Upper Tract Imaging in Patients with Initial or Terminal Hematuria Suggestive of Bleeding from the Lower Urinary Tract: How Often is the Upper Urinary Tract Responsible for the Hematuria?

OBJECTIVES: Visible hematuria (VH) is a common urological complaint. A history of initial or terminal VH in men is indicative of a lower urinary tract (LUT) source. A careful clinical history could limit unnecessary extensive upper tract imaging in this group of patients with VH. We conducted a single-center prospective study to examine the usefulness of investigating the upper tract in patients with a history of VH likely from a LUT source (initial and/or terminal VH) with specific reference to the incidence of demonstrable significant upper tract abnormalities. METHODS: We conducted a single-center prospective study of consecutive male patients presenting with VH over eight months. All patients underwent standard investigations including physical examination, flexible cystoscopy (FC), and radiological imaging (ultrasound scan (USS) and/or computed tomography urogram (CTU)). Those with a clear history of initial or terminal VH were identified for further scrutiny with regards to detectable upper tracts abnormalities. RESULTS: In total, 57 patients (aged 23-95 years) with initial or terminal VH were identified. Of these, 56 had FC and nine patients were subsequently diagnosed with a LUT malignancy. With regards to upper urinary tract (UUT), 35 patients (61.4%) had an USS, 46 (80.7%) underwent a CTU, and 25 (43.9%) patients had both. In this group, no UUT malignancy was identified on upper tract imaging. CONCLUSIONS: Initial or terminal VH patients may not need extensive upper tract imaging. FC is recommended, but a non-invasive USS can be a safe initial investigation for the UUT, with a CTU subsequently considered in those with abnormalities on USS and those with ongoing bleeding. Further combined multicenter analysis will help corroborate these findings and could have several beneficial outcomes including a reduction in investigations cost, patient inconvenience, and ionizing radiation.

Early prostate cancer--which treatment do men prefer and why?

STUDY TYPE: Preference (prospective cohort). LEVEL OF EVIDENCE: 1b. What's known on the subject? and What does the study add? In general the literature suggests that there is a need for improvement in aiding men diagnosed with early prostate cancer in their decision making about treatment options and that our understanding of this process is inadequate. There is limited data analyzing the reasons why these men decide between potentially curative or observational treatments and data evaluating patients' views before and after definitive therapy are scarce. This study begins the process of understanding the reasons underlying a patient's final treatment decision. Being a prospective study, it looks at the thought processes of these men before treatment during the time the decision is made. It also documents how satisfied patients are with their choice after their treatment and whether they would choose the same treatment again. OBJECTIVE: To identify the reasons for patients with localised prostate cancer choosing between treatments and the relationship of procedure type to patient satisfaction post-treatment. PATIENTS AND METHODS: 768 men with prostate cancer (stage T1/2, Gleason≤7, PSA<20 ug/L) chose between four treatments: radical prostatectomy, brachytherapy, conformal radiotherapy and active surveillance. Prior to choosing, patients were counselled by a urological surgeon, clinical (radiation) oncologist and uro-oncology specialist nurse. Pre-treatment reasons for choice were recorded. Post-treatment satisfaction was examined via postal questionnaire. RESULTS: Of the 768 patients, 305 (40%) chose surgery, 237 (31%) conformal beam radiotherapy, 165 (21%) brachytherapy and 61 (8%) active surveillance. Sixty percent of men who opted for radical prostatectomy were motivated by the need for physical removal of the cancer. Conformal radiotherapy was mainly chosen by patients who feared other treatments (n=63, 27%). Most men chose brachytherapy because it was more convenient for their lifestyle (n=64, 39%). Active surveillance was chosen by patients for more varied reasons. Post-treatment satisfaction was assessed in a subgroup who took part in the QOL aspect of this study. Of the respondents to the questionnaire, 212(87.6%) stated that they were satisfied/extremely satisfied with their choice and 171(92.9%) indicated they would choose the same treatment again. CONCLUSION: Men with early prostate cancer have clear reasons for making decisions about treatment. Overall, patients were satisfied with the treatment and indicated that despite different reasons for choosing treatment, they would make the same choice again.

Does increasing hydrostatic pressure ("bag squeeze") during flexible cystoscopy improve patient comfort: a randomized, controlled study.

OBJECTIVES: To determine whether increased hydrostatic pressure by simple manual compression ("bag squeeze") of the irrigation solution bag (500 mL of 0.9% saline) during passage of the flexible cystoscope will reduce patient discomfort. METHODS: A total of 151 male patients undergoing diagnostic and review flexible cystoscopies were randomized to "squeeze" (n = 72) or "no squeeze" (n = 79) as the cystoscope was passed from below the external sphincter until after the bladder neck was negotiated. All patients had received 10 mL of 2% lidocaine gel beforehand. A 10-point visual analog pain scale assessing cystoscopy insertion was completed by the patients after the procedure. RESULTS: The mean pain score was 1.38 (95% confidence interval 0.99-1.77) in the squeeze group and 3.00 (95% confidence interval 2.55-3.46) in the no-squeeze group (P < .001, Mann-Whitney U test). Patient age, procedure indication (diagnostic and review), and grade of clinician performing the cystoscopy had no effect on the findings. CONCLUSIONS: The results of our study have shown that the squeeze technique during insertion of a flexible cystoscope significantly decreases the discomfort of the procedure. It is strongly recommended in all male patients.