GreenLight Laser Vaporisation for Benign Prostate Enlargement

/0 Comments/in , /by

A Modern, Low-Bleeding Treatment for an Enlarged Prostate

Benign prostate enlargement, also called benign prostatic hyperplasia (BPH), is extremely common as men get older. As the prostate enlarges around the urethra, it can gradually restrict urinary flow, rather like slowly tightening a collar around the urinary pipe.

Symptoms may include:

  • A slow or weak urinary stream
  • Difficulty starting urination
  • Straining to urinate
  • Intermittent or stop-start flow
  • A feeling that the bladder has not emptied properly
  • Urinary frequency and urgency
  • Getting up several times at night to urinate
  • Episodes of urinary retention

Many men can initially be managed with lifestyle modification or medication. When symptoms become troublesome, complications develop, or medication is no longer effective or desirable, surgery may be considered.

One well-established minimally invasive surgical option is GreenLight laser photoselective vaporisation of the prostate (PVP).

What Is GreenLight Laser Prostate Surgery?

GreenLight PVP is an endoscopic procedure performed through the urethra. There are no abdominal incisions.

A telescope is passed through the urethra to the prostate. A specialised laser fibre is then used to progressively vaporise the obstructing prostate tissue and create a wider channel through which urine can flow.

Unlike TURP, where pieces of prostate tissue are physically cut away, GreenLight treatment predominantly converts the obstructing tissue into vapour while simultaneously sealing blood vessels.

The result is a combination of tissue removal and excellent haemostasis.

What Laser Is Used?

The GreenLight system uses a 532-nanometre green laser.

Modern GreenLight systems commonly use a lithium triborate (LBO) crystal to generate the 532 nm wavelength, with the contemporary high-powered platform delivering up to 180 watts.

Earlier systems included:

Generation Laser Maximum power
Early GreenLight KTP 80 W
GreenLight HPS LBO 120 W
GreenLight XPS LBO 180 W

The current European Association of Urology guideline describes the 180 W system as the contemporary standard platform for GreenLight PVP.

Why Is the Laser Green?

The colour is not merely decorative.

The 532 nm wavelength is strongly absorbed by haemoglobin, the pigment contained within red blood cells. It is much less strongly absorbed by water.

This property allows the laser energy to be preferentially absorbed by the vascular prostate tissue.

The laser has a relatively shallow tissue penetration of approximately 0.8 mm, producing rapid vaporisation while creating a limited zone of coagulation underneath the treated surface.

This gives GreenLight its two particularly useful characteristics:

Vaporisation + haemostasis

As prostate tissue is vaporised, small blood vessels are simultaneously coagulated.

This is why the operative field can remain remarkably clear and why GreenLight surgery generally produces less bleeding than traditional TURP.

Who May Benefit from GreenLight Laser Surgery?

GreenLight PVP may be considered for men with moderate to severe urinary symptoms caused by benign prostatic obstruction, particularly when conservative or medical treatment has not provided adequate relief.

Surgery may also be recommended when BPH results in complications such as:

  • Recurrent urinary retention
  • Dependence on a urinary catheter
  • Recurrent urinary tract infections associated with obstruction
  • Bladder stones
  • Recurrent visible haematuria attributable to BPH
  • Progressive bladder dysfunction
  • Significant residual urine
  • Upper urinary tract deterioration or renal impairment secondary to obstruction

Surgery is also reasonable when symptoms remain sufficiently troublesome despite medication, or when a patient does not wish to continue long-term medical therapy.

What Size Prostate Can Be Treated?

GreenLight PVP is particularly well established for prostates approximately 30–80 mL in volume.

The 2026 European Association of Urology guidelines recommend 532 nm GreenLight PVP as an alternative to TURP for men with moderate-to-severe LUTS and benign prostatic obstruction in this prostate-size range.

Larger prostates can certainly be treated by experienced GreenLight surgeons, but the operation becomes progressively more time-consuming as prostate volume increases.

Importantly, evidence supporting PVP in prostates above approximately 100 mL is less robust than the evidence supporting anatomical enucleation procedures such as HoLEP.

The AUA guideline similarly notes that PVP may be less effective in very large prostates and that retreatment becomes an increasingly important consideration.

For a very large prostate, HoLEP or robotic-assisted simple prostatectomy/enucleation may therefore provide more complete adenoma removal.

What Happens During GreenLight PVP?

The operation is usually performed under general or spinal anaesthesia.

A telescope is passed through the penis and urethra until the obstructing prostate is visualised.

The laser fibre is introduced through the telescope.

The surgeon progressively vaporises the obstructing prostate tissue, generally working from the bladder neck towards the apex of the prostate while carefully protecting the urinary sphincter.

The goal is not necessarily to remove the entire prostate.

Instead, the obstructing transition-zone tissue is removed sufficiently to create a wide, low-resistance urinary channel.

A urinary catheter is usually placed at the end of the operation.

Because bleeding is generally limited, catheterisation and hospitalisation can often be shorter than following conventional TURP.

Some appropriately selected patients can undergo the procedure as day surgery.

Advantages of GreenLight Laser Surgery

Less bleeding

This is arguably GreenLight’s greatest strength.

Because the 532 nm wavelength is absorbed by haemoglobin, tissue vaporisation and coagulation occur simultaneously.

Compared with TURP, studies have demonstrated lower transfusion rates and less bleeding.

Particularly useful when bleeding risk matters

GreenLight may be attractive in older patients or men with cardiovascular disease who require antiplatelet or anticoagulant medication.

The EAU guidelines specifically recognise GreenLight PVP as an option in selected patients receiving anticoagulant or antiplatelet therapy, although individual management of these medications still needs to be determined before surgery.

Shorter catheterisation

Many patients can have their catheter removed relatively quickly after surgery.

Shorter hospital stay

GreenLight surgery is frequently suitable for overnight or even day-case treatment in appropriately selected patients.

No external incision

The entire procedure is performed through the urethra.

No TUR syndrome

GreenLight PVP uses saline irrigation and does not carry the classical dilutional hyponatraemia or “TUR syndrome” associated with older monopolar TURP techniques.

Effective symptom improvement

GreenLight PVP can produce substantial improvements in:

  • Urinary flow
  • Bladder emptying
  • IPSS symptom scores
  • Quality of life

Randomised trials of contemporary GreenLight PVP have demonstrated symptom and flow improvements broadly comparable with TURP over short- to medium-term follow-up.

What Are the Side Effects?

Most men experience some temporary urinary irritation during the recovery period.

Burning or stinging when urinating

This is common initially and usually improves as the prostatic urethra heals.

Urinary frequency and urgency

The bladder may remain irritable for several weeks.

It is important to remember that removing the obstruction does not instantly reset a bladder that may have been struggling against that obstruction for many years.

Blood in the urine

Small amounts of bleeding can occur intermittently during healing, despite the excellent haemostatic properties of the laser.

Temporary difficulty urinating

Occasionally swelling after surgery means that the catheter needs to remain in place longer or needs to be reinserted.

Urinary infection

As with any endoscopic urinary procedure, urinary infection can occur.

Retrograde Ejaculation

One of the most important issues to discuss before surgery is ejaculation.

Following conventional GreenLight PVP, semen may travel backwards into the bladder rather than forwards through the penis during orgasm.

This is called retrograde ejaculation.

The orgasm usually remains present, but little or no semen may be produced.

This is particularly important for younger men concerned about fertility or preservation of ejaculation.

GreenLight should therefore not automatically be described as an “ejaculation-preserving” operation.

Does GreenLight Cause Erectile Dysfunction?

For most men, erectile function is preserved.

Current evidence does not demonstrate a major difference in erectile-function outcomes between GreenLight PVP and conventional TURP.

Sexual function, however, is influenced by many factors including age, vascular health, diabetes, medications and pre-existing erectile function.

Less Common Complications

Potential complications include:

  • Significant bleeding
  • Urinary tract infection
  • Temporary urinary retention
  • Urethral stricture
  • Bladder-neck contracture
  • Temporary urinary incontinence
  • Rare persistent urinary incontinence
  • Persistent urgency or overactive bladder symptoms
  • Incomplete removal of obstructing tissue
  • Recurrent prostate enlargement
  • Requirement for further prostate surgery

One Important Limitation: There Is Usually No Tissue for Pathology

This is an important difference between GreenLight PVP and TURP or HoLEP.

With TURP, prostate chips are removed.

With HoLEP, the enucleated adenoma is morcellated and retrieved.

With GreenLight PVP, much of the treated tissue is vaporised.

Consequently, there may be little or no prostate tissue available for histological examination.

For this reason, appropriate assessment for prostate cancer should be undertaken before GreenLight surgery when clinically indicated, using PSA, examination, MRI and/or prostate biopsy where appropriate.

GreenLight vs TURP vs HoLEP vs Robotic-Assisted Simple Prostatectomy

There is no single “best” prostate operation for every man.

The appropriate procedure depends on:

prostate size + prostate anatomy + bleeding risk + bladder function + patient priorities + surgeon expertise.

Feature GreenLight PVP TURP HoLEP Robotic Simple Prostatectomy / Enucleation
Approach Transurethral Transurethral Transurethral Abdominal robotic
Energy 532 nm laser Electrical 2,140 nm holmium laser Robotic dissection ± energy
Tissue treatment Vaporisation Resection Anatomical enucleation Anatomical enucleation
Tissue for pathology Limited/none Yes Yes Yes
Bleeding Very low Low-moderate Very low Low-moderate
Best established size ~30–80 mL ~30–80 mL Virtually size-independent Large/very large prostates
Large prostate >100 mL Possible, but less ideal Less attractive Excellent option Excellent option
Catheter duration Usually short Short Usually short Usually longer
Hospital stay Short Short Short Generally longer
Anticoagulation advantage Good Less favourable Good Less favourable
Learning curve Moderate Familiar technique Significant Significant
Durability in very large glands Less certain Good Excellent Excellent
Incisions None None None Abdominal port incisions

GreenLight vs TURP

TURP has traditionally been regarded as the benchmark operation against which newer BPH procedures are compared.

GreenLight achieves broadly similar improvements in urinary symptoms and flow for appropriately selected prostates.

Its principal advantages over TURP are:

  • Less perioperative bleeding
  • Lower transfusion requirements
  • Shorter catheterisation
  • Shorter hospitalisation
  • Excellent visibility during surgery
  • Potential advantages in patients at increased bleeding risk

Its disadvantages include:

  • Longer operating time in some patients
  • Lack of tissue for histology
  • Potentially higher retreatment rates over longer follow-up
  • Reduced efficiency as prostate size becomes very large

Long-term population data suggest that although reoperations for bleeding are less common after PVP, overall cumulative reoperation may be higher than after TURP.

So GreenLight’s strength is low perioperative morbidity, while TURP retains excellent durability and provides tissue for histology.

GreenLight vs HoLEP

HoLEP is fundamentally different.

GreenLight predominantly vaporises the obstructing prostate.

HoLEP enucleates the adenoma anatomically from the surgical capsule, rather like removing the inside of an orange while leaving the peel behind.

HoLEP uses a pulsed 2,140 nm holmium laser, which is strongly absorbed by water rather than haemoglobin.

The major advantage of HoLEP is that it is essentially prostate-size independent.

A 40 mL prostate can be enucleated.

So can a 100, 150 or even 200+ mL prostate in experienced hands.

The AUA guideline specifically recognises HoLEP as a prostate size-independent surgical option.

HoLEP also removes a larger proportion of the obstructing adenoma and provides tissue for histological examination.

Its principal disadvantages are its technical complexity, significant learning curve and potential for temporary postoperative stress urinary incontinence, particularly following treatment of very large glands.

For very large prostates, HoLEP will generally provide more complete anatomical adenoma removal than conventional GreenLight vaporisation.

GreenLight vs Robotic-Assisted Prostate Enucleation

For very large benign prostates, another option is robot-assisted simple prostatectomy (RASP), sometimes described as robotic prostate adenoma enucleation.

This is very different from a robotic radical prostatectomy performed for prostate cancer.

The entire prostate is not removed.

Instead, the enlarged benign adenoma is dissected away from the remaining prostate capsule.

It essentially achieves the same anatomical objective as HoLEP but approaches the prostate through the abdomen and bladder or prostate capsule rather than through the urethra.

Robotic simple prostatectomy is particularly attractive for very large or anatomically complex prostates, particularly when associated bladder pathology can be addressed simultaneously.

Its disadvantages include:

  • Abdominal surgery
  • Robotic port incisions
  • Longer catheterisation
  • Longer hospital stay
  • Greater surgical invasiveness
  • Higher resource utilisation

Recent comparative evidence suggests that both robotic simple prostatectomy and laser enucleation provide excellent outcomes for prostates ≥80 mL, while endoscopic laser enucleation generally provides faster perioperative recovery.

So Which Operation Is Best?

A useful way of thinking about these procedures is not as competitors, but as different tools for different prostates.

GreenLight PVP

Particularly attractive for:

  • Small-to-moderately enlarged prostates
  • Approximately 30–80 mL glands
  • Patients where minimising bleeding is particularly important
  • Older or medically complex patients
  • Patients requiring rapid recovery and short catheterisation

TURP

Remains an excellent option for:

  • Small-to-moderately enlarged prostates
  • Conventional benign prostatic obstruction
  • Situations where prostate tissue for histology is desirable
  • Centres with extensive TURP experience

HoLEP

Particularly attractive for:

  • Moderate, large and extremely large prostates
  • Men requiring maximal adenoma removal
  • Recurrent BPH after previous surgery
  • Patients where long-term durability is particularly important
  • Patients wishing to avoid abdominal surgery despite a very large prostate

Robotic-Assisted Simple Prostatectomy

Particularly attractive for:

  • Very large prostates
  • Complex prostate anatomy
  • Large intravesical adenomas
  • Patients with associated bladder pathology requiring treatment
  • Situations where endoscopic enucleation expertise is unavailable or a robotic approach offers anatomical advantages

The Bottom Line

GreenLight laser photoselective vaporisation is an effective, minimally invasive surgical treatment for benign prostate enlargement.

Its 532 nm laser is selectively absorbed by haemoglobin, allowing prostate tissue to be vaporised while simultaneously achieving excellent haemostasis.

Its particular strengths are:

less bleeding, short catheterisation, short hospitalisation and rapid recovery.

For appropriately selected men with moderate-sized prostates, symptom improvement is broadly comparable with TURP.

As prostate size increases, however, anatomical enucleation becomes increasingly attractive. HoLEP and robotic-assisted simple prostatectomy remove the adenoma more completely and are particularly effective for very large prostates. HoLEP achieves this endoscopically, whereas robotic surgery achieves it through an abdominal approach.

The choice therefore should not simply be:

“Which operation is newest?”

A better question is:

“Which operation best suits this prostate, this bladder and this patient?”

Prostate size and shape, urinary symptoms, bladder function, bleeding risk, medications, general health, PSA assessment, sexual priorities and the surgeon’s experience should all contribute to the final decision.

This information is intended for general patient education and does not replace individual assessment and discussion with a urologist.

So, if you want to learn more and are interested in having the Greenlight, come see your local Brisbane Urologist, Uro-Jo. This procedure is also offered in Caboolture at the Caboolture private Hospital as well as St Andrews War Memorial Hospital in Brisbane City.

Urethral Caruncle: A Small Lump That Can Cause Big Concern

/0 Comments/in , /by

Finding a red or fleshy lump around the opening of the urethra can understandably be alarming. Fortunately, one of the most common causes, particularly in women after menopause, is a urethral caruncle.

A urethral caruncle is usually benign (non-cancerous) and may cause no problems at all. However, because several other conditions can look similar, a new, enlarging, bleeding or unusual urethral lesion deserves proper assessment.

What is a urethral caruncle?

A urethral caruncle is a small, fleshy growth arising from the lining of the urethral opening, or urethral meatus.

It typically appears as a soft red, pink or sometimes darker-red polypoid lesion at the edge of the urethral opening. It most commonly arises from the posterior or lower margin of the urethral meatus.

Caruncles occur predominantly in postmenopausal women, although they can occasionally occur in younger women.

Importantly, a urethral caruncle is not considered a precancerous condition. Its significance lies mainly in the symptoms it can produce and the fact that other urethral conditions can occasionally imitate its appearance.

What causes a urethral caruncle?

The exact cause is not completely understood, but several factors are thought to contribute.

Reduced oestrogen after menopause

This is probably the most important association.

After menopause, falling oestrogen levels cause thinning and reduced elasticity of the tissues surrounding the vagina and urethra. This is part of what is now commonly called genitourinary syndrome of menopause (GSM).

The urethral lining may become more fragile and susceptible to irritation, inflammation and prolapse.

Chronic inflammation and irritation

Repeated local irritation may contribute to inflammation around the urethral opening and subsequent formation of a caruncle.

Urethral mucosal prolapse

A caruncle may represent a localised form of prolapse of the urethral lining. This helps explain why the lesion usually occurs at the edge of the urethral opening.

What does a urethral caruncle look like?

A typical caruncle is:

  • Small and fleshy
  • Red or pink
  • Soft
  • Usually located along the lower edge of the urethral opening
  • Occasionally friable, meaning that it bleeds easily when touched
  • Sometimes tender or inflamed

They vary considerably in size. Some are barely noticeable, while larger lesions may protrude sufficiently to be felt or seen by the patient.

Although the appearance may be quite characteristic, appearance alone should not always be relied upon when a lesion is atypical.

What symptoms can it cause?

Many urethral caruncles are discovered incidentally during a pelvic examination and cause absolutely no symptoms.

When symptoms do occur, they may include:

Bleeding

The surface of a caruncle can be delicate and vascular. Patients may notice:

  • Spotting on underwear
  • Blood after wiping
  • Bleeding after intercourse
  • Blood noticed after passing urine

One important distinction is determining whether the blood is actually coming from the urethral lesion or whether there is true blood within the urine (haematuria).

Persistent haematuria may require additional investigation.

Pain or tenderness

An inflamed caruncle can become uncomfortable, particularly with wiping, intercourse or local pressure.

Burning when passing urine

Some patients experience dysuria or a stinging sensation as urine passes across the inflamed tissue.

A visible or palpable lump

Some women first become aware of the condition because they see or feel a small lump at the urethral opening.

Urinary symptoms

Large caruncles only rarely interfere significantly with urinary flow. If there is difficulty passing urine, a weak stream or urinary retention, other causes should also be considered.

How is a urethral caruncle diagnosed?

Diagnosis usually begins with a careful examination of the urethral opening and surrounding genital tissues.

A typical small caruncle in a postmenopausal woman often has a characteristic appearance.

Your doctor may also assess for associated vaginal and urethral atrophy and ask about urinary symptoms, recurrent urinary infections, bleeding and haematuria.

Depending on the circumstances, investigations may include:

  • Urinalysis
  • Urine culture if infection is suspected
  • Assessment for haematuria
  • Cystoscopy if there are unexplained urinary symptoms or blood in the urine
  • Biopsy or removal of the lesion when its appearance is atypical

Does a urethral caruncle need treatment?

Not necessarily.

A small, typical caruncle that causes no symptoms may simply be observed.

Treatment is generally considered when the lesion causes bleeding, pain, irritation or bothersome urinary symptoms, or when there is uncertainty about the diagnosis.

1. Observation

If the lesion is small, has a typical appearance and causes no symptoms, reassurance and observation may be all that is required.

This avoids treating something that is essentially harmless.

2. Topical vaginal oestrogen

In postmenopausal women, topical oestrogen therapy is frequently used, particularly when there are accompanying features of genitourinary syndrome of menopause.

Oestrogen can improve the quality and thickness of the tissues around the urethra and vagina and may allow a small caruncle to shrink considerably or resolve.

Treatment usually requires several weeks rather than several days.

The suitability of vaginal oestrogen should be discussed with your doctor, particularly if you have a history of an oestrogen-sensitive malignancy or another reason to avoid hormonal therapy.

3. Anti-inflammatory and supportive treatment

Where local inflammation is prominent, conservative measures may occasionally include:

  • Avoidance of irritating soaps and products
  • Treatment of associated infection if present
  • Appropriate topical therapy
  • Simple analgesia when required

These treatments may improve symptoms but do not necessarily remove the lesion itself.

When is surgery required?

Surgical removal may be recommended when the caruncle is:

  • Persistently painful
  • Repeatedly bleeding
  • Large or bothersome
  • Not responding to conservative treatment
  • Increasing in size
  • Firm, irregular, ulcerated or otherwise atypical
  • Associated with uncertainty about the diagnosis

Surgery usually involves excision of the lesion at its base, often as a relatively minor procedure.

The removed tissue can then be sent to a pathologist for examination under the microscope.

Possible complications are uncommon but can include bleeding, infection, discomfort, recurrence and, rarely, scarring or narrowing of the urethral opening.

Can a urethral caruncle be cancerous?

A true urethral caruncle is benign.

The more important question is whether a lesion that looks like a caruncle could occasionally be something else.

Several conditions may resemble a caruncle, including:

  • Urethral mucosal prolapse
  • Urethral polyps
  • Periurethral cysts
  • Urethral diverticulum
  • Genital warts
  • Inflammatory lesions
  • Melanoma
  • Urethral carcinoma
  • Other uncommon benign or malignant tumours

Cancer masquerading as an apparently innocent urethral lesion is uncommon, but this is precisely why an atypical lesion should not simply be labelled a caruncle and forgotten.

When should a biopsy be considered?

Biopsy or complete excision is particularly worth considering when a lesion is:

  • Irregular or unusually firm
  • Ulcerated
  • Pigmented
  • Rapidly enlarging
  • Persistently bleeding
  • Unusually large
  • Not responding as expected to conservative treatment
  • Associated with enlarged groin lymph nodes
  • Clinically inconsistent with a typical caruncle

In medicine, sometimes the smallest lump deserves a second look rather than a dramatic name.

Urethral caruncle versus urethral prolapse

These conditions can look similar but are not quite the same.

A urethral caruncle generally involves only a portion of the circumference of the urethral opening, most commonly its posterior margin.

A urethral prolapse usually involves the entire circumference of the urethral lining, creating a circular or doughnut-shaped ring of tissue surrounding the opening.

The distinction can influence management.

What about blood in the urine?

This is particularly important.

A caruncle may bleed externally and make it appear that blood has come from the urine. However, visible haematuria should not automatically be attributed to a urethral caruncle.

Depending on age, symptoms and individual risk factors, haematuria may require investigation of the bladder, kidneys and urinary tract.

The presence of a convenient little red lump should therefore not distract from investigating genuine haematuria appropriately.

Will a urethral caruncle come back?

Recurrence after treatment is possible, particularly if the underlying postmenopausal tissue changes persist.

Treatment of associated genitourinary syndrome of menopause may therefore remain useful even after the immediate caruncle has improved or been removed.

When should you see a urologist?

Consider seeking medical assessment if you notice:

  • A new lump around the urethral opening
  • Persistent urethral pain
  • Recurrent bleeding
  • Blood in the urine
  • A lesion that is enlarging
  • Difficulty passing urine
  • Recurrent urinary infections
  • A lesion that does not improve with treatment

Most urethral caruncles turn out to be harmless, but examination provides reassurance and ensures that less common conditions are not overlooked.

The Bottom Line

A urethral caruncle is a common benign lesion of the urethral opening, seen particularly in postmenopausal women.

Many require no treatment at all. When symptoms occur, topical vaginal oestrogen and conservative measures are often appropriate first-line options. Persistent, troublesome or atypical lesions may require surgical excision and pathological examination.

The most important message is simple: a typical urethral caruncle is usually nothing to fear, but an unusual urethral lesion deserves proper assessment rather than assumption.

So, if you are experiencing any of the above and you are concerned, come see your local Brisbane urologist, Uro-Jo for advice on further management

Patient information disclaimer

This information is intended for general education and should not replace individual medical advice. A urethral or vulval lump, unexplained bleeding or blood in the urine should be assessed by an appropriately qualified healthcare professional.

Focal Therapy for Prostate Cancer: Treating the Cancer, Preserving the Prostate

/0 Comments/in , /by

For many years, treatment of localised prostate cancer largely involved choosing between active surveillance and treatment of the whole prostate gland with surgery or radiotherapy.

Modern multiparametric MRI, targeted transperineal biopsy and increasingly accurate image-guided treatment have opened a third pathway for carefully selected men: focal therapy.

Rather than treating or removing the entire prostate, focal therapy aims to identify the clinically significant cancer and destroy that area together with an appropriate safety margin, while leaving as much normal prostate tissue as possible.

A useful analogy is treating the troublesome patch rather than replacing the entire lawn.

The attraction is obvious: if the cancer can be controlled without treating the whole prostate, it may be possible to reduce the risks of urinary incontinence, erectile dysfunction and other quality-of-life effects associated with radical treatment.

However, focal therapy is not suitable for every prostate cancer, and it comes with an important trade-off: long-term cancer-control evidence is less mature than it is for radical prostatectomy and radiotherapy. Current European guidance therefore remains cautious, recommending focal therapy within clinical trials or well-designed prospective registries until stronger long-term comparative evidence becomes available.

What is focal therapy?

Focal therapy treats a selected region of the prostate containing clinically significant cancer rather than treating the entire gland.

Depending on the size and location of the tumour, treatment may involve:

  • Focal ablation of an individual lesion
  • Hemi-ablation, treating approximately one side of the prostate
  • Quadrant or zonal ablation
  • A wider “hockey-stick” ablation where disease distribution requires a larger treatment field

The treatment zone normally includes both the visible tumour and a planned margin around it.

The challenge is that prostate cancer is frequently multifocal. The largest or most biologically significant lesion is often referred to as the index lesion, but smaller cancer deposits may exist elsewhere in the gland.

For this reason, careful imaging, biopsy and follow-up are fundamental to a successful focal therapy program.

Who may be suitable for focal therapy?

The ideal candidate is generally a man with localised, clinically significant prostate cancer that can be accurately identified and safely targeted.

Potential candidates may include men with:

  • Disease confined to the prostate
  • A clearly identifiable lesion on multiparametric MRI
  • Cancer confirmed by targeted and systematic or mapping transperineal biopsy
  • Favourable intermediate-risk disease, commonly ISUP Grade Group 2 / Gleason 3+4, in an appropriate anatomical distribution
  • Selected higher-volume Grade Group 1 disease where active surveillance is considered unsuitable or unacceptable
  • Occasionally carefully selected Grade Group 3 disease in experienced centres, although the evidence is less established
  • A lesion that can be treated with an adequate margin without unacceptable injury to the urethra, sphincter, rectum or neurovascular structures
  • A strong preference to minimise the potential urinary and sexual consequences of whole-gland treatment

The decision should ideally follow review of the MRI, biopsy pathology, PSA, PSA density, prostate volume, tumour location and overall risk profile, rather than simply asking whether a particular machine can reach the tumour.

Who is generally NOT a good candidate?

Focal treatment becomes less attractive when there is:

  • Extensive multifocal clinically significant cancer
  • Significant bilateral disease
  • High-volume high-grade cancer
  • Extracapsular extension
  • Seminal vesicle invasion
  • Lymph-node involvement
  • Metastatic disease
  • Cancer that cannot be reliably seen or mapped
  • Disease immediately adjacent to structures that cannot safely be included in the treatment margin
  • A patient preference for the treatment with the longest-established oncological follow-up

Some men with very low-risk disease may also be better served by active surveillance rather than focal treatment, avoiding treatment altogether until there is evidence that treatment is actually necessary.

How do we determine whether focal treatment is appropriate?

Successful focal therapy begins with accurate cancer mapping.

Assessment will usually include:

Multiparametric MRI

MRI identifies suspicious lesions and helps establish their size, location and relationship to the urethra, capsule, sphincter and neurovascular bundles.

Transperineal prostate biopsy

MRI alone is not enough.

Targeted biopsy confirms the grade and extent of the MRI-visible lesion, while systematic or mapping biopsies help determine whether significant cancer exists elsewhere in the prostate.

PSA and PSA density

PSA remains useful, although interpretation after focal therapy differs from interpretation following radical prostatectomy because normal prostate tissue remains behind.

PSMA PET/CT

PSMA PET may be useful in selected patients, particularly those with higher-risk characteristics or when there is concern about disease outside the proposed treatment area.

What focal therapy options are available?

Several technologies can destroy a selected area of prostate tissue.

These include:

Irreversible Electroporation: NanoKnife

NanoKnife® is a system used to perform irreversible electroporation, or IRE.

Several fine needle electrodes are inserted through the perineum around the tumour under imaging guidance. Very short, high-voltage electrical pulses are passed between the electrodes.

Rather than primarily heating or freezing the tissue, the electrical field creates irreversible disruption of cell membranes, resulting in cell death.

IRE is therefore principally considered a non-thermal ablative technology.

Focal Laser Ablation

A laser fibre is placed directly into the target lesion and laser energy produces controlled thermal destruction of cancerous tissue.

ProFocal-Rx® is an Australian-developed focal laser technology designed specifically for targeted prostate treatment.

High-Intensity Focused Ultrasound

HIFU focuses ultrasound energy within the prostate, heating and destroying the targeted tissue without requiring needles to be placed directly throughout the treatment zone.

Cryotherapy

Needles are placed into the prostate and tissue is repeatedly frozen and thawed, producing cellular destruction.

Other technologies

Photodynamic therapy, radiofrequency ablation, focal brachytherapy and other energy-based approaches have also been investigated.

The Prostate Cancer Foundation of Australia notes that focal therapies including IRE/NanoKnife, laser ablation, HIFU and other technologies have been investigated or used in Australia, although availability varies.

NanoKnife versus ProFocal Laser Therapy

Both technologies attempt to achieve the same broad objective: destroy the cancer while preserving as much normal prostate and surrounding function as possible.

They achieve this in very different ways.

NanoKnife / IRE ProFocal-Rx Laser
Energy High-voltage electrical pulses Laser energy
Mechanism Irreversible electroporation Thermal coagulative ablation
Thermal treatment Principally non-thermal Yes
Access Transperineal needles/electrodes Transperineal laser applicator
Treatment planning Electrode geometry surrounds treatment zone Laser applicator positioned within/adjacent to target
MRI/TRUS planning Yes Yes
Tissue effect Cell membrane disruption Controlled heating and tissue necrosis
Treatment margin Created by electrical field between electrodes Created by laser ablation zone
Near neurovascular structures Potential theoretical advantage of non-thermal mechanism Requires careful thermal planning
Anaesthesia General anaesthesia with profound muscle relaxation generally required General anaesthesia typically used
Cardiac synchronisation Required with IRE Not required in the same manner
Repeat treatment Possible in selected cases Potentially possible
Long-term oncological evidence Growing medium-term evidence Earlier-stage clinical evidence
Australian regulatory status IRE devices are represented on the ARTG; specific device/indication should be checked ProFocal is currently not included on the ARTG

NanoKnife: potential advantages

The major attraction of IRE is that it does not rely primarily upon heating or freezing the prostate.

The electrical field disrupts cell membranes while potentially allowing relative preservation of extracellular structures. This makes IRE particularly interesting when treating cancers close to delicate structures.

Potential advantages include:

  • Precise treatment planning
  • No ionising radiation
  • No prostate removal
  • Preservation of untreated prostate tissue
  • Low reported rates of significant urinary incontinence
  • Potentially better preservation of erectile function compared with whole-gland treatment
  • Ability to consider repeat focal treatment in selected patients
  • Radical surgery or radiotherapy may remain possible if subsequent clinically significant cancer develops

Australian and international experience with IRE is considerably more mature than that of many newer focal technologies, although long-term comparative data against radical prostatectomy and radiotherapy are still developing. Published reviews cited by the AUA report residual or recurrent clinically significant cancer after focal ablation across all technologies, reinforcing the need for surveillance rather than considering focal therapy a “treat it and forget it” procedure.

NanoKnife: disadvantages and potential complications

IRE is still an invasive procedure.

Potential complications include:

  • Temporary urinary frequency and urgency
  • Dysuria
  • Haematuria
  • Perineal bruising or discomfort
  • Urinary retention
  • Temporary catheter requirement
  • Urinary tract infection
  • Prostatitis
  • Urethral injury or stricture
  • Erectile dysfunction
  • Ejaculatory changes
  • Rare urinary incontinence
  • Incomplete tumour ablation
  • Residual cancer within the treated field
  • Development or recognition of cancer elsewhere in the prostate
  • Need for repeat focal treatment
  • Subsequent need for radical prostatectomy or radiotherapy

Because IRE uses high-voltage electrical pulses, treatment requires appropriate anaesthesia, muscle relaxation and cardiac synchronisation.

ProFocal-Rx: focal laser therapy

ProFocal-Rx is a targeted laser ablation system developed in Australia.

A treatment applicator is placed transperineally into the prostate tumour. Laser energy is then delivered into the planned treatment area, producing controlled thermal destruction.

Early Australian studies have evaluated the feasibility and safety of this approach, including clinical trials of targeted treatment for MRI-localised prostate cancer.

Potential attractions include:

  • Highly localised treatment
  • Direct placement of the treatment fibre into the tumour
  • Relatively small treatment volumes
  • Preservation of surrounding prostate tissue
  • Short treatment and recovery pathways
  • Potential preservation of urinary continence
  • Potential preservation of erectile and ejaculatory function

However, ProFocal remains a newer technology with substantially less long-term oncological follow-up than radical prostatectomy, radiotherapy and even some other focal therapy platforms.

ProFocal: potential risks and limitations

Because laser treatment is thermal, careful treatment planning is required to prevent unintended heat injury.

Possible complications include:

  • Urinary frequency or urgency
  • Dysuria
  • Haematuria
  • Temporary urinary retention
  • Infection
  • Perineal discomfort
  • Urethral thermal injury
  • Erectile dysfunction
  • Ejaculatory changes
  • Rectal injury, although uncommon with appropriate treatment planning
  • Incomplete ablation
  • Residual clinically significant cancer
  • Cancer developing or being detected elsewhere in the prostate
  • Need for repeat treatment
  • Need for subsequent radical prostatectomy or radiotherapy

An important additional consideration is simply the maturity of the evidence. Early results can be encouraging without necessarily predicting cancer control at 10, 15 or 20 years.

What is the TGA status in Australia?

This point deserves particular clarity.

The Australian Register of Therapeutic Goods (ARTG) is the TGA’s public register of therapeutic products that can legally be supplied in Australia, subject to applicable exemptions and special-access pathways.

IRE / NanoKnife

Irreversible electroporation technology is available in Australia and is being used clinically for selected prostate cancers. The Medical Services Advisory Committee currently has an application assessing IRE using the NanoKnife system for prostate tumour tissue, including a proposed Medicare Benefits Schedule item. That MSAC application remains under assessment rather than representing an established Medicare item.

It is important not to confuse TGA/ARTG regulatory status with Medicare funding or with endorsement of focal therapy as oncologically equivalent to prostatectomy or radiotherapy. These are separate questions.

ProFocal-Rx

As of August 2026, the manufacturer’s Australian website specifically states that:

ProFocal is not included on the TGA’s ARTG in Australia.

TGA documents also demonstrate previous Australian patient access to ProFocal-Rx through the Special Access Scheme, which is a pathway for accessing an unapproved therapeutic good in particular circumstances and is not the same as general ARTG inclusion.

This distinction is important when discussing ProFocal with Australian patients.

Regulatory status can change, so the current ARTG should always be checked when treatment is being considered.

Does focal therapy cure prostate cancer?

It can achieve local control of appropriately selected prostate cancers, but the word “cure” needs to be used carefully.

Unlike radical prostatectomy, focal therapy deliberately leaves much of the prostate behind.

There are therefore two important potential sites of future cancer:

In-field recurrence
Cancer persists or recurs within the treated area.

Out-of-field cancer
Clinically significant cancer is subsequently detected elsewhere in the untreated prostate.

Neither necessarily means that focal therapy was inappropriate, but patients need to understand from the outset that continued prostate cancer surveillance is part of the treatment strategy.

The AUA’s salvage guideline notes clinically significant cancer following focal treatment across different modalities and emphasises that recurrence remains an important consideration after focal ablation.

Follow-up after focal therapy

Focal therapy does not end prostate cancer surveillance.

Follow-up typically involves a combination of:

  • Regular PSA testing
  • Clinical review
  • Multiparametric MRI
  • Repeat targeted and systematic biopsy
  • Additional imaging where clinically indicated

A common strategy is to establish a new PSA baseline after treatment and combine PSA behaviour with MRI and scheduled biopsy rather than relying on PSA alone.

This is important because the remaining normal prostate continues to produce PSA. Unlike after radical prostatectomy, the PSA is therefore not expected to become undetectable.

What happens if the cancer returns?

One of the advantages of focal treatment is that further treatment options usually remain available.

Depending upon the location, grade and extent of recurrent disease, options may include:

  • Continued surveillance for insignificant disease
  • Repeat focal therapy
  • Radical prostatectomy
  • External-beam radiotherapy
  • Other appropriate salvage treatment

Patients should nevertheless understand that salvage surgery after previous focal therapy may be technically more challenging because of fibrosis and altered tissue planes.

For clinically significant recurrence following focal ablation, AUA salvage guidance recommends that men considering definitive salvage treatment be offered whole-gland treatment with radical prostatectomy or radiotherapy.

Focal therapy versus radical treatment

Focal therapy occupies an increasingly interesting middle ground.

Active surveillance aims to avoid treatment until treatment becomes necessary.

Focal therapy aims to treat the clinically significant cancer while preserving the remainder of the prostate.

Radical prostatectomy or radiotherapy aims to treat the entire prostate and therefore both known and potentially occult cancer within the gland.

There is no universally “best” choice.

The appropriate treatment depends upon:

  • Cancer grade
  • Cancer volume
  • MRI findings
  • Biopsy distribution
  • PSA and PSA density
  • Age and life expectancy
  • Baseline urinary function
  • Baseline erectile function
  • Other medical conditions
  • Individual attitude towards cancer risk
  • Willingness to undergo continued MRI and biopsy surveillance
  • Personal priorities regarding continence and sexual function

The key question: are we treating the right cancer?

The success of focal therapy depends less on the glamour of the machine and more on patient selection, accurate imaging, meticulous biopsy mapping, treatment planning and rigorous follow-up.

NanoKnife, laser, HIFU and cryotherapy are different tools. The most important step occurs before any of them are switched on: establishing exactly where the clinically significant cancer is and whether disease elsewhere in the prostate has been adequately excluded.

For the appropriately selected man, focal therapy offers an attractive possibility:

Treat the cancer that needs treatment while preserving as much of the prostate, urinary function and sexual function as possible.

For other men, active surveillance, radical prostatectomy or radiotherapy will remain the safer oncological strategy.

Important perspective

Focal therapy is an exciting and rapidly evolving field, but it should not be presented as a universally equivalent replacement for established prostate cancer treatments.

Current evidence suggests excellent functional outcomes in appropriately selected patients, while definitive long-term comparative oncological evidence remains incomplete. European guidelines consequently continue to recommend focal therapy within clinical trials or prospective registries.

The decision is therefore best made after a detailed discussion with a urologist experienced in prostate MRI, transperineal biopsy, focal therapy and established radical treatment options.

Australian regulatory note

At the time of writing in August 2026, ProFocal-Rx is not included on the Australian ARTG, while IRE/NanoKnife technology is available in Australia and IRE for prostate cancer is currently undergoing an MSAC assessment relating to proposed Medicare funding. Regulatory status and funding arrangements may change and should be confirmed before treatment.

This information is intended for general patient education and does not replace individual medical advice. Suitability for focal therapy requires assessment of the patient’s pathology, imaging, prostate anatomy, overall health and personal treatment priorities.

So, if this is of interest to you, come have a chat to your local Brisbane urologist, Dr Jo to discuss this with you

Mitomycin C for Non-Muscle-Invasive Bladder Cancer

/0 Comments/in , /by

Treating the tumour and reducing the risk of it coming back

Bladder cancer has an inconvenient habit: even after a visible tumour has been completely removed, new tumours can sometimes return elsewhere in the bladder.

For selected patients with non-muscle-invasive bladder cancer (NMIBC), previously often called superficial bladder cancer, Mitomycin C can be placed directly into the bladder to destroy residual cancer cells and reduce the chance of recurrence.

This treatment is called intravesical Mitomycin C.

The advantage of intravesical treatment is rather elegant: instead of sending chemotherapy around the entire body, the medication is delivered directly to the bladder lining where it is needed.

What is Mitomycin C?

Mitomycin C is an anti-cancer chemotherapy medication originally derived from Streptomyces bacteria.

When used for bladder cancer, the medication is usually introduced directly into the bladder through a urinary catheter rather than being given intravenously.

This allows a relatively high concentration of chemotherapy to come into direct contact with the urothelium while limiting systemic exposure.

Intravesical Mitomycin is used particularly following transurethral resection of bladder tumour (TURBT) and in selected patients requiring an induction course of intravesical chemotherapy.

Why is Mitomycin C used?

The first and most important treatment for most visible non-muscle-invasive bladder tumours is a TURBT.

During TURBT, the visible tumour is removed and tissue is sent to pathology to determine:

  • tumour type
  • tumour grade
  • depth of invasion
  • presence or absence of carcinoma in situ (CIS)
  • whether muscle is present in the specimen
  • whether cancer has invaded the bladder muscle.

The pathology results allow the tumour to be classified into a recurrence and progression risk category.

Mitomycin C may then be recommended to reduce the risk of tumour recurrence.

When is Mitomycin C used?

There are several different situations in which intravesical Mitomycin C may be considered.

1. A single dose immediately after TURBT

In appropriately selected patients, a single dose of intravesical chemotherapy can be given following TURBT.

Australian eviQ guidance describes administration within 24 hours and preferably within six hours of TURBT. AUA guidance similarly recommends considering a single postoperative instillation within 24 hours for suspected or known low- or intermediate-risk disease.

The purpose is to destroy:

  • microscopic tumour cells remaining after resection
  • free-floating tumour cells released during surgery
  • tumour cells that might otherwise implant elsewhere on the bladder lining.

Think of TURBT as removing the weeds you can see, while the immediate intravesical treatment targets some of the microscopic seeds left behind.

Importantly, a single postoperative instillation primarily reduces recurrence. It has not been shown to provide the same benefit for progression or survival.

2. Induction Mitomycin C

Some patients with intermediate-risk NMIBC may benefit from a course of intravesical chemotherapy rather than a single treatment.

A commonly used regimen is:

Mitomycin C once weekly for six weeks.

Australian eviQ protocols include a six-week induction course for appropriate patients with Ta, T1 or CIS-containing urothelial carcinoma classified as intermediate risk, as an alternative to BCG in selected circumstances.

The exact treatment schedule should be individualised according to:

  • tumour grade
  • pathological stage
  • tumour size
  • number of tumours
  • previous recurrence rate
  • previous intravesical therapy
  • presence of CIS
  • tolerance of treatment
  • overall risk of progression.

What about aggressive superficial bladder cancer?

The term “superficial bladder cancer” can be misleading.

A cancer can remain confined to the bladder lining or lamina propria and still behave aggressively.

Higher-risk features include:

  • high-grade urothelial carcinoma
  • T1 disease
  • carcinoma in situ
  • multiple tumours
  • large tumours
  • frequently recurrent disease
  • certain adverse pathological features.

For genuinely high-risk NMIBC, particularly high-grade T1 disease and CIS, intravesical BCG immunotherapy generally has a central role when bladder preservation is appropriate.

Mitomycin C should therefore not automatically be regarded as a substitute for BCG in every patient with aggressive NMIBC.

Treatment needs to be based on the patient’s pathological risk group and previous response to therapy.

In selected circumstances, Mitomycin may nevertheless be considered, including when BCG is unsuitable, poorly tolerated, unavailable or as part of specific sequential intravesical treatment protocols.

Patients with very-high-risk disease also require discussion about whether bladder-preserving intravesical treatment remains appropriate or whether radical cystectomy should be considered.

How does Mitomycin C work?

Mitomycin C is an alkylating anti-tumour agent.

After entering a cancer cell, the drug is activated and produces reactive metabolites that bind to DNA.

It causes cross-linking of DNA strands, preventing the DNA from separating normally.

As a result, the cancer cell has difficulty:

  • replicating its DNA
  • dividing
  • repairing damaged DNA
  • continuing normal cellular function.

Ultimately, susceptible tumour cells die.

Because Mitomycin is placed directly into the bladder, it can attack residual malignant cells while generally producing much less systemic exposure than intravenous chemotherapy.

What happens during treatment?

Intravesical treatment is usually performed as an outpatient procedure.

A small urinary catheter is passed through the urethra into the bladder.

The bladder is emptied completely and the Mitomycin solution is then introduced through the catheter.

The catheter may then be removed or temporarily clamped, depending upon the treatment protocol.

The medication is usually retained within the bladder for approximately one to two hours.

Patients are generally advised to restrict fluids beforehand so that the medication is not excessively diluted. Australian eviQ protocols advise restricting fluids for approximately four to six hours before and during treatment, with appropriate adjustment of diuretic medication where relevant.

After the prescribed treatment period, the medication is passed out with the urine or drained through the catheter.

Side effects of intravesical Mitomycin C

Most patients tolerate treatment reasonably well because relatively little of the medication is normally absorbed into the bloodstream.

The commonest problems involve irritation of the bladder.

Chemical cystitis

Mitomycin can irritate the bladder lining and cause:

  • burning when passing urine
  • urinary frequency
  • urgency
  • bladder discomfort
  • pelvic discomfort
  • mild haematuria.

These symptoms frequently develop within hours of treatment and usually settle over the following few days.

Urinary tract infection

A urinary infection can occasionally occur following catheterisation.

Symptoms may include:

  • increasing dysuria
  • cloudy or offensive urine
  • fever
  • chills
  • worsening urinary frequency
  • feeling generally unwell.

A urine culture may be required if infection is suspected.

Skin irritation

Mitomycin is a cytotoxic medication and contact with the skin should be avoided.

Urine containing residual medication may irritate the skin around the urethra or genital area.

Patients should therefore follow the specific hygiene and toilet precautions provided by their treating unit.

Allergic reaction

Hypersensitivity reactions are uncommon but possible.

Symptoms can include:

  • skin rash
  • itching
  • facial redness
  • wheezing
  • breathlessness
  • dizziness
  • fever or chills.

Severe allergic reactions are rare but require urgent medical attention.

Less common but important complications

Although uncommon, Mitomycin can occasionally produce significant complications.

Severe chemical cystitis

Repeated bladder irritation can occasionally become severe.

Persistent inflammation may lead to:

  • chronic bladder pain
  • reduced bladder capacity
  • bladder fibrosis
  • rarely, bladder contraction.

Patients who already have a small-capacity bladder require particular caution because of the potential risk of further bladder contraction.

Extravasation

One of the most important complications is Mitomycin extravasation.

This means that Mitomycin escapes through an injured or perforated bladder wall into the surrounding tissues.

Although rare, this can produce significant tissue injury.

Reported complications include:

  • severe pelvic inflammation
  • tissue necrosis
  • abscess formation
  • bladder injury
  • fistula formation
  • damage to surrounding genital tissues.

Symptoms can occur immediately, but importantly they may also appear weeks or even months after treatment. Persistent or unexplained pelvic or abdominal pain following intravesical Mitomycin therefore deserves investigation.

An important precaution after TURBT

Intravesical Mitomycin should not simply be administered automatically following every TURBT.

If there is any suspicion that the bladder has been perforated, the medication should not be given.

AUA guidance advises against postoperative intravesical chemotherapy following a suspected perforation or extensive resection. Australian eviQ guidance similarly excludes postoperative Mitomycin when bladder perforation has occurred.

This is important because chemotherapy escaping through a bladder perforation can cause substantial tissue injury.

When should Mitomycin treatment be postponed?

Intravesical Mitomycin is generally avoided or postponed in the presence of:

  • visible haematuria
  • confirmed urinary tract infection
  • traumatic catheterisation
  • fever or unexplained febrile illness
  • known allergy to Mitomycin
  • suspected or confirmed bladder perforation
  • significant bladder injury following surgery.

Australian protocols specifically advise against treatment following traumatic catheterisation, with visible haematuria, active UTI or recent bladder injury.

If catheterisation is traumatic or produces bleeding on the day of treatment, the treatment is usually deferred.

Does Mitomycin cause the usual chemotherapy side effects?

Usually not.

Because the medication is placed into the bladder rather than routinely given intravenously, systemic absorption is generally very low.

Therefore classic chemotherapy problems such as:

  • hair loss
  • severe nausea
  • widespread immunosuppression
  • profound fatigue
  • bone marrow suppression

are unusual with standard intravesical therapy.

Systemic absorption can occur rarely, however, particularly when the bladder lining has been significantly disrupted. Myelosuppression is considered a potential but uncommon complication, and a full blood count may be appropriate if a patient becomes unexpectedly systemically unwell.

Precautions after treatment

Mitomycin remains a cytotoxic chemotherapy drug, even when delivered directly into the bladder.

Patients should therefore follow their treating unit’s instructions carefully regarding:

  • toilet hygiene
  • handling urine
  • washing contaminated skin
  • hand washing
  • fluid intake following treatment
  • management of contaminated clothing.

Patients should also tell their treating team about all medications they are taking and whether they are receiving antibiotics, diuretics or other cancer treatments.

When should you seek urgent medical advice?

Contact your treating team promptly if you develop persistent or worsening urinary symptoms after treatment.

More urgent assessment is required for symptoms such as:

  • temperature of 38°C or higher
  • inability to pass urine
  • significant or persistent haematuria
  • severe pelvic or abdominal pain
  • chills or shaking
  • shortness of breath
  • severe rash or suspected allergic reaction
  • persistent symptoms that are worsening rather than settling.

Severe pelvic or abdominal pain following intravesical Mitomycin is particularly important because, although uncommon, it may indicate bladder injury or extravasation.

Mitomycin does not replace surveillance

One of the most important points about NMIBC is that successful treatment does not mean surveillance can stop.

Even after apparently complete removal and intravesical chemotherapy, urothelial tumours can recur.

Depending upon the original tumour’s risk category, ongoing surveillance may include:

  • flexible cystoscopy
  • urine cytology
  • repeat TURBT
  • upper urinary tract imaging
  • further intravesical treatment.

Patients with higher-risk disease require considerably closer surveillance than those with a solitary low-grade tumour.

Mitomycin C versus BCG

These treatments are sometimes discussed together, but they work differently.

Mitomycin C is chemotherapy. It directly damages the DNA of susceptible tumour cells.

BCG is immunotherapy. It stimulates a local immune response within the bladder that attacks urothelial cancer cells.

The appropriate treatment depends upon the biological behaviour and risk category of the tumour.

For some patients, Mitomycin provides an effective and relatively well-tolerated strategy for reducing recurrence. For patients with higher-risk disease, BCG or more aggressive treatment may be preferable.

The important question is therefore not simply:

“Mitomycin or BCG?”

It is:

“What is the risk of this particular bladder cancer recurring or progressing, and which treatment provides the safest and most effective way of reducing that risk?”

The Bottom Line

Intravesical Mitomycin C is an established treatment for selected patients with non-muscle-invasive urothelial carcinoma of the bladder.

It may be used as a single treatment immediately following TURBT or as a course of intravesical chemotherapy in appropriately selected patients.

By placing chemotherapy directly into the bladder, Mitomycin can destroy residual cancer cells and reduce tumour recurrence while limiting exposure of the rest of the body.

Most side effects are related to temporary bladder irritation. Serious complications such as bladder injury, extravasation, fibrosis and tissue necrosis are uncommon but important, which is why careful patient selection and attention to precautions are essential.

And perhaps the most important message: Mitomycin reduces risk. It does not make follow-up optional.

Bladder cancer has a reputation for making return appearances, so regular cystoscopic surveillance remains an essential part of treatment.

This information is intended for general education and should not replace individual medical advice. Treatment of non-muscle-invasive bladder cancer should be tailored to the tumour’s stage, grade and recurrence/progression risk, previous treatments and the individual patient’s circumstances.

So, there are options in reducing your risk for recurrences. Speak to your Brisbane urologist, Dr Jo Schoeman about reducing your risks.

Intravesical BCG for High-Risk Bladder Cancer

/0 Comments/in , /by

What is BCG treatment?

BCG, short for Bacillus Calmette–Guérin, is one of the most effective treatments available for high-risk non-muscle-invasive bladder cancer (NMIBC).

BCG is best known as a vaccine originally developed against tuberculosis. In bladder cancer, however, it is used in a very different way. Rather than being injected as a vaccination, a solution containing BCG is placed directly into the bladder through a fine urinary catheter.

BCG is not conventional chemotherapy. It is a form of local immunotherapy. Its purpose is to stimulate the body’s immune system inside the bladder so that immune cells recognise and attack remaining bladder cancer cells.

For appropriately selected patients, BCG can significantly reduce the risk of bladder cancer returning and, importantly, reduce the risk of progression to more invasive disease.

Which bladder cancers are treated with BCG?

BCG is primarily used for high-risk or locally aggressive non-muscle-invasive urothelial carcinoma following adequate transurethral resection of the bladder tumour (TURBT).

Typical indications include:

  • Carcinoma in situ (CIS or Tis)
  • High-grade Ta urothelial carcinoma, particularly when large, multifocal or recurrent
  • High-grade T1 urothelial carcinoma
  • Recurrent high-grade non-muscle-invasive bladder cancer
  • Selected patients with multiple adverse pathological features
  • Selected patients with urothelial CIS involving the prostatic urethra as part of a bladder-preserving strategy

Current international guidelines recommend a six-week induction course of BCG for high-risk NMIBC, followed by maintenance treatment in patients who respond.

BCG is generally not required for a solitary low-risk, low-grade Ta bladder tumour. These cancers have a different biological behaviour and are usually managed with TURBT, sometimes combined with immediate intravesical chemotherapy and subsequent surveillance.

Why is BCG particularly important for carcinoma in situ?

Carcinoma in situ (CIS) deserves special attention.

Unlike the familiar papillary bladder tumour that projects into the bladder cavity, CIS can appear as a relatively flat, red or velvety abnormality of the bladder lining. Despite looking less dramatic, it is biologically aggressive.

CIS has a significant risk of recurrence and progression to muscle-invasive bladder cancer if inadequately treated. It cannot simply be “scraped away” by TURBT and forgotten.

For this reason, CIS generally requires either:

BCG immunotherapy
or, in selected very-high-risk circumstances,
radical cystectomy.

BCG produces substantially better response rates for CIS than intravesical chemotherapy in appropriate patients and has been shown to reduce the risk of progression.

How does BCG actually work?

The mechanism is fascinating because BCG does not simply poison cancer cells in the way traditional chemotherapy does.

Think of it less as dropping a bomb on the tumour and more as turning on the bladder’s local security system.

After BCG is introduced into the bladder, organisms interact with the urothelial surface and tumour cells. This produces a strong local inflammatory and immune response.

The process includes:

BCG attachment and internalisation

BCG interacts with urothelial cells, tumour cells and immune cells within the bladder.

Activation of innate immunity

Neutrophils, macrophages, dendritic cells and other immune cells are recruited into the bladder.

Cytokine release

A complex inflammatory signalling response develops, involving multiple cytokines and chemokines.

Activation of adaptive immunity

T lymphocytes and other components of the immune system become involved in recognising and destroying malignant urothelial cells.

The end result is an intentionally stimulated immune environment that makes the bladder a considerably less comfortable neighbourhood for residual cancer cells.

Before starting BCG

Successful BCG treatment starts with adequate staging and tumour clearance.

Patients will usually have undergone TURBT with pathological assessment confirming the tumour grade and stage.

In high-grade T1 disease, a repeat or second-look TURBT is frequently recommended to ensure complete resection and exclude previously unrecognised muscle-invasive disease.

Depending upon the tumour characteristics, assessment may also include:

  • Urine cytology
  • CT urography or other upper urinary tract imaging
  • Repeat cystoscopy
  • Re-resection of the original tumour site
  • Assessment of the prostatic urethra in selected patients
  • Review of pathology where variant histology or unusual findings are present

Very-high-risk cases are increasingly appropriate for multidisciplinary discussion because some patients may benefit more from early radical cystectomy than prolonged attempts at bladder preservation.

How is BCG given?

BCG is administered as an outpatient procedure.

A small catheter is gently passed through the urethra into the bladder. After the bladder has been drained, the BCG solution is instilled through the catheter.

The catheter is then removed unless there is a particular reason for it to remain temporarily.

The BCG solution is generally retained within the bladder for approximately two hours, where tolerated.

Patients receive specific instructions regarding fluid intake before treatment and safe handling of urine afterwards because BCG contains live attenuated Mycobacterium bovis.

The standard induction course

The traditional induction course consists of:

BCG once weekly for six weeks

This remains the standard initial regimen for high-risk disease.

Importantly, attempts to substantially reduce the number of induction and maintenance instillations have resulted in inferior cancer control. The six-week induction course therefore remains an important part of established treatment.

What happens after the first six treatments?

Following induction BCG, the bladder is reassessed.

This will generally involve:

  • Cystoscopy
  • Urinary cytology
  • Biopsy or repeat TURBT if an abnormality is detected
  • Additional investigation when cytology remains suspicious despite a normal-looking bladder

The key question is simple:

Has the cancer responded?

If it has, the next step is usually maintenance BCG.

Maintenance BCG

BCG works better in high-risk bladder cancer when appropriate maintenance treatment is added rather than simply giving six doses and stopping.

A widely used maintenance schedule consists of:

Induction

Once weekly × 6 weeks

followed by:

Maintenance

Once weekly × 3 weeks at:

  • 3 months
  • 6 months
  • 12 months
  • 18 months
  • 24 months
  • 30 months
  • 36 months

This is often referred to as a SWOG-style maintenance schedule.

Current European guidance recommends full-dose BCG for one to three years in high-risk disease, with the benefit of years two and three balanced against toxicity, patient tolerance and BCG availability. Three years of maintenance provides additional protection against recurrence in high-risk patients compared with one year.

Not every patient will receive every planned dose. Treatment may need to be delayed, reduced or discontinued because of side effects, infection, BCG availability or changes in the cancer.

When should BCG NOT be given?

Because BCG contains live attenuated bacteria, certain precautions are essential.

BCG should not be administered:

  • Within the first two weeks after TURBT
  • When there is visible haematuria
  • Following traumatic catheterisation
  • In the presence of a symptomatic urinary tract infection

Treatment should instead be delayed until it can be administered safely.

Additional caution is required in significantly immunocompromised patients, and individual circumstances should be discussed with the treating urologist.

Common side effects of BCG

BCG deliberately produces inflammation within the bladder, so some urinary symptoms are expected.

The most common side effects include:

Urinary frequency and urgency

Patients may feel the need to urinate frequently or suddenly.

Burning during urination

Mild-to-moderate dysuria is common for a day or two following treatment.

Blood in the urine

A small amount of haematuria can occur.

Bladder discomfort

Some patients describe suprapubic discomfort, cramping or a sensation resembling cystitis.

Flu-like symptoms

Fatigue, muscle aches, chills and a low-grade temperature can occur as the immune system responds to treatment.

These symptoms usually settle within approximately 24–48 hours.

The bladder may complain rather loudly about BCG, but mild short-lived irritation is usually part of the intended inflammatory response rather than evidence that something has gone wrong.

When should you contact your urologist?

Patients should contact their treating team if symptoms are unusually severe or fail to settle.

Particular attention should be paid to:

  • Persistent fever
  • High fever or rigors
  • Severe urinary symptoms
  • Inability to pass urine
  • Persistent or heavy haematuria
  • Significant deterioration in general wellbeing
  • Symptoms continuing substantially longer than expected

Persistent fever after BCG deserves particular attention.

Serious complications of BCG

Serious complications are uncommon, but they are important because BCG contains viable attenuated bacteria.

Potential complications include:

Severe BCG cystitis

Persistent bladder inflammation may occasionally become sufficiently troublesome that treatment needs to be delayed or discontinued.

Granulomatous prostatitis

BCG can produce an inflammatory reaction within the prostate. This can occasionally produce an abnormal prostate examination or elevated PSA and may mimic prostate cancer clinically.

Epididymo-orchitis

Rarely, BCG-related inflammation or infection can involve the epididymis or testis.

Upper urinary tract involvement

Granulomatous infection of the kidney is uncommon but recognised.

BCG infection

Localised or systemic infection with Mycobacterium bovis can occur.

BCG sepsis

This is a rare but potentially life-threatening complication.

A patient who becomes systemically unwell with persistent high fever, rigors, hypotension, respiratory symptoms or other features of sepsis following BCG requires urgent medical assessment.

Treatment may require hospital admission, infectious diseases involvement, anti-mycobacterial therapy and other supportive treatment.

BCG should therefore be respected. It is an extraordinarily useful treatment, but it is not simply another bladder wash.

What if BCG is poorly tolerated?

Treatment does not always have to proceed according to the calendar regardless of symptoms.

Depending upon severity, management can include:

  • Postponing the next instillation
  • Symptomatic treatment
  • Investigation for bacterial urinary infection
  • Assessment for BCG-related infection
  • Dose modification in selected circumstances
  • Discontinuation of BCG when toxicity becomes unacceptable

Persistent significant symptoms should be assessed rather than repeatedly giving further BCG and hoping the bladder eventually stops protesting.

What if the cancer returns after BCG?

This is one of the most important aspects of BCG treatment.

Not every recurrence after BCG means the same thing. The timing, pathology and amount of previous BCG exposure all matter.

Terms such as:

  • BCG-exposed
  • BCG-relapsing
  • BCG-refractory
  • BCG-unresponsive

describe different clinical situations.

Of these, BCG-unresponsive disease is particularly important because these tumours are unlikely to benefit from simply giving more BCG.

Current guidelines recommend radical cystectomy as the oncologically preferred treatment for appropriate patients with BCG-unresponsive high-grade disease.

When should radical cystectomy be considered?

BCG is intended to preserve the bladder, but preserving the bladder should never become more important than controlling the cancer.

Early radical cystectomy should be discussed in patients with very-high-risk features such as:

  • Persistent high-grade T1 disease
  • Recurrent high-grade disease despite adequate BCG
  • BCG-unresponsive disease
  • T1 disease associated with CIS
  • Certain variant histologies
  • Lymphovascular invasion
  • Extensive or multifocal high-grade disease
  • Other features suggesting a particularly high risk of progression

For very-high-risk NMIBC, current EAU guidance recommends discussing radical cystectomy upfront. BCG for one to three years remains an option for appropriately selected patients, particularly those who decline cystectomy or are medically unsuitable for major surgery.

Delaying cystectomy in a biologically aggressive tumour that is clearly failing BCG may compromise cancer outcomes.

Are there alternatives when BCG fails?

For patients with BCG-unresponsive disease who are unable or unwilling to undergo radical cystectomy, bladder-preserving alternatives are evolving rapidly.

Depending upon availability, tumour characteristics and local regulatory approval, options may include:

  • Sequential intravesical gemcitabine/docetaxel
  • Other intravesical chemotherapy combinations
  • Novel intravesical therapies
  • Systemic immunotherapy for selected CIS
  • Gene-based intravesical therapy in jurisdictions where available
  • Device-assisted intravesical therapy
  • Clinical trials

These treatments should not automatically be considered equivalent substitutes for radical cystectomy in a surgically fit patient with genuinely BCG-unresponsive aggressive disease. The risk of progression needs to remain at the centre of the decision.

Surveillance after BCG

BCG treatment does not eliminate the need for careful surveillance.

High-risk bladder cancer requires long-term follow-up because recurrence can occur even after an excellent initial response.

Follow-up generally involves:

Cystoscopy + urine cytology

initially at approximately 3 months, with subsequent surveillance determined by tumour risk and previous findings.

High-risk patients typically undergo frequent cystoscopy during the first two years, with gradually increasing intervals thereafter if they remain disease-free.

Periodic upper urinary tract imaging is also appropriate because high-risk urothelial carcinoma can occasionally develop within the ureters or kidneys.

Surveillance is usually long term and, for high-risk disease, often lifelong.

A practical BCG pathway

A typical pathway for high-risk non-muscle-invasive urothelial carcinoma is:

TURBT

↓

Histological confirmation of high-risk NMIBC

↓

Repeat TURBT when indicated, particularly high-grade T1 disease

↓

BCG induction: weekly × 6

↓

Cystoscopy + cytology and assessment of response

↓

If responding:

Maintenance BCG

3 weekly treatments at 3, 6 and 12 months, with continued maintenance to as long as 36 months in appropriate high-risk patients.

↓

Long-term cystoscopic surveillance

If persistent or recurrent high-grade disease:

Re-stage the bladder and determine whether the tumour represents BCG-unresponsive disease.

↓

Discuss radical cystectomy versus carefully selected bladder-preserving alternatives/clinical trials where appropriate.

The bottom line

Intravesical BCG remains a cornerstone of treatment for high-risk non-muscle-invasive urothelial carcinoma of the bladder.

Its strength lies in stimulating a powerful local immune response that reduces recurrence and helps prevent progression of aggressive superficial bladder cancer.

The usual treatment begins with six weekly instillations, followed by maintenance therapy for appropriately responding high-risk patients.

But BCG is not appropriate for every bladder tumour, and it should not be continued indefinitely when aggressive cancer is clearly failing treatment.

The most important principle is therefore not simply:

“Can we preserve the bladder?”

It is:

“Can we preserve the bladder safely without compromising cancer control?”

For patients with very-high-risk or BCG-unresponsive disease, timely discussion of radical cystectomy can be every bit as important as the BCG treatment itself.

This information is intended as general patient education and does not replace individual assessment by a urologist. BCG protocols, product availability and management of BCG-resistant disease may vary between patients and treatment centres.

So, this is a trusted, established therapy with good results for the locally aggressive urothelial cancers. Come chat to your local Brisbane Urologist Dr Jo Schoeman to discuss this option in your management.

Superficial Urothelial Carcinoma of the Bladder

/0 Comments/in , /by

Understanding non-muscle-invasive bladder cancer, TURBT, intravesical therapy and long-term surveillance

Being told that you have a bladder tumour is understandably alarming. The reassuring part is that many bladder cancers are discovered while they are still confined to the inner layers of the bladder and have not invaded the bladder muscle.

This is called non-muscle-invasive bladder cancer (NMIBC), historically referred to as superficial bladder cancer. NMIBC includes Ta tumours, T1 tumours and carcinoma in situ (CIS). These tumours behave very differently depending on their stage, grade and other pathological features, so treatment is tailored according to the risk of the cancer coming back (recurrence) or becoming more aggressive (progression).

The good news is that most NMIBC can initially be treated through the urethra without making an incision in the abdomen. The less convenient news is that bladder cancer has a habit of returning, which is why careful surveillance becomes an important part of treatment.

What is urothelial carcinoma?

The inside of the bladder is lined by specialised cells called urothelial cells. Cancer arising from these cells is known as urothelial carcinoma.

Urothelial carcinoma can develop anywhere along the urinary tract, including the:

  • renal collecting system
  • ureters
  • bladder
  • urethra

The bladder is by far the most common site.

When a bladder tumour has not invaded the muscular wall of the bladder, it is classified as non-muscle-invasive bladder cancer.

https://images.openai.com/static-rsc-4/y3Nkc3nnwnLWbduLwtOBo9wlGDPYvlRZ3hqmZmerWsmC4HUjhpIEvsXgWPs9IwZOQ9PLgJllQH1edLQmAni1U_538dO2IEbu48myP0AM4El4gyVQqzEuJjxyZdTq2Ak6qThyv190dh_MhP59fXKNJByHY8EL-AhSnzHK3LUJq2tbc5vhmHhLL8WBeJitn-Wb?purpose=fullsize

What causes bladder cancer?

There is rarely one identifiable cause. Instead, bladder cancer develops following genetic changes within urothelial cells, often influenced by environmental exposures over many years.

Smoking

Cigarette smoking is the most important preventable risk factor for bladder cancer.

Chemicals absorbed through cigarette smoke enter the bloodstream, are filtered by the kidneys and eventually become concentrated in the urine. The bladder lining is therefore repeatedly exposed to these carcinogens.

Stopping smoking after a bladder cancer diagnosis is strongly encouraged.

Other risk factors

These include:

  • increasing age
  • occupational exposure to certain industrial chemicals
  • previous pelvic radiotherapy
  • previous treatment with cyclophosphamide
  • chronic urinary tract irritation in selected circumstances
  • a personal history of urothelial carcinoma

Sometimes there is no obvious risk factor at all.

How does bladder cancer present?

Blood in the urine

The classic presentation is haematuria, or blood in the urine.

This may be:

Visible haematuria

The urine may suddenly become:

  • pink
  • red
  • burgundy
  • tea-coloured
  • or contain blood clots

Importantly, bleeding from a bladder tumour is frequently painless and intermittent.

The bleeding may disappear completely for days, weeks or even months. Its disappearance does not necessarily mean that the underlying problem has resolved.

Unexplained visible haematuria should always be investigated.

Microscopic haematuria

Sometimes blood is detected only on urine testing and cannot be seen with the naked eye.

Other possible symptoms

Some patients, particularly those with carcinoma in situ (CIS), may experience bladder irritation rather than obvious bleeding.

Symptoms can include:

  • urinary frequency
  • urgency
  • burning when passing urine
  • nocturia
  • pelvic or bladder discomfort
  • recurrent symptoms resembling a urinary tract infection

Persistent urinary symptoms with repeatedly negative urine cultures may therefore warrant further investigation.

Investigating suspected bladder cancer

The investigation usually involves a combination of urine testing, imaging and direct examination of the bladder.

Urine testing

A urine sample may be checked for:

  • blood
  • infection
  • inflammatory cells
  • abnormal malignant cells

Urine cytology

Urine cytology examines cells shed from the urinary tract under a microscope.

It is particularly useful for detecting high-grade urothelial carcinoma and CIS, but is considerably less sensitive for low-grade tumours.

A negative cytology therefore does not exclude bladder cancer.

Imaging the urinary tract

Patients with haematuria may require imaging of the kidneys, ureters and bladder.

Depending on the clinical circumstances, this may include:

  • renal tract ultrasound
  • CT urinary tract imaging
  • CT urography

CT urography is particularly useful when investigating haematuria because urothelial carcinoma can occasionally arise within the renal collecting system or ureters as well as the bladder.

Cystoscopy

A cystoscopy allows the urologist to look directly inside the bladder.

A thin flexible telescope is passed through the urethra, usually under local anaesthetic.

Most bladder tumours have a characteristic appearance. They may resemble delicate fronds, seaweed or a tiny underwater cauliflower attached to the bladder wall.

Flat lesions such as CIS can be much more difficult to see.

If a suspicious lesion is identified, the next step is usually a transurethral resection of bladder tumour (TURBT).

TURBT: biopsy and removal of the bladder tumour

TURBT stands for:

Transurethral Resection of Bladder Tumour

This procedure serves two important purposes:

  1. Treatment: removing all visible tumour where possible.
  2. Diagnosis and staging: providing tissue for the pathologist to determine exactly what type of tumour is present and how deeply it has invaded.

The procedure is usually performed under general or spinal anaesthesia.

A telescope called a resectoscope is passed through the urethra into the bladder. The tumour is carefully removed, usually using an electrical or bipolar resection system.

There is therefore generally no external incision or abdominal scar.

Why obtaining bladder muscle matters

An adequate TURBT should establish how deeply the tumour extends.

For many tumours, particularly T1 and high-grade lesions, the specimen should contain muscularis propria (detrusor muscle) so that the pathologist can determine whether the cancer has reached the muscle layer. The pathological report should document the presence and involvement of muscularis propria where applicable.

This distinction dramatically changes treatment.

Understanding bladder cancer staging

A simplified view of the bladder wall is:

Urine

↓

Urothelium

↓

Lamina propria

↓

Detrusor muscle

↓

Fat surrounding the bladder

The important early stages are:

Ta

The tumour is confined to the urothelial surface and has not invaded the supporting tissue underneath.

Tis: carcinoma in situ

CIS is a flat, high-grade malignant lesion confined to the urothelium.

Unlike the typical papillary bladder tumour, CIS may be difficult to identify visually.

Despite being superficial anatomically, CIS is biologically aggressive and requires appropriate treatment.

T1

The tumour has invaded into the lamina propria, but has not invaded the muscularis propria.

T1 disease, particularly high-grade T1 disease, carries a greater risk of recurrence and progression.

T2

The cancer has invaded the bladder muscle.

Once muscle invasion is identified, the disease is no longer classified as NMIBC and requires a different treatment pathway.

Stage and grade are not the same thing

This distinction frequently causes confusion.

Stage describes how deeply the cancer has travelled into the bladder wall.

Grade describes how abnormal and biologically aggressive the cancer cells appear under the microscope.

A tumour may therefore be superficial but still be high grade.

Broadly, urothelial tumours are classified as:

Low grade

These generally grow more slowly and have a relatively low risk of progressing to muscle-invasive cancer, although they may recur.

High grade

These cells look significantly abnormal and have a greater potential for:

  • recurrence
  • invasion
  • progression
  • spread beyond the bladder

Risk stratification

Following TURBT, the tumour is classified into a risk category.

Risk assessment considers factors such as:

  • stage
  • grade
  • tumour size
  • number of tumours
  • previous recurrence rate
  • presence of CIS
  • T1 disease
  • pathological features including lymphovascular invasion
  • certain variant histological subtypes

This classification helps determine whether the patient requires:

TURBT alone → intravesical chemotherapy → BCG → or, in selected very-high-risk situations, consideration of radical cystectomy.

Modern guidelines emphasise risk-adapted rather than one-size-fits-all management.

Do I need another TURBT?

Sometimes.

A second-look or re-staging TURBT may be recommended when:

  • the initial tumour was incompletely removed
  • adequate muscle was not present in an important specimen
  • high-grade disease is present in selected circumstances
  • T1 disease is identified
  • there is concern that the original tumour may have been understaged
  • certain variant histologies are identified

The aim is to ensure that residual tumour has not been left behind and, crucially, that muscle-invasive disease has not been missed.

Intravesical treatment

Intravesical simply means that medication is placed directly into the bladder through a catheter.

This allows the treatment to come into direct contact with the bladder lining while reducing systemic exposure compared with intravenous chemotherapy.

Two important treatments are:

Mitomycin C

and

BCG

They are not interchangeable and are used for different risk groups.

Intravesical Mitomycin C

Mitomycin C is a chemotherapy drug that can be placed directly into the bladder.

Immediate Mitomycin C following TURBT

For appropriate patients with suspected low- or intermediate-risk NMIBC, a single postoperative instillation of intravesical chemotherapy may be given soon after TURBT.

Current guidelines recommend that, when used, the immediate instillation should generally occur within 24 hours of TURBT.

Its purpose is to destroy microscopic tumour cells remaining in the bladder and tumour cells released during the resection.

This reduces the risk of recurrence.

When should immediate Mitomycin C be avoided?

It should generally not be administered if there is:

  • suspected bladder perforation
  • significant bleeding requiring bladder irrigation
  • an extensive or very deep resection where perforation is a concern

This is important because chemotherapy leaking outside the bladder can cause significant local tissue injury.

Further courses of intravesical chemotherapy

Selected patients with recurrent or intermediate-risk low-grade NMIBC may receive a course of intravesical chemotherapy rather than simply a single postoperative dose.

The exact drug, schedule and duration depend upon the tumour risk profile and local treatment protocols.

Side effects of intravesical Mitomycin C

Most patients tolerate treatment reasonably well.

Possible side effects include:

  • urinary frequency
  • urgency
  • burning
  • bladder discomfort
  • haematuria
  • chemical cystitis
  • skin irritation if the medication contacts the genital skin

Rarely, severe bladder inflammation or tissue injury can occur.

Intravesical BCG

BCG stands for Bacillus Calmette-Guérin.

Yes, it originated as a tuberculosis vaccine. In the bladder it performs a completely different job.

BCG stimulates a powerful local immune response against urothelial cancer cells and remains one of the most effective bladder-preserving treatments for high-risk NMIBC.

Who should receive BCG?

BCG is principally considered for patients with:

  • high-grade Ta tumours
  • high-grade T1 tumours
  • carcinoma in situ
  • other appropriately selected high-risk or intermediate-risk NMIBC

For high-risk NMIBC, full-dose BCG with maintenance treatment for one to three years remains a guideline-supported treatment, while immediate radical cystectomy should also be discussed in appropriate high-risk and particularly very-high-risk disease.

How is BCG given?

BCG is inserted into the bladder through a small catheter.

A typical induction course consists of:

One treatment per week for six weeks.

The solution is retained within the bladder for a prescribed period and then passed out in the urine.

Patients who respond may subsequently receive maintenance BCG.

A commonly used maintenance approach involves three weekly treatments at defined intervals after induction. In high-risk disease, guideline schedules may continue maintenance for up to three years depending upon tumour risk, treatment tolerance and BCG availability.

When should BCG not be given?

BCG is a live attenuated organism and must be administered carefully.

Treatment should generally be postponed in patients with:

  • visible haematuria
  • symptomatic urinary tract infection
  • traumatic catheterisation
  • very recent TURBT

The EAU lists the first two weeks following TURBT, visible haematuria, traumatic catheterisation and symptomatic urinary infection as absolute contraindications to an intravesical BCG instillation.

Side effects of BCG

A degree of bladder irritation is common.

Patients may experience:

  • frequency
  • urgency
  • burning
  • bladder discomfort
  • mild haematuria
  • fatigue
  • low-grade fever
  • flu-like symptoms

These symptoms usually settle.

Rarely, BCG can cause a more significant systemic infection or inflammatory reaction.

Persistent high fever, chills, marked deterioration or severe illness following BCG requires urgent medical assessment.

What if BCG does not work?

Persistent or recurrent high-grade cancer despite adequate BCG treatment requires careful reassessment.

This situation should not simply be managed by repeatedly giving more BCG indefinitely.

Patients meeting criteria for BCG-unresponsive NMIBC should be counselled regarding further treatment, and radical cystectomy remains the oncological standard for suitable patients with BCG-unresponsive high-risk disease. Bladder-preserving alternatives may be considered for patients who are medically unsuitable for cystectomy or decline surgery, ideally within appropriate specialist or clinical-trial pathways.

When should radical cystectomy be considered?

Most patients with superficial bladder cancer will never require removal of their bladder.

However, early radical cystectomy may be discussed for very-high-risk disease, including selected patients with:

  • aggressive high-grade T1 disease
  • associated CIS
  • variant histology
  • lymphovascular invasion
  • persistent high-grade disease
  • BCG-unresponsive disease
  • other features associated with a high risk of progression

The decision involves balancing the risks of major surgery against the danger of allowing biologically aggressive disease to progress.

Surveillance after treatment

Removing the tumour is only the first chapter.

NMIBC has a significant tendency to recur, and some high-risk tumours can progress. Consequently, regular cystoscopic surveillance is essential.

The first surveillance cystoscopy is generally performed approximately three months after TURBT.

After this, surveillance is tailored to the patient’s risk category.

A practical risk-adapted surveillance framework

Risk group Typical cystoscopy schedule Cytology Upper tract imaging
Low risk 3 months, 12 months, then annually Usually not routinely required Not routinely required
Intermediate risk 3 months, then approximately every 6 months for 2 years, then annually Risk-dependent Selected patients
High / very high risk Approximately every 3 months initially, with intervals gradually extended Usually included Periodic upper urinary tract imaging

The 2026 EAU guidance continues to recommend that follow-up intensity and duration be determined by the patient’s risk category, with the first cystoscopy at three months.

Individual surveillance schedules may differ depending on pathology, previous recurrences, treatment response, age, comorbidities and the treating urologist’s protocol.

Why is surveillance so important?

A recurrence does not automatically mean that treatment has failed or that the cancer has become life-threatening.

Low-grade papillary tumours may recur while remaining superficial and biologically low risk.

The purpose of surveillance is to identify recurrence early, while it can still be treated appropriately.

High-grade disease requires closer attention because the consequences of missing progression are considerably greater.

Can bladder cancer come back after years?

Yes.

This is why follow-up for intermediate- and particularly high-risk NMIBC can continue for many years.

The frequency of cystoscopy usually decreases when repeated examinations remain clear, but high-risk patients generally require prolonged surveillance.

What can I do after a diagnosis?

One of the most important modifiable factors is:

Stop smoking

Smoking cessation reduces exposure to the carcinogens responsible for many urothelial cancers and provides substantial additional cardiovascular, respiratory and general health benefits.

Patients should also:

  • attend every scheduled cystoscopy
  • report recurrent visible haematuria
  • complete prescribed intravesical treatment
  • report significant side effects from BCG or chemotherapy
  • maintain appropriate hydration unless medically restricted
  • discuss occupational chemical exposure where relevant

The bottom line

Non-muscle-invasive urothelial carcinoma is bladder cancer that has not invaded the muscular wall of the bladder.

The pathway typically involves:

Haematuria or urinary symptoms
↓
Urine tests + imaging
↓
Cystoscopy
↓
TURBT and pathological examination
↓
Stage + grade + risk classification
↓
Risk-adapted treatment

For some patients, TURBT followed by surveillance may be sufficient.

Others benefit from intravesical Mitomycin C or another intravesical chemotherapy to reduce recurrence.

Patients with high-grade disease, T1 cancer or CIS frequently require intravesical BCG, usually incorporating induction and maintenance treatment.

Very-high-risk or BCG-unresponsive disease may require consideration of radical cystectomy.

Most importantly, bladder cancer treatment does not finish when the initial tumour has been removed. Long-term cystoscopic surveillance is an integral part of treatment.

A final word

Bladder cancer can be a persistent visitor, but surveillance means we do not leave the front door unattended.

Early detection, complete TURBT, accurate pathological staging, appropriate intravesical therapy and structured follow-up provide the best opportunity to keep non-muscle-invasive bladder cancer under control.

This information is intended as general patient education and does not replace individual assessment or treatment advice from your urologist. Management should be tailored to the pathology, tumour risk category, general health and individual circumstances of each patient.

So, come see your friendly Brisbane urologist, Dr Jo Schoeman to discuss this with you.

Urodynamic Studies: Understanding How Your Bladder Works

/0 Comments/in , /by

Bladder problems are not always as straightforward as they appear.

Two people may both complain of urinary urgency, leakage or difficulty emptying their bladder, yet the underlying causes can be completely different. One bladder may be contracting when it should be relaxing, another may not contract strongly enough, and sometimes the bladder is behaving perfectly well while the outlet is causing all the trouble.

This is where urodynamic studies, often simply called urodynamics, can help.

Think of urodynamics as a stress test for the bladder. Rather than simply looking at its anatomy, we observe how the bladder fills, stores urine and empties while simultaneously measuring pressures, urine flow and sometimes pelvic floor activity.

The aim is not merely to produce a collection of colourful graphs. The important question is:

What is the bladder actually doing, and will knowing this change the treatment?

What Are Urodynamic Studies?

Urodynamics refers to a group of tests that assess the function of the bladder, urethra and urinary sphincter.

Depending on the clinical situation, testing may evaluate:

  • How much urine the bladder can comfortably hold
  • Bladder sensation during filling
  • Whether the bladder remains relaxed while filling
  • Whether involuntary bladder contractions occur
  • Whether urinary leakage occurs and why
  • The pressure required to store urine
  • The strength of the bladder muscle during urination
  • Whether there is obstruction to urinary flow
  • Whether the bladder empties completely
  • How the urinary sphincter and pelvic floor behave during filling and voiding

Urodynamics therefore investigates function rather than simply structure.

An ultrasound or cystoscopy may show us what the urinary tract looks like. Urodynamics tells us what it is doing.

Who May Need Urodynamic Testing?

Not every patient with urinary symptoms requires urodynamics.

For many straightforward urinary problems, the diagnosis can be made from the history, examination, bladder diary, urine testing, flow studies and ultrasound.

Urodynamics becomes particularly useful when the diagnosis is uncertain, symptoms are complex, previous treatments have failed, neurological disease is present, or an invasive treatment is being considered where understanding bladder function may alter the choice of treatment.

Common indications include:

Urinary Incontinence

Urodynamics may be useful when assessing:

  • Stress urinary incontinence
  • Urgency urinary incontinence
  • Mixed urinary incontinence
  • Persistent leakage following previous continence surgery
  • Incontinence following prostate surgery
  • Complex or unexplained urinary leakage

In straightforward female stress urinary incontinence, urodynamics is not necessarily required before treatment. It becomes more useful when symptoms and clinical findings do not agree or when there are complicating factors.

Overactive Bladder

Patients with overactive bladder may experience:

  • Urinary urgency
  • Frequent urination
  • Nocturia
  • Urgency urinary incontinence

Urodynamics can sometimes demonstrate detrusor overactivity, where the bladder muscle contracts involuntarily during filling.

Importantly, a normal urodynamic study does not necessarily exclude overactive bladder. Symptoms and urodynamic findings do not always travel together.

Difficulty Emptying the Bladder

Patients may report:

  • Poor urinary flow
  • Hesitancy
  • Straining
  • Intermittent flow
  • Incomplete emptying
  • Urinary retention

The challenge is determining why.

Is there an obstruction?

Or is the bladder muscle simply not contracting strongly enough?

The symptoms can look remarkably similar, but the treatments can be very different.

Men With Lower Urinary Tract Symptoms

In men with prostate enlargement, urodynamics may help distinguish between:

Bladder outlet obstruction

and

Detrusor underactivity, where the bladder muscle has insufficient strength to empty effectively.

This distinction may be particularly valuable before prostate surgery when there is uncertainty about whether removing the obstruction will improve urinary flow.

Neurological Bladder Dysfunction

Urodynamics has an especially important role in patients with neurological conditions such as:

  • Spinal cord injury
  • Multiple sclerosis
  • Parkinson’s disease
  • Spina bifida
  • Stroke
  • Certain spinal disorders

In these patients, we are interested not only in urinary symptoms but also in whether bladder pressures could potentially damage the kidneys.

Before or After Certain Urinary Procedures

Urodynamics may also be considered:

  • Before complex continence surgery
  • Following unsuccessful continence surgery
  • Before some bladder outlet procedures
  • Following prostate surgery when symptoms persist
  • When considering treatments such as bladder Botox or sacral neuromodulation in selected complex patients

What Happens During a Urodynamic Study?

The test is usually performed as an outpatient procedure.

It generally takes approximately 30–60 minutes, although this varies depending on the type of study being performed.

You can usually eat, drink and take your normal medications unless specifically instructed otherwise.

Step 1: Arriving With a Comfortably Full Bladder

You may be asked to arrive with a reasonably full bladder.

You will urinate into a special toilet called a uroflowmeter.

This measures:

  • Urine volume
  • Maximum urinary flow rate
  • Average flow rate
  • The shape of the urinary flow curve
  • How long urination takes

An ultrasound may then measure how much urine remains in the bladder.

This is called the post-void residual.

Step 2: Placement of Small Catheters

A very fine catheter is gently passed through the urethra into the bladder.

A second small pressure catheter is usually placed into the rectum, or occasionally the vagina.

Why two pressure measurements?

Because pressure inside the abdomen affects pressure inside the bladder.

By measuring both, the computer can calculate the pressure generated specifically by the bladder muscle:

Detrusor pressure = bladder pressure − abdominal pressure

This simple equation sits at the heart of conventional urodynamics.

Step 3: Filling the Bladder

The bladder is slowly filled with sterile fluid.

During filling, you will be asked to describe what you feel.

We may record:

  • First sensation of bladder filling
  • First desire to urinate
  • Strong desire to urinate
  • Maximum bladder capacity

The pressure inside the bladder is continuously monitored.

Normal filling cystometrogram

https://images.openai.com/static-rsc-4/Hgriy5E9FGtRilFNQh3tQE53yrlbWRzHlZE-lg73YC5P10G0EFIrVgMREqgOL5uEui9m4vTZQa3aZdbm2IQos6eTVRAdTIXlg1d841nyByIJ3GZk8QFyf9avtCBCjESBk_UcSEGbJGzOSIvZvPI6wZtNpz7LHnbB3kQIYDHsibqiwXmWpERNixUhOeW6Tm2B?purpose=fullsize
https://images.openai.com/static-rsc-4/BXwVAcldUDjh2tAaV2En87FX0ONS1oomHAkm4Z6BLZyoexIiDmaACUh8t4rB7TDfao-guZf76ULaTYX-VsV554nagvCAPRpNzs7HNQvKKZYuX8N6oPO5c_n_74de2tABnoEt69kwxCY_fJyF86M5rduxVEOG1zrNzm0SXMSrnXPiadRMzOfo1hPUnKvP1ahH?purpose=fullsize
https://images.openai.com/static-rsc-4/ySZcZmtN_5IZCgz4scVLbu2KqbZD3OVebnVIjG7F41-xqaWl2-D1RqW5T2NMWjugPRIkt7H-S3JB2UGWLPXIYYyURXURsMwzaASQ1zMpc7f1yB8UJcFDYMc1HW3qPkSw7rWCM7V8cMPh-oI2CVWQYD1HhlPxcJ6eJY6HJvYEz3QSK5VgEbfQgqejsiCVUfkK?purpose=fullsize
4

Normal filling cystometrogram. During filling, the bladder accommodates increasing volume while detrusor pressure (Pdet) remains relatively stable. Coughs cause corresponding rises in Pves and Pabd without a true detrusor contraction. Sensations such as first sensation, first desire and strong desire can be marked on the tracing.

 

Step 4: Provocative Testing

You may be asked to:

  • Cough
  • Strain
  • Stand
  • Change position
  • Listen to running water

These manoeuvres are not designed to make the test unnecessarily theatrical. They help reproduce the circumstances under which your symptoms normally occur.

If urinary leakage occurs during coughing without an involuntary bladder contraction, this may demonstrate urodynamic stress incontinence.

Step 5: Voiding

Once the bladder is comfortably full, you will be asked to urinate.

During urination we simultaneously measure:

  • Urinary flow
  • Bladder pressure
  • Abdominal pressure
  • Detrusor pressure

This is called a pressure-flow study.

It can be extremely useful when determining whether poor urinary flow is caused by obstruction or weak bladder contraction.

What Does Urodynamics Measure?

Bladder Sensation

We assess when you first become aware that the bladder is filling and when the desire to urinate becomes stronger.

Sensation may be:

  • Normal
  • Increased
  • Reduced
  • Absent

Abnormal bladder sensation may occur in several neurological and functional bladder disorders.

Bladder Capacity

The amount of urine the bladder can comfortably hold is measured.

A small functional capacity may occur with conditions such as severe urgency or bladder hypersensitivity, although capacity must always be interpreted in clinical context.

Bladder Compliance

A healthy bladder should behave rather like a flexible reservoir.

As it fills, its volume should increase without a major rise in pressure.

Poor bladder compliance means pressure rises excessively as the bladder fills.

This is particularly important in some neurological bladder disorders because persistently elevated storage pressures can potentially threaten the upper urinary tract.

Detrusor Overactivity

If the bladder muscle contracts involuntarily during filling, this is called:

Detrusor overactivity.

It may be associated with:

  • Urgency
  • Urgency incontinence
  • Frequency
  • Nocturia

When associated with an underlying neurological condition, it may be described as neurogenic detrusor overactivity.

Examples of terminal, phasic, wet and dry detrusor overactivity.

https://images.openai.com/static-rsc-4/Snzbj3YLBffWTq3-7c6jgZQWHTjwV03Siqh8rQZor7nWrcUTSujo5I4h9H6QmPWIw5TQO8oSYgzzugdooybbroYfbxONiyj0mx1Qe1uBjCwkL4K0AR5hGhULd9PKwFrw7LhUIrL8ZxpKQO1sQjk0qtqph3By5IOK30vdjd9Iahom6SUGG32ajdo2KW48nbhP?purpose=fullsize
https://images.openai.com/static-rsc-4/kx0pZHTOwdE7kDcSE1Awe3tnf1oB9kJizr_DFgQV0kdb9o6N2KxN9PW2lGCO4Rxcyx__zDzECnRwDhOrCXcXYbHZKkw4yASruDH4PtFNhlq6LqHzLF1d6NmcZkyOnoMHG_lNoKxw1Y5hCVuog5TIJqiN5O_zT8m7FtEhZkE-uHlwJMGAWpqcUhXKZdvq-h6c?purpose=fullsize
https://images.openai.com/static-rsc-4/9Fkv2MrdLw18QItSBrvBMWrFM_bRYOzwvod8KcVnSNQcBgQhcEl7m90lhNqlnqb3sX1pkEmdrx3XvCJxwi0gyzVvPse-T2lyODyK7BrW5xC3GJ2ZMggrrj7i-iArmLIQ05FXaE_4Cl8FYZ8yrU3dqXP5YN2gEVqQjCLOqH_xcbXAxuyLiYNLNijADJM9eUNR?purpose=fullsize

Detrusor overactivity. During bladder filling there is an involuntary increase in Pdet that cannot be explained by a corresponding increase in abdominal pressure. The contraction may be associated with urgency and, when leakage occurs, urgency urinary incontinence.

View the LABORIE-based detrusor-overactivity tracings

Stress Urinary Incontinence

If urine leaks when coughing or straining without a detrusor contraction, this supports a diagnosis of:

Urodynamic stress incontinence.

Additional measurements such as leak-point pressures may occasionally contribute to assessment in selected patients.

Bladder Outlet Obstruction

During urination, a pattern of:

High bladder pressure + low urinary flow

may suggest obstruction.

In men, benign prostate enlargement is a common cause.

Other causes include:

  • Urethral stricture
  • Bladder neck obstruction
  • Previous continence surgery
  • Dysfunctional voiding

Bladder outlet obstruction: pressure-flow study

https://images.openai.com/static-rsc-4/Efx8v2pSLdy0yriNx_qrcdTAHacUkb8mu_Sb7IjS9JvC0wxMQnPCPhcGQqAt0MQUNQ5jvnXe4yfU0qsIfsNRYrR7VLV4HhGFH6Ko01-kkE8GfSflqXD25Q6gkF3bmxyKYN9iYNHRqCJ0bV-igYyNfPP-21Nuvrls3kleV1a2fqsUDDQTALKE8mVkjEwglUbr?purpose=fullsize
https://images.openai.com/static-rsc-4/tQjdaSX6-MApQNNeYZuCDcT--H0Z_StPvpdtjnAdqL29pMWjRBGXsV_1KAe9iBU0kahuMqsxvNOoXDeZHFfSLBLxXg9w9uWzWnQxuEBsHfk3yjNkiDLedV-AQMJTHLPoif8aUAghyfhiv605EryWDjmBxVWKeBTNK3ky_okFHyRdz9rN1G-HNnhJBUnvnQhG?purpose=fullsize

Bladder outlet obstruction. During voiding the bladder generates a relatively high detrusor pressure, but urinary flow remains reduced. This high-pressure, low-flow relationship is characteristic of increased bladder outlet resistance.

In men, pressure-flow studies allow calculation of the Bladder Outlet Obstruction Index (BOOI):

BOOI = PdetQmax − 2(Qmax)

For men, BOOI >40 is generally classified as obstructed, 20–40 as equivocal and <20 as unobstructed.

Detrusor Underactivity

Sometimes the urinary flow is poor because the bladder muscle does not generate sufficient pressure.

This is known as:

Detrusor underactivity.

This distinction matters.

Operating on the prostate of a patient whose main problem is a very weak bladder may not produce the expected improvement in urinary flow.

Urodynamics can therefore occasionally prevent us from treating the wrong end of the plumbing.

Dysfunctional Voiding

Some patients involuntarily contract their pelvic floor or urinary sphincter while attempting to urinate.

Instead of the outlet opening smoothly, it intermittently closes.

Pelvic floor electromyography may help identify this pattern in selected patients.

Understanding the Urodynamic Tracing

A urodynamic report typically contains several pressure and flow curves.

At first glance, the tracing can resemble an enthusiastic seismograph.

The important measurements usually include:

Pves: pressure measured inside the bladder.

Pabd: pressure measured within the abdomen.

Pdet: pressure generated by the bladder muscle.

Flow: the rate at which urine leaves the bladder.

The relationship between these measurements allows us to understand what is happening during bladder filling and emptying.

Common Findings and What They May Mean for Treatment

Urodynamic Finding Possible Interpretation Potential Treatment Direction
Normal storage and emptying Normal urodynamic study Treatment guided by symptoms and other investigations
Detrusor overactivity Overactive bladder physiology Bladder training, medication, Botox, neuromodulation
Stress leakage Stress urinary incontinence Pelvic floor therapy, bulking agents, sling or other continence surgery
High pressure + low flow Bladder outlet obstruction Treatment of obstruction where appropriate
Low pressure + low flow Detrusor underactivity Emptying strategies, intermittent catheterisation or selected treatments
Poor compliance High-pressure storage Pressure-reducing treatment and upper urinary tract surveillance
Pelvic floor activation during voiding Dysfunctional voiding Pelvic floor physiotherapy/biofeedback
Significant residual urine Incomplete bladder emptying Identify obstruction versus impaired bladder contraction

The urodynamic result is not a treatment plan by itself.

It must be interpreted alongside symptoms, examination findings, bladder diaries, ultrasound, cystoscopy and other investigations where appropriate.

How Urodynamics Can Guide Treatment

If Detrusor Overactivity Is Found

Initial treatment may include:

  • Bladder training
  • Fluid modification
  • Pelvic floor physiotherapy
  • Antimuscarinic medication
  • Beta-3 agonist medication

For persistent symptoms, options may include:

  • Intravesical Botox injections
  • Sacral neuromodulation
  • Other specialist treatments in selected patients

If Stress Incontinence Is Demonstrated

Treatment depends on severity, sex, previous surgery and individual circumstances.

Options may include:

  • Pelvic floor rehabilitation
  • Continence devices
  • Peri-urethral bulking agents
  • Sling procedures
  • Colposuspension in selected women
  • Male sling following prostate surgery
  • Artificial urinary sphincter in appropriate men

If Bladder Outlet Obstruction Is Demonstrated

Treatment depends on the underlying cause.

For benign prostate enlargement, options may include:

  • Medication
  • Minimally invasive prostate treatments
  • Laser prostate surgery
  • Transurethral prostate surgery
  • Other surgical procedures appropriate to prostate size and anatomy

A urethral stricture or bladder neck obstruction requires a different treatment strategy.

If the Bladder Muscle Is Weak

Treatment may involve:

  • Double voiding
  • Timed voiding
  • Reviewing medications
  • Treating reversible causes
  • Intermittent self-catheterisation when necessary
  • Long-term catheterisation in selected circumstances
  • Sacral neuromodulation in carefully selected patients with non-obstructive urinary retention

The key issue is avoiding unnecessary outlet surgery when obstruction is not actually the problem.

If Bladder Storage Pressures Are High

This is particularly important in neurological bladder disease.

Treatment may include:

  • Medication
  • Intermittent catheterisation
  • Intravesical Botox
  • Regular renal imaging
  • Monitoring kidney function
  • Repeat urodynamic assessment
  • Reconstructive bladder surgery in uncommon severe cases

Here the objective extends beyond improving symptoms. We may also be trying to protect kidney function over the long term.

Are Urodynamic Studies Uncomfortable?

Most patients tolerate the investigation well.

Passing the small catheter can cause brief discomfort, and there may be some mild burning when urinating afterwards.

Having an audience while your bladder performs under laboratory conditions is admittedly not anyone’s preferred afternoon entertainment, but the clinical staff performing these studies do this routinely and will make the process as private and comfortable as possible.

Possible Side Effects and Complications

Urodynamic testing is generally safe.

Possible side effects include:

  • Temporary burning during urination
  • Urinary urgency
  • Minor urethral discomfort
  • A small amount of blood in the urine
  • Urinary tract infection
  • Temporary difficulty urinating

Significant complications are uncommon.

Patients should seek medical advice if they develop fever, chills, worsening urinary symptoms, significant bleeding or an inability to urinate following the test.

Does Everyone With Bladder Symptoms Need Urodynamics?

No.

This is an important point.

Urodynamics should generally be performed when the result is likely to answer a clinically relevant question or potentially alter management.

The investigation is particularly valuable when:

  • Symptoms are complex
  • The diagnosis remains uncertain
  • Symptoms and examination findings disagree
  • Previous treatment has failed
  • Neurological bladder dysfunction is suspected
  • There is significant urinary retention
  • Complex surgery is being considered
  • Understanding bladder pressure or contractility could change treatment

Testing simply because “we haven’t done one yet” is not a particularly compelling indication.

Urodynamics: Turning Symptoms Into Physiology

Patients often arrive describing urgency, leakage, poor flow or difficulty emptying their bladder.

These symptoms tell us what is happening.

Urodynamics can sometimes tell us why.

By measuring how the bladder stores and releases urine, we can distinguish between problems involving the bladder muscle, urinary sphincter, pelvic floor and bladder outlet.

Most importantly, urodynamics can help ensure that treatment is directed at the underlying problem rather than simply the symptom.

The Bottom Line

Urodynamics is not necessary for every bladder problem. But when the diagnosis is uncertain or treatment decisions depend on understanding bladder function, it can provide exceptionally useful information.

A good urodynamic study does more than generate graphs.

It helps answer the question that matters most:

What treatment is most likely to work for this particular bladder?

This information is intended for general patient education and does not replace individual medical assessment. The need for urodynamic testing and interpretation of results should be discussed with your treating urologist or continence specialist.

So, if you have incontinence symptoms and they are bothersome and you have tried pelvic floor rehabilitation and at least 2 of the available drugs for overactive bladder with no results, come see you friendly Brisbane Urologist, Uro-Jo to assist you in regaining continence and confidence.

Small Renal Masses: When a Small Kidney Tumour Needs Watching, Treating or Removing

/0 Comments/in , /by

Finding a small mass on the kidney can be unsettling, particularly when it appears unexpectedly on an ultrasound or CT scan performed for something completely unrelated.

The reassuring news is that small does not automatically mean dangerous, and a renal mass does not automatically mean kidney cancer. Even when a small renal mass is malignant, many grow slowly and have a low risk of spreading. This means that immediate surgery is not always necessary.

Modern management has therefore moved away from a simple philosophy of “there is a lump, so it must come out”. Instead, treatment is tailored to the size and appearance of the mass, its growth rate, kidney function, the patient’s age and general health, and individual preferences.

Options range from:

  • Active surveillance
  • Percutaneous biopsy
  • Minimally invasive ablation, including cryoablation and thermal techniques
  • Robotic partial nephrectomy
  • Occasionally, radical nephrectomy

The aim is straightforward: control the cancer when treatment is necessary while preserving as much normal kidney function as possible.

What Is a Small Renal Mass?

A small renal mass (SRM) generally refers to a kidney tumour measuring 4 cm or less, corresponding to a clinical T1a renal tumour when confined to the kidney.

Many are discovered incidentally during imaging performed for abdominal pain, gallstones, bowel problems, back pain or another unrelated condition. The kidney lesion is often an unexpected passenger on the scan.

Importantly, not every small renal mass is cancer.

Benign lesions include:

  • Oncocytoma
  • Angiomyolipoma
  • Some complex renal cysts
  • Other uncommon benign tumours

Among malignant masses, renal cell carcinoma is the most important diagnosis. However, many small renal cancers demonstrate relatively indolent behaviour. Published guideline data suggest that more than 20% of small renal masses may ultimately prove benign, while many malignant lesions within this size range have relatively favourable biology.

This creates an important clinical dilemma: we want to treat a potentially dangerous cancer, but we also want to avoid unnecessary treatment of a tumour that may never have caused harm.

Step One: Properly Characterising the Mass

An incidental renal mass generally requires appropriate imaging before deciding what to do.

This usually involves a:

  • Multiphasic contrast CT scan, or
  • MRI scan

These scans help determine:

  • Exact tumour size
  • Whether the lesion is solid or cystic
  • Whether it enhances with contrast
  • Its position within the kidney
  • Relationship to blood vessels and the collecting system
  • Whether there are concerning features suggesting malignancy
  • Whether there is any evidence of disease outside the kidney

High-quality contrast CT or MRI is recommended for the characterisation of a newly discovered small renal mass.

Blood tests will usually include kidney function, particularly serum creatinine and estimated glomerular filtration rate (eGFR).

What About Complex Kidney Cysts?

Not every suspicious renal lesion is a solid tumour.

Complex renal cysts are usually classified according to the Bosniak classification, which estimates the likelihood that a cystic lesion represents malignancy.

Some Bosniak III and selected predominantly cystic lesions can also be considered for surveillance, particularly when they are small or when the risks of treatment outweigh the anticipated benefits. Larger or increasingly complex lesions are more likely to require intervention.

Do We Need a Kidney Biopsy?

Sometimes.

A renal mass biopsy involves passing a needle through the skin into the tumour, usually under ultrasound or CT guidance, and obtaining small samples for examination by a pathologist.

Biopsy can be particularly useful when:

  • The diagnosis is uncertain
  • Active surveillance is being considered
  • The biopsy result could change management
  • Ablation is planned
  • Imaging suggests a tumour that may not require surgery
  • There is a possibility of metastatic disease or another unusual diagnosis

A biopsy is not automatically necessary for every small renal mass.

Possible complications include:

  • Pain
  • Bruising
  • Bleeding around the kidney
  • Rare significant haemorrhage
  • Non-diagnostic biopsy
  • Sampling error

The important question is not simply “Can we biopsy it?” but rather:

“Will knowing the biopsy result change what we do?”

Option 1: Active Surveillance

Active surveillance is increasingly recognised as a legitimate management strategy rather than simply “doing nothing.”

There is an important difference.

Doing nothing means ignoring the tumour.

Active surveillance means deliberately monitoring it and treating it if its behaviour changes.

For appropriately selected small renal masses, particularly those less than 2 cm, active surveillance can be an excellent initial strategy. The AUA notes very favourable cancer-specific and metastasis-free outcomes in published surveillance series of these very small tumours.

The overall risk of metastatic progression among carefully selected patients undergoing surveillance for small renal masses has been reported at approximately 1–2% or less in early follow-up series, although risk varies according to tumour and patient characteristics and increases with more aggressive biological behaviour.

Who May Be Suitable for Active Surveillance?

Surveillance may be particularly attractive for:

  • Tumours less than 2 cm
  • Small tumours with favourable imaging characteristics
  • Slowly growing lesions
  • Older patients
  • Patients with significant medical problems
  • Patients with impaired kidney function
  • Patients with a solitary kidney
  • Patients at increased anaesthetic or surgical risk
  • Patients who wish to avoid or delay intervention

For renal masses measuring 2–4 cm, both surveillance and definitive treatment may be reasonable depending upon individual circumstances.

What Does an Active Surveillance Protocol Look Like?

There is no single surveillance schedule suitable for every patient.

A commonly used approach is:

Baseline

Obtain good-quality CT or MRI imaging to accurately document:

  • Tumour size
  • Tumour characteristics
  • Location
  • Complexity

A renal mass biopsy may be considered when the result would influence management.

First follow-up

Repeat cross-sectional imaging is commonly performed approximately 3–6 months after entering surveillance to determine whether there is meaningful interval growth. This approach is specifically supported by AUA guidance.

Ongoing surveillance

If the lesion remains stable, imaging may then be performed approximately:

Every 6–12 months, depending upon the patient’s age, tumour characteristics, previous growth rate and overall health.

Ultrasound can sometimes reduce the number of CT scans required, provided that the lesion can be reliably visualised and measured. CT or MRI is preferred if there is uncertainty regarding growth or tumour characteristics.

The Canadian guideline notes that commonly used protocols involve abdominal imaging every 3–6 months during the first year and every 6–12 months thereafter if stable, although there is no universally agreed schedule.

When Do We Stop Watching and Start Treating?

This is perhaps the most important aspect of active surveillance.

Treatment may be recommended if there is:

  • Significant tumour growth
  • Increasing radiological complexity
  • Growth towards or beyond 4 cm
  • A consistent growth rate greater than approximately 5 mm per year
  • Concerning biopsy findings
  • Evidence of spread
  • Development of symptoms
  • A change in the patient’s health or treatment preference

Commonly recognised triggers include tumour growth beyond 4 cm or consecutive growth exceeding approximately 0.5 cm per year, although no single measurement should be considered in isolation.

A tumour that grows by a millimetre on one scan has not necessarily sounded the alarm bell. Small differences can occur simply because of how the scan or measurement was performed.

The trend matters more than a single measurement.

Risks and Disadvantages of Active Surveillance

The main advantages are avoiding or delaying unnecessary treatment and preserving kidney function.

Potential disadvantages include:

  • Anxiety associated with living with an untreated renal mass
  • Repeated scans
  • Radiation exposure from repeated CT imaging
  • Contrast exposure
  • Possibility of tumour growth
  • Small risk of metastatic progression
  • Possibility that treatment becomes technically more difficult if the tumour grows substantially

Active surveillance therefore works best when there is a clear follow-up plan rather than a vague agreement to “scan it again sometime.”

Option 2: Minimally Invasive Tumour Ablation

For selected small renal masses, it may be possible to destroy the tumour without surgically removing it.

This is known as renal tumour ablation.

The principal techniques include:

Cryoablation

Cryoablation uses extremely low temperatures to freeze and destroy tumour cells.

Radiofrequency Ablation

Radiofrequency ablation uses thermal energy to heat and destroy tumour tissue.

Microwave Ablation

Microwave energy can similarly produce controlled heating and destruction of tumour tissue.

These treatments can often be performed percutaneously, meaning probes are inserted through the skin under CT or ultrasound guidance without requiring conventional surgery.

Who Is Suitable for Renal Ablation?

Ablation may be considered for patients with:

  • A small renal tumour
  • A tumour in a technically accessible location
  • Significant medical comorbidities
  • Increased surgical or anaesthetic risk
  • Reduced kidney function
  • A solitary kidney
  • Previous kidney surgery
  • A strong preference for a less invasive treatment

Current European guidance particularly supports tumour ablation as an alternative for patients with small cT1 renal tumours who require treatment but are unfit for surgery, while emphasising that long-term comparative evidence against partial nephrectomy remains less robust.

Renal mass biopsy is generally recommended before percutaneous ablation.

Advantages of Ablation

Potential benefits include:

  • No large surgical incision
  • Shorter hospital stay
  • Faster recovery
  • Less postoperative discomfort
  • Preservation of kidney tissue
  • Potential suitability for patients who are poor surgical candidates
  • Ability to repeat treatment in selected cases

Risks and Complications of Ablation

Possible complications include:

  • Bleeding
  • Haematoma
  • Infection
  • Pain
  • Damage to nearby organs
  • Injury to the collecting system
  • Urine leakage
  • Thermal injury to surrounding structures
  • Incomplete treatment
  • Persistent viable tumour
  • Local tumour recurrence
  • Need for repeat ablation
  • Need for subsequent surgery

Tumour size matters. European guidance advises against routinely using radiofrequency ablation for tumours larger than approximately 3 cm and cryoablation for tumours larger than approximately 4 cm, because recurrence becomes more concerning as tumour size increases.

Long-term oncological evidence for ablation is also less mature than the evidence supporting surgical excision, and local recurrence appears somewhat more frequent than following partial nephrectomy.

Option 3: Robotic Partial Nephrectomy

When definitive surgical treatment is appropriate, the modern objective is usually:

Remove the tumour, not the entire kidney.

A partial nephrectomy removes the renal tumour together with an appropriate margin while leaving the remaining healthy kidney intact.

For suitable T1a renal masses, partial nephrectomy is generally preferred over removing the whole kidney because it provides excellent cancer control while preserving more functioning renal tissue.

Increasingly, this operation is performed using robotic-assisted laparoscopic surgery.

What Happens During Robotic Partial Nephrectomy?

Several small incisions are made in the abdomen.

Using robotic instruments, the surgeon:

  1. Identifies the kidney and renal tumour.
  2. Carefully defines the tumour margins.
  3. May temporarily control blood flow to the kidney.
  4. Removes the tumour while preserving as much healthy kidney as possible.
  5. Repairs any opening into the collecting system if necessary.
  6. Controls bleeding.
  7. Reconstructs the remaining kidney.

The removed tumour is then sent to pathology, providing definitive information regarding:

  • Whether the tumour is benign or malignant
  • Type of renal tumour
  • Tumour grade
  • Exact size
  • Surgical margin status

This pathological information is one of the major advantages of surgical excision.

Who Should Consider Robotic Partial Nephrectomy?

Surgery may be preferred for:

  • Young and otherwise healthy patients
  • Enlarging tumours
  • Tumours approaching or exceeding 4 cm
  • Tumours with concerning imaging characteristics
  • Aggressive findings on biopsy
  • Patients with a long life expectancy
  • Tumours unsuitable for ablation
  • Patients who prefer definitive removal

Partial nephrectomy is particularly valuable when preserving kidney function is important, including patients with:

  • Chronic kidney disease
  • A solitary functioning kidney
  • Bilateral renal tumours
  • Conditions that may threaten future kidney function

Complications of Robotic Partial Nephrectomy

Although robotic surgery is minimally invasive, it remains a significant operation.

Potential complications include:

  • Bleeding
  • Blood transfusion
  • Infection
  • Urinary tract infection
  • Injury to surrounding organs
  • Urine leakage from the kidney
  • Damage to the renal collecting system
  • Temporary reduction in kidney function
  • Permanent loss of some kidney function
  • Blood clots
  • Anaesthetic complications
  • Hernia
  • Positive surgical margin
  • Conversion to open surgery
  • Conversion to radical nephrectomy
  • Rare loss of the kidney
  • Rare cardiovascular or other serious complications

One particular delayed complication is a renal artery pseudoaneurysm, which may cause bleeding several days or even weeks after surgery and occasionally requires radiological embolisation.

Fortunately, most patients undergoing uncomplicated robotic partial nephrectomy recover relatively quickly and retain excellent kidney function.

Does the Whole Kidney Ever Need to Be Removed?

Yes, but for a straightforward small renal mass this is increasingly avoided when partial nephrectomy is technically and oncologically appropriate.

A radical nephrectomy removes the entire kidney.

It may still be necessary when:

  • The tumour is very large
  • The tumour occupies much of the kidney
  • Tumour location makes partial nephrectomy unsafe
  • There is extensive involvement of major renal blood vessels
  • The remaining kidney tissue would provide little useful function
  • Cancer control would be compromised by attempting partial nephrectomy

The decision is therefore not simply based upon tumour diameter. Tumour anatomy matters enormously.

What Happens After Treatment?

Treating the tumour does not mean that follow-up disappears.

Continued surveillance is important following both ablation and surgery.

The intensity of follow-up depends upon:

  • Final pathology
  • Tumour stage
  • Tumour grade
  • Surgical margins
  • Treatment performed
  • Kidney function
  • Patient age and general health
  • Risk of recurrence

Follow-Up After Partial Nephrectomy

Patients will generally undergo periodic assessment including:

  • Blood pressure
  • Kidney function
  • Serum creatinine and eGFR
  • Urinalysis when indicated
  • Abdominal imaging
  • Chest imaging when clinically appropriate

CT, MRI or ultrasound may be used depending upon the patient’s recurrence risk and kidney function.

Higher-grade or higher-stage cancers generally require more intensive surveillance than a small, completely excised low-grade tumour.

Long-term follow-up is important because renal cell carcinoma can occasionally recur many years after apparently successful treatment.

Follow-Up After Ablation

Imaging is particularly important after tumour ablation because the tumour remains physically present even though the tissue has been destroyed.

Follow-up CT or MRI is therefore used to assess whether there is any persistent or recurrent contrast enhancement, which may indicate viable tumour.

Patients commonly require imaging relatively early after treatment followed by continued surveillance over subsequent years.

If residual tumour is identified, options may include:

  • Repeat ablation
  • Partial nephrectomy
  • Other surgical treatment
  • Continued surveillance in selected circumstances

And What About the Other Kidney?

Follow-up is not only about looking for recurrence.

Kidney health matters.

Patients who have undergone treatment for a renal tumour should pay attention to:

  • Blood pressure
  • Diabetes control
  • Smoking cessation
  • Healthy body weight
  • Kidney function
  • Avoidance of unnecessary kidney-toxic medications
  • Cardiovascular health

Preserving functioning kidney tissue is one reason partial nephrectomy and appropriately selected minimally invasive approaches have become so important.

The Bottom Line

A small renal mass is not automatically an emergency and not automatically a cancer requiring immediate surgery.

Modern management is increasingly personalised.

For one patient, the safest option may be:

Watch it carefully.

For another:

Biopsy it first.

For another:

Ablate it.

And for another:

Remove the tumour robotically while preserving the kidney.

The decision depends upon the tumour’s size, location, appearance, growth and biology, balanced against the patient’s age, kidney function, general health and personal preferences.

Perhaps the most important message is this:

Small renal masses deserve respect, but not necessarily panic.

Active surveillance can be an active treatment strategy in itself. Minimally invasive ablation can provide an alternative for selected patients, particularly those who are less suitable for surgery. And when definitive surgery is appropriate, robotic partial nephrectomy allows many tumours to be removed while preserving the majority of the kidney.

Whichever strategy is chosen, the story does not finish on treatment day. Continued imaging and kidney-function surveillance remain an important part of long-term care.

This information is intended for general patient education and should not replace individual assessment by a urologist. Management of a renal mass should be personalised according to imaging findings, kidney function, medical history, tumour characteristics and patient preferences.

Please note, I no longer do surgery for renal cancer but will continue with your surveillance as long as it does not require surgery. I will then refer you to a Urologist interested in doing these procedures. I can however manage this for you where focal therapy is done by the intervention radiologist.

The Long Foreskin: When a Little Extra Skin Is Just… Extra

/0 Comments/in , /by

Foreskins come in all shapes and sizes. Some are short, some sit neatly over the tip of the penis, and others extend well beyond the glans, occasionally giving the penis the appearance that it has ordered the extra-long sleeve option.

A long foreskin, sometimes described medically as a redundant or elongated prepuce, is usually simply a normal anatomical variation. Length alone is not a disease and does not automatically require treatment.

The important question is not “How long is it?” but rather:

Does it cause any problems?

What is a long or redundant foreskin?

The foreskin, or prepuce, is the fold of skin covering the glans (head) of the penis. Its length varies considerably between men.

In some men, the foreskin extends only slightly beyond the glans when the penis is flaccid. In others, there may be a considerable amount of skin extending beyond the tip.

The appearance can also change substantially between the flaccid and erect states. A foreskin that looks impressively generous when flaccid may retract quite normally during an erection.

There is therefore no particular measurement at which a foreskin suddenly becomes “too long.”

If it retracts comfortably, causes no symptoms and can be kept clean, there is generally no medical reason to shorten it.

Can a very long foreskin cause problems?

Most men with a long foreskin have no problems whatsoever.

Occasionally, however, additional foreskin can contribute to several issues.

Hygiene

A longer foreskin may make cleaning beneath the foreskin slightly more important.

Smegma, dead skin cells and moisture can accumulate underneath the foreskin if it is not regularly retracted and washed. This may produce irritation or an unpleasant smell.

Fortunately, the solution is usually wonderfully low-tech: water, gentle washing and regular hygiene.

Aggressive scrubbing, strong soaps, antiseptics and fragranced products can actually irritate this rather sensitive real estate.

Recurrent balanitis

Balanitis is inflammation of the glans. When both the glans and foreskin are inflamed, the condition is called balanoposthitis.

Symptoms may include:

  • Redness
  • Swelling
  • Itching or burning
  • Discomfort
  • Discharge
  • Unpleasant odour
  • Difficulty retracting the foreskin

Recurrent inflammation deserves assessment because there may be an underlying cause such as infection, dermatitis, diabetes or a chronic inflammatory skin condition.

Difficulty retracting the foreskin

A long foreskin and a tight foreskin are not the same thing.

A very long foreskin that retracts easily is generally harmless. If the opening is too narrow to retract comfortably over the glans, however, this is phimosis.

Phimosis can cause discomfort, recurrent infections, painful erections or difficulty with sexual activity.

Paraphimosis

Occasionally a tight foreskin is pulled behind the glans and becomes trapped there. The foreskin swells and cannot be returned to its normal position.

This is called paraphimosis.

Unlike having a long foreskin, paraphimosis is not merely an interesting anatomical conversation starter. It can compromise blood flow to the glans and requires urgent medical attention.

Problems during sex

Some men with considerable redundant foreskin notice excessive movement or bunching of the skin during intercourse.

Others experience:

  • Irritation
  • Small tears
  • Discomfort
  • Difficulty using condoms
  • Foreskin becoming trapped behind the glans
  • Problems associated with an accompanying short frenulum

Importantly, many men with long foreskins have completely normal and comfortable sexual function.

Urination

A long foreskin may occasionally balloon during urination or cause the urinary stream to spray.

A little post-urination dribbling from urine retained beneath a long foreskin can also occur.

If the foreskin opening is normal and there are no other symptoms, this is often more inconvenient than medically significant. Persistent ballooning associated with a very narrow opening, pain or difficulty passing urine should be assessed.

Does a long foreskin increase the risk of cancer?

Having a long foreskin by itself does not mean that a man will develop penile cancer.

Penile cancer is uncommon, particularly in Australia. Important risk factors include persistent HPV infection, smoking, chronic inflammation and certain foreskin disorders such as lichen sclerosus.

Any persistent penile ulcer, lump, thickened area, bleeding lesion, unusual discharge or change in the skin should therefore be examined rather than waiting for it to disappear.

The penis, regrettably, has never been particularly good at diagnosing itself.

Does a long foreskin need treatment?

Usually, no.

If the foreskin:

  • Retracts comfortably
  • Can be cleaned easily
  • Does not cause recurrent infections
  • Does not interfere with urination
  • Does not cause pain during erections or intercourse
  • Does not bother the patient cosmetically

then no treatment is required.

The medical principle here is refreshingly simple:

If it isn’t causing a problem, there may be nothing to fix.

Conservative management

When symptoms are minor, treatment may involve improving foreskin hygiene and treating any underlying inflammation or infection.

Where there is associated mild phimosis, a doctor may recommend a course of topical corticosteroid cream combined with gentle stretching.

Forceful stretching should be avoided. Small tears can produce scarring, and scarring can make the foreskin progressively tighter, turning a relatively minor problem into a considerably more stubborn one.

Surgical options

Surgery may be considered when there are significant or recurrent problems.

Circumcision

Circumcision removes the foreskin and permanently exposes the glans.

It is a reliable treatment for recurrent balanitis, troublesome phimosis and certain chronic foreskin diseases.

Potential complications include bleeding, infection, altered sensation, cosmetic dissatisfaction, wound problems and, rarely, more significant complications.

Foreskin-preserving surgery

Not every foreskin problem requires complete circumcision.

Depending upon the anatomy and underlying problem, procedures such as preputioplasty can widen a tight foreskin while preserving much of the foreskin.

In selected men with excessive redundant skin but an otherwise healthy foreskin, surgical shortening may also be discussed.

The appropriate operation depends upon the reason for treatment rather than simply the number of centimetres of foreskin involved.

What about appearance?

Some men simply dislike having a long foreskin.

That is a legitimate concern to discuss with a urologist, but cosmetic surgery deserves careful consideration because surgery permanently changes normal anatomy.

It is particularly important to distinguish between a genuinely troublesome anatomical issue and anxiety created by comparisons with pornography, photographs or other men.

There is an enormous range of normal penile anatomy.

Normal does not come in one factory setting.

When should you see a urologist?

Consider seeking medical advice if you have recurrent infections, difficulty retracting or replacing the foreskin, painful erections, tearing or bleeding, problems during intercourse, difficulty passing urine, persistent skin changes or simply uncertainty about whether your foreskin is normal.

A foreskin that suddenly becomes swollen and trapped behind the glans requires urgent assessment, particularly if the glans becomes increasingly swollen, painful or discoloured.

The bottom line

A very long foreskin is usually a variation of normal anatomy rather than a medical condition.

There is no prize for having the shortest foreskin, and fortunately no excess-baggage fee for having the longest.

What matters is function.

If your foreskin retracts normally, stays healthy, allows comfortable erections and intercourse, and can be kept clean, its length alone is unlikely to require treatment.

If it becomes tight, painful, repeatedly inflamed or simply troublesome, however, a urological assessment can determine whether conservative treatment or surgery is appropriate.

When it comes to foreskins, longer isn’t necessarily better or worse. Sometimes it is simply… longer.

So, if this does not answer your questions, come see your Brisbane Urologist, Dtr Jo Schoeman for peace of mind.

Testicular Torsion: When a Testicle Takes a Very Wrong Turn

/0 Comments/in , /by

Sudden testicular pain is an emergency. This is not a “wait until tomorrow and see how it goes” situation.

There are few occasions in life when being twisted is definitely not a good thing. Testicular torsion is one of them.

Testicular torsion occurs when a testicle rotates around the spermatic cord, twisting the blood vessels that supply it. Think of a garden hose being twisted until the water stops flowing, except this particular hose supplies a rather important piece of anatomy.

The result can be sudden, severe pain and, if the blood supply is not restored quickly enough, permanent damage or loss of the testicle.

The good news is that prompt treatment can often save the testicle. The important word here is prompt.

Sudden severe testicular pain should be treated as testicular torsion until proven otherwise. Go directly to an Emergency Department.

What exactly is testicular torsion?

Normally, each testicle has enough mobility to accommodate everyday movement without being able to rotate freely.

Some boys and men have an anatomical arrangement commonly called a “bell-clapper” deformity, in which the testicle is more mobile within the scrotum than usual. This allows it to rotate around the spermatic cord.

When the cord twists, venous drainage is obstructed first, followed by arterial blood flow. The testicle becomes swollen, increasingly painful and eventually starved of oxygen.

This is why testicular torsion is a time-critical surgical emergency.

Although torsion is particularly common in adolescents, it can occur at almost any age, including infancy and adulthood.

What does testicular torsion feel like?

The classic presentation is difficult to ignore:

  • Sudden onset of severe pain in one testicle
  • Rapidly increasing scrotal pain or swelling
  • A testicle sitting higher than usual or lying at an unusual angle
  • Lower abdominal or groin pain
  • Nausea and vomiting
  • Marked tenderness of the affected testicle
  • Occasionally pain that wakes someone from sleep

Some patients experience previous episodes of sudden testicular pain that disappear spontaneously. This may represent intermittent torsion, where the testicle twists and then untwists itself.

A disappearing pain does not necessarily mean that the problem has disappeared.

The clock starts ticking immediately

With torsion, time matters.

The two major factors determining whether a testicle survives are how long it has been twisted and how tightly the spermatic cord has rotated. Current European Association of Urology guidance recommends surgical exploration as soon as possible and notes that the best outcomes occur with very early intervention, ideally within approximately 4–6 hours of symptom onset.

There isn’t a magical cliff at six hours where the testicle suddenly gives up and packs its bags. Salvage may still be possible later, which is precisely why patients should seek emergency treatment regardless of how long the pain has been present.

Don’t wait to see whether it gets better.

And perhaps more importantly:

Don’t be embarrassed.

Emergency doctors and urologists have seen testicles before. Quite a few of them.

How is testicular torsion diagnosed?

The diagnosis begins with the history and examination.

A doctor will examine the abdomen, groin and scrotum and assess the position, swelling and tenderness of the affected testicle.

A Doppler ultrasound can assess blood flow to the testicle and is extremely useful when the diagnosis is uncertain.

However, there is an important catch.

An ultrasound should not delay surgery when torsion is strongly suspected.

The EAU specifically recommends that Doppler ultrasound be used as an adjunct without delaying intervention.

In other words, when the clinical picture is shouting “torsion”, we shouldn’t spend precious time politely asking the ultrasound machine for a second opinion.

Can the testicle simply be untwisted?

Sometimes a doctor can attempt manual detorsion while arrangements for surgery are being made.

This involves carefully rotating the testicle in the direction that releases the twist. Relief of pain may be dramatic when successful.

But this is important:

Successful manual detorsion does not replace surgery.

Residual twisting may remain even when the pain improves, and the testicle can twist again. EAU guidance therefore states that manual detorsion may be attempted while awaiting surgery but must not delay surgical exploration.

Emergency surgery: scrotal exploration

Definitive treatment is an operation called scrotal exploration.

Under anaesthesia, the surgeon makes an incision in the scrotum and examines the affected testicle.

The spermatic cord is untwisted and the testicle is allowed time to recover its blood supply.

Sometimes a rather alarming blue or purple testicle gradually becomes reassuringly pink again. Few colour changes make a urologist happier.

If the testicle appears viable, it is preserved.

Orchiopexy: preventing another twist

If the testicle can be saved, it is secured inside the scrotum using an operation called an orchiopexy or orchidopexy.

The testicle is fixed so that it cannot freely rotate around the spermatic cord again.

But there is another important part of the operation.

We usually fix the other testicle too.

The anatomical predisposition that allowed one testicle to twist may also be present on the opposite side. Therefore, when torsion is confirmed, the unaffected testicle is commonly fixed during the same operation.

Current guidance recommends contralateral orchiopexy at the time of surgery rather than returning later for an elective procedure.

Think of it as discovering that one wheel on the car was loose and sensibly checking the other one while you’re already holding the spanner.

What if the testicle cannot be saved?

Unfortunately, sometimes the blood supply has been absent for too long and the testicular tissue is irreversibly damaged.

If the testicle is clearly non-viable or necrotic, it may need to be removed.

This operation is called an orchidectomy or orchiectomy.

Losing a testicle can understandably be upsetting, particularly for an adolescent or young man. Concerns about appearance, masculinity, testosterone, sexual function and fertility are extremely common.

These concerns deserve a proper conversation rather than a hurried reassurance.

The encouraging news is that one healthy testicle is generally sufficient to maintain normal testosterone production, sexual function and fertility.

What about fertility after testicular torsion?

This subject is more complicated than simply asking whether the testicle survived.

Torsion can damage sperm-producing tissue through the original loss of blood supply and potentially through ischaemia-reperfusion injury when circulation returns.

Long-term studies have therefore reported abnormalities in semen parameters in some men following torsion. The EAU notes reported rates of subfertility of approximately 36–39%, although study results vary considerably and long-term paternity may remain comparable with control populations.

Importantly, having had testicular torsion does not automatically mean that a man will be infertile.

Many men subsequently have normal fertility, particularly when the other testicle is healthy. Studies have also reported normal pregnancy rates following unilateral torsion, whether the affected testicle was preserved or ultimately removed.

For patients concerned about future fertility, particularly after severe torsion, testicular atrophy or problems involving the remaining testicle, subsequent assessment may include:

  • Testicular examination and ultrasound
  • Measurement of testicular volume
  • Semen analysis when appropriate
  • Testosterone and reproductive hormone testing
  • Fertility counselling where indicated

Can a rescued testicle shrink later?

Unfortunately, yes.

A testicle may look viable during surgery and still subsequently undergo testicular atrophy, becoming smaller over the following months.

Current EAU guidance notes that testicular atrophy can occur even following timely detorsion and fixation, which is why appropriate follow-up is important.

This does not mean the operation failed. The initial period without adequate blood supply may simply have caused microscopic damage that wasn’t visible during surgery.

What about testosterone and sexual function?

For most patients with a normal opposite testicle, testosterone production remains adequate.

Long-term studies suggest that hormonal measurements may differ somewhat following torsion, but overall endocrine testicular function generally remains within the normal range.

Removal of one testicle therefore does not normally cause erectile dysfunction, loss of masculinity or the need for testosterone replacement.

The remaining testicle usually quietly gets on with the job.

Testicular prosthesis: replacing what has been lost

Some patients are bothered by the cosmetic asymmetry following removal of a testicle.

A testicular prosthesis can be placed inside the scrotum to restore a more natural appearance and feel.

The prosthesis does not produce sperm or testosterone. Its purpose is cosmetic and psychological rather than functional.

Depending upon the circumstances, a prosthesis may be inserted during the original operation or at a later date. Prosthesis placement is an established option following orchidectomy, and current EAU guidance recommends that patients undergoing removal of a testicle be offered the opportunity to discuss a testicular prosthesis.

The decision is entirely personal.

Some men want one.

Some don’t.

Both decisions are perfectly reasonable.

Recovery after torsion surgery

Most patients recover relatively quickly following uncomplicated orchiopexy.

There will usually be some swelling, bruising and discomfort for several days. Supportive underwear can be surprisingly valuable during this period. The humble pair of supportive briefs finally gets its moment of glory.

Patients are generally advised to avoid strenuous activity, heavy lifting, cycling and contact sports until healing is satisfactory.

Timing for returning to work, school, sport and sexual activity should be discussed with the treating surgeon because this varies according to the operation and individual recovery.

Could torsion happen again after orchiopexy?

It is unusual, but recurrent torsion after orchiopexy is possible.

The EAU guideline describes recurrence after fixation as rare, but documented.

Therefore, even someone who has previously undergone orchiopexy should seek urgent medical attention if they develop sudden severe testicular pain.

Previous surgery doesn’t grant a testicle diplomatic immunity.

The message worth remembering

Testicular torsion is one of the true emergencies in urology.

If you or your son develops sudden severe pain in one testicle, particularly when associated with swelling, nausea, vomiting or an abnormally positioned testicle:

Don’t wait.

Don’t Google for three hours.

Don’t go to bed hoping it will disappear.

Go to an Emergency Department.

When it comes to testicular torsion, hours matter.

Early surgery may mean the difference between fixing a testicle in place and having to remove it.

And in this particular corner of medicine, keeping both passengers on board is very much the preferred destination.

So, get to your local Emergency Department urgently. I operate out of The Wesley and St Andrews War Memorial hospitals where I am on the on call roster. Ask for your local Brisbane Urologist, Dr Jo Schoeman.

Medical disclaimer

This information is intended for general patient education and does not replace individual medical assessment. Acute or sudden testicular pain requires urgent medical evaluation. If testicular torsion is suspected, attend an Emergency Department immediately. Your local Brisbane Urologist is on an on-call roster at both the Wesley Hospital and St Andrews War Memorial Hospital. Don’t delay!