Grey Zones in the Field of Urinary Tract Infections.

Urinary tract infections are a very common clinical problem with various knowledge gaps requiring urgent attention in areas including pathophysiology, diagnosis, antibiotic resistance, and prophylaxis. These grey zones preclude optimal management of urologic patients.

Mechanisms of cryoablation: clinical consequences on malignant tumors.

While the destructive actions of a cryoablative freeze cycle are long recognized, more recent evidence has revealed a complex set of molecular responses that provides a path for optimization. The importance of optimization relates to the observation that the cryosurgical treatment of tumors yields success only equivalent to alternative therapies. This is also true of all existing therapies of cancer, which while applied with curative intent; provide only disease suppression for periods ranging from months to years. Recent research has led to an important new understanding of the nature of cancer, which has implications for primary therapies, including cryosurgical treatment. We now recognize that a cancer is a highly organized tissue dependent on other supporting cells for its establishment, growth and invasion. Further, cancer stem cells are now recognized as an origin of disease and prove resistant to many treatment modalities. Growth is dependent on endothelial cells essential to blood vessel formation, fibroblasts production of growth factors, and protective functions of cells of the immune system. This review discusses the biology of cancer, which has profound implications for the diverse therapies of the disease, including cryosurgery. We also describe the cryosurgical treatment of diverse cancers, citing results, types of adjunctive therapy intended to improve clinical outcomes, and comment briefly on other energy-based ablative therapies. With an expanded view of tumor complexity we identify those elements key to effective cryoablation and strategies designed to optimize cancer cell mortality with a consideration of the now recognized hallmarks of cancer.

[Antibiotic prophylaxis in urology]. / Antibiotikaprophylaxe in der Urologie.

The aim of perioperative antibiotic prophylaxis is the prevention of surgical site infections and urinary tract infections during urological procedures. The indication for antibiotic prophylaxis comprises several risk factors such as the degree of contamination of the operative site, duration of surgery, implantation of devices and comorbidities of the individual patient. In general this involves a single antibiotic administration before the operative procedure. The antibiotic prophylaxis is part of the total antibiotic consumption and thus a factor contributing to emergence of antibiotic resistance. It is not a substitute for hygiene measures or operative precision.

Cryoablation of the prostate: technical recommendations.

The European Association of Urology guidelines on prostate cancer state that cryotherapy is a true therapeutic alternative for patients with clinically localized prostate cancer. The aim of this paper is to establish a uniform practice for performing prostate cryoablation. A collaboration has been set up among five European centres with experience in almost 1000 prostate cancer patients on the use of cryotherapy. The present recommendations were developed through sharing of experience and thorough discussions within the group. This first paper from the group establishes the technical recommendations for use of prostate cryotherapy.

[Cryosurgical ablation as primary treatment in prostate cancer patients]. / Crioterapia prostática como tratamiento primario en pacientes con cáncer de próstata.

OBJECTIVE: Cryosurgical ablation (CSA) is one treatment option that has been developed and it is now recognised as a true therapeutic alternative in the treatment of localised disease. The aim of this paper is to present the preliminary experience with CSA in prostate cancer from the centre in Norway. MATERIALS AND METHODS: A total of 132 patients with prostate cancer have been treated with CSA since September 2003. In 90 patients, CSA was the primary therapy used and these patients included those with low (LR; n=27), intermediate (IR; n=37) and high risk (HR: n=26) disease. Low risk patients were defined as those with T1a-T2a, NO, MO, Gleason score < or = 6 and prostate-specific antigen (PSA) <10 ng/ml. Intermediate risk were patients with T2b tumours or a PSA level of 10-20 ng/ml or Gleason score 7. High risk were defined as those with T2c tumours or Gleason score >7 or PSA >20 ng/ml. The remaining 42 patients either had locally advanced disease or had received salvage treatment after previous external beam radiation (EBRT), cryotherapy or hormone treatment. Patients were evaluated at 3 and 6 months and thereafter at 6 month intervals. A voiding history was taken and the following tests conducted: uroflowmetry, residual urine. RESULTS: Results are presented for those patients receiving CSA as a primary therapy. Currently, the longest follow-up period is 42 months. The median observation period is 21 months and 39% of patients have been seen at the 24-month follow-up visit. No evidence of clinical progression has been observed in patients in the LR or HR group. Two patients in the IR group had clinical evidence of progression. The most common side effects seen during the first year post CSA were urinary tract obstruction and the need for removal of dead prostatic tissue or calcifications. Histological examination of the removed tissue did not shown evidence of prostate cancer. All patients in the LR and IR group that were sexually active before treatment were also sexually active on last follow-up, 37% using some kind of aid. 86% of patients in the LR and IR groups reported no bother as to sexual function. CONCLUSIONS: CSA is now recognised by the EAU as a true therapeutic alternative for the treatment of prostate cancer. Many institutions offer CSA only to older patients due to the lack of long-term data. If longer follow-up data confirm the short-term effect seen in my series, and if comparable side effects are reported in other studies, CSA might also be offered as primary treatment to younger patients.

EAU guidelines for the management of urinary and male genital tract infections. Urinary Tract Infection (UTI) Working Group of the Health Care Office (HCO) of the European Association of Urology (EAU).

A short version of the UTI Guidelines elaborated by the Urinary Tract Infection Working Group of the Health Care Office of the European Association of Urology is presented. The topics include classification, diagnosis, treatment and follow-up of uncomplicated UTI, UTI in children, UTI in diabetes mellitus, renal insufficiency, renal transplant recipients and immunosuppression, complicated UTI due to urological disorders, sepsis syndrome, urosepsis, urethritis, prostatitis, epididymitis, orchitis and principles of perioperative prophylaxis in urology.

The role of antibiotics in the treatment of chronic prostatitis: a consensus statement.

Practical guidelines for the diagnosis and treatment of chronic prostatitis are presented. Chronic prostatitis is classified as chronic bacterial prostatitis (culture-positive) and chronic inflammatory prostatitis (culture-negative). If chronic bacterial prostatitis is suspected, based on relevant symptoms or recurrent UTIs, underlying urological conditions should be excluded by the following tests: rectal examination, midstream urine culture and residual urine. The diagnosis should be confirmed by the Meares and Stamey technique. Antibiotic therapy is recommended for acute exacerbations of chronic prostatitis, chronic bacterial prostatitis and chronic inflammatory prostatitis, if there is clinical, bacteriological or supporting immunological evidence of prostate infection. Unless a patient presents with fever, antibiotic treatment should not be initiated immediately except in cases of acute prostatitis or acute episodes in a patient with chronic bacterial prostatitis. The work-up, with the appropriate investigations should be done first, within a reasonable time period which, preferably, should not be longer than 1 week. During this period, nonspecific treatment, such as appropriate analgesia to relieve symptoms, should be given. The minimum duration of antibiotic treatment should be 2-4 weeks. If there is no improvement in symptoms, treatment should be stopped and reconsidered. However, if there is improvement, it should be continued for at least a further 2-4 weeks to achieve clinical cure and, hopefully, eradication of the causative pathogen. Antibiotic treatment should not be given for 6-8 weeks without an appraisal of its effectiveness. Currently used antibiotics are reviewed. Of these, the fluoroquinolones ofloxacin and ciprofloxacin are recommended because of their favourable antibacterial spectrum and pharmacokinetic profile. A number of clinical trials are recommended and a standard study design is proposed to help resolve some outstanding issues.

[Renal angiomyolipoma as a cause of acute retroperitoneal hemorrhage]. / Renalt angiomyolipom som årsak til akutt retroperitoneal blødning.

Angiomyolipoma is a mesenchymal tumor, usually found in the kidney. The pleomorphic appearance and involvement of regional lymph nodes may simulate malignancy, but angiomyolipomas are classified as benign. Renal angiomyolipomas are found in approximately 40% of tuberous sclerosis patients and are usually small, bilateral and asymptomatic nodules. Spontaneous rupture and retroperitoneal haemorrhage may be experienced with larger tumours. Although findings by ultrasonography and computerized tomography are specific for this lesion, histological examination is necessary for a final diagnosis. Small asymptomatic angiomyolipomas should be followed up with sequential CT scans and be removed by enucleation or partial nephrectomy when they reach a size of more than 4 cm in diameter. If the patient suffers from massive bleeding, it is very difficult to preserve the kidney. We report on a 61-year old women who experienced acute retroperitoneal haemorrhage. She was given ten blood transfusions before she was operated on with en bloc removal of the left kidney, an angiomyolipoma with a diameter of 10 cm and a large haematoma.

Diagnosis and treatment of enterovesical fistula.

The records of 24 patients with enterovesical fistula treated at the urology sections of Telemark and Vestfold Central Hospitals are presented. Most fistulas were due to diverticulitis or a malignant tumor. The part of the intestine most frequently affected was the sigmoid colon in 14 patients, the rectum in 3, the cecum in 2 and the small intestine in 2. Of the 21 patients operated on, 12 underwent a one-stage procedure with resection of the fistula and primary anastomosis of the intestine. The postoperative course was uneventful for 16 patients. Recurrence of the fistula occurred in 1 patient. Three patients were conservatively treated. We recommend a one-stage operation for patients in a good general operating condition, with a well-organized fistula and no systemic infection.

Testicular histology after treatment with the new antiandrogen Casodex for carcinoma of the prostate. A preliminary report.

Five men aged 55-78 years, had received Casodex 50 mg p.o. daily for seven to 12 months. Because of tumour progression orchiectomy was performed. All testes were examined with light- and electronmicroscopy. Evidence of Leydig cell hyperplasia was present in testes from three patients. However, the ultrastructural appearance of the Leydig cells was normal. The spermatogenesis was reduced in all testes, although not significantly different from controls. We believe the Leydig cell hyperplasia reflects an increased proliferative stimulation by luteinizing hormone or a direct effect of Casodex.

[Xanthogranulomatous pyelonephritis. A benign, solid kidney tumor]. / Xantogranulomatøs pyelonefritt. En benign, solid nyretumor.

We report the case of a 68 year-old woman who underwent surgical treatment for xanthogranulomatous pyelonephritis. Xanthogranulomatous pyelonephritis is a rare, chronic, inflammatory lesion of the kidney. It is most frequently seen in middle-aged women. Because of its clinical and radiological similarities to other renal lesions it can be difficult to establish a preoperative diagnosis. Nephrectomy is needed in most patients.

Non-union of testis and epididymis. Description of an experimental model in the rat. Effect on testicular descent.

Most of the reported anomalies in undescended male gonads involve disruption of continuity in the proximal reproductive tract. In order to study the effect of this anomaly on the testis, an experimental model was developed. 16-day-old Sprague-Dawley rats were operated on. The testes were mobilized through a midline abdominal incision and further dissection was carried out under an operation microscope with 20X magnification. The efferent ducts were dissected free, clamped with a microclip, severed and ligated. The epididymis and testis were separated to the level of the inferior epididymal artery. Following surgery 11 of 35 operated testes (31%) remained in the abdomen while three (9%) descended into the opposite hemiscrotum. One of these atrophied due to torsion. The rest descended normally as did all in the sham-operated group. No surgical complications were seen. At 30-37 days the non-union operated testes were edematous, but no tubular distension was seen. The operative procedure probably involves ligation of lymphatic vessels from the testis as well as ductuli efferentes causing an interstitial edema.

Ultrasound in the evaluation of retractile and truly undescended testes.

The aim of this study was to evaluate ultrasound and clinical examination in the assessment of the exact position of an undescended testicle, and to see whether ultrasound could help discern retractile and truly undescended testicles. One hundred and twenty-three undescended testicles were examined. Of 113 detectable testicles 47 were assessed retractile and 66 truly undescended of which 60 were operated. Ultrasound had a sensitivity, specificity and accuracy of 100% for testicles positioned distally to the internal ring. The results of clinical examination by a urologist was poor, especially for testicles located in the inguinal canal. Bilateral symptoms were most common in the retractile group. Retractile testicles dominated at the age group 6-8 years and were most commonly found in the intermediate and external ring positions. Truly undescended testicles preferred the inguinal canal and a subcutaneous everted position. Differences are statistically significant. A discrimination analysis between retractility and true maldescent was performed based on whether symptoms were uni- or bilateral, patient's age and the position of the testicle. The most dominant factor was whether symptoms were uni- or bilateral.

Extraskeletal Ewing's sarcoma contiguous with the seminal vesicle.

A 25-year-old man presented with acute pain in the right lower quadrant of the abdomen and a locally palpable mass. The tumour was extirpated together with the right seminal vesicle, adjacent ureter and bladder wall. The histologic diagnosis was extraskeletal Ewing's sarcoma. No tumour tissue was seen within the seminal vesicle. Intensive postoperative chemotherapy was given and at 18-months follow-up the patient was apparently tumour-free.