A rare case of testicular metastasis of bladder transitional cell carcinoma.

Metastases from bladder transitional cell carcinoma (TCC) to the testis are very rare. These are usually found on autopsy and occur in advanced or metastatic bladder cancers. More common, known primary tumors that metastasize to the testis include prostate, lungs, melanoma, gastro-intestinal tract and the kidney. We report a rare case of solitary and synchronous metastatic TCC of the bladder to the testis, discovered on histological examination. This case illustrates that metastatic neoplasm to uncommon sites should be considered in the differential diagnosis for patients with a history of advanced bladder TCC.

Diethylstilboestrol for the treatment of prostate cancer: past, present and future.

The aim of this review was to discuss the most recent data from current trials of diethylstilboestrol (DES) to identify its present role in advanced prostate cancer treatment as new hormonal therapies emerge. The most relevant clinical studies using DES in castration-refractory prostate cancer (CRPC) were identified from the literature. The safety, efficacy, outcomes and mechanisms of action are summarized. In the age of chemotherapy this review highlights the efficacy of oestrogen therapy in CRPC. The optimal point in the therapeutic pathway at which DES should be prescribed remains to be established.

Urodynamics in the octogenarian female: is it worthwhile?

INTRODUCTION AND HYPOTHESIS: We hypothesized that urinary symptoms in elderly females correlate poorly with urodynamic diagnosis, which would impact on management. METHODS: Charts of 53 consecutive females over age 80 undergoing multichannel urodynamics according to the International Continence Society standards were retrospectively analyzed. RESULTS: Median age was 83 years. Urodynamic stress incontinence was the most common diagnosis, in 26/53 (49%). Detrusor overactivity was found in only 12 (29%) of 42 females presenting with pure storage symptoms, and reduced compliance was seen in eight (19%). Urodynamics resulted in complete change in patient management in 43% of cases and helped 52% of referring physicians in confirming provisional diagnosis prior to drug or surgical treatment. CONCLUSIONS: In octogenarian females, there is poor correlation between storage symptoms and urodynamic diagnosis. Thus, urodynamics guides patient management and may avoid empirical prescribing associated with adverse effects in this clinically vulnerable population.

A contemporary standard for morbidity and outcome after radical cystectomy.

OBJECTIVE: To report the temporal changes in peri-operative outcome over an extended period in patients undergoing radical cystectomy (RC) for all causes, irrespective of the previous treatment or pathology; and to establish a current standard of peri-operative outcome for RC by analysis of contemporary operative mortality rates (2000-5) factored for risk factors that might predict outcome. PATIENTS AND METHODS: All patients undergoing RC between 1970 and 2005 were analysed; this was an unselected single-centre series and included patients previously treated by definitive radiotherapy, chemotherapy, and cases of RC where the primary tumour involved the bladder but was not of bladder origin. RESULTS: In all, 846 patients had a RC, of whom 647 had a bladder primary tumour and 199 a primary tumour elsewhere (gynaecological, colorectal and others). There was a progressive reduction in 30- and 60-day mortality rates, such that the current peri-operative mortality (1999-2005) was 0.4% and 2.6%, respectively. There was a significant reduction in the re-operation rate over the decades (P=0.01), which is currently 4.7%. Patient age was a significant factor in 30- and 60-day mortality rates (P<0.001 for both) but there was no significant association between either American Society of Anesthesiologists grade or T stage with complication rates (P=0.61 and 0.12, respectively). CONCLUSION: There has been a progressive reduction in mortality related to RC, associated with both cases of RC and pelvic exenteration. The contemporary standard for 30-and 60-day mortality rates for these operations is 0.4% and 2.6%, respectively.

Phimosis as a presenting feature of diabetes.

OBJECTIVE: To determine the prevalence of diabetes in men presenting with phimosis, and to establish the incidence of undiagnosed diabetes in men presenting with acquired or life-long phimosis. PATIENTS AND METHODS: We prospectively collected data on 100 men (mean age 38.5 years, range 17-82) who presented to our department with phimosis during 2006. Urinary glucose levels and random serum glucose levels were analysed, and if abnormal, the patient had further diagnostic tests for diabetes. RESULTS: In all, 31 men presented with a life-long history of phimosis and 69 with a history of acquired phimosis. There was no history of diabetes and no abnormal serum glucose levels in those with life-long phimosis. Eighteen of 69 (26%) of those with acquired phimosis had a history of type 2 diabetes. Type 2 diabetes was newly diagnosed in four of 50 (8%) men presenting with acquired phimosis and no history of a glycaemic disorder. A further two (4%) were diagnosed with impaired fasting glycaemia and impaired glucose tolerance. Urine analysis was positive for glucose in all new diagnoses of glycaemic disorders, except in one man. CONCLUSION: Diabetes can be associated with acquired phimosis in almost a third of cases, and 12% of men presenting with acquired phimosis and no history of diabetes were diagnosed with a disorder of glycaemic control. Therefore it is important that serum glucose levels are analysed when assessing men with acquired phimosis.

Factors affecting successful outcome from ICSI in men following previous vasectomy.

There are conflicting reports as to whether the interval between vasectomy and surgical sperm retrieval (SSR) for intra-cytoplasmic sperm injection (ICSI) is related to clinical pregnancy (CPR), and live birth (LBR), rates. This study aimed to evaluate factors that may influence the outcome of ICSI in males with secondary azoospermia due to previous vasectomy. We analysed the medical records of 198 azoospermic males following vasectomy who underwent percutaneous epididymal sperm aspiration (PESA) and/or testicular sperm extraction (TeSE), between 1997 and 2005 by a single urologist, and whose sperm was subsequently frozen for use in an IVF treatment programme on their partner's behalf. Hundred and forty-four (73%) males had a positive PESA, and the remaining 54 (27%) had a positive TeSE. Forty-four percent of males with no clinical evidence of epididymal distension still had epididymal sperm retrieved successfully. Hundred and twenty-eight patients proceeded with ICSI, and a total of 237 cycles were performed. The CPR and LBR overall were 29 and 27%, respectively. Using logistic regression there was no association between time since vasectomy and CPR (P = 0.17) or LBR (P = 0.31). A history of an attempted reversal of vasectomy did not negatively affect retrieval rates or CPR and LBR. The success of SSR and the outcome of ICSI, using frozen sperm, are independent of male age and time since vasectomy. Epididymal sperm may be retrieved in over 40% of men in whom there is no clinical evidence of epididymal distension.

Sperm retrieval rates in subgroups of primary azoospermic males.

OBJECTIVES: Men presenting with primary infertility and azoospermia may be offered surgical sperm retrieval (SSR) as a prelude to intracytoplasmic sperm injection (ICSI). We evaluated sperm retrieval rates in subgroups of men with azoospermia, based on obstructive aetiology, testicular volume and FSH. METHODS: 106 patients with primary infertility underwent clinical evaluation and SSR with percuataneous epididymal aspiration (PESA) and/or testicular sperm extraction (TeSE) by a single urologist over a five year period. Ten percent of this group (11 patients) had a clear cause of obstruction, congenital absence of the vas deferens (CBAVD), labelled group A. Ninety percent (95 patients) had no definite cause of obstruction, labelled group B. RESULTS: All eleven patients in group A had adequate sperm retrieved, compared with 56% of 95 men in group B. Clinical pregnancy and live birth rates were 47% and 44% for group A respectively compared with 21% and 20% for group B. Twenty-one men had testes <4 cm and FSH>10; a significantly lower sperm retrieval rate was seen in this subgroup (29%) compared to men with normal testicular volume and FSH (77%), p=0.0001, which corresponded to a LBR of 28% and 14% respectively. CONCLUSIONS: In the absence of testicular histology prior to SSR clinical parameters can be used to aid in counselling. Azoospermic males with normal sized testes and normal FSH can expect acceptable numbers of sperm to be retrieved by SSR for ICSI. Less than one third of men with raised FSH and small testes will have successful SSR.

Validation of the CR-POSSUM risk-adjusted scoring system for major colorectal cancer surgery in a single center.

PURPOSE: Scoring systems to predict mortality from surgery are important tools used to give information to the operator and patient and in the auditing of clinical practice. This study was designed to validate the recently developed the Colorectal Physiologic and Operative Severity Score for the Enumeration of Mortality and Morbidity (CR-POSSUM) scoring system in a single center for colorectal cancer surgery. We also analyzed whether albumin may have a role in the CR-POSSUM model. METHODS: We compared this model with two other scoring systems: POSSUM and Portsmouth-POSSUM (P-POSSUM) models. In-hospital mortality was used as the outcome, and Hosmer-Lemeshow statistic was used to determine goodness of fit. RESULTS: Complete data were collected prospectively from 304 patients from 1990 to the present. The overall operative mortality was 6.5 percent. Observed to expected ratios were used to compare the scoring systems at a given predicted mortality. The overall observed to expected ratio was 1.25 for CR-POSSUM, 1.59 for P-POSSUM, and 3.37 for POSSUM. The CR-POSSUM model showed a good fit with the data (Hosmer-Lemeshow statistic, 3.86; P = 0.795) and the area under the receiver operator curve was 0.74. After correcting for factors used in the CR-POSSUM, logistic regression showed a significant correlation between albumin and mortality (P = 0.016). CONCLUSIONS: We have shown that the CR-POSSUM model is an accurate predictor of outcome for major colorectal surgery. The POSSUM and P-POSSUM models over-predicted mortality. Albumin, which is not a factor included in these three systems, may be an important addition in improving the accuracy of the CR-POSSUM model.

The use of prostate-specific antigen testing in men presenting with haematuria.

OBJECTIVES: To analyse prostate-specific antigen (PSA) levels and clinical outcome in men presenting with haematuria, to develop an evidence-base for the use of PSA testing in this setting, as haematuria is a known complication of locally invasive prostate cancer, and so PSA levels are often measured in patients presenting with haematuria. PATIENTS AND METHODS: We reviewed the records of 637 men presenting with haematuria to our urology department between April 2002 and June 2005. RESULTS: Of 373 men aged 50-79 years, 278 (75%) had their PSA level measured, and 50 were abnormal. Prostate biopsies were taken in 27 men with an abnormal PSA level (54%) and one man with a normal PSA level but an abnormal digital rectal examination. Prostate cancer was detected in 22 patients (8% of those tested, and 71% of those biopsied); 4.7% of all men presenting with macroscopic haematuria and aged 50-79 years were found to have prostate cancer, vs 8.5% of those with microscopic haematuria. CONCLUSIONS: We report a higher proportion of prostate cancers in men presenting with haematuria and aged 50-79 years than reported in previous screening studies, and a cancer detection rate of 71% of those biopsied, which is at least double the detection rates seen in screening studies. In the absence of a prospective controlled trial, PSA testing will remain part of our protocol for both macroscopic and microscopic haematuria.