Methods to improve efficacy of intravesical mitomycin C: results of a randomized phase III trial.

BACKGROUND: Intravesical chemotherapy (i.e., placement of the drug directly in the bladder) with mitomycin C is beneficial for patients with superficial bladder cancer who are at high risk of recurrence, but standard therapy is empirically based and patient response rates have been variable, in part because of inadequate drug delivery. We carried out a prospective, two-arm, randomized, multi-institutional phase III trial to test whether enhancing the drug's concentration in urine would improve its efficacy. METHODS: Patients with histologically proven transitional cell carcinoma and at high risk for recurrence were eligible for the trial. Patients in the optimized-treatment arm (n = 119) received a 40-mg dose of mitomycin C, pharmacokinetic manipulations to increase drug concentration by decreasing urine volume, and urine alkalinization to stabilize the drug. Patients in the standard-treatment arm (n = 111) received a 20-mg dose without pharmacokinetic manipulations or urine alkalinization. Both treatments were given weekly for 6 weeks. Primary endpoints were recurrence and time to recurrence. Treatment outcome was examined by use of Kaplan-Meier analysis with log-rank tests. Statistical tests were two-sided. RESULTS: Patients in the two arms did not differ in demographics or history of intravesical therapy. Dysuria occurred more frequently in the optimized arm but did not lead to more frequent treatment termination. In an intent-to-treat analysis, patients in the optimized arm showed a longer median time to recurrence (29.1 months; 95% confidence interval [CI] = 14.0 to 44.2 months) and a greater recurrence-free fraction (41.0%; 95% CI = 30.9% to 51.1%) at 5 years than patients in the standard arm (11.8 months; 95% CI = 7.2 to 16.4 months) and 24.6% (95% CI = 14.9% to 34.3%) (P =.005, log-rank test for time to recurrence). Improvements were found in all risk groups defined by tumor stage, grade, focality, and recurrence. CONCLUSIONS: This study identified a pharmacologically optimized intravesical mitomycin C treatment with statistically significantly enhanced efficacy.

[Routine intravenous pyelography not diagnostically useful in men with lower urinary tract infections]. / Routinematige intraveneuze pyelografie bij mannen met een lage-urineweginfectie diagnostisch niet zinvol.

OBJECTIVE: Evaluation of intravenous urography (IVU) in men with a lower urinary tract infection. SETTING: Leyenburg Hospital, the Hague, the Netherlands. DESIGN: Retrospective. METHODS: In 28 male patients with a diagnosed lower urinary tract infection, an IVU was made in order to find causative urogenital tract abnormalities. We determined whether the IVU provided additional diagnostic information. RESULTS: Only I IVU (4%) of the 28 showed abnormalities (a bladder stone in a patient with epididymitis). The finding was not statistically significant (Fisher's exact test). CONCLUSION: In men with a symptomatic lower urinary tract infection showing symptoms such as frequent and burning micturition, whether or not complicated or not by epididymitis, an IVU gives no additional diagnostic information.

[Acute urinary retention in women]. / Acute urineretentie bij vrouwen.

Acute urinary retention in women is not a common problem. The incidence is 0.07 per 1000 inhabitants per year. The causes of acute urinary retention can be divided into four groups: obstructive, neurological, pharmacological and psychogenic. More than half of acute urinary retentions occur after surgery or parturition. The most common obstructive cause is a gynaecologic tumor. A psychogenic cause is a diagnosis per exclusionem. The treatment of the acute urinary retention has to be catheterisation before further investigation is done.

[A patient with a vesico-uterine fistula]. / Een patiënte met een vesico-uteriene fistel.

In a 20-year-old woman with a uterus didelphys a vesicouterine fistula was diagnosed after caesarean section. The symptoms suggested a vesico-vaginal fistula but no abnormalities could be detected vaginally and the methylene-blue test was negative. The fistula was visualised by instillation of radiopaque contrast fluid into the vesical fistula opening, using a ureter catheter. The patient was operated via a transperitoneal route with interposition of peritoneum between the urinary bladder and the uterus.

Functional extracorporeal magnetic stimulation as a treatment for female urinary incontinence: 'the chair'.

OBJECTIVE: To evaluate, in a prospective study, the efficiency and applicability of functional magnetic stimulation (FMS) of the pelvic floor for treating urinary incontinence in women. PATIENTS AND METHODS: FMS was provided by a 'magnetic chair'; 24 patients were treated twice weekly for 8 weeks (12 with urge incontinence and 12 with a mixture of urge and stress incontinence). The outcome was assessed urodynamically, by a pad test, and by patient satisfaction. RESULTS: In 58% of the patients there was an objective improvement in incontinence; three patients were completely dry and 71% reported a subjective improvement (P < 0.001). CONCLUSION: FMS is a safe, noninvasive and painless treatment for urinary incontinence; it is effective and easy to administer as an outpatient treatment.

Isothermic irrigation during transurethral resection of the prostate: effects on peri-operative hypothermia, blood loss, resection time and patient satisfaction.

OBJECTIVES: To investigate the effect using irrigation fluid at body temperature (isothermic) on patients' (core) temperature during a transurethral resection of the prostate (TURP) and on the amount of peri-operative blood loss, the resection time and the subjective assessment of comfort by the patients. PATIENT AND METHODS: In a randomized study, patients undergoing TURP under spinal anaesthesia were divided into those receiving either isothermic irrigation fluid (Group 1.28 patients) or fluid at room temperature (Group 2.31 patients). In Group 1, a fluid heater maintained the irrigation fluid at body temperature until it reached the bladder. The body temperature of the patients was recorded rectally and orally during and after TURP and the peri-operative blood loss was also measured. The patients were interviewed on the first day after TURP to determine their assessment of comfort during the procedure. RESULTS: The decrease in body temperature was 0.74 degree C in Group 1 and 1.71 degrees C in Group 2, which was significantly different (P < 0.001). There was no significant difference in blood loss or resection-time. In Group 1, only four (14%) of the patients were aware that their body was cooler, compared to 15 (50%) in Group 2 (P = 0.038). CONCLUSION: Isothermic irrigation during TURP prevents excessive cooling and reduces the level of hypothermia. The reported increased mortality after TURP is probably related to peri-operative cardiac stress, an important factor which could be caused by the rapid decrease in body temperature which accompanies normal irrigation. Because the heating equipment presently available does not interfere with TURP, there are strong arguments for performing every TURP with irrigation fluid at body temperature.

The effect of orgasm on prostate-specific antigen.

To identify the effect of orgasm on serum prostate-specific antigen (PSA) levels, a prospective trial before and after orgasm was performed in 14 healthy colleagues aged 32-62 years (mean, 44.4 years) with no evidence of prostatic disease. PSA determinations were performed on serum samples obtained before and after orgasm. Significant changes in PSA levels after orgasm were found (P = 0.002, analysis of variance). We conclude that the impact of orgasm on PSA levels should be taken into account when the latter are used for the detection of prostatic disease.

Bilateral hydronephrosis with urosepsis due to neglected pessary. Case report.

In an 86-year-old woman a neglected pessary and extreme coprostasis gave rise to anuria, urosepsis and bilateral ureteropelvic dilatation with an empty bladder. This seems to be the first reported case of its kind.

Treatment of corpus cavernosum abscess by aspiration and intravenous antibiotics.

We report the successful treatment of an abscess in the corpus cavernosum of a paraplegic man on intracavernous papaverine injection therapy by means of percutaneous aspiration and intravenous antibiotics. After 3 months of intracavernous pharmacotherapy the patient experienced good erections again and only minimal fibrosis could be found on palpation.