Comparison of laparoscopic and open pyeloplasty in 100 patients with pelvi-ureteric junction obstruction.

BACKGROUND: This study aimed to determine whether the morbidity and outcome rates for laparoscopic transperitoneal dismembered pyeloplasty are different from those for dismembered pyeloplasty, to analyze the learning curve of laparoscopic pyeloplasty, and to determine whether preoperative stent placement affects outcome. METHODS: For this study, 49 laparoscopic pyeloplasties (period 2000-2005) and 51 open pyeloplasties (period 1992-2003) were reviewed. RESULTS: Compared with open procedures, laparoscopic procedures were associated with a longer mean operating time (159 vs 91 min; p < 0.001), a shorter mean time to normal diet (38 vs 72 h; p < 0.001), and a similar mean hospital stay (5 days; p = 0.6). The operative complication rates were 17% for primary laparoscopic pyeloplasties and 24% for primary open pyeloplasties. The rates were higher for secondary procedures. The success rates for primary and secondary procedures were, respectively, 98% (41/42) and 57% (4/7) for laparoscopy and 96% (46/48) and 67% (2/3) for open surgery. Failed procedures showed no improvement in loin pain or obstruction. At the 6-month follow-up evaluation, 29% of the open surgery patients but none of the laparoscopic surgery patients reported wound pain. CONCLUSIONS: The efficacy of laparoscopic pyeloplasty is equivalent to that of open pyeloplasty, with less wound pain at 6 months. The outcome for secondary procedures is inferior. There was a trend toward a reduction in complications and the conversion rates with time, suggesting that there may be a learning curve of approximately 30 laparoscopic pyeloplasty cases. Preoperative stent insertion did not seem to affect any objective measures of outcome for laparoscopic pyeloplasty.

Proteomic analysis of the cell-surface membrane in chronic lymphocytic leukemia: identification of two novel proteins, BCNP1 and MIG2B.

B-cell-specific plasma-membrane proteins are potential targets for either small molecule or antibody-based therapies. We have sought to annotate proteins expressed at the cell surface membrane in patients with chronic lymphocytic leukemia (CLL) using plasma-membrane-based proteomic analysis to identify previously uncharacterized and potentially B-cell-specific proteins. Proteins from plasma-membrane fractions were separated on one-dimensional gels and trypsinized fractions subjected to high-throughput MALDI-TOF mass spectrometry. Using this method, many known B-cell surface antigens were detected, but also known proteins not previously described in this disease or in this cellular compartment, including cell surface receptors, membrane-associated enzymes and secreted proteins, and completely unknown proteins. To validate the method, we show that BLK, a B-cell-specific kinase, is located in the CLL-plasma-membrane fraction. We also describe two novel proteins (MIG2B and B-cell novel protein #1, BCNP1), which are expressed preferentially in B cells. MIG2B is in a highly conserved and defined gene family containing two plasma-membrane-binding ezrin/radixin/moesin domains and a pleckstrin homology domain; the Caenorhabditis elegans homolog (UNC-112) is a membrane-associated protein that colocalizes with integrin at cell-matrix adhesion complexes. BCNP1 is a completely unknown protein with three predicted transmembrane domains, with three alternatively spliced final exons. Proteomic analysis may thus define new potential therapeutic targets.

Synergized pyrethrin mousse, a new approach to head lice eradication: efficacy in field and laboratory studies.

The purpose of this study was to evaluate the pediculicidal and ovicidal efficacy of a new, single-application formulation of synergized natural pyrethrins (presented in an aerosol mousse form) compared with an established, effective formulation based on permethrin (in a creme rinse form). The trial was a single-blind, comparative, randomized, parallel-group study. Children between the ages 7 and 15 years and adults with active head lice infections, identified by the presence of live lice, were enrolled from a school and a children's home in Dhaka, Bangladesh. Prevalence of infection ranged from 75% to 100% in the two study centers. The field study confirmed laboratory findings showing pyrethrin mousse to be effective at killing both lice and their eggs with a single 10-minute application. Of 52 patients identified with lice, 42 were treated with pyrethrin mousse and 10 with permethrin creme rinse. In each case, a sample of viable louse eggs was taken from the patients' hair before and after treatment. The eggs were then incubated to assess ovicidal activity. After treatment, the patients were examined for lice on alternate days until day 8 and then again on day 14. None of the patients in either group was found to have lice up to 2 days after treatment. One patient was found to have two moribund hatchlings on day 4. By day 6, when any eggs still present on the scalp would be expected to hatch, 19 pyrethrin mousse-treated patients were available for assessment. Two patients had been reinfected from contacts.(ABSTRACT TRUNCATED AT 250 WORDS)

Review of laparoscopic urology.

Laparoscopy in urology has been slow to develop in the United Kingdom. Much of the pioneering work has been done in America and continental Europe. It is gradually gaining in popularity as urologists and the general public become more aware of the advantages it offers in terms of patient morbidity and surgical results. The aim of this review is to summarize the development of laparoscopic urology to date and to examine the various indications and the benefits of its application.

Mobile versus fixed site lithotripsy.

The efficacy of a mobile Dornier HM4 lithotriptor, was compared with that of a fixed site Siemens Lithostar. A total of 115 calculi in 98 patients were treated, 55 on the mobile Dornier and 60 on the Lithostar. The groups were similar except for stone size, the mean of the Lithostar group being 11 mm compared with 7.7 mm in the Dornier group. Fragmentation rates were not significantly different, 88% and 75% on the mobile and fixed site machines, respectively and, at 3 months follow-up 66% and 46% were stone free or with fragments of less than 2 mm. There were no serious complications, and the incidence of mild complications was similar in the two groups. We conclude that the mobile Dornier HM4 is an effective lithotriptor and can offer several advantages over fixed site machines.

Prediction of complications after partial nephrectomy by RENAL nephrometry score.

INTRODUCTION: Discussing and planning the appropriate management for suspicious renal masses can be challenging. With the development of nephrometry scoring methods, we aimed to evaluate the ability of the RENAL nephrometry score to predict both the incidence of postoperative complications and the change in renal function after a partial nephrectomy. METHODS: This was a retrospective study including 128 consecutive patients who underwent a partial nephrectomy (open and laparoscopic) for renal lesions in a tertiary UK referral centre. Univariate and multivariate ordinal regression models were used to identify associations between Clavien-Dindo classification and explanatory variables. The Kendall rank correlation coefficient was used to examine an association between RENAL nephrometry score and a drop in estimated glomerular filtration rate (eGFR) following surgery. RESULTS: An increase in the RENAL nephrometry score of one point resulted in greater odds of being in a higher Clavien-Dindo classification after controlling for RENAL suffix and type of surgical procedure (odds ratio [OR]: 1.29, 95% confidence interval [CI]: 1.04-1.64, p=0.043). Furthermore, a patient with the RENAL suffix 'p' (ie posterior location of tumour) had increased odds of developing more serious complications (OR: 2.60, 95% CI: 1.07-6.30, p=0.042). A correlation was shown between RENAL nephrometry score and postoperative drop in eGFR (Kendall's tau coefficient -0.24, p=0.004). CONCLUSIONS: To our knowledge, this is the first study that has shown the predictive ability of the RENAL nephrometry scoring system in a UK cohort both in terms of postoperative complications and change in renal function.

A prospective randomized single-blind comparison of ureteral stents composed of firm and soft polymer.

PURPOSE: Ureteral stents are composed of different polymers and it is unclear if stent composition influences patient comfort. We compared the impact of stents composed of firm and soft polymer on patient health related quality of life. MATERIALS AND METHODS: A total of 130 patients requiring insertion of ureteral stents during the treatment of urinary calculi were randomized to receive a stent composed of firm (Percuflex, group 1) or soft (Contour, group 2) polymer. Patients were asked to complete the Ureteric Stent Symptoms Questionnaire, a validated instrument, at weeks 1 and 4 with the stent in situ and 4 weeks after its removal, this served as the main outcome measure. Additional assessments included difficulty in stent insertion and the need for early stent removal. RESULTS: There were 78 men and 38 women in total (61 in group 1 and 55 in group 2) with a mean age of 51 years (range 22 to 79) and no difference in age between the 2 groups (p = 0.9). Comparison of the results of the Ureteric Stent Symptoms Questionnaire survey at weeks 1 and 4 with stent in situ revealed no significant differences in the domain scores of urinary symptoms (p = 0.9 and p = 0.8), pain (p = 0.8 and p = 0.6) and general health (p = 0.6 and p = 0.4). Similarly, there were no differences in the number of days with reduced activities, work performance (p = 0.7) and sexual dysfunction between the 2 groups. A similar number of patients (8 and 7 in groups 1 and 2, respectively) required stent removal earlier than planned due to stent related symptoms. CONCLUSIONS: This randomized study showed no difference in the impact on patient quality of life between ureteral stents composed of firm or soft polymer.

Trends in death rates and registration rates for prostate cancer in England and Wales.

OBJECTIVE: To describe trends in deaths from prostate cancer between 1970 and 1990, and trends in registrations of prostate cancer between 1971 and 1986. METHODS: Data on prostate cancer deaths and registrations were obtained from the Office of Population Censuses and Surveys, and age specific rates were calculated. RESULTS: The number of deaths from prostate cancer rose by 107% between 1970 and 1990, from 3906 to 8098. The number of registrations of prostate cancer rose by 75% between 1971 and 1986, from 5819 to 10,180. Age-specific death rates and registration rates also increased but by a smaller amount than the rise in absolute numbers. CONCLUSIONS: A component of the increase seen in both the number of prostate cancer deaths and registrations can be explained by a concomitant increase in the elderly male population, the group at highest risk, but the rises seen in rates are more difficult to explain. The rises are likely to have had considerable implications for the workload of urologists and should be taken into account when planning future health services. With further increases expected over the next decade in the elderly male population, deaths and registrations from prostate cancer will continue to rise. Research will be required to determine possible reasons for the increase seen in prostate cancer rates over the last 20 years, to determine the true incidence and prevalence of prostate cancer in the general population and to identify possible aetiological factors.

Pyoderma gangrenosum with large circumferential perianal skin loss in a child.

Pyoderma gangrenosum is an uncommon skin disorder characterised by deep ulcers surrounded by a violaceous over-hanging edge. Although in many instances there is no clear association with any underlying disease, pyoderma gangrenosum has been described in ulcerative colitis, Crohn's disease, polyarthritis, diabetes mellitus and myeloma. Pyoderma gangrenosum may also be seen as a rare manifestation of myeloproliferative disease including leukaemia. In children, as in our case, it may be the presenting feature.

Childhood extradural haematomas, not always obvious.

Extradural haematomas in children are rare, but they may occur following a trivial head injury. We report a case where, following an unrecognised head injury to a three-year-old child, the insidious non-specific presentation of the extradural haematoma led to delay in the diagnosis and treatment.

Percutaneous stone surgery in the obese: outcome stratified according to body mass index.

OBJECTIVE: To report our experience of percutaneous surgery for treating renal pelvicalyceal stones over 6 years, to show that this approach is feasible and safe in obese and morbidly obese patients, as the prevalence of obesity and stone disease has risen in the last 20 years. PATIENTS AND METHODS: We retrospectively reviewed the results of 223 percutaneous nephrolithotomies (PCNLs) by one urologist between 1995 and 2001. Patients were stratified into four groups according to the World Health Organization classification of body mass index (BMI), i.e. <25, 25-29.9 (overweight), 30-39.9 (obese) and > 40 kg/m(2) (morbidly obese). The outcomes of surgery in these four groups were compared. RESULTS: There were no statistically significant differences in operative duration, decrease in haemoglobin concentration, postoperative analgesic use, hospital stay and stone-free rates; nor was there a higher complication rate in patients who were obese. CONCLUSION: The outcome of PCNL is independent of the patients' BMI and results can be favourable in most patients. We therefore advocate treating obese patients with symptomatic stone disease based on individual status, using percutaneous surgery where appropriate.

An 11-year experience of arterial embolectomy in a district general hospital.

We present a retrospective audit of all arterial embolectomies performed at the East Glamorgan General Hospital over an 11-year period (1980-1990). Eighty-seven patients (47M:40F), mean age 67 years (50-90 years) underwent 95 embolectomies, an incidence consistent with previous studies. There were 17 upper and 71 lower limb emboli with a mean delay before diagnosis of 29 h (range 1-264 h). In 66% of cases the cause was atrial fibrillation; 33% received immediate heparinization and 14% prophylactic antibiotics. Surgery was performed by a consultant in 12 and registrars in 75 cases, and under local anaesthesia in 80% and general anaesthesia in 20%. There was no anaesthetist present in 54% of cases. Few pre- or peroperative arteriograms were performed. The 30-day mortality was 45%, with an amputation rate of 15% and an overall postoperative complication rate of 62% with little improvement in these figures over the last 10 years. Factors increasing mortality were: delay before diagnosis, grade of surgeon performing the operation, and inadequate inflow or outflow at operation. Factors found to affect limb salvage rate adversely were a history of intermittent claudication, although such a history was not recorded in many cases, and lack of immediate preoperative heparinization. Although embolectomy is considered a 'registrar operation', reviewing our results it can be seen that it is an uncommon operation, in our series eight or nine being performed annually. Sometimes inappropriate surgery is performed upon patients in whom severe systemic illness may contraindicate any form of surgical intervention.(ABSTRACT TRUNCATED AT 250 WORDS)

The management of ureteric obstruction secondary to malignant pelvic disease.

AIM: Management of upper-tract obstruction secondary to a malignant pelvic process is a difficult problem and is best dealt with by a multi-disciplinary team. In the present audit, we address the question: is staged antegrade stenting better than retrograde ureteric stenting? MATERIALS AND METHODS: We reviewed our present management of upper-tract obstruction secondary to malignant pelvic disease in 65 patients treated over a period of 2 years. Fifty-eight patients had urological cancer and seven patients had non-urological cancers; 70% of all cases had renal impairment. Twenty-four of 65 patients had an attempt at endoscopic retrograde ureteric stenting as a primary method of decompression while percutaneous nephrostomy followed by antegrade ureteric stenting was performed in 41/65 patients. RESULTS: Endoscopic retrograde stenting had a success rate of 21% whereas two-stage antegrade stenting was successful in 98% of patients. The antegrade approach had minimal morbidity. CONCLUSION: Obstruction of the pelvic ureter secondary to any pelvic malignancy is best managed by two-stage antegrade ureteric stenting. This approach has a high success rate with minimal morbidity, and should be preferred to an endoscopic approach. This highlights the important role of an interventional uroradiologist in the management of these patients.

A review of pancreatico-pleural fistula in pancreatitis and its management.

Pancreatico-pleural fistula is a rare condition in which pancreatic enzymes drain directly in to the pleural cavity, most commonly from an enlarging pseudocyst. We review the literature on the causes, investigations and treatment of pancreatico-pleural fistulae and compare this with our own experience of the case of a 41 year old man with a left sided pancreatico-pleural fistula associated with pancreatic duct obstruction. The fistula could not be demonstrated by USS, CT or ERCP, and after these investigations the patient was managed conservatively. However, deterioration in the patients' condition led to an urgent but not emergency laparotomy and operative pancreatogram. This demonstrated the distally obstructed pancreatic duct, with associated pleural fistula for which aggressive surgical intervention was indicated. The patient subsequently completely recovered.