Patient tolerability during office cystoscopy and bladder tumor cauterization: a multivariate analysis of risk factors

. 2023 Apr;47(3):165-171.

doi: 10.1016/j.acuroe.2022.08.011.

Epub 2022 Aug 5.

[Article in

English,
Spanish]

S D Lokeshwar 
¹
, S N Rahman 
²
, A Choksi 
³
, B H Press 
²
, D Shaheen 
³
, M S Soloway 
³

Affiliations

Affiliations

• ¹ Yale University, Department of Urology, New Haven, CT, USA. Electronic address: [email protected].
• ² Yale University, Department of Urology, New Haven, CT, USA.
• ³ Urologic Oncology, Memorial Physician Group, Division of Urology, Memorial Healthcare System, Aventura, FL, USA.

• PMID:

  36319555

• DOI:

  10.1016/j.acuroe.2022.08.011

[Article in

English,
Spanish]

S D Lokeshwar et al.

Actas Urol Esp (Engl Ed).

2023 Apr.

. 2023 Apr;47(3):165-171.

doi: 10.1016/j.acuroe.2022.08.011.

Epub 2022 Aug 5.

Authors

S D Lokeshwar 
¹
, S N Rahman 
²
, A Choksi 
³
, B H Press 
²
, D Shaheen 
³
, M S Soloway 
³

Affiliations

• ¹ Yale University, Department of Urology, New Haven, CT, USA. Electronic address: [email protected].
• ² Yale University, Department of Urology, New Haven, CT, USA.
• ³ Urologic Oncology, Memorial Physician Group, Division of Urology, Memorial Healthcare System, Aventura, FL, USA.

• PMID:

  36319555

• DOI:

  10.1016/j.acuroe.2022.08.011

Abstract

Objective:

Cystoscopy and cauterization performed in the operating room is expensive and exposes patients to anesthesia risks. Patient tolerability during office cystoscopy and cauterization is critical to the office management of bladder cancer (BC) and other urologic diseases. We evaluated the risk factors for pain of flexible cystoscopy in the office-setting with emphasis on a sub-group of BC patients who underwent cauterization.

Materials and methods:

Retrospective analyses of 110 anonymous patient surveys completed after cystoscopy and/or cauterization. Survey information included age, gender, indication for cystoscopy, number of prior cystoscopies, number of prior office-based cauterizations, anxiety prior/during cystoscopy, and pain during cystoscopy and/or cauterization. Univariate/multivariate and linear-regression analyses were performed to evaluate the association of pain with clinical parameters.

Results:

Average pain during cystoscopy (1.75 ± 1.331) was not significantly different when cauterization was also performed (2.37 ± 2.214) (p < 0.001) (p = 0.2840). Patients in the lower age group (<66 years) indicated higher anxiety levels (p = 0. 0005), more pain at cystoscopy (P = 0.004) and cauterization (p < 0.001). Although the patients’ overall anxiety level was low (1-3/10), it was associated with some pain during cystoscopy (p = 0.0005) and cauterization (p < 0.000). In multivariate analysis, anxiety was the only independent predictor of pain during cystoscopy (p = 0.03, OR: 6.52,95% CI: 1.2-35.6) and cauterization (p = 0.0012, OR: 3.4, 95%CI: 1.6-7.0). In BC patients, pain scores during cystoscopy and cauterization were not significantly different (p = 0.4772) but associated with anxiety.

Conclusion:

Office-based cystoscopy and cauterization are tolerable with minimal pain. Higher pain levels during cystoscopy were associated with procedure anxiety, and pain during cauterization was associated with procedure anxiety and younger age. Younger and more anxious patients may need more counseling before cystoscopy.

Keywords:

Bladder cancer; Cauterización; Cauterization; Cistoscopia; Cystoscopy; Cáncer de vejiga; Manejo ambulatorio; Office management; Tolerabilidad; Tolerability.

Copyright © 2022 AEU. Published by Elsevier España, S.L.U. All rights reserved.

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MeSH terms

Bladder Cancer Treatment | Johns Hopkins Medicine

Over 75 percent of bladder cancers remain confined to the lining of the bladder and do not invade the bladder wall. These are called nonmuscle-invasive bladder cancer, or superficial bladder cancer, and when managed well, they are associated with excellent prognoses.

Muscle-invasive bladder cancer, or advanced bladder cancer, is cancer that has invaded the bladder wall or spread outside of the bladder. These cancers require more aggressive clinical management.

Bladder cancer treatment options vary depending on whether the cancer is nonmuscle-invasive or muscle-invasive, and specific treatments are determined based on the stage and grade of the tumor(s).

Treatments for Nonmuscle-Invasive (Superficial) Bladder Cancer

Cystoscopy with Cautery Destruction of the Bladder Tumor

Cystoscopy is an outpatient procedure during which a thin, lighted tube with a camera is passed through the urethra into the bladder, allowing your doctor to see the inside of the bladder.

Most modern cystoscopes are also equipped with channels that permit small instruments to be passed into the bladder. During a cystoscopy, your doctor may use these instruments to remove tissue, stop bleeding with a special electrical device called an electrocautery or even perform laser treatment. If the bladder cancer tumor is small enough, this cautery may be used to remove the cancer.

Transurethral Resection of the Bladder Cancer Tumor

This is when the tumor is removed from the urinary tract through the urethra using an electrical force. Transurethral resection (TUR) is an endoscopic or scope procedure that does not involve making an incision in the body.

Drug therapy after TUR is commonly prescribed for patients with large, multiple or high-grade tumors.

Intravesical Drug Therapy (Chemotherapy and Immunotherapy)

Intravesical drug therapy involves placing medicines directly into the bladder via a urethral catheter to lower the recurrence rates of bladder tumors. It is usually used for multiple carcinomas in situ that cover a large area (5 centimeters-plus), or for high-grade or high-stage tumors.

Commonly used intravesical drugs are:

• Mitomycin C is a chemotherapy drug that kills the normal DNA function in cancer cells and is easily absorbed into the bloodstream through the bladder’s lining.
• Bacille Calmette–Guerin (BCG) is an immunotherapy drug that makes the body’s immune system respond to the BCG drug in the lining of the bladder, forcing the immune system to help fight off the cancer. About 50 to 68 percent of patients with nonmuscle-invasive bladder cancer have a very good response to BCG.

Bladder Cancer | Q&A

Understand the basics of bladder cancer, from risk factors and diagnosis to the various treatment and urinary diversion options available. Armine Smith, M.D., a surgeon at the Johns Hopkins Greenberg Bladder Cancer Institute, tells you what you need to know.

Treatments for Muscle-Invasive (Advanced) Bladder Cancer

Cystectomy (Bladder Removal) Surgery

When bladder cancer tumors completely invade the bladder’s muscular wall, the standard of care is to perform bladder removal surgery. Typically, complete removal of the bladder (radical cystectomy) is required.

Partial cystectomy is rare because the requirements are that the tumor is easily accessible and small in size, and that there are no tumors in the rest of the bladder. This approach is usually used only if the cancer has not left its site of origin. Additionally, partial cystectomy may be an alternative option for nonmuscle-invasive bladder cancer if all other treatments fail.

Radiation Therapy

Radiation therapy, used to treat cancer, is a special high-energy X-ray that is more powerful than the X-rays used for imaging studies. Radiation therapy is planned and executed in a way to kill cancer cells or alter their ability to reproduce, while the surrounding healthy cells are minimally affected.

Historically, radiation therapy alone has been used for muscle-invasive bladder cancer, but current treatment usually involves a combined approach of maximal local surgery, radiation and chemotherapy. The role of radiation therapy in this combined approach is to kill the bladder cancer cells in the bladder that are not visible to the surgeon. Chemotherapy is used to enhance the effects of the radiation and kill cells outside the bladder. Local lymph nodes are frequently radiated as part of the therapy to treat the microscopic cancer cells that may be there.

Chemotherapy

Chemotherapy uses chemical agents to interfere with replication and other normal functions of cells, resulting in tumor shrinkage or cancer cell death. The use of two or more chemotherapy drugs together has been found to be more effective than a single drug alone. There are several types of chemotherapy. The most common chemotherapeutic drug used in bladder cancer is cisplatin.

Immunotherapy

Immunotherapy is a cancer treatment approach that uses drugs and vaccines to harness the immune system’s natural ability to fight cancer, in the same way it fights off infections. The approach is still being researched and there is a lot left to learn, but clinical studies have shown that immunotherapy holds a lot of promise in its ability to treat a wide range of malignancies, including some types of bladder cancer.

There are a few FDA-approved immunotherapy drugs available for treating advanced and metastatic bladder cancer that has worsened after chemotherapy. Scientists are also investigating the possibility that combinations of immunotherapy drugs could be more effective than individual drugs.

Illustration showing inside and outside views of an ileal conduit.

Types of Surgical Reconstruction to Replace the Removed Bladder 

Ileal Conduit

This procedure has been routinely performed since the 1950s. The internal pouch that holds the urine is made from a small portion of intestinal tract. One end is closed with sutures, while the other end is attached to skin on the front side of the abdomen. A stoma is the open end of the conduit attached to the skin. An external appliance (ostomy bag) covers the stoma to collect urine. The ureters are implanted into the back of the ileal conduit.

Catheterizable Continent Diversion Pouch

This is a reservoir of bowel with a stoma that is catheterizable for emptying the bladder. The urine is siphoned out of the urinary reservoir with a small catheter every four to six hours. The catheterizable pouch may require surgical repair at some point after surgery due to the wear and tear of frequent catheterization. This type of reconstruction is not performed on patients with a history of bowel disease.

Neobladder

A neobladder is a new bladder made from a section of the patient’s small intestine. This internal, new bladder is connected to the urethra and ureters. After this reconstruction, the patient needs to relearn how to void. Some disadvantages of this type of reconstruction are the possibility of incontinence and scar tissue formation at the connection of the urethra and new bladder.

Minimizing the Impact of Bladder Cancer: Organ Preservation in Male and Female Cystectomy

Learn more about who is a candidate for organ preservation in cystectomy for bladder cancer during this webinar with urologic oncologist Armine Smith.

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Bladder leukoplakia – symptoms, causes, diagnosis and treatment in women in the “SM-Clinic”

This disease is treated by a Urologist

• About the disease
• Bladder leukoplakia symptoms
• Causes
• Diagnostics
• Treatment of bladder leukoplakia
• Prophylaxis
• Rehabilitation
• Questions and Answers
• Expert opinion
• Doctors

About disease

Normally, the mucous membrane is covered with stratified squamous epithelium, which performs a protective role (protects the organ from the aggressive action of urine). With leukoplakia, zones appear in which the cells cease to form glycogen and gradually turn into keratinizing cells, capable of exfoliating and thereby exposing the submucosal layer.

Most often, areas of leukoplakia of the bladder appear in the region of Lieto’s triangle. This is a space in the bottom of the bladder, the tops of which are the ureteral orifices on 2 sides and the internal urethral opening from below.

Leukoplakia is considered the least studied disease in urology. To date, the exact causes of development and the full mechanism of the ongoing pathological changes have not been established.

In the zone of leukoplakia of the bladder, the mucosa is devoid of a protective barrier. Urine gradually “leaks” through the epithelium into the submucosal layer, irritating the nerve endings passing through it. This causes long-lasting discomfort in the suprapubic region, a frequent desire to empty the bladder, while the act of urination is accompanied by pain. Such patients are treated for a long time for recurring cystitis, exacerbations of which occur shortly after the end of the course of therapy. This is due to the fact that in the area that has undergone leukoplakia, the production of mucus is disrupted. Therefore, bacteria that have entered the bladder can easily be fixed to the mucous membrane and cause inflammation.

Bladder leukoplakia is treated mainly by conservative methods. However, with the ineffectiveness of drug therapy and a short interrelapse period, the issue is resolved in favor of minimally invasive surgical intervention. Such patients may be shown resection of the mucosal area that has undergone keratinization. The operation is performed transurethral – the instruments are inserted through the natural openings of the urethra. The recovery period is short, the therapeutic efficacy of the method is high.

Bladder leukoplakia symptoms

Clinical signs of leukoplakia of the bladder are usually presented:

• frequent urination, which is accompanied by discomfort;

• unpleasant or painful sensations behind the pubic joint or in the suprapubic region;

• sudden and little controlled urge to go to the toilet “in a small way.”

A decrease in the protective reserves of the bladder makes it more vulnerable to infections, so the symptoms of cystitis appear again and again.

Causes

Currently, the causes of bladder leukoplakia are considered in the context of urogenital infections, among which particular importance is given to those caused by chlamydia, ureaplasma, gonococci, Trichomonas, herpesvirus types 1 and 2, as well as genital mycoplasma. These pathogens are thought to cause damage to the epithelium lining the bladder. As a result, the formation of foci of squamous metaplasia is initiated. However, subsequently the causal role of the infection is gradually lost and further damage to the urothelium occurs under the influence of other factors. So, with leukoplakia, the normal glycosaminoglycan layer is destroyed, covering the outside (from the bladder cavity) of the mucous membrane.

Get advice

If you experience these symptoms, we recommend that you make an appointment with your doctor. Timely consultation will prevent negative consequences for your health.

To learn more about the disease, prices for treatment and sign up for a consultation with a specialist, you can call:

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Treatment is carried out in accordance with clinical guidelines

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Comprehensive assessment of the nature of the disease and treatment prognosis

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Diagnostics

Patients with complaints suspicious of leukoplakia are given urine and blood tests. In the blood, as a rule, no significant changes are found. In the urine, due to the frequent addition of the inflammatory process, an increased content of leukocytes can be detected. However, a similar situation can occur with ordinary cystitis. If the inflammation of the bladder repeatedly recurs, despite the correct antimicrobial therapy, then cystoscopy is added to the diagnostic program.

Cystoscopy is the main method for visualizing leukoplakic changes. They appear as silvery-white or pearlescent plaques set against a pink mucosa. In some cases, the keratinizing epithelium can cover large areas, and the normal sheath with compensatory dilated arteries is preserved only for a small extent.

Despite the characteristic cystoscopy, endoscopic diagnosis can sometimes be difficult. This is due to the incrustation of leukoplakic foci with phosphate salts, as a result of which they lose their characteristic silvery coloration. In such cases, the diagnosis is established solely with the help of histological examination, the material for the biopsy is a sample of a piece of film taken together with the underlying tissues.

It should be noted that histological confirmation of the diagnosis, even with a clear cystoscopic picture, is a prerequisite. First of all, this is dictated by the fact that it is required to exclude squamous papilloma and sometimes even bladder cancer. Treatment is prescribed only after morphological verification of the pathological process. Women with leukoplakia are also shown to consult a gynecologist to exclude genital infections.

Expert opinion

Leukoplakia should be treated as a potentially precancerous condition. Metaplasia of squamous epithelium into keratinizing against the background of long-term disorders of trophism and innervation predisposes to the appearance of pro-oncogenic mutations in cells (this fact has been established in other organs). Leukoplakia requires dynamic monitoring and control by the urologist.

Kalinina Svetlana Aleksandrovna

Urologist-andrologist of the highest category

Treatment of bladder leukoplakia

Bladder leukoplakia in women and men is treated mainly by complex conservative therapy. With the ineffectiveness of the latter and persistent complaints after a series of repeated courses, it is recommended to remove the altered area of ​​the mucosa. This allows you to get rid of characteristic complaints and normalize the general condition of the patient.

Conservative treatment

Conservative therapy involves the appointment of antibiotics for established infection. However, even despite adequate antibacterial treatment, complaints usually persist. Therefore, the second direction is the restoration of the disturbed glycosaminoglycan layer. For this purpose, analogues of glycosaminoglycans, in particular hyaluronic acid, are prescribed. It can be administered as an instillation or by point injections under cystoscopic guidance. In the course of such therapy, patients notice a significant improvement in well-being – pain in the suprapubic region decreases or completely stops, the frequency of urination decreases, which become more controlled and painless.

Surgical treatment

Surgical treatment is indicated in the following cases:

• inefficiency of the complex therapy;

• concomitant pseudopolyposis of the bladder neck, which significantly increases oncological risks.

The volume of surgical intervention is resection of the altered mucosal area. The removed material must be sent for histological examination to exclude a malignant process. The operation is performed by a transurethral method without external incisions.

Prophylaxis

Specific preventive measures have not been developed. However, to reduce the risk of developing leukoplakia, the use of condoms, which prevent sexually transmitted infections, may be helpful. It is important to treat inflammatory processes of the genitourinary organs in a timely manner, which will protect the epithelium of the bladder from long-term damage.

Rehabilitation

Within a few days after the operation, antibiotics are administered to the patient to reduce infectious and inflammatory risks. Urinary diversion is carried out through a urethral catheter, which is usually removed on the second postoperative day. It is recommended to consume at least 2 liters of water per day to clear the surgical wound faster.

FAQ

Issues of diagnostics and development of treatment tactics are within the competence of urologists.

It has long been proven that leukoplakia of another localization can transform into a malignant neoplasm, therefore, patients with bladder leukoplakia are monitored. However, so far in the world literature there is not a single case of the transformation of bladder leukoplakia into carcinoma. Perhaps this is due to the fact that bladder cancer, according to the histological picture, is predominantly transitional cell, and not squamous, like leukoplakia.

Most women diagnosed with leukoplakia suffer from sexual dysfunction. This is due to a long-term pain syndrome, which reduces social activity, leads to neuropsychic exhaustion and the rejection of sexual intercourse.

Smirnov D.S. Features of diagnostics and treatment of patients with bladder leukoplakia. Auth. diss. Saint Petersburg. 2007.

Bladder leukoplakia: diagnosis and treatment / A.I. Neimark, E.V. Ilinskaya, Z.N. Lebedeva, T.S. Taranina // Urology – 2009. – No. 2. – pp.18-22.

Frumkin A.P. Cystoscopic atlas. Moscow, 1951.

>

Diseases referred to Urologist

Prostate adenoma
Azoospermia
Renal amyloidosis
Angiolipoma of the kidney
Balanoposthitis
Varicocele
Vesiculitis
Human papillomavirus (HPV)
Inflammation of the kidneys (nephritis)
hydronephrosis
hydrocele
overactive bladder
hypogonadism
Glomerulonephritis
bladder diverticulum
Benign prostatic hyperplasia (BPH)
Sexually transmitted diseases (STDs)
Urinary retention
Interstitial nephritis
Interstitial cystitis
Stones in the bladder
Stones in the ureter
Stones in the kidneys
kidney cyst
Cyst of the spermatic cord
Urachus cyst
warts
Short frenulum of the penis
cryptorchidism
cooperite
Mycoplasmosis
urinary syndrome
Urolithiasis disease
male infertility
Urinary incontinence
neurogenic bladder
Nephroptosis (prolapsed kidney)
Nephrosclerosis
Tumors of the ureter
Bladder tumor
Testicular tumor
Kidney prolapse
Orchitis
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Pyelitis
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Pyelectasis
Kidney damage
horseshoe kidney
Polycystic kidney disease
Urethral polyp
Postcoital cystitis
Renal colic
kidney failure
premature ejaculation
Prostatitis
bladder cancer
Cancer of the penis
kidney cancer
prostate cancer
urethral cancer
testicular cancer
Bladder fistula
Chronic pelvic pain syndrome
Sclerosis of the bladder neck
Urethral stricture
Bladder injury
penis injury
Trichomoniasis
Uremia
ureterocele
Urethritis
phimosis
Chlamydia
Chronic pyelonephritis
Chronic prostatitis
Chronic cystitis
Cystitis
cystitis (in women)
cystitis in men
Enuresis
Epididymitis
Erectile dysfunction

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Bladder leukoplakia: causes, symptoms and treatment

Bladder leukoplakia is a disease characterized by the degeneration of urothelial tissue into a squamous epithelium with many layers, in some cases keratinization occurs. Pathology can be asymptomatic, but most often patients complain of discomfort during urination and pelvic pain. Leukoplakia of the urinary organ is most often found in women, men rarely suffer from this pathology.

Causes

Predisposing factors for leukoplasia include the following:

Bladder leukoplakia develops under the influence of dystrophic disorders. When blood circulation is disturbed, normal trophism is also disturbed. The mucous membrane acquires a loose structure, as a result, viruses and bacteria easily penetrate into it. Predisposing factors include regular constipation, physical inactivity and varicose veins in the pelvic area.

Risk factors also include chronic alcoholism, lack of vitamin A, improper intake of certain medications.

Pathogenesis

Inflammatory processes lead to deterioration of local and general immunity, as a result of which pathogenic and conditionally pathogenic microflora easily enters the mucous membrane of the organ. With persistent infection, metaplasia gradually develops, fibrous tissue is formed. In some cases, keratinization of the stratified epithelial membrane occurs.

Bladder neck leukoplakia develops under the influence of urine on altered cells. This maintains a chronic inflammatory process, causing pain even after prior antibiotic therapy.

Varieties

Leukoplakia of the bladder neck in women is divided into the following types:

Non-keratized variety. Develops on the bladder triangle, may be normal. When symptoms appear, estrogens are prescribed.

The pathological process is divided into three stages. At the first, the transitional epithelium has metaplastic changes that can only be seen on histology. At the second stage, the epithelium continues to change, a plaque appears on the mucous membrane of the organ, which can be seen on cystoscopy. At the third stage, the entire mucous membrane is involved in the process, an inflammatory process is noticeable in the form of thickening of the walls of the organ, dilated vessels.

Bladder leukoplakia: symptoms

Signs include:

Difficulty urinating, pain during the process.

Deterioration of the quality of life, which is accompanied by neurosis, insomnia.

At the same time, at the first stage, the disease proceeds without symptoms.

Possible complications

In 20 percent of cases, the keratinized form leads to carcinoma. In the third stage, women complain of pain during intercourse, men suffer from erectile dysfunction. Of the complications, it is worth highlighting a chronic urinary tract infection.

With a constant inflammatory process, fibrous tissue is formed, which makes normal urination difficult, leads to pyelonephritis and chronic renal failure.

Diagnosis

Diagnosis of the disease is possible at the appointment of a urologist. The specialist directs the patient to laboratory tests, including a general urinalysis to detect an inflammatory process, PCR diagnostics for genital infections, urine culture on a nutrient medium to identify the exact pathogens of the infection. Women also donate blood for hormones.

Cystoscopy is distinguished from instrumental diagnostics, which reveals modified areas on the organ. Ultrasound of the pelvic organs and kidneys is performed to diagnose complications.

Bladder leukoplakia: treatment

Non-keratized form requires systematic monitoring, when symptoms appear, the woman is prescribed a course of estrogens. With a keratized form, a conservative or surgical method is chosen, depending on the stage of the disease.

Drug therapy includes antibiotics (pre-susceptibility test), anti-inflammatory drugs, and drugs to improve the immune system, including prebiotics. If the disease is accompanied by cystitis, antiseptic and analgesic formulations can be injected into the bladder. In case of fungal infection, appropriate antifungal drugs are prescribed.

Treatment of leukoplakia of the bladder neck in women is effective with physiotherapy. For this, magnetotherapy, electrophoresis, laser therapy are practiced. Physiotherapy reduces the inflammatory process, improves blood circulation, and also increases the concentration of drugs in the mucous membrane of the organ.

In the last stages, surgical treatment is prescribed. Of the methods, it is worth highlighting sparing laser therapy, which minimizes the risk of complications, as well as transurethral type resection. During resection, the surgeon inserts a cystoscope into the urethra, after which the pathological areas in the bladder cavity are cut off with a loop, the integrity of the organ can be preserved. With an extensive process, removal of the bladder is prescribed, but in practice this operation is rarely performed.

Prognosis and preventive measures

The prognosis depends on the stage and form of pathology, if the form does not have keratinization, the prognosis will be favorable. In case of a disease with keratinization, the prognosis is considered favorable, provided that a specialist is contacted in a timely manner. With the advanced stage and the development of complications, the patient’s disability is possible.

Preventive measures include seeking medical attention at the first sign of illness, timely diagnosis, using barrier contraceptives during sexual intercourse, and maintaining a healthy lifestyle in general.

Nutritional guidelines for leukoplakia

The diet should be based on natural products. The diet should include cereals, vegetables and fruits, herbs, boiled meat and fish, herbal teas. It is worth giving up foods with a high salt content, which lead to fluid retention in the body.

Fried and fatty foods, sweets should also be limited. Do not drink carbonated drinks, refrain from alcohol.

Features of the disease during pregnancy

Bladder leukoplakia in women during pregnancy is not a fully understood fact. In most cases, the pathology begins to develop before the conception of the child. In pregnant patients, HPV, hormonal imbalances, true erosions and pseudo-erosions are simultaneously detected, and the general immune system suffers.

An increased concentration of estrogens in the body of a pregnant woman negatively affects the course of leukoplakia. At the same time, during the gestation of the fetus during treatment, it is important to prescribe such drugs that will not harm the health of the child.