NHS - Lincoln & Louth County Hospitals, UK 
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Mr.H.VARADARAJ
Consultant Urological Surgeon
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BLADDER CANCER RELATED QUESTIONS
 
1) I had a bladder tumor resected via telescope (Trans-Urethral Resection of Bladder Tumor ~ TURBT) for the first time  4 weeks ago and told to have pT1 G3 cancer of the bladder. Why am I having a second operation (TURBT) within 4 weeks of the first?
 
Mr.Varadaraj -  For high grade bladder cancer (grade 3) and carcinoma-in-situ a second look TURBT is undertaken, as there is 10% chance of the tumor being upstaged to show involvement of the bladder muscle, which will require a more radical treatment. It has been demonstrated that a second TURBT within 4 weeks with further resection around and through the base of the original tumor can remove any residual tumor and leads to reduced recurrence and improved prognosis in high grade bladder cancer.
 
 
2) I am on the 6 monthly intravesical BCG maintenance (at 12 months stage now) and getting the weekly once instillation for 3 weeks. I have severe urgency, frequency, bladder discomfort after the first two instillation now and anticholinergics tablets to slow the bladder, has not been of much help. There is no blood in the urine after the instillations or urinary tract infection but I have fever  which settles in 48 hours. The severe bladder symptoms, fever were similar after every maintenance instillation previously and took a while to settle. I am considering the option of dropping out  of the maintenance treatment. Is there any alternative?
 
Mr.Varadaraj - Many studies have shown reducing the BCG maintenance dose to one third is equally effective with less side effects and is followed in USA in few centres. In UK however due to  current guidelines relating to intravesical BCG and risk of infection with live tubercle bacilli at the time of reconstitution, it is not permissible to dilute the reconstituted standard intravesical BCG 81mg dose in any alternative way to calibrate the reduced final dose (a complex process).
 
There are two alternatives available which can be tried instead of dropping out of the maintenance BCG treatment.

The First option is to decrease the dwell time or the time the BCG solution is left in your bladder from the standard 2 hours duration down to 30 minutes. The decreased duration of BCG contact with the bladder lining helps to reduce the adverse effects  without affecting efficacy  (long term results awaited) and this may represent a treatment alternative for patients with BCG intolerance
(reference 1, reference 2)

The second option is to consider the use of two doses of antibiotic Ofloxacin 200mg  with the first dose administered 6 hours after first urination after intravesical BCG and the second dose 12 hours after the first dose. Ofloxacin has tuberculostatic properties, excreted in active form in the urine and therefore may decrease the prolonged action of the BCG on the bladder leading to a decrease in the adverse events (reference1,
reference 2)

Please discuss your problem with the Urology Specialist  Nurse who looks after your intravesical instillations or your Consultant Urologist for the possible options before your decide to discontinue treatment. 
 
 
3) After my ileal conduit urinary diversion 2 weeks ago my urinary stoma bag is leaking regularly at night and making it frustrating to manage and I have to change clothes constantly due to urine leak. Any solution for this?
 
Mr.Varadaraj - You can always connect your stoma bag to a urine drainage/collection "thigh" or "leg" bag. This will enable the urine to keep draining and collecting in the drainage bag which has got a non-return mechanism. When the stoma bag is not adherent properly to a small area on the skin, urine starts to leak from here when the stoma bag fills up ,especially when you are lying down. Connecting it to a drainage bag will prevent the stoma bag from filling up and leaking urine. You can  contact your Stoma Nurse or Urology Specialist Nurse for further advise if needed and  discuss about the short term use of a stoma appliance with a belt to ensure a snug fit of the stoma bag around the ileal conduit or any alternative they may advice.
 
 
4) A gentleman I know who has bladder tumor is getting intravesical BCG. I have been offered intravesical Mitomycin chemotherapy for a recurrent small multisite grade 1, pTa bladder cancer. Why have I not been offered intravesical BCG as I understand it is more effective?
 
Mr.Varadaraj -  Intravesical BCG immunotherapy is primarily used for high grade (G3) bladder cancer including carcinoma-in-situ, intermediate risk bladder cancer and has been shown to be superior to intravesical mitomycin chemotherapy in preventing recurrence of the cancer and progression to muscle invasive bladder cancer. Intravesical BCG is associated with significant bladder and systemic side-effects/toxicity compared to intravesical mitomycin. For recurrent or small superficial multiple tumors with grade 1, pTa bladder cancer intravesical mitomycin is effective in reducing the recurrence of such bladder tumors and is preferred to BCG in the first instance. If there is recurrence of the bladder cancer after intravesical mitomycin full course and your tumor grade & stage increases, intravesical BCG will be considered (reference).
 
 
5) I have undergone a Radical Cystectomy for muscle invasive high grade bladder cancer with pelvic lymph node dissection a few weeks ago. I have been informed that my histological/Pathological stage(p) is pT3a,N2 cancer. My preoperative scan had not shown any spread/metastasis or any significant pelvic lymph nodes. Considering the cancer has spread to my  pelvic lymph nodes and there is no obvious metastasis (M0) is there any role for chemotherapy after the surgery? I have been informed that I will not be having chemotherapy as it is not standard part of the treatment after my radical cystectomy.
 
Mr.Varadaraj - Chemotherapy after surgery is referred to as "adjuvant" chemotherapy. Adjuvant chemotherapy for Bladder Cancer following Radical Cystectomy with pT3/4 and/or lymph node positive (N+) disease without clinically detectable metastases (M0) is under debate. Neither randomized trials nor a meta-analysis (complex result analysis of many studies/trials) have provided sufficient data to support the routine use of adjuvant chemotherapy in bladder cancer. Unless there is an ongoing clinical trial for adjuvant chemotherapy for bladder cancer  where a patient can be referred, this form of treatment is not provided as standard treatment based on current guidelines. Also from the evidence so far available, it is unclear whether immediate adjuvant chemotherapy or chemotherapy at the time of recurrence of the bladder cancer is superior as far as cancer specific survival benefit is concerned. Adjuvant chemotherapy has significant side effects also, which may be detrimental, given especially after a major surgery during the recovery phase.  Pelvic lypmh node dissection provides a good clearance of the cancer in the nodes. The decision about your treatment would have been taken after discussion of your medical history,  current health status, histology details etc at your local Multi-disciplinary team (MDT) meeting by the Urologists and Oncologists together.  Some details of bladder cancer research and trials are available at this Link.
 
 
PROSTATE CANCER RELATED QUESTIONS
 
1) I started the 3 monthly hormone injection Zoladex for my prostate cancer 4 months ago  and I have excessive sweating and my clothes are drenched at night. I get hot flashes during the day with intermittent sweating and this is bothering me.  Is there any treatment to stop this?
 
Mr.Varadaraj -  Zoladex is a luteinizing hormone releasing hormone (LHRH) agonist which acts on your pitutory gland and stops the production of testosterone from your testicles. The drop in testosterone will slow or stop the growth of prostate cancer. LHRH agonists have the side effect of bringing on episodic hotflashes and sweating. This can be controlled with a tablet called cypreterone acetate (Andocur) 50mg initially and can be increased  after few days with upward titration by 50mg till the hot flashes are controlled  (maximum dose 150mg if necessary). Please contact your General Practitioner, discuss the problem and then your GP can prescribe cypreterone acetate after looking at your medical history to outrule any contraindications to this medication.
 
Diethy-stilbesterol (DES) 0.5 mg/day or medroxyprogesterone acetate are alternatives to cypreterone acetate that reduce the frequency and severity of hot flashes.
 
URINARY CATHETER ISSUES RELATED QUESTIONS
 
1) My husband has had a long term catheter coming out of his penis for 4 years. I have noted in the last 6 months his penis at the tip is splitting and there is regular discharge which we have been dressing and cleaning with the advice of the district nurse. He has a lot of discomfort  at times when his catheter moves while he is pulling his pants up or when  he is walking around. Is there any solution for this?
 
Mr.Varadaraj - When a catheter is left in for a long period in the water passage (urethra), due to downward pressure of the indwelling "urethral catheter" (UC), the urethra is injured and starts to split on the ventral aspect (under suface) of the penis in men and into anterior vaginal wall in women. Over a period of  years this spilt will go right through the penis as if the penis has been split into two halves. In women it may split through the short urethra and into the bladder neck through the urinary sphincter.
 
The urethra below the lowest part of the bladder (the bladder neck) is encircled by a muscle (the urinary sphincter) that remains contracted to close off the water passage and prevent urine leaking. This splitting can damage the urinary sphincter  causing leaking  of urine through the water passage and around the catheter. The balloon of the catheter can also erode through the bladder neck at times due to pressure over time. making the bladder neck wide open and incompetent. Once the sphincter and bladder neck is damaged (especially in females due to a short urethra of approximately  4cm compared to 20 cm in  men) urinary incontinence sets in as urine freely leaks by the side of the catheter and it becomes difficult to manage the incontinence with a catheter or any other drainage appliance.
 
The possible solution in your husband's case is to consider  a "Suprapubic Catheter" (SPC). Some of the advantages of  SPC are: 1) majority of patients find SPC more comfortable than  UC, 2) Urinary tract infections related to indwelling catheter is lesser with SPC compared to UC,  3) if there are problems with the UC getting blocked with debris the SPC catheter size can be increased in size gradually upto size 20 unlike the preferred restriction on lower sizes  (12-16) for UC. The SPC will stop the urethral splitting and hopefully stop the urethral/ penile pain. Your husband can discuss this option of  SPC with his Urologist (after referral from your GP). Depending on the medical, surgical details and bladder capacity a decision can be taken about  the insertion of the SPC with the new mediplus SPC system under Local anaesthesia  or under General anaesthesia, if he is suitable for SPC option.
 
 
2) Is Suprapubic catheter an option in women with a long term catheter? I have progressive multiple sclerosis and bladder contraction failure due to my neurological condition and have had a urethral catheter for 3 years now.
 
Mr.Varadaraj - Suprapubic Catheter (SPC) is  a better option than urethral catheter for long term catheter in both women and men, if the option of Intermittent Self Catheterisation is ruled out due to any reason. If you read the answer in question 1 above you will understand why women are at a higher risk of urinary incontinence with long term urethral catheter. You can discuss the option of SPC with your Urologist. Depending on the medical, surgical details and bladder capacity a decision can be taken about  the insertion of the SPC with the new mediplus SPC system under Local anaesthesia  or under General anaesthesia, if you are suitable for the SPC option.
 

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