Cystodistension: No Standards And No Benefits-Survey Of UK Practice - When Data Is Limited, The Place Of Hydrodistention And Hunner's Lesion Ablation
December 17, 2017
UroToday - Cystoscopy with hydrodistention is not practiced in any standardized fashion despite proposals by the National Institute of Diabetes Digestive and Kidney Disorders (NIDDK) 2 decades ago and more recently the European Society for the Study of Interstitial Cystitis (ESSIC) to establish such standards. Mahendru and Al-Taher from Colchester and Kings Lynn UK posted questionnaires to 486 Consultant gynecologists, and urologists in the UK to assess current practices. Ninety-six percent of the 153 responders performed distention under general anesthesia, 66% distending the bladder only once during the procedure. Distention volumes and pressures varied widely with 76 of distentions less than 5 minutes in duration. Bladder rupture was observed by 4.4% of the physicians. The procedure was deemed valuable by 76% of respondents. The authors conclude that distention practices are very variable, results difficult to compare, and the overall value remains questionable in the absence of prospective, controlled trials.
The above study nicely segues into a provocative and interesting retrospective study brought to my attention by Jane Meijlink of the International Painful Bladder Foundation. Payne and colleagues from Milwaukee reviewed the charts of 14 patients, all female, who were treated with cystoscopically identified bladder lesions presumed to be Hunner's lesion. None had a hydrodistention. All patients had failed multiple standard therapies for BPS. Flexible cystosopcy was performed under local anesthesia to identify the presence of Hunner's lesions. Any erythematosus lesion was considered a Hunner's lesion if, upon touch with then cystoscope, the patient's pain was reproduced . Often these lesions demonstrated small vessels radiating toward a central area of pallor, sometimes associated with a fibrinous exudate. At a later date, under anesthesia, the lesions were biopsied and ablated, generally by cauterization. Hydrodistention was avoided in all cases.
Payne and associates report that 12 of 14 patients experienced greater than 50% improvement in symptoms with 50% of patients noting complete resolution. Responses were durable, lasting 8-55 months, and in 4 patients experiencing recurrence of symptoms after a mean response of 1 year, excellent results with reoperation were noted. Were these Hunner's lesions pathologically? Twelve of 14 specimens showed epithelial denudation and 13 of 14 had chronic inflammatory cells. Only 3 patients had mast cells, which the authors attribute to the superficiality of the biopsy specimens.
Thus, it may be possible to avoid hydrodistention in the search for treatable Hunner's lesions. The question is how reliable in picking up these lesions is the authors' technique. The sensitivity and specificity will await a larger, controlled prospective trial which should be easy to construct using each patient as his or her own control. It is conceivable that the current tendency in many areas to avoid cystoscopy as a first line diagnostic tool may change if future findings bear out the results in this report.
Mahendru AA, Al-Taher H
Int Urogynecol J Pelvic Floor Dysfunct. 2010 Feb;21(2):135-9
UroToday Contributing Editor Philip M. Hanno, MD, MPH
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