The demographic features, clinical outcomes, prognosis and treatment options for patients with sarcomatoid carcinoma of the urinary bladder: a single centre experience.

INTRODUCTION: Carcinosarcoma of the bladder is a very rare neoplasm. The pathogenesis of carcinosarcomas is not clearly understood and remains a subject of debate. Whilst there is some research conceptualizing the histopathological findings of bladder carcinosarcomas, the demographic features, clinical outcomes, prognosis and treatment options remain unclear. MATERIALS AND METHODS: We analyzed 12 consecutive cases of patients with sarcoma-toid bladder cancer who were treated surgically at a single Urology Department be-tween 1999 and 2015. Radiology, pathology and surgical reports were reviewed to determine the pathological staging at the time of cystectomy. These were directly compared with 230 patients having cystectomies for urothelial cell carcinoma. The sarcomatoid patients, were compared to patients with urothelial cell cancers. The other histological sub types, squamous cell (17), neuroendocrine (9), metastatic (7), mixed (4), adenocarcinoma (3), were not included. RESULTS AND CONCLUSION: Carcinosarcoma of the urinary bladder is often described in the literature as a highly malignant neoplasm that is rapidly lethal. We found that the sarcoma does not offer a worse prognosis than conventional high-grade urothelial car-cinoma. There is no significant difference in grade, stage, positive surgical margin rate, nodal involvement, associated prostate cancer or incidence rates of progression, all cause or disease specific mortality. There was a barely significant difference in carcinoma in-situ. However, carcinosarcomas are three times the volume of urothelial cell tumors which may contribute to its reputation as an aggressive tumour (44cc v 14cc). Sarcomatous elements do not appear, from our small study, to bestow a worse prognosis.

Ergonomic use of the fourth arm to oversew the dorsal vascular complex (DVC) during robot-assisted laparoscopic prostatectomy (RALP).

OBJECTIVE: To demonstrate an ergonomic fourth arm technique to oversew the dorsal vascular complex (DVC) during robot-assisted laparoscopic prostatectomy (RALP). PATIENTS AND METHODS: Balloon of a Foley catheter inflated in the bulbar urethra. Fourth arm cranial traction via suture in the tip of the catheter. DVC oversewn under direct vision. RESULTS: Oversew of DVC with minimal patient-side surgical assistance. About a 50% reduction in apical positive margin rate. CONCLUSION: A useful, ergonomic method of oversewing the DVC during RALP.

The discovery of prostate-specific antigen.

The discovery of prostate-specific antigen (PSA) was beset with controversy; as PSA is present in prostatic tissue and semen, it was independently discovered and given different names, thus adding to the controversy. In this review we document the early research in this field to describe the chronology of the discovery of PSA. Using a comprehensive Medline search of the historical aspects of PSA, all relevant papers were reviewed; communication with the scientists involved in the discovery of PSA was an invaluable contribution. In 1960, Flocks was the first to experiment with antigens in the prostate and 10 years later Ablin reported the presence of precipitation antigens in the prostate. In 1971, Hara characterized a unique protein in the semen fluid, gamma-seminoprotein. Li and Beling, in 1973, isolated a protein, E1, from human semen in an attempt to find a novel method to achieve fertility control. In 1978, Sensabaugh identified semen-specific protein p30, but proved that it was similar to E1 protein, and that prostate was the source. In 1979, Wang purified a tissue-specific antigen from the prostate ('prostate antigen'). PSA was first measured quantitatively in the blood by Papsidero in 1980, and Stamey carried out the initial work on the clinical use of PSA as a marker of prostate cancer. Thus the discovery of PSA is interesting and surrounded by controversy. Although the credit for purifying PSA goes to Wang, other eminent scientists published research on this antigen. The initial work on PSA in semen was to asses its properties as a forensic marker for rape victims, but soon its potential as a marker for prostate cancer became evident.

Isolated bladder schwannoma: a rare presentation.

Bladder schwannoma is a rare tumour arising from Schwann cells in nerve sheaths. It is usually more common in patients diagnosed with neurofibromatosis. However, isolated cases of urinary bladder schwannoma is incredibly rare, attributing to <0.1% of bladder tumours. A literature review and analysis revealed that it presents in adulthood, is mostly symptomatic and diagnosis is established histologically. We report a case of isolated bladder schwannoma in 25 year-old female who presented with dyspareunia.

Incisional hernia around the suprapubic catheter: an unusual complication.

Hernia through the suprapubic catheterization (SPC) site is rare. Attention is required for such hernias as they get obstructed due to the narrow neck. We report this rare presentation in an elderly gentleman with obstructed incisional hernia through the SPC site, which was reduced and subsequently had a successful mesh repair.

Robotic assisted laparoscopic partial nephrectomy using contrast-enhanced ultrasound scan to map renal blood flow.

OBJECTIVE: The paper describes novel real-time 'in situ mapping' and 'sequential occlusion angiography' to facilitate selective ischaemia robotic partial nephrectomy (RPN) using intraoperative contrast enhanced ultrasound scan (CEUS). MATERIALS AND METHODS: Data were collected and assessed for 60 patients (61 tumours) between 2009 and 2013. 31 (50.8%) tumours underwent 'Global Ischaemia', 27 (44.3%) underwent 'Selective Ischaemia' and 3 (4.9%) were removed 'Off Clamp Zero Ischaemia'. Demographics, operative variables, complications, renal pathology and outcomes were assessed. RESULTS: Median PADUA score was 9 (range 7-10). The mean warm ischaemia time in selective ischaemia was less and statistically significant than in global ischaemia (17.1 and 21.4, respectively). Mean operative time was 163 min. Postoperative complications (n = 10) included three (5%) Clavien grade 3 or above. Malignancy was demonstrated in 47 (77%) with negative margin in 43 (91.5%) and positive margin in four (8.5%). Long-term decrease in eGFR post selective ischaemia robotic partial nephrectomy was less compared with global ischaemia (four and eight, respectively) but not statistically significant. CONCLUSIONS: This technique is safe, feasible and cost-effective with comparable perioperative outcomes. The technical aspects elucidate the role of intraoperative CEUS to facilitate and ascertain selective ischaemia. Further work is required to demonstrate long-term oncological outcomes. © 2016 The Authors. The International Journal of Medical Robotics and Computer Assisted Surgery published by John Wiley & Sons, Ltd.

Nephroureterectomy for emphysematous pyelonephritis: An aggressive approach is sometimes necessary. A case report and literature review.

INTRODUCTION: Emphysematous pyelonephritis (EPN) is a life-threatening urological emergency. A high index of suspicion is required for diagnosis as such patients may present to physicians with typical features of pyelonephritis. PRESENTATION OF CASE: A 67 year old lady presented atypically to the Emergency Department with symptoms of renal colic. The diagnosis of emphysematous pyelonephritis was established on prompt CT scanning. She did not respond to conservative management. Due to acute, critical deterioration, she underwent a radical right nephroureterectomy. The resected kidney involved a long segment of necrotic, gangrenous ureter. The patient had a smooth post-operative recovery and was successfully discharged. She remains well on follow-up after one year. DISCUSSION: Early radiological diagnosis is imperative for risk stratification of EPN. Current evidence recommends percutaneous catheter drainage with interval nephrectomy as the gold standard treatment. We review the literature for pathophysiology and clinical prognostic factors. This case adds onto the limited evidence base on ureteric involvement in EPN, suggesting a revision of EPN classification. CONCLUSION: Further research on ureteric involvement and treatment outcomes in EPN is required. Even in the current era of minimally invasive surgery and renal preservation therapies, early open nephrectomy still has a role in the management of EPN.

Trichobezoar of urinary bladder with secondary calculus: case report.

A trichobezoar with a calculus in the center was diagnosed in a young woman on long-term urethral catheter drainage. Urologists need to be aware of this potentially preventable complication to save patients from significant morbidity.

The demographic features, clinical outcomes, prognosis and treatment options for patients with sarcomatoid carcinoma of the urinary bladder: a single centre experience

ABSTRACT Introduction Carcinosarcoma of the bladder is a very rare neoplasm. The pathogenesis of carcinosarcomas is not clearly understood and remains a subject of debate. Whilst there is some research conceptualizing the histopathological findings of bladder carcinosarcomas, the demographic features, clinical outcomes, prognosis and treatment options remain unclear. Materials and Methods We analyzed 12 consecutive cases of patients with sarcoma-toid bladder cancer who were treated surgically at a single Urology Department be-tween 1999 and 2015. Radiology, pathology and surgical reports were reviewed to determine the pathological staging at the time of cystectomy. These were directly compared with 230 patients having cystectomies for urothelial cell carcinoma. The sarcomatoid patients, were compared to patients with urothelial cell cancers. The other histological sub types, squamous cell (17), neuroendocrine (9), metastatic (7), mixed (4), adenocarcinoma (3), were not included. Results and conclusion Carcinosarcoma of the urinary bladder is often described in the literature as a highly malignant neoplasm that is rapidly lethal. We found that the sarcoma does not offer a worse prognosis than conventional high-grade urothelial car-cinoma. There is no significant difference in grade, stage, positive surgical margin rate, nodal involvement, associated prostate cancer or incidence rates of progression, all cause or disease specific mortality. There was a barely significant difference in carcinoma in-situ. However, carcinosarcomas are three times the volume of urothelial cell tumors which may contribute to its reputation as an aggressive tumour (44cc v 14cc). Sarcomatous elements do not appear, from our small study, to bestow a worse prognosis.

Occlusion angiography using intraoperative contrast-enhanced ultrasound scan (CEUS): a novel technique demonstrating segmental renal blood supply to assist zero-ischaemia robot-assisted partial nephrectomy.

BACKGROUND: Recent innovations in technology and operative techniques have enabled safe performance of robot-assisted zero-ischaemia partial nephrectomy (PN), thus preventing the deleterious effect of warm ischaemia time. OBJECTIVE: To describe a novel technique of occlusion angiography using intraoperative contrast-enhanced ultrasound scan (CEUS) for zero-ischaemia robot-assisted PN (RAPN). DESIGN, SETTING, AND PARTICIPANTS: We used a prospective cohort evaluation of five patients who had imaging suspicious of renal cell carcinoma (RCC) treated at a single centre. SURGICAL PROCEDURE: We used computed tomography with three-dimensional reconstruction to identify renal arterial anatomy and its relationship to the tumour. Then, RAPN was performed with selective clamping and demonstration of a nonperfused segment of kidney (occlusion angiography) using intraoperative CEUS. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We prospectively collected data on baseline, perioperative, and postoperative parameters. RESULTS AND LIMITATIONS: We describe the effects seen on ultrasound contrast administration. Contrast flare is seen in the segment of the kidney that is perfused. When selective clamping is performed, a watershed (line of demarcation) between the perfused and nonperfused segments of the kidney is clearly seen, allowing excision of the tumour in a relatively avascular plane and ensuring an adequate oncologic margin, when feasible. The mean age was 68.2 yr of age (range: 36-85), and the mean tumour size was 29.6mm (range: 20-42). The mean intraparenchymal extension of the tumour was 22.6mm (range: 12-30). Three tumours were located on the right kidney and two on the left. The mean blood loss was 420ml (range: 200-1000). The histology revealed clear cell RCC in two patients, oncocytoma in two patients, and type 1 papillary RCC in one patient. All the surgical specimens had negative surgical margins. The mean decrease in glomerular filtration rate was 8.4ml (range: 0-24). The mean follow-up was 6.4 mo (range: 5-8), with no evidence of recurrence in any patient. The only limitation in adopting this technique is the need for an intraoperative ultrasound probe with a CEUS mode. However, most specialists who perform minimally invasive surgery for small renal tumours believe that intraoperative ultrasound scan imaging is essential to achieving adequate resection margins. CONCLUSIONS: Intraoperative CEUS can be a useful adjunct in determining whether zero-ischaemia RAPN is feasible by delineating the area of nonperfusion. This technique has several advantages over the currently available techniques, such as indigo carmine green and Doppler probes.

A single-center experience of symptomatic male urethral diverticula.

OBJECTIVES: To describe our experience of the etiology, presentation, management and outcomes of male urethral diverticula, which are uncommon, with few reports of large series published. METHODS: Twenty-one patients with male urethral diverticula were treated at a single institution during a 7-year period. Their case notes were retrospectively reviewed. RESULTS: Of the 21 diverticula, 7 (33.3%) were congenital as determined from the history and histologic analysis. These 7 patients' mean age at presentation was 25 years, and they complained mainly of obstructive symptoms, poor bladder emptying, and a palpable perineal swelling. The 14 patients with acquired diverticula presented later, at a mean age of 35 years, but with almost identical symptoms and signs. The most common aetiolgical factors included trauma in 3, urethral stricture disease in 3, and previous urethroplasty in 3. The anterior urethra and penoscrotal junction were the most commonly affected sites in both groups (18 of 21). Overall, 12 patients underwent open surgical repair, 6 underwent endoscopy, and in 3, the diverticulum was left in situ. Postoperative complications were more frequent in the acquired group (64% versus 27%) and included urethrocutaneous fistula in 5, urethral stricture in 2, and wound infection in 4. CONCLUSIONS: Urethral diverticula are uncommon, but should always be considered in young men with lower urinary tract symptoms or in those with a history of urethral trauma. Treatment should be individualized and determined according to the patient's fitness and the site and size of the diverticulum.

Does intraprostatic inflammation have a role in the pathogenesis and progression of benign prostatic hyperplasia?

OBJECTIVE: To compare the incidence of acute and/or chronic intraprostatic inflammation (ACI) in men undergoing transurethral resection of the prostate (TURP) for urinary retention and lower urinary tract symptoms (LUTS), as recently a role was suggested for ACI in the pathogenesis and progression of BPH, and urinary retention is considered an endpoint in the natural history of this condition. PATIENTS AND METHODS: Details of TURPs done between January 2003 and December 2005 at one institution were obtained from the operating theatre database. Patients were divided by indication (retention/LUTS). Clinical data and histology reports were then reviewed and bivariate and logistic regression used to compare the pathological features between these groups. RESULTS: Of 406 patients, 374 had evaluable data; 70% of men with urinary retention had ACI, vs 45% of those with LUTS (P < 0.001). On logistic regression, the pathological factors associated with TURP for acute retention compared to that for LUTS were ACI, old age, and resection weight to a lesser degree. CONCLUSION: Inflammation appears to be important in the pathogenesis and progression of BPH. In this study, the risk of urinary retention due to BPH was significantly greater in men with ACI than in those without, and the association of TURP for retention with ACI was stronger than that with prostate weight. This finding might offer new avenues for the medical treatment of men with LUTS due to BPH.

Publication rate of abstracts presented at the British Association of Urological Surgeons Annual Meeting.

OBJECTIVE: To determine the number of peer-reviewed publications arising from the abstracts presented at the annual meetings of the British Association of Urological Surgeons (BAUS), and to assess urological trainees' attitudes to research in relationship to the pursuit of Specialist Registrar (SpR) training numbers and their perception of academic urology in the UK. METHODS: Publications resulting from presentations at the annual meetings of the BAUS 2001 and 2002 were searched for using the PubMed database. Variables that might influence the subsequent publication of abstracts in peer-reviewed journals were analysed. Whether institutions from other countries had similar publication rates to those in the UK was also assessed. SpRs were interviewed about their motivation to convert presentations to publications before and after their appointment to SpR training. RESULTS: In July 2004, 142 of 449 abstracts presented at BAUS 2001 and 2002 were published, giving a publication rate of approximately 42% on Kaplan-Meier analysis. The rate of publication appeared to continue to the end of the period of searching for publications. The publication rate arising from UK presentations was lower than that from the non-UK presentations (hazard ratio 0.75, 95% confidence interval 0.49-1.15, P = 0.14). Publication rates from podium and poster presentations were similar. Urology journals accounted for 75% of the publications. Of the SpRs evaluated, 83% did research and presented papers to obtain a training number rather than because of an inherent interest to pursue an academic career. CONCLUSIONS: The conversion rate from BAUS presentation to peer-reviewed publication at 36 months was similar on Kaplan-Meier analysis to that of the American Urological Association (AUA, 38%). Interestingly, the rate of publication from the AUA seems to be faster than from BAUS. In addition, presentations from outside the UK appeared to be published faster than those from the UK. Delegates attending these conferences need to consider this when deciding whether a particular presentation will influence their practice. British urology requires academics who are interested in pursuing high-quality research, and which is presented at major conferences with an intention to publish it in peer-reviewed journals.

Voiding dysfunction after tension-free vaginal tape: a conservative approach is often successful.

The published literature has focused mainly on the efficacy of tension-free vaginal tape (TVT) in correcting stress incontinence with few reports of complications. We report our experience with the first 52 cases of TVT, specifically assessing voiding dysfunction after the procedure. We carried out a retrospective study of patients undergoing TVT surgery for stress urinary incontinence (SUI) between April 2001 and July 2003. Data were collected on period of catheterization, voiding and storage symptoms, their duration and management. Fifty-two women with a mean age 54 years (36-77) were included. Postoperatively, the urethral catheter was removed routinely within 12 h. Twelve patients (23%) failed to void spontaneously and needed recatheterization. Ten of them (83%) were able to resume spontaneous voiding within 3 months. Twenty patients (38%) complained of storage symptoms postoperatively. Sixteen (80%) responded to conservative treatment. Transient urinary symptoms after TVT sling for SUI are common but can usually be managed conservatively.

Role of i.v. urography in patients with haematuria.

OBJECTIVE: Traditionally, patients presenting with haematuria undergo a series of investigations, including urine cytology, cystoscopy, i.v. urography (IVU) and renal tract ultrasound (US). Studies have suggested that the omission of IVU as a routine investigation for painless haematuria does not dramatically reduce the detection rate of malignant conditions. In this large retrospective study we evaluated the impact of the omission of IVU on the diagnosis of renal tract malignancies and other non-malignant but significant conditions. MATERIAL AND METHODS: A retrospective analysis of all patients attending our haematuria clinic between January 2000 and August 2002 was carried out. The diagnostic yields of IVU and a US scan were compared and the significance of abnormalities missed by either modality was assessed with regard to the overall management of patients. Diagnoses were divided into those that were significant and potentially harmful [e.g. tumour, pelvi-ureteric junction (PUJ) obstruction, hydronephrosis] and those that were insignificant and harmless (e.g. simple cyst, non-obstructing calculus). Liddell's exact test for matched pairs was used to test for statistical significance and to give the relative risk of a positive result. RESULTS: A total of 1211 patients were included in the study. When cytology, cystoscopy and US were normal, IVU did not detect any additional malignant pathology. Performing IVU instead of a US scan would have resulted in 74 non-malignant conditions remaining undiagnosed. Similarly, US alone would have missed 64 non-malignant lesions. Six non-malignant but significant conditions, including PUJ obstruction (n = 5) and benign ureteric stricture with hydronephrosis (n = 1), were missed by US but detected by IVU. CONCLUSION: In this cohort of retrospectively studied patients attending a haematuria clinic, IVU could safely have been omitted without decreasing the overall detection of malignant pathologies. Nevertheless, significant non-malignant pathologies would have remained undiagnosed. The authors suggest that US combined with a MAG III renogram could be considered as a first-line investigation instead of IVU. This is likely to result in maximum detection of malignant and non-malignant conditions, while reducing the radiation exposure to the patient.