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Objective: To develop and evaluate an assessment tool for endourological skills during simulation including cystoscopy, ureteroscopy (URS) and transurethral resection (TUR) procedures., Methods: We designed a Global Assessment of Urological Endoscopic Skills (GAUES) tool, comprised of nine endourology task-specific and two global-rating skills items. The tool was developed through two rounds of the Delphi process. The GAUES tool was used to assess acquisition of URS and TUR skills of novices (Year 2 core surgical trainees, CT2) and intermediate level trainees (residents at the start of the UK higher surgical training programme in Urology, Speciality Trainee Year 3, ST3) at the Urology Simulation Boot Camp (USBC) between 2016 and 2018. Validity was evaluated by comparing scores between trainees with different levels of urological experience. Inter-rater reliability was also assessed., Results: We evaluated 130 residents, 52% of trainees were at an intermediate stage of training and 39% were novices. In all, 9% of the anonymous forms were missing demographics. The completion rate of the GAUES tool during the USBC for URS and TUR was 85% and 89%, respectively. Our analysis demonstrated a significant difference in all domains between intermediates and novices at assessment in URS, except for one domain more suited to clinical assessment (P = 0.226). There was excellent intraclass correlation (ICC) overall between the two experts' judgements, ICC = 0.841 (95% confidence interval 0.767-0.893; P < 0.001, n = 88)., Conclusions: We have developed the novel GAUES tool for cystoscopic, URS and TUR skills. Overall, we demonstrated good face, content and construct validity and excellent reliability, suggesting that the GAUES tool can be useful for endourological skills assessment., (© 2020 The Authors BJU International © 2020 BJU International Published by John Wiley & Sons Ltd.)

Objectives: The aim of this study was to assess the test performance and clinical effectiveness of photodynamic diagnosis (PDD) compared with white light cystoscopy (WLC) in people suspected of new or recurrent bladder cancer., Methods: A systematic review was conducted of randomized controlled trials (RCTs), nonrandomized comparative studies, or diagnostic cross-sectional studies comparing PDD with WLC. Fifteen electronic databases and Web sites were searched (last searches April 2008). For clinical effectiveness, only RCTs were considered., Results: Twenty-seven studies (2,949 participants) assessed test performance. PDD had higher sensitivity than WLC (92 percent, 95 percent confidence interval [CI], 80-100 percent versus 71 percent, 95 percent CI, 49-93 percent) but lower specificity (57 percent, 95 percent CI, 36-79 percent versus 72 percent, 95 percent CI, 47-96 percent). For detecting higher risk tumors, median range sensitivity of PDD (89 percent [6-100 percent]) was higher than WLC (56 percent [0-100 percent]) whereas for lower risk tumors it was broadly similar (92 percent [20-95 percent] versus 95 percent [8-100 percent]). Four RCTs (709 participants) using 5-aminolaevulinic acid (5-ALA) as the photosensitising agent reported clinical effectiveness. Using PDD at transurethral resection of bladder tumor (TURBT) resulted in fewer residual tumors at check cystoscopy (relative risk [RR], 0.37, 95 percent CI, 0.20-0.69) and longer recurrence-free survival (RR, 1.37, 95 percent CI, 1.18-1.59), compared with WLC., Conclusions: PDD detects more bladder tumors than WLC, including more high-risk tumors. Based on four RCTs reporting clinical effectiveness, 5-aminolaevulinic acid-mediated PDD at TURBT facilitates a more complete resection and prolongs recurrence-free survival.

Background Photodynamic diagnosis increases the detection rate and hence decreases recurrence rates of urothelial cancer (UC) of the bladder. This technique has been implemented in the upper urinary tract and like in the bladder, has shown to increase the detection rate of urothelial lesions. Objectives To determine the sensitivity, specificity, and detection rates for photodynamic diagnostic flexible ureterorenoscopy (PDD-FURS) and white light ureterorenoscopy (WL-FURS). Design between 2009 and 2013, PDD-FURS was performed within 106 Upper urinary tract (UUT) Units (Mean age—72.6 ± 9.5). Indications for the procedure included abnormal upper urinary tract on imaging, normal flexible cystoscopy with abnormal urine cytology, endoscopic treatment and follow-up of UUT UC. Oral 5-aminolevulinic acid was used as the photosensitizer administered 3-4 h pre-operatively. Results 48 lesions were detected, of which 95.8% (46/48) where visualised by PDD-FURS compared to 47.9% (23/48) shown by WL-FURS ( P < 0.0001). PDD-FURS detected significantly more carcinoma in situ (CIS) or dysplasia lesions than WL-FURS (93.75% (15/16) vs. 18.75% (3/16), respectively, ( P = 0.0006)). Furthermore, PDD-FURS detected significantly more UC lesions than WL-FURS (96.9% (31/32) vs. 62.5% (20/32) ( P = 0.007)). PDD-FURS was more sensitive (95.8; range: 85.7–99.5) than WL-FURS (53.5; range: 37.7–68.8) in detecting UUT-UC ( P < 0.0001). There was no difference ( P = 0.716) in the specificity between PDD-FURS (96.6; range: 88.1–99.6) and WL-FURS (95.2; range: 86.7–99). Conclusions Our results PDD-FURS with oral 5-ALA as photosensitizer suggest higher sensitivity and detection rate of urothelial tumours than WL-FURS, with a good safety profile. In our series, PDD-FURS enhanced the visualisation of flat lesions, such as CIS and dysplasia that otherwise would have been missed. [ABSTRACT FROM AUTHOR]

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? The idea of using photosensitizing agents to enhance visualization of cancer tissue dates back to 1900. 5-Aminolevulinic acid (5-ALA) was first suggested for photodynamic diagnosis (PDD) of transitional cell cancer (TCC) of the bladder in 1992. Since then, PDD with intravesical application of 5-ALA or its ester hexaminolevulinate (Hexvix) has proven to be superior over standard white-light cystoscopy in detection of carcinoma in situ and dysplasia as well as enhancing margins of TCC. PDD of upper urinary tract TCC is under-studied because of trouble with delivery of the photosensitizer. Fluorescence after oral 5-ALA was initially reported in 1956. Oral 5-ALA for photodynamic therapy was suggested for upper urinary tract TCC in 1998 and for refractory non-muscle invasive bladder cancer in 2001. A study in 2012 on oral and intravesical application of 5-ALA for bladder PDD showed no difference in diagnostic accuracy for each modality. To our knowledge our series is the first report on use of oral 5-ALA for PDD in detection of upper urinary tract tumours. We published our initial results in 2010. We think that our recent audit is quite encouraging. PDD ureterorenoscopy resulted in detection of additional urothelial tumours that could have been missed by the conventional white-light endoscopy. We suggest that this technique should be used in large multicentre trials to replicate our results. OBJECTIVE To evaluate the diagnostic accuracy of photodynamic diagnostic ureterorenoscopy after oral administration of 5-aminolevulinic acid (5-ALA) for upper urinary tract urothelial cancers., PATIENTS AND METHODS In this audit, twenty-six patients underwent thirty-nine procedures (cystoscopy/ureterorenoscopy) following oral administration of 5-ALA for photodynamic diagnosis (PDD)., Twenty mg/kg body weight of 5-ALA was given orally 3-4 hours prior to the planned endoscopic visualisation., Following standard white light cystoscopy and ureterorenoscopy, photodynamic diagnostic endoscopy was performed using D-light system (Olympus PDD cystoscope and 7.5Fr KARL STORZ PDD Flex-X ureterorenoscope) to detect fluorescence., Biopsies were carried out from all suspicious areas, noting if lesions were detected under white or blue light or both., RESULTS A total of sixty-two biopsies were performed for suspicious urothelial lesions (35 bladder, 26 ureter/renal pelvis and 1 from prostatic urethra)., Of the 35 bladder biopsies, 11 lesions were seen under both white and blue light and 91% of these were malignant., While 24 (68.5%) biopsies were taken from lesions seen only under blue light and 45.8% of these were malignant., Similarly, of the 26 ureteric/renal pelvicalyceal biopsies, 11 were concurrent in both white and blue light and 100% of these were malignant., While 10 (38.5%) lesions were seen only under blue light and 70% of these were malignant., CONCLUSIONS Photodynamic diagnosis using oral 5-ALA is safe and feasible with additional advantages of detecting lesions not visualised with conventional white light endoscopy., This may translate into more complete treatment thereby decreasing subsequent recurrences and possibly progression of the upper urinary tract urothelial cancers. [ABSTRACT FROM AUTHOR]

Carcinoma of urinary bladder ranks among the top ten most common cancers worldwide. Approximately 80% of the disease is superficial (limited to mucosa and lamina propria) at the time of presentation. However, the majority of these tumors recur and 15-20% progress into muscle-invasive disease. Cystoscopic surveillance of the urinary bladder remains the standard of care to identify these recurrences on follow-up. Not only is this an invasive procedure, but the sensitivity of cystoscopy can be as low as 70%, so there can be up to 30% of tumors that are missed. Urinary cytology, with recognized limitations, has been used as an adjunct to this procedure, pending discovery of alternate urinary biomarkers. In the past decade there has been tremendous advancement in producing urinary biomarkers for urinary bladder cancer research, reflecting advancements in genomics and proteomics. An ideal biomarker should be able to replace cystoscopic examination and be cost effective. Unfortunately, most of the identified protein or molecular biomarkers have failed this test. This article critically appraises the status of these urinary biomarkers in urinary bladder cancer, in addition to highlighting some of the difficulties in this research area. [ABSTRACT FROM AUTHOR]