo (20 ml normal saline) or botulinum toxin B (5,000 IU diluted up to 20 ml) intravesically in a day case setting. After 6 weeks the treatments were crossed over without washout in line with previous findings. The primary outcome was the paired difference in change in average voided volumes. Frequency, incontinence episodes and paired differences in quality of life measured by the King's Health Questionnaire were the secondary outcome measures. RESULTS: The Wilcoxon signed ranks test was used to test the paired difference in change between treatment phases. Little carryover was noted in the second arm placebo and the placebo data from both arms were included in analysis. There were clinically statistically significant paired differences in the change in average voided volume, urinary frequency and episodes of incontinence between active treatment and placebo (average voided volume: 95% CI difference 16, 122; Z2.5; p = 0.012/weekly frequency: 95% CI -21, -1; Z2.1, p=0.033/weekly incontinence: 95% CI -26, -7; Z3.3; p = 0.001). There were similarly significant paired differences in the change in quality of life affecting 5 domains of the King's Health Questionnaire. CONCLUSIONS: This double-blind, placebo controlled, crossover study provides evidence of the efficacy of botulinum toxin B in the treatment of overactive bladder. Autonomic side effects were observed in 4 patients. The short duration of action will presumably limit the use to patients who have experienced tachyphylaxis with botulinum toxin A.

Using the circumstances of symptom experience to assess the severity of urgency in the overactive bladder.

PURPOSE: We identified a method for quantifying the symptoms of the overactive bladder that addresses the assessment of urgency. MATERIALS AND METHODS: An observational study of a cohort was used. Data were collected prospectively from 5,423 consultations on 1,797 patients (158 males and 1,639 females) being assessed and treated for the overactive bladder. The study was conducted during 5 years. The reported frequencies and incontinence episodes were recorded. Using ranked ordinal scales (none, mild, moderate, severe) the symptoms of urgency and urge incontinence associated with waking and rising, hearing running water, arriving home ("latchkey"), cold weather and when feeling tired or worried were noted. The experiences of urgency and urge incontinence, without reference to the circumstances in which they were experienced were similarly assessed and if on treatment, they were asked to grade their overall response. RESULTS: Reported urinary frequency and incontinence episodes were strongly associated with patient grading of response to treatment. Therefore, the symptoms assessed on the scale of none, mild, moderate and severe were compared with disease severity by using reported frequency and incontinence episodes. The description of the symptoms with reference to the situations in which they were experienced showed clear associations with frequency and incontinence, falling along a progressive scale. An overall pattern could be detected in that at points on the scale of none, mild, moderate and severe, the least frequency and incontinence tended to be associated with waking, rising and latchkey symptoms. Next followed symptoms precipitated by running water and cold weather. Aggravation by fatigue or worry was associated with the greatest disease severity (ANOVA F = 8.9, p <0.001). This scale covered a wide range from frequencies of 7 to 15 times daily and incontinence episodes through 0 to 4 times daily. CONCLUSIONS: Qualifying the experience of urgency and urge incontinence, according to the circumstances in which these symptoms are experienced, seems to offer a promising new method for assessing the severity of urgency and urge incontinence.

Prenatal detection of a solitary liver adenoma.

Solitary liver adenomas are rare in children, especially in neonates, and can be difficult to distinguish from other more common liver tumors of newborns and infants. An otherwise healthy male neonate with a prenatal diagnosis of a liver mass underwent ultrasound and MRI followed by resection of the mass. The final histopathological diagnosis was hepatic adenoma. A discussion of the imaging evaluation, differential diagnosis, and literature review is presented.