- Email: [email protected]
Re: Air Cystoscopy is Superior to Water Cystoscopy for the Diagnosis of Active Hematuria
LETTERS TO THE EDITOR/ERRATA
1931
Reply by Authors: The members of the International Bladder Cancer Group are pleased to accept the recommendation of Bryan et al to adopt the term “biological progression” as our new definition of progression. As stated, the new definition includes important disease characteristics beyond simple increase in stage, or “stage progression.” After careful consideration and discussion we decided to omit physician treatment decisions, such as cystectomy, systemic chemotherapy and radiation, from the definition, since these may reflect the biology of the urologist rather than the tumor. Therefore, we define “biological progression” as an increase in tumor stage from Ta to T1 or higher, from T1 to T2 or higher, in CIS to T1 or higher and in low grade, Ta or T1 to CIS or other high grade disease. We, too, believe that this definition will improve the interpretation and performance of clinical trials of patients with NMIBC, and appreciate further efforts to popularize and promote this term as the new standard.
Re: Air Cystoscopy is Superior to Water Cystoscopy for the Diagnosis of Active Hematuria A. Ciudin, M. G. Diaconu, D. Gosalbez, L. Peri, E. Garcia-Cruz, A. Franco and A. Alcaraz J Urol 2013; 190: 2097e2101.
To the Editor: We read with interest this article comparing air cystoscopy with water cystoscopy. We congratulate the authors for establishing the greater sensitivity and specificity of air cystoscopy over water cystoscopy in active hematuria by flexible cystoscopy with no outlet channel. This study revives the concept of air cystoscopy, which is cheaper and has better tolerability scores. However, certain points need clarification. The authors performed water cystoscopy first, which would have washed the bladder and may have removed bladder clots. As air cystoscopy was done after water cystoscopy, vision would definitely be better since the wash was already done during water cystoscopy. The authors also need to clarify whether air needed to be continuously insufflated with a Luer lock syringe during air cystoscopy or was just insufflated once. In our institutional experience significant pericystoscope leakage of water sometimes occurs, particularly with a full bladder during water cystoscopy. Whether leakage occurred during air cystoscopy also needs to be clarified. The authors should also have mentioned hematuria grade in the active hematuria group and vision quality score according to hematuria grade. Respectfully, Saurabh Gupta, Vishwajeet Singh and Kuldeep Sharma King George’s Medical University Lucknow, Uttar Pradesh India
To the Editor: We read this article with immense interest. We appreciate the idea of comparing air cystoscopy to water cystoscopy in diagnosing the cause of hematuria. We would like to discuss a few practical aspects in the diagnostic evaluation of a patient with hematuria. In this study of 57 patients with active hematuria prostatic bleeding is considered the cause in 17. Is there any evidence of active bleeding from the prostate in these cases, or it is considered a diagnosis of exclusion? In addition, what is the reason for water cystoscopy being inferior to air cystoscopy in diagnosing prostatic bleeding? There is no need to perform invasive office flexible cystoscopy before rigid cystoscopy in bladder tumors that can be easily diagnosed by a noninvasive bedside ultrasound of the kidneys, ureters and bladder (KUB). Flexible cystoscopy should be considered for diagnosing the cause of hematuria only in those patients in whom the bladder was normal on ultrasound. If a larger tumor with active hematuria is present on ultrasound, there is no need to perform diagnostic flexible cystoscopy before rigid therapeutic cystoscopy. Ultrasound KUB is not done before cystoscopy, and this may lead to missing an upper tract tumor as a cause of bleeding.
1932
LETTERS TO THE EDITOR/ERRATA
Even minimal trauma to the bladder neck during initial water cystoscopy can lead to bleeding, which can be misinterpreted as prostatic bleeding causing active hematuria on air cystoscopy. This can lead to increased diagnosis of prostatic bleeding during air cystoscopy vs water cystoscopy, as observed in this study. While urethroscopy is already done using saline as irrigation, only a small amount of extra saline is needed for cystoscopy. So cost is not a concern for doing water cystoscopy compared to air cystoscopy. Since prostatic bleeding is caused by rupture of engorged prostatic veins, there is a risk of air embolism with air cystoscopy, and it is necessary to know how much intravesical pressure is created by air cystoscopy (venous air embolism after transurethral prostatectomy).1 Finally, in the present study small tumors are seen better with water cystoscopy and larger tumors can easily be seen with ultrasound. So what is the need for using air cystoscopy over water cystoscopy? These issues should be considered while accepting the conclusion of the study that air cystoscopy is better than water cystoscopy for the diagnosis of active hematuria. Flexible cystoscopy is an invasive procedure, and it should be considered only after routine ultrasound KUB for diagnosing the cause of hematuria. This will avoid unnecessary cystoscopy before definitive bladder biopsy. Respectfully, Santosh Kumar, Gautam Ram Choudhari and Sudheer K. Devana Department of Urology Postgraduate Institute of Medical Education and Research Chandigarh India e-mail: [email protected]
Reply by Authors: Apart from the facts, numbers and conclusions in our article, some clarification might be needed. The fact that water cystoscopy was performed first raised the doubt that this might have presented an advantage for the second observer performing air cystoscopies, as the first observer performing water cystoscopy might have washed away the blood and clots. Nonetheless, in our study both observers had the liberty of washing the bladder or even inserting a bladder catheter to do it, trying to achieve better visualization. So even if the first observer washed the bladder, the diagnosis was established at the end of the procedure, when the bladder was already washed, leaving it in the same condition for the second observer performing air cystoscopy. In our practice we did not encounter the need for continuous insufflation of air, and the insertion of 100 to 150 cc atmospheric air used to be enough to perform a good air cystoscopy. On the other hand, the fact that air is compressible and water is not, resulting in a difference in pressure for a given volume (lower for air), might explain why we did not encounter air leakage when the bladder was filled. Several authors reported cases of possible air embolism after transurethral prostatectomy or transurethral incision of the prostate.1,2 Nonetheless, these cases were related to actively pumping an estimated volume of 400 ml air for 15 to 30 seconds due to an operating room error into a patient with gross hematuria during transurethral prostatectomy, and also the use of the low lithotomy position with the head and thorax beneath the plane of the prostate. This extreme case has nothing in common with the technique used in our study. To our knowledge there is no validated classification of hematuria intensity. Thus, we could not perform a stratification of visibility score result according to hematuria intensity. Nonetheless, the subjective sense was that even a small degree of persistent active hematuria rapidly modified the visibility in water, while air vision maintained a much higher quality.
LETTERS TO THE EDITOR/ERRATA
1933
In our experience KUB ultrasound has limitations in patients with active hematuria. The images are difficult to interpret because of the simultaneous presence of clots and the urinary catheter. Furthermore, not even Doppler evaluation is always useful because of urine, blood and saline inflows. On the other hand, air cystoscopy, although more invasive, has the advantage of being able to wash the bladder and set the diagnosis, and also is a priority for rigid cystoscopy. Due to the limitations of our health system, there is a waiting list for surgery, and knowing the diagnosis preoperatively is important, as for example tumors with a muscle invasive aspect should be given priority over prostatic bleeding. On the other hand, if cystoscopy is normal, then KUB ultrasound, or even better, excretory urography or computerized tomography of the urinary tract, should be performed to identify an upper urinary tract source of bleeding. At our centers air cystoscopy yielded good results in patients with active hematuria, becoming the standard procedure for these patients in daily practice. The data from our study showed that air cystoscopy might be the better option in patients with active hematuria. Our final conclusion is that all urologists who perform classic water cystoscopy might be able to perform air cystoscopy, as it only represents a small technical variation, being better tolerated with superior results in patients with active hematuria. 1. Matsuno D, Cho S, Isshiki S et al: A case of venous air embolism during transurethral resection of the prostate. Hinyokika Kiyo 2007; 53: 409. 2. Frasco PE, Caswell RE and Novicki D: Venous air embolism during transurethral resection of the prostate. Anesth Analg 2004; 99: 1864.
Re: Effect of Prior Radiotherapy and Ablative Therapy on Surgical Outcomes for the Treatment of Rectourethral Fistulas B. J. Linder, E. C. Umbreit, D. Larson, E. J. Dozois, P. Thapa and D. S. Elliott J Urol 2013; 190: 1287e1291.
To the Editor: This recent publication by Linder et al advocates consideration of early permanent urinary and fecal diversion for patients with rectourethral fistulas (RUFs) secondary to radiation/ablative therapy. Of the 29 patients with radiation/ablative RUFs only 6 underwent attempted closure, with 1 successful repair. An interposition muscle flap was used in only 2 of the 6 patients, and none underwent attempted repair with an onlay graft. In our experience the majority of cases of radiation/ablative RUF can be successfully reconstructed, thereby avoiding permanent urinary diversion. In our previously published series of 39 patients with radiation/ablative RUF 84% underwent successful closure in a single operation.1 Although 31% of our patients required permanent fecal diversion, the majority maintained an intact bladder and rectum. The basis of our successful closure in these complex RUFs is use of a buccal mucosal graft patch to close the prostatic defect, which is not amenable to traditional wound edge closure. Additionally a gracilis muscle interposition flap has a significant role in serving as a viable graft bed, providing separation of the urethral and rectal suture lines, and closure of dead space. Our continued experience with a transperineal repair with buccal graft onlay and gracilis muscle interposition flap has confirmed the role of reconstruction in the repair of the majority of radiation/ablative RUFs. Respectfully, Alex Vanni and Leonard Zinman Department of Urology Lahey Hospital and Medical Center Burlington, Massachusetts 1. Vanni AJ, Buckley JC and Zinman LN: Management of surgical and radiation induced rectourethral fistulas with an interposition muscle flap and selective buccal mucosal onlay graft. J Urol 2010; 184: 2400.
1931
Reply by Authors: The members of the International Bladder Cancer Group are pleased to accept the recommendation of Bryan et al to adopt the term “biological progression” as our new definition of progression. As stated, the new definition includes important disease characteristics beyond simple increase in stage, or “stage progression.” After careful consideration and discussion we decided to omit physician treatment decisions, such as cystectomy, systemic chemotherapy and radiation, from the definition, since these may reflect the biology of the urologist rather than the tumor. Therefore, we define “biological progression” as an increase in tumor stage from Ta to T1 or higher, from T1 to T2 or higher, in CIS to T1 or higher and in low grade, Ta or T1 to CIS or other high grade disease. We, too, believe that this definition will improve the interpretation and performance of clinical trials of patients with NMIBC, and appreciate further efforts to popularize and promote this term as the new standard.
Re: Air Cystoscopy is Superior to Water Cystoscopy for the Diagnosis of Active Hematuria A. Ciudin, M. G. Diaconu, D. Gosalbez, L. Peri, E. Garcia-Cruz, A. Franco and A. Alcaraz J Urol 2013; 190: 2097e2101.
To the Editor: We read with interest this article comparing air cystoscopy with water cystoscopy. We congratulate the authors for establishing the greater sensitivity and specificity of air cystoscopy over water cystoscopy in active hematuria by flexible cystoscopy with no outlet channel. This study revives the concept of air cystoscopy, which is cheaper and has better tolerability scores. However, certain points need clarification. The authors performed water cystoscopy first, which would have washed the bladder and may have removed bladder clots. As air cystoscopy was done after water cystoscopy, vision would definitely be better since the wash was already done during water cystoscopy. The authors also need to clarify whether air needed to be continuously insufflated with a Luer lock syringe during air cystoscopy or was just insufflated once. In our institutional experience significant pericystoscope leakage of water sometimes occurs, particularly with a full bladder during water cystoscopy. Whether leakage occurred during air cystoscopy also needs to be clarified. The authors should also have mentioned hematuria grade in the active hematuria group and vision quality score according to hematuria grade. Respectfully, Saurabh Gupta, Vishwajeet Singh and Kuldeep Sharma King George’s Medical University Lucknow, Uttar Pradesh India
To the Editor: We read this article with immense interest. We appreciate the idea of comparing air cystoscopy to water cystoscopy in diagnosing the cause of hematuria. We would like to discuss a few practical aspects in the diagnostic evaluation of a patient with hematuria. In this study of 57 patients with active hematuria prostatic bleeding is considered the cause in 17. Is there any evidence of active bleeding from the prostate in these cases, or it is considered a diagnosis of exclusion? In addition, what is the reason for water cystoscopy being inferior to air cystoscopy in diagnosing prostatic bleeding? There is no need to perform invasive office flexible cystoscopy before rigid cystoscopy in bladder tumors that can be easily diagnosed by a noninvasive bedside ultrasound of the kidneys, ureters and bladder (KUB). Flexible cystoscopy should be considered for diagnosing the cause of hematuria only in those patients in whom the bladder was normal on ultrasound. If a larger tumor with active hematuria is present on ultrasound, there is no need to perform diagnostic flexible cystoscopy before rigid therapeutic cystoscopy. Ultrasound KUB is not done before cystoscopy, and this may lead to missing an upper tract tumor as a cause of bleeding.
1932
LETTERS TO THE EDITOR/ERRATA
Even minimal trauma to the bladder neck during initial water cystoscopy can lead to bleeding, which can be misinterpreted as prostatic bleeding causing active hematuria on air cystoscopy. This can lead to increased diagnosis of prostatic bleeding during air cystoscopy vs water cystoscopy, as observed in this study. While urethroscopy is already done using saline as irrigation, only a small amount of extra saline is needed for cystoscopy. So cost is not a concern for doing water cystoscopy compared to air cystoscopy. Since prostatic bleeding is caused by rupture of engorged prostatic veins, there is a risk of air embolism with air cystoscopy, and it is necessary to know how much intravesical pressure is created by air cystoscopy (venous air embolism after transurethral prostatectomy).1 Finally, in the present study small tumors are seen better with water cystoscopy and larger tumors can easily be seen with ultrasound. So what is the need for using air cystoscopy over water cystoscopy? These issues should be considered while accepting the conclusion of the study that air cystoscopy is better than water cystoscopy for the diagnosis of active hematuria. Flexible cystoscopy is an invasive procedure, and it should be considered only after routine ultrasound KUB for diagnosing the cause of hematuria. This will avoid unnecessary cystoscopy before definitive bladder biopsy. Respectfully, Santosh Kumar, Gautam Ram Choudhari and Sudheer K. Devana Department of Urology Postgraduate Institute of Medical Education and Research Chandigarh India e-mail: [email protected]
Reply by Authors: Apart from the facts, numbers and conclusions in our article, some clarification might be needed. The fact that water cystoscopy was performed first raised the doubt that this might have presented an advantage for the second observer performing air cystoscopies, as the first observer performing water cystoscopy might have washed away the blood and clots. Nonetheless, in our study both observers had the liberty of washing the bladder or even inserting a bladder catheter to do it, trying to achieve better visualization. So even if the first observer washed the bladder, the diagnosis was established at the end of the procedure, when the bladder was already washed, leaving it in the same condition for the second observer performing air cystoscopy. In our practice we did not encounter the need for continuous insufflation of air, and the insertion of 100 to 150 cc atmospheric air used to be enough to perform a good air cystoscopy. On the other hand, the fact that air is compressible and water is not, resulting in a difference in pressure for a given volume (lower for air), might explain why we did not encounter air leakage when the bladder was filled. Several authors reported cases of possible air embolism after transurethral prostatectomy or transurethral incision of the prostate.1,2 Nonetheless, these cases were related to actively pumping an estimated volume of 400 ml air for 15 to 30 seconds due to an operating room error into a patient with gross hematuria during transurethral prostatectomy, and also the use of the low lithotomy position with the head and thorax beneath the plane of the prostate. This extreme case has nothing in common with the technique used in our study. To our knowledge there is no validated classification of hematuria intensity. Thus, we could not perform a stratification of visibility score result according to hematuria intensity. Nonetheless, the subjective sense was that even a small degree of persistent active hematuria rapidly modified the visibility in water, while air vision maintained a much higher quality.
LETTERS TO THE EDITOR/ERRATA
1933
In our experience KUB ultrasound has limitations in patients with active hematuria. The images are difficult to interpret because of the simultaneous presence of clots and the urinary catheter. Furthermore, not even Doppler evaluation is always useful because of urine, blood and saline inflows. On the other hand, air cystoscopy, although more invasive, has the advantage of being able to wash the bladder and set the diagnosis, and also is a priority for rigid cystoscopy. Due to the limitations of our health system, there is a waiting list for surgery, and knowing the diagnosis preoperatively is important, as for example tumors with a muscle invasive aspect should be given priority over prostatic bleeding. On the other hand, if cystoscopy is normal, then KUB ultrasound, or even better, excretory urography or computerized tomography of the urinary tract, should be performed to identify an upper urinary tract source of bleeding. At our centers air cystoscopy yielded good results in patients with active hematuria, becoming the standard procedure for these patients in daily practice. The data from our study showed that air cystoscopy might be the better option in patients with active hematuria. Our final conclusion is that all urologists who perform classic water cystoscopy might be able to perform air cystoscopy, as it only represents a small technical variation, being better tolerated with superior results in patients with active hematuria. 1. Matsuno D, Cho S, Isshiki S et al: A case of venous air embolism during transurethral resection of the prostate. Hinyokika Kiyo 2007; 53: 409. 2. Frasco PE, Caswell RE and Novicki D: Venous air embolism during transurethral resection of the prostate. Anesth Analg 2004; 99: 1864.
Re: Effect of Prior Radiotherapy and Ablative Therapy on Surgical Outcomes for the Treatment of Rectourethral Fistulas B. J. Linder, E. C. Umbreit, D. Larson, E. J. Dozois, P. Thapa and D. S. Elliott J Urol 2013; 190: 1287e1291.
To the Editor: This recent publication by Linder et al advocates consideration of early permanent urinary and fecal diversion for patients with rectourethral fistulas (RUFs) secondary to radiation/ablative therapy. Of the 29 patients with radiation/ablative RUFs only 6 underwent attempted closure, with 1 successful repair. An interposition muscle flap was used in only 2 of the 6 patients, and none underwent attempted repair with an onlay graft. In our experience the majority of cases of radiation/ablative RUF can be successfully reconstructed, thereby avoiding permanent urinary diversion. In our previously published series of 39 patients with radiation/ablative RUF 84% underwent successful closure in a single operation.1 Although 31% of our patients required permanent fecal diversion, the majority maintained an intact bladder and rectum. The basis of our successful closure in these complex RUFs is use of a buccal mucosal graft patch to close the prostatic defect, which is not amenable to traditional wound edge closure. Additionally a gracilis muscle interposition flap has a significant role in serving as a viable graft bed, providing separation of the urethral and rectal suture lines, and closure of dead space. Our continued experience with a transperineal repair with buccal graft onlay and gracilis muscle interposition flap has confirmed the role of reconstruction in the repair of the majority of radiation/ablative RUFs. Respectfully, Alex Vanni and Leonard Zinman Department of Urology Lahey Hospital and Medical Center Burlington, Massachusetts 1. Vanni AJ, Buckley JC and Zinman LN: Management of surgical and radiation induced rectourethral fistulas with an interposition muscle flap and selective buccal mucosal onlay graft. J Urol 2010; 184: 2400.