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 ournew definition of progression. As stated, the new definition includes important disease charac-teristics beyond simple increase in stage, or “stage progression.” After careful consideration anddiscussion we decided to omit physician treatment decisions, such as cystectomy, systemicchemotherapy and radiation, from the definition, since these may reflect the biology of theurologist rather than the tumor. Therefore, we define “biological progression” as an increasein tumor stage from Ta to T1 or higher, from T1 to T2 or higher, in CIS to T1 or higher and inlow grade, Ta or T1 to CIS or other high grade disease. We, too, believe that this definitionwill 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 theDiagnosis 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 aircystoscopy over water cystoscopy in active hematuria by flexible cystoscopy with no outletchannel. This study revives the concept of air cystoscopy, which is cheaper and has bettertolerability scores. However, certain points need clarification. The authors performed watercystoscopy 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 thewash was already done during water cystoscopy. The authors also need to clarify whether airneeded to be continuously insufflated with a Luer lock syringe during air cystoscopy or was justinsufflated once. In our institutional experience significant pericystoscope leakage of watersometimes occurs, particularly with a full bladder during water cystoscopy. Whether leakageoccurred during air cystoscopy also needs to be clarified. The authors should also have mentionedhematuria grade in the active hematuria group and vision quality score according to hematuriagrade.

Respectfully,

Saurabh Gupta, Vishwajeet Singh and Kuldeep SharmaKing 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 discussa 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 in17. Is there any evidence of active bleeding from the prostate in these cases, or it is considered adiagnosis of exclusion? In addition, what is the reason for water cystoscopy being inferior to aircystoscopy in diagnosing prostatic bleeding?

There is no need to perform invasive office flexible cystoscopy before rigid cystoscopy inbladder 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 causeof hematuria only in those patients in whom the bladder was normal on ultrasound. If a largertumor with active hematuria is present on ultrasound, there is no need to perform diagnosticflexible cystoscopy before rigid therapeutic cystoscopy. Ultrasound KUB is not done beforecystoscopy, 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 watercystoscopy, as observed in this study.

While urethroscopy is already done using saline as irrigation, only a small amount of extrasaline is needed for cystoscopy. So cost is not a concern for doing water cystoscopy compared toair cystoscopy.

Since prostatic bleeding is caused by rupture of engorged prostatic veins, there is a risk of airembolism with air cystoscopy, and it is necessary to know how much intravesical pressure iscreated by air cystoscopy (venous air embolism after transurethral prostatectomy).1

Finally, in the present study small tumors are seen better with water cystoscopy and largertumors can easily be seen with ultrasound. So what is the need for using air cystoscopy overwater cystoscopy?

These issues should be considered while accepting the conclusion of the study that aircystoscopy is better than water cystoscopy for the diagnosis of active hematuria. Flexiblecystoscopy is an invasive procedure, and it should be considered only after routine ultrasoundKUB for diagnosing the cause of hematuria. This will avoid unnecessary cystoscopy beforedefinitive bladder biopsy.

Respectfully,

Santosh Kumar, Gautam Ram Choudhari and Sudheer K. DevanaDepartment of Urology

Postgraduate Institute of Medical Education and Research

Chandigarh

India

e-mail: santoshsp1967jaimatadi@yahoo.co.in

Reply by Authors: Apart from the facts, numbers and conclusions in our article, some clarifi-cation might be needed. The fact that water cystoscopy was performed first raised the doubt thatthis might have presented an advantage for the second observer performing air cystoscopies, asthe 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 insertinga bladder catheter to do it, trying to achieve better visualization. So even if the first observerwashed the bladder, the diagnosis was established at the end of the procedure, when the bladderwas already washed, leaving it in the same condition for the second observer performing aircystoscopy.

In our practice we did not encounter the need for continuous insufflation of air, and theinsertion of 100 to 150 cc atmospheric air used to be enough to perform a good air cystoscopy. Onthe other hand, the fact that air is compressible and water is not, resulting in a difference inpressure for a given volume (lower for air), might explain why we did not encounter air leakagewhen the bladder was filled. Several authors reported cases of possible air embolism aftertransurethral prostatectomy or transurethral incision of the prostate.1,2 Nonetheless, thesecases were related to actively pumping an estimated volume of 400 ml air for 15 to 30 secondsdue to an operating room error into a patient with gross hematuria during transurethral pros-tatectomy, and also the use of the low lithotomy position with the head and thorax beneath theplane of the prostate. This extreme case has nothing in common with the technique used inour study.

To our knowledge there is no validated classification of hematuria intensity. Thus, we couldnot perform a stratification of visibility score result according to hematuria intensity. None-theless, the subjective sense was that even a small degree of persistent active hematuria rapidlymodified 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. Theimages are difficult to interpret because of the simultaneous presence of clots and the urinarycatheter. Furthermore, not even Doppler evaluation is always useful because of urine, blood andsaline inflows. On the other hand, air cystoscopy, although more invasive, has the advantage ofbeing 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 thediagnosis preoperatively is important, as for example tumors with a muscle invasive aspectshould be given priority over prostatic bleeding. On the other hand, if cystoscopy is normal, thenKUB ultrasound, or even better, excretory urography or computerized tomography of theurinary 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, becomingthe standard procedure for these patients in daily practice. The data from our study showed thatair cystoscopy might be the better option in patients with active hematuria. Our final conclusionis that all urologists who perform classic water cystoscopymight be able to perform air cystoscopy,as it only represents a small technical variation, being better tolerated with superior resultsin 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 SurgicalOutcomes 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 permanenturinary and fecal diversion for patients with rectourethral fistulas (RUFs) secondary to radia-tion/ablative therapy. Of the 29 patients with radiation/ablative RUFs only 6 underwentattempted closure, with 1 successful repair. An interposition muscle flap was used in only 2 ofthe 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 recon-structed, thereby avoiding permanent urinary diversion. In our previously published seriesof 39 patients with radiation/ablative RUF 84% underwent successful closure in a singleoperation.1 Although 31% of our patients required permanent fecal diversion, the majoritymaintained an intact bladder and rectum. The basis of our successful closure in these complexRUFs is use of a buccal mucosal graft patch to close the prostatic defect, which is not amenableto traditional wound edge closure. Additionally a gracilis muscle interposition flap has a sig-nificant role in serving as a viable graft bed, providing separation of the urethral and rectalsuture lines, and closure of dead space. Our continued experience with a transperineal repairwith buccal graft onlay and gracilis muscle interposition flap has confirmed the role of recon-struction in the repair of the majority of radiation/ablative RUFs.

Respectfully,

Alex Vanni and Leonard ZinmanDepartment 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 andselective buccal mucosal onlay graft. J Urol 2010; 184: 2400.