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A New Technique for Bladder Washing
0022-5347/92/1&71-0189$03.00/0 THE JOURNAL OF UROLOGY Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, !NC.
Vol.
A NEW TECHNIQUE FOR BLADDER WASHING DAVID C. MILLER, DAVID L. FITKIN, KENNETH A. KROPP, AND STEVEN H. SELMAN* From the Department of Urology, Medical College of Ohio, Toledo, Ohio
ABSTRACT We describe a simple adaption of the Water Pik (Teledyne Water Pik, Fort Collins, Colorado) irrigating device which allows vigorous, direct-vision agitation of the bladder wall. Three groups of mongrel dogs were subjected to cystoscopy and either syringe barbotage, half-speed Water Pik irrigation, or full-speed Water Pik irrigation of the bladder wall. Transitional cell counts were then done on centrifuged aliquots of each bladder wash specimen. The average number of transitional cells per high-power field were similar between the control group and the syringe barbotage group (2.5 and 1.5 respectively). However, both the half-speed and the full-speed Water Pik groups demonstrated statistically higher cell counts (5.7 and 13.7) when compared to both the controls and syringe barbotage groups. We conclude that Water Pik irrigation is an effective method to increase cell yield in bladder wash specimens. KEY WORDS: cytology, cystoscopy, bladder The cornerstone of bladder cancer detection and follow-up has long been surveillance cystoscopy. Although conflicting reports exist in the literature concerning the diagnostic accu racy of cytology, it is accepted that increased cellular material in a bladder specimen increases the diagnostic accuracy of cytologic examination.1-4 With the introduction of flexible cytoscopy, evaluation and follow-up of the patient with bladder cancer can be done under local anesthesia in the outpatient setting. Recovery of bladder cells for both routine cytologic examination and flow cytometry has become an integral part of the evaluation of the patient with bladder cancer. Vigorous bladder washing and recovery of cells from the bladder through the flexible cytoscope has not been optimized. Usually a second catheter or instrument must be introduced to obtain a "bladder wash" for bladder cell recovery. Our experience has been that in many patients blad der cell recovery is poor using manual irrigation of the bladder. This study was undertaken to evaluate a new method for increasing transitional cell yield in bladder wash specimens.
mately one cm. from the bladder wall, 100 cc aliquots of saline were used to irrigate the dome, anterior, posterior, and lateral walls for a total of 500 cc. Group III consisted of six dogs. Each dog underwent Water Pik irrigation in an identical manner as described for Group II with the exception that Water Pik irrigation was done at "full speed" on the Water Pik device. Transitional cell counts were done on each initial urine and each bladder wash specimen from each group. A well-mixed, 10 cc aliquot from each specimen was centrifuged at 1,000 rpm for 10 minutes.5 The supernatant was discarded. The cellular debris was then cytocentrifuged at 15,000 rpm for two minutes. The supernatant was again discarded. Each specimen was then evaluated by counting the transitional cells seen in 10 high power (400X) fields. These counts were then averaged for each of the three groups. The results were subjected to statistical analysis using Student's t test analysis. RESULTS
Cultures of the initial urine specimens revealed no significant bacterial colony counts in all cases. The average transitional cell counts per high-power field were similar between the con trol group (2.5) and Group I in which syringe barbotage was used to wash the bladder (1.5). Group II and Group III, half speed and full-speed Water Pik irrigation respectively, dem onstrated statistically significantly higher transitional cell counts (5.7 and 13.7 respectively) when compared to both the controls and the syringe barbotage groups. The results are summarized in table 1. Furthermore, cystoscopic evaluation after the bladder wash ings were completed revealed no gross significant, observable differences of the bladder mucosa between each of the three groups. In each case very small areas of submucosal hemorrhage could be identified. No perforation or mucosa! lacerations could be identified cystoscopically.
MATERIALS AND METHODS
Nineteen mongrel dogs underwent cystoscopy under general anesthesia. A perineal urethrostomy was required in the male canine to access the bladder cystoscopically. Once inside the bladder, the urine and initial cystoscopic fluid was collected and submitted for culture and transitional cell counts which comprised the control cell counts. The dogs were then random ized to three groups for bladder washings. Group I underwent Toomey syringe barbotage. Group II and III underwent Water Pik irrigation. We created a simple adaption of the Water Pik irrigation device to accommodate an 8F-tapered ureteral cath eter (figure 1). The overall experimental scheme is depicted in figure 2. Group I consisted of six dogs which underwent manual bladder barbotage with a 60 cc glass Toomey syringe through an 18.5 F cystoscope sheath. The bladders were irrigated with 100 cc aliquots of normal saline on the dome, anterior, posterior and lateral walls for a total of 500 cc. Each saline aliquot was irrigated in and out of the bladder five times before collecting it and proceeding with the next aliquot. Group II consisted of seven dogs which underwent Water Pik irrigation at half-speed on the Water Pik device. Under direct vision with the tapered ureteral catheter tip approxiAccepted for publication June 25, 1991. * Requests for reprints: Division of Urology, Medical College of Ohio, PO Box 10008, Toledo OH 43699.
DISCUSSION
Bladder cancer is the second most common urologic malig nancy. It requires intermittent, long-term follow-up and early detection, especially in high-grade tumors, to attain successful local control. The cornerstone of bladder cancer detection has long been surveillance cystoscopy. In recent years, however, the role of urinary cytology has gained increasing importance for early detection.1, • • Although conflicting reports exist in the literature concerning the diagnostic accuracy of cytology, it is
189
2 6 7
190
MILLER AND ASSOCIATES TABLE 1. Results Group Control Syringe 1/2 Speed Full speed * p <0.05, t test.
FIG. 1. A, view of normal Water Pik irrigating tip and adaption made to accommodate SF ureteral catheter. B, view of entire ureteral catheter adapted to Water Pik tip.
19 DOGS CYSTOSCOPY & CULTURE
GROUP I
GROUP II
GROUP /II
SYRINGE
WATER-PIK
WATER-PIK
BARBOTAGE
112-SPEED
FULL SPEED
CELL COUNTS FIG. 2. Experimental scheme.
accepted that increased cellular material in a bladder specimen increases the diagnostic accuracy of cytologic examination.H In 1971, Harris et al. were the first to describe the use of a Toomey syringe to manually wash the bladder to obtain in creased cellular material for cytologic examination.6 Trott and Edwards directly compared cytology from voided urine and bladder washings.7 They found a significant increase in the accuracy of cancer diagnosis in the bladder washings. They cited the increased cellularity of the specimens as a major contribution to the increased accuracy.
Average Transitional Cells Per H.P.F.
Standard Error
2.5 1.5 5.7* 13.7*
(0.6) (0.9) (1.6) (3.8)
In 1978, Flanagan described a technique of bladder washing through a Foley catheter and cited mechanical agitation of the bladder wall by irrigation as one of the factors contributing to the effectiveness of bladder washings.1 On the contrary, Solo way et al cgukl-not document a.consistent difference in eellular yield when comparing simultaneously collected cystoscopic urine and bladder washings.2 They found that 13% of the cancers would have been missed if the cystoscopic urine had not been examined. More recently, Badalament et al. have shown that bladder irrigation specimens are more sensitive than voided urine specimens in the cytologic detection of blad der cancer.4 With the introduction of flexible cystoscopy, eval uation and follow-up of the patient with bladder cancer can be done under local anesthesia in the outpatient setting. Recovery of bladder cells for both routine cytologic examination and flow cytometry has become an integral part of the evaluation of the patient with bladder cancer. This study was undertaken to evaluate a new method for increasing transitional cell yield in bladder wash specimens. The Water Pik irrigating device has been used in urologic practice in the management of post-ESWL steinstrasse.8 We used a simple adaption to this device to allow vigorous, direct vision agitation of the bladder wall. Three groups of mongrel dogs were subjected to cystoscopy and either syringe barbotage, half-speed Water Pik irrigation, or full-speed Water Pik irri gation of the bladder wall (figure 1). Transitional cell counts were then done on centrifuged aliquots of each bladder wash specimen. The average number of transitional cells per high power field was similar between the control group and the syringe barbotage group (2.5 and 1.5 respectively). However, both the half-speed and the full-speed Water Pik groups dem onstrated statistically higher cell counts (5.7 and 13.7) when compared to both the controls and syringe barbotage groups (figure 2). We conclude that Water Pik irrigation is an effective method to increase cell yield in bladder wash specimens. Furthermore, the potential clinical applications may be of significant importance. Specifically, increased cell yield may lead to increased sensitivity of cytologic examination. Also, direct visualization may allow for selective irrigation of suspi cious areas. The method and delivery system described would certainly be amenable to upper tract irrigation. Thus, this could potentially be a welcome addition to the diagnostic modalities available to the practicing urologist, allowing for improved diagnosis of difficult upper tract lesions. Finally, vigorous me chanical bladder lavage through the flexible cystoscope has not been optimized. Usually, a second catheter or instrument must be introduced to obtain a "bladder wash" for bladder cell recovery. Our experience has been that in many patients, bladder cell recovery is poor using manual irrigation of the bladder. This system could be adapted to allow for bladder washings via a flexible cystoscope thereby eliminating the need for a second catheterization. It should be emphasized that these experimental findings in the normal canine urinary bladder may not be directly applicable to the patient with bladder cancer. Further studies both in the laboratory and clinical setting are needed to further evaluate these potential clinical applications. Acknowledgment. We wish to acknowledge the unselfish ex pertise of Mr. Ted Kleaver in performing the necessary urine cultures, urinalyses, and transitional cell counts.
H\JCREASI:t�G CELLULAR YIELD II'¼T BLADDER \VASI-I SPECI!A:ENS
REFERENCES 1. Flanagan, M. J. and Miller, A.: Evaluation of bladder washing cytology for bladder cancer surveillance. J. Urol., 119: 42, 1978. 2. Murphy, W. M., Crabtree, W. N., Jukkola, A. F., and Soloway, M. S.: The diagnostic value of urine versus bladder washing in patients with bladder cancer. J. Urol., 126: 320, 1981. 3. Klein, F.A. and White, F. K. H.: Flow cytometry deoxyribonucleic acid determinations and cytology of bladder washings: practical experience. J. Urol., 139: 275, 1988. 4. Badalament,R.A., Hermansen, D. K., Kimmel, M., Gay, H., Herr, H. W., Fair, W.R., Whitmore, W. F. and Melamed, M.R.: The sensitivity of bladder wash flow cytometry, bladder wash cytol-
191
ogy, and voided cytology in the detection of bladder carcinoma. Cancer, 60: 1423, 1987. 5. Crabtree, W. N. and Murphy, W. M.: The value of ethanol as a fixative in urinary cytology.Acta Cytologica, 24: 452, 1980. 6. Harris, M. J., Schwinn, C. P., Morrow, J. W., Gray, R. L. and Bromwell, B. M.: Exfoliative cytology of the urinary bladder irrigation specimen.Acta Cytologica, 15: 385, 1971. 7. Trott, P.A. and Edwards, L.: Comparison of bladder washings and urine cytology in the diagnosis and urine cytology in the diag nosis of bladder cancer. J. Urol., 110: 664, 1976. 8. Rubenstein, M. A. and Norris, D. M.: Variation on Water Pik technique for treatment of steinstrasse after ESWL. Urology, 32: 429, 1988.
Vol.
A NEW TECHNIQUE FOR BLADDER WASHING DAVID C. MILLER, DAVID L. FITKIN, KENNETH A. KROPP, AND STEVEN H. SELMAN* From the Department of Urology, Medical College of Ohio, Toledo, Ohio
ABSTRACT We describe a simple adaption of the Water Pik (Teledyne Water Pik, Fort Collins, Colorado) irrigating device which allows vigorous, direct-vision agitation of the bladder wall. Three groups of mongrel dogs were subjected to cystoscopy and either syringe barbotage, half-speed Water Pik irrigation, or full-speed Water Pik irrigation of the bladder wall. Transitional cell counts were then done on centrifuged aliquots of each bladder wash specimen. The average number of transitional cells per high-power field were similar between the control group and the syringe barbotage group (2.5 and 1.5 respectively). However, both the half-speed and the full-speed Water Pik groups demonstrated statistically higher cell counts (5.7 and 13.7) when compared to both the controls and syringe barbotage groups. We conclude that Water Pik irrigation is an effective method to increase cell yield in bladder wash specimens. KEY WORDS: cytology, cystoscopy, bladder The cornerstone of bladder cancer detection and follow-up has long been surveillance cystoscopy. Although conflicting reports exist in the literature concerning the diagnostic accu racy of cytology, it is accepted that increased cellular material in a bladder specimen increases the diagnostic accuracy of cytologic examination.1-4 With the introduction of flexible cytoscopy, evaluation and follow-up of the patient with bladder cancer can be done under local anesthesia in the outpatient setting. Recovery of bladder cells for both routine cytologic examination and flow cytometry has become an integral part of the evaluation of the patient with bladder cancer. Vigorous bladder washing and recovery of cells from the bladder through the flexible cytoscope has not been optimized. Usually a second catheter or instrument must be introduced to obtain a "bladder wash" for bladder cell recovery. Our experience has been that in many patients blad der cell recovery is poor using manual irrigation of the bladder. This study was undertaken to evaluate a new method for increasing transitional cell yield in bladder wash specimens.
mately one cm. from the bladder wall, 100 cc aliquots of saline were used to irrigate the dome, anterior, posterior, and lateral walls for a total of 500 cc. Group III consisted of six dogs. Each dog underwent Water Pik irrigation in an identical manner as described for Group II with the exception that Water Pik irrigation was done at "full speed" on the Water Pik device. Transitional cell counts were done on each initial urine and each bladder wash specimen from each group. A well-mixed, 10 cc aliquot from each specimen was centrifuged at 1,000 rpm for 10 minutes.5 The supernatant was discarded. The cellular debris was then cytocentrifuged at 15,000 rpm for two minutes. The supernatant was again discarded. Each specimen was then evaluated by counting the transitional cells seen in 10 high power (400X) fields. These counts were then averaged for each of the three groups. The results were subjected to statistical analysis using Student's t test analysis. RESULTS
Cultures of the initial urine specimens revealed no significant bacterial colony counts in all cases. The average transitional cell counts per high-power field were similar between the con trol group (2.5) and Group I in which syringe barbotage was used to wash the bladder (1.5). Group II and Group III, half speed and full-speed Water Pik irrigation respectively, dem onstrated statistically significantly higher transitional cell counts (5.7 and 13.7 respectively) when compared to both the controls and the syringe barbotage groups. The results are summarized in table 1. Furthermore, cystoscopic evaluation after the bladder wash ings were completed revealed no gross significant, observable differences of the bladder mucosa between each of the three groups. In each case very small areas of submucosal hemorrhage could be identified. No perforation or mucosa! lacerations could be identified cystoscopically.
MATERIALS AND METHODS
Nineteen mongrel dogs underwent cystoscopy under general anesthesia. A perineal urethrostomy was required in the male canine to access the bladder cystoscopically. Once inside the bladder, the urine and initial cystoscopic fluid was collected and submitted for culture and transitional cell counts which comprised the control cell counts. The dogs were then random ized to three groups for bladder washings. Group I underwent Toomey syringe barbotage. Group II and III underwent Water Pik irrigation. We created a simple adaption of the Water Pik irrigation device to accommodate an 8F-tapered ureteral cath eter (figure 1). The overall experimental scheme is depicted in figure 2. Group I consisted of six dogs which underwent manual bladder barbotage with a 60 cc glass Toomey syringe through an 18.5 F cystoscope sheath. The bladders were irrigated with 100 cc aliquots of normal saline on the dome, anterior, posterior and lateral walls for a total of 500 cc. Each saline aliquot was irrigated in and out of the bladder five times before collecting it and proceeding with the next aliquot. Group II consisted of seven dogs which underwent Water Pik irrigation at half-speed on the Water Pik device. Under direct vision with the tapered ureteral catheter tip approxiAccepted for publication June 25, 1991. * Requests for reprints: Division of Urology, Medical College of Ohio, PO Box 10008, Toledo OH 43699.
DISCUSSION
Bladder cancer is the second most common urologic malig nancy. It requires intermittent, long-term follow-up and early detection, especially in high-grade tumors, to attain successful local control. The cornerstone of bladder cancer detection has long been surveillance cystoscopy. In recent years, however, the role of urinary cytology has gained increasing importance for early detection.1, • • Although conflicting reports exist in the literature concerning the diagnostic accuracy of cytology, it is
189
2 6 7
190
MILLER AND ASSOCIATES TABLE 1. Results Group Control Syringe 1/2 Speed Full speed * p <0.05, t test.
FIG. 1. A, view of normal Water Pik irrigating tip and adaption made to accommodate SF ureteral catheter. B, view of entire ureteral catheter adapted to Water Pik tip.
19 DOGS CYSTOSCOPY & CULTURE
GROUP I
GROUP II
GROUP /II
SYRINGE
WATER-PIK
WATER-PIK
BARBOTAGE
112-SPEED
FULL SPEED
CELL COUNTS FIG. 2. Experimental scheme.
accepted that increased cellular material in a bladder specimen increases the diagnostic accuracy of cytologic examination.H In 1971, Harris et al. were the first to describe the use of a Toomey syringe to manually wash the bladder to obtain in creased cellular material for cytologic examination.6 Trott and Edwards directly compared cytology from voided urine and bladder washings.7 They found a significant increase in the accuracy of cancer diagnosis in the bladder washings. They cited the increased cellularity of the specimens as a major contribution to the increased accuracy.
Average Transitional Cells Per H.P.F.
Standard Error
2.5 1.5 5.7* 13.7*
(0.6) (0.9) (1.6) (3.8)
In 1978, Flanagan described a technique of bladder washing through a Foley catheter and cited mechanical agitation of the bladder wall by irrigation as one of the factors contributing to the effectiveness of bladder washings.1 On the contrary, Solo way et al cgukl-not document a.consistent difference in eellular yield when comparing simultaneously collected cystoscopic urine and bladder washings.2 They found that 13% of the cancers would have been missed if the cystoscopic urine had not been examined. More recently, Badalament et al. have shown that bladder irrigation specimens are more sensitive than voided urine specimens in the cytologic detection of blad der cancer.4 With the introduction of flexible cystoscopy, eval uation and follow-up of the patient with bladder cancer can be done under local anesthesia in the outpatient setting. Recovery of bladder cells for both routine cytologic examination and flow cytometry has become an integral part of the evaluation of the patient with bladder cancer. This study was undertaken to evaluate a new method for increasing transitional cell yield in bladder wash specimens. The Water Pik irrigating device has been used in urologic practice in the management of post-ESWL steinstrasse.8 We used a simple adaption to this device to allow vigorous, direct vision agitation of the bladder wall. Three groups of mongrel dogs were subjected to cystoscopy and either syringe barbotage, half-speed Water Pik irrigation, or full-speed Water Pik irri gation of the bladder wall (figure 1). Transitional cell counts were then done on centrifuged aliquots of each bladder wash specimen. The average number of transitional cells per high power field was similar between the control group and the syringe barbotage group (2.5 and 1.5 respectively). However, both the half-speed and the full-speed Water Pik groups dem onstrated statistically higher cell counts (5.7 and 13.7) when compared to both the controls and syringe barbotage groups (figure 2). We conclude that Water Pik irrigation is an effective method to increase cell yield in bladder wash specimens. Furthermore, the potential clinical applications may be of significant importance. Specifically, increased cell yield may lead to increased sensitivity of cytologic examination. Also, direct visualization may allow for selective irrigation of suspi cious areas. The method and delivery system described would certainly be amenable to upper tract irrigation. Thus, this could potentially be a welcome addition to the diagnostic modalities available to the practicing urologist, allowing for improved diagnosis of difficult upper tract lesions. Finally, vigorous me chanical bladder lavage through the flexible cystoscope has not been optimized. Usually, a second catheter or instrument must be introduced to obtain a "bladder wash" for bladder cell recovery. Our experience has been that in many patients, bladder cell recovery is poor using manual irrigation of the bladder. This system could be adapted to allow for bladder washings via a flexible cystoscope thereby eliminating the need for a second catheterization. It should be emphasized that these experimental findings in the normal canine urinary bladder may not be directly applicable to the patient with bladder cancer. Further studies both in the laboratory and clinical setting are needed to further evaluate these potential clinical applications. Acknowledgment. We wish to acknowledge the unselfish ex pertise of Mr. Ted Kleaver in performing the necessary urine cultures, urinalyses, and transitional cell counts.
H\JCREASI:t�G CELLULAR YIELD II'¼T BLADDER \VASI-I SPECI!A:ENS
REFERENCES 1. Flanagan, M. J. and Miller, A.: Evaluation of bladder washing cytology for bladder cancer surveillance. J. Urol., 119: 42, 1978. 2. Murphy, W. M., Crabtree, W. N., Jukkola, A. F., and Soloway, M. S.: The diagnostic value of urine versus bladder washing in patients with bladder cancer. J. Urol., 126: 320, 1981. 3. Klein, F.A. and White, F. K. H.: Flow cytometry deoxyribonucleic acid determinations and cytology of bladder washings: practical experience. J. Urol., 139: 275, 1988. 4. Badalament,R.A., Hermansen, D. K., Kimmel, M., Gay, H., Herr, H. W., Fair, W.R., Whitmore, W. F. and Melamed, M.R.: The sensitivity of bladder wash flow cytometry, bladder wash cytol-
191
ogy, and voided cytology in the detection of bladder carcinoma. Cancer, 60: 1423, 1987. 5. Crabtree, W. N. and Murphy, W. M.: The value of ethanol as a fixative in urinary cytology.Acta Cytologica, 24: 452, 1980. 6. Harris, M. J., Schwinn, C. P., Morrow, J. W., Gray, R. L. and Bromwell, B. M.: Exfoliative cytology of the urinary bladder irrigation specimen.Acta Cytologica, 15: 385, 1971. 7. Trott, P.A. and Edwards, L.: Comparison of bladder washings and urine cytology in the diagnosis and urine cytology in the diag nosis of bladder cancer. J. Urol., 110: 664, 1976. 8. Rubenstein, M. A. and Norris, D. M.: Variation on Water Pik technique for treatment of steinstrasse after ESWL. Urology, 32: 429, 1988.