A 62-year-old man presented with frank haematuria; a 2.5 cm papillary lesion was seen on¯exible cystoscopy, close to the right ureteric ori®ce. The tumour was resected, together with partial-thickness loop biopsies of the underlying muscle; histology con®rmed pTa G2 TCC. After the intravesical administration of 40 mg mitomycin C 24 h later, the catheter was removed. The patient voided with no pain and was discharged. When seen the following week he complained of right testicular and groin discomfort, which developed into a severe and unremitting pain over the course of the next month. There was no response to antibiotics and IVU showed mild right hydronephrosis. Cystoscopy at 9 weeks revealed a normal right ureteric ori®ce with an adjacent ulcer at the resection site. A ureteric stent was inserted and the ulcer biopsied, revealing necrotic and in¯am-matory cells only. On bimanual examination there was a hard, ®xed mass in the right hemipelvis. Severe pain continued even after removing the stent and commencement of continuous antibiotics and oxybutynin, so a urinary diversion was contemplated. CT, performed 19 weeks after surgery, showed a focal defect in the right bladder wall with abnormal perivesical enhancement and a small extravesical¯uid collection (Fig. 1a) which ®lled with contrast medium on voiding cystography (Fig. 1b). A catheter was left in situ for one month and removed after a normal repeat cystogram. At cystoscopy the necrotic ulcer was smaller and only slight residual pelvic thickening was palpable bimanually. The pain then resolved, but complete re-epithelialization of the ulcer was not apparent until 18 months after the resection. The patient remains well 48 months after presentation, but an epithelialized crater is still visible endoscopically (Fig. 2). CommentPersistent asymptomatic ulceration after the administration of intravesical chemotherapy is well known [1]. Furthermore, the presence of transmural muscle necrosis and perivesical fat necrosis has recently been reported in a b Fig. 1. a, CT showing thickening of the right lateral bladder wall, a focal bladder wall defect (arrow) and an adjacent extra-vesical¯uid collection. The external surface of the bladder wall and the obturator internus muscle are thickened and show enhancement of their opposing surfaces consistent with in¯ammatory change. b, Right anterior oblique view of a micturating cystogram showing contrast medium passing through a bladder wall defect into a paravesical collection.

Objective To evaluate two methods of reducing the urine output during treatment (the most easily manipulated variable) in patients undergoing intravesical instillation with mitomycin C, where the concentration-time curve also depends upon dose, diluent volume, residual urine volume, and drug absorption and degradation. Patients and methods The study comprised 20 consecutive patients undergoing a course of six weekly instillations of mitomycin C (40 mg in 40 mL for 1 h) for super®cial bladder carcinoma. Urine production during treatment was calculated by adding the voided volume and ultrasonographically measured residual urine after treatment, and subtracting 40 mL; the patient's bladder was emptied before instillation. Before the ®rst and second visit the patients were asked to drink normally. Before the third and fourth visit patients fasted for 6 h before treatment. For the ®fth and sixth visit the patients had not fasted, but 200 mg of desmopressin was given orally 1 h before instillation. Any urinary side-effects were graded on a four-point scale.Results There were 17 patients with complete data; one patient failed to take desmopressin, one had detrusor instability and one developed chemical cystitis. The mean (SD) urine production in unprepared patients was 209 (123) mL, which decreased to 143 (80) mL (P=0.039, t-test) after fasting and 103 (51) mL (P<0.001) with desmopressin. This equates to a 20% increase in mean intravesical drug concentration with fasting and a 38% increase with desmopressin. Urinary side-effects were graded as mild in each group. Conclusion Unprepared patients produce variable and often substantial volumes of urine during intravesical chemotherapy. There was a signi®cant reduction in urine output after fasting or by administering desmopressin before instillation. These measures increase the area under the concentration-time curve for mitomycin C and potentially increase the ef®cacy of treatment.

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A 61-year-old woman presented with left loin pain and was found to have a long standing left-sided hydronephrosis. CT IVU showed a 2.5 cm soft tissue in the region of the distal left ureter with marked proximal dilatation (Figures 1-3). Her urine cytology, flexible cystoscopy and renal function were normal. She underwent a left laparoscopic nephroureterectomy; histology revealed periureteric metastatic adenocarcinoma with clear margin. On immunohistochemistry, oestrogen receptor, CK7, BerEp4, and CEA were strongly expressed (Figures 4 and 5). She had a history of hysterectomy 20 years earlier for ovarian and fallopian tube endometriosis. It was found that adenocarcinoma had arisen within a focus of periureteric endometriosis persisting as hydronephrosis.