No abstract

The detection of bladder cancer continues to rely on direct visualization with cystoscopy. Efforts are underway to improve the utility of urinary markers and cystoscopy through fluorescence endoscopy. The management of superficial bladder cancer is based on transurethral resection of the tumor with perioperative intravesical instillation of chemotherapy strongly suggested for most patients. Risk stratifying patients with high-risk superficial bladder cancer remain a challenge and area of future research.

Bladder cancer continues to provide urologists and researchers with a clinical and scientific challenge. Several urinary markers used in the detection and screening of patients with bladder cancer are currently under investigation. Improvements in intravesical therapy are proving to help decrease both tumor recurrence and progression in patients with high-risk disease. In patients with organ-confined, node-negative bladder cancer, radical cystectomy provides excellent local control and long-term disease-free survival. The use of an extended lymphadenectomy at the time of cystectomy may yield improved prognostic information as well as a potential survival benefit. Neoadjuvant chemotherapy and less toxic combination chemotherapy regimens are offering potential improvements in patients with extravesical or nodal extension. The current methods of detection, as well as available therapeutic treatment options are reviewed.

We developed a guideline for urinary management in the elderly in March 2003. This guideline includes the algorithm for the diagnosis of different types of urinary dysfunction (stress incontinence, urge incontinence, overflow incontinence, functional incontinence, and voiding difficulty) and the procedures of urinary management for each condition. The procedures of urinary management are described for nurses or caregivers, general practitioners and urologists, respectively. The diagnosis of the type of urinary dysfunction is made by nurses or caregivers themselves, using a diagnostic questionnaire comprising 22 items. In the present study, reliability of the diagnostic questionnaire in the guideline was tested and effectiveness of the introduction of the guideline for urinary management in the elderly at nursing homes was assessed.METHODS: The reliability of the diagnostic questionnaire was assessed in 290 institutionalized elderly people in nursing homes by comparing the results of the same patient diagnosed by two different nurses using the questionnaire. In addition, correspondence between diagnosis by urologists and by the questionnaire was also assessed in Ill elderly patients consulting a urology clinic. The guideline was introduced for urinary management to 306 elderly people institutionalized at 20 nursing homes and change of voiding condition was assessed before and after the introduction of the guideline.RESULTS: Agreements of the diagnosis by the questionnaire between the two evaluators were excellent, ranging from 81.4 to 85.5% according to the types of incontinence. Correspondence between diagnosis by urologists and by the questionnaire was also good, ranging from 61.9 to 98.6% according to the types of incontinence. In the nursing homes, 254 elderly people underwent evaluation and urinary management according to the guideline. The introduction of the guideline was very effective in 16.1% of the elderly in whom urinary incontinence disappeared or diapers could be removed. In 25.1 %, the introduction of the guideline was effective, the urinary incontinence or voiding difficulty being improved. The introduction of the guideline brought no significant change for the remaining elderly, among whom dementia and impaired physical activity were significant impediment factors.CONCLUSIONS: The introduction of the guideline for urinary management in the elderly was effective in the evaluation and management of urinary dysfunction in the institutionalized elderly.