The effect of office based flexible and rigid cystoscopy on pain experience in female patients.

PURPOSE: Rigid and flexible cystoscopies are both routinely used in female patients. Literature is conflicting whether flexible cystoscopy is less painful compared to rigid cystoscopy. The aim of this study was therefore to investigate whether using flexible cystoscopy leads to less discomfort and pain compared to rigid cystoscopy in female patients who underwent first time cystoscopy. MATERIALS AND METHODS: One hundred eighty-nine female patients, who never had undergone cystoscopy, were randomized into 2 groups: 92 patients underwent rigid cystoscopy and 97 patients flexible cystoscopy. Directly after the cystoscopy procedure all patients were asked to fill out their pain experience on a 100-mm visual analogue pain scale (VAS). RESULTS: Median VAS score was significantly lower for women undergoing flexible cystoscopy (0 [0-20]) compared to rigid cystoscopy (15 [0-38], p<0.001). In addition, age was inversely associated with VAS score, indicating that younger females experienced more pain (R=-0.30, p=0.001). The use of flexible cystoscopy was associated with a decrease in VAS score and remained significant after adjustment for age, sex of urologist, performing urologist and indication (standardized ß=-0.17, p=0.048). CONCLUSIONS: The use of flexible cystoscopy resulted in a significantly lower pain experience compared to rigid cystoscopy. Based on patient's pain experience during cystoscopy, this study implicates to use flexible cystoscopy in female patients who undergo first time cystoscopy.

[Value of a multidisciplinary team for patients with a urological malignancy]. / Toegevoegde waarde van het uro-oncologische multidisciplinair overleg.

OBJECTIVE: To evaluate degree of agreement between treatment proposals from urologist and a multidisciplinary team (MDT) for patients with an urological malignancy. DESIGN: Retrospective cohort study. METHOD: All letters from patients with an urological malignancy of prostate, bladder, kidney or testicle who were discussed at the MDT in Ziekenhuisgroep Twente from January 2011 until January 2013 were collected. This study studied the level and frequency of agreement between treatment proposals from urologist and MDT. Level of agreement was expressed by using Cohen's Kappa. Also treatments proposed by the MDT were compared to the final treatment choice of the patient. RESULTS: A total of 788 letters were analysed. For 9%, the MDT disagreed with the treatment recommended by the urologist. This disagreement was most often observed in patients with malignancy of kidney (κ: 0.507; p < 0.001). Agreement for patients with malignancy of bladder, testicle and prostate were substantial (respectively κ: 0.719; p < 0.001, κ: 0.803; p < 0.001, κ: 0.634; p < 0.001). Treatment proposals "brachytherapy" and "external radiotherapy" for prostate malignancy showed only moderate agreement (κ: 0.564 and κ: 0.568; p < 0.001 respectively). 93% of all patients elected to take (one of) the treatment proposals made by the MDT. CONCLUSION: A multidisciplinary approach seems particularly useful for patients with malignancy of kidney. The additative value of MDT was less visible for patients with malignancy of prostate, which could be due to less consistent guidelines. Final treatment decision might be influenced by explanation and guidance of the treating urologist.

Components of the plasminogen activator system and their complexes in renal cell and bladder cancer: comparison between normal and matched cancerous tissues.

OBJECTIVE: To analyse and compare the concentration of plasminogen activator (PA), urokinase-type PA (uPA), tissue-type PA (tPA), PA inhibitor (PAI)-1 and PAI-2, and the complexes uPA-PAI-1 and tPA-PAI-1 and calculated uPA and tPA uncomplexed with PAI-1 ('free') in urothelial cell carcinoma and matched benign urothelium, and in renal cell carcinoma (RCC) and matched benign renal tissue. PATIENTS AND METHODS: Tissue samples were obtained during cystectomy (33 patients) and nephrectomy (55), and specific enzyme-linked immunosorbent assays were used to assess the PA components in extracts of these tissues. RESULTS: Tissue levels of uPA-PAI-1 and tPA-PAI-1, but also PAI-1 itself, were greater in tumorous bladder and kidney tissue than in matched normal tissue (by 1.5-7.8 times). Free tPA was clearly lower in tumour tissue (by 0-0.12-fold). In bladder cancer, but not in RCC, levels of uPA (15.8-fold) and free uPA (16.4-fold) were greater in tumour tissue. Free uPA levels were less in RCC (0.41-fold). For both normal bladder and kidney tissue, there was no clear correlation between uPA-PAI-1 complex and either component. However, the formation of tPA-PAI-1 complexes in normal bladder and kidney tissue was primarily determined by PAI-1. Interestingly, in tumour tissues there was a strong, significant correlation between complex levels and both components. CONCLUSION: RCC and bladder cancer show distinct profiles of components of the PA system. This study provides a basis for further studies into both the (patho)physiological role of the PA system in these tumours, and into a possible relation with tumour progression and prognosis, and as target for therapy.

The predictive value of p53, p27(kip1), and alpha-catenin for progression in superficial bladder carcinoma.

OBJECTIVE: The aim of the study was to confirm the predictive value of cell cycle regulatory proteins, p53 and p27(kip1), and the cell adhesion complex protein alpha-catenin, for progression in patients with superficial bladder carcinoma. METHODS: Forty-one patients with progression after primary superficial bladder carcinoma were individually matched to patients with nonprogressive superficial bladder carcinoma. Matching was done for sex, age, tumor stage and grade, concomitant carcinoma in situ (CIS), and duration of follow-up. Immunohistochemical analysis of p53, p27(kip1), and alpha-catenin was performed on each primary bladder tumor. Analysis for the p53 mutation was done on 41 bladder tumor samples. Conditional logistic regression analysis was used to establish the prognostic value of immunohistochemical p53, p27(kip1), and alpha-catenin status. RESULTS: The independent odds ratios for progression were 0.3 (95% confidence interval [CI], 0.1-1.2) for high-risk p27(kip1), 3.4 (95%CI, 0.8-15.2) for high-risk p53, and 2.5 (95%CI, 0.6-10.3) for high-risk alpha-catenin. Combinations of different markers had no synergistic effects. Two p53 mutations were found in 21 DNA samples analyzed from nonprogressive tumors (9.5%); 8 of 20 samples (40%) from progressive tumors showed a p53 mutation. The probability of high-risk p53 immunostaining was 5-fold increased in case of mutations in p53. The estimated positive predictive value of high-risk p53 or high-risk alpha-catenin was about 23%. CONCLUSIONS: We confirm that high-risk p53, p53 mutation, and alpha-catenin immunohistochemistry do have an additional prognostic value in primary bladder carcinoma. However, the clinical value of the investigated parameters remains limited.

The role of urodynamics in the treatment of lower urinary tract symptoms in women.

PURPOSE OF REVIEW: Urodynamic investigation was developed as an extension of patient history and physical examination in order to reveal the pathology of a patient's complaints. Much progress in standardizing definitions and procedures has been made in recent years. In particular, stress urinary incontinence and overactive bladder can be differentiated with urodynamics. The developed parameters, however, cannot distinguish the various types of stress urinary incontinence. Moreover the definition and diagnosis of voiding dysfunction is not clear. Finally our understanding of bladder sensations and the impact on voiding behaviour has only started to emerge. This review is about last year's publications that focus on urodynamics and lower urinary tract symptoms in women. RECENT FINDINGS: Defining bladder outlet obstruction is based on voiding pressure, urinary flow speed and residual urine but standardization is lacking. Urodynamics to reveal occult stress urinary incontinence in patients with pelvic organ prolapse needs standardization of the reducing manoeuvres. The quest for urodynamic tools for distinguishing intrinsic sphincter deficiency from urethral hypermobility continues. Urodynamics are still not good enough to discriminate between treatment options for stress urinary incontinence. The use of urodynamics in overactive bladder is developing and has elicited new findings. Voiding habit seems to be independent from bladder sensations. Also bladder sensations appear to be imperfectly correlated with bladder filling. Even bladder volumes do not predict entirely bladder fullness sensations. SUMMARY: In order to use urodynamics as a proper clinical tool, defining subtypes of stress urinary incontinence and standardization of urodynamics in pelvic organ prolapse and bladder outlet obstruction in women is needed.