Randomised evaluation of alternative electrosurgical modalities to treat bladder outflow obstruction in men with benign prostatic hyperplasia.

OBJECTIVES: To compare and evaluate the clinical and cost-effectiveness of transurethral vaporisation of the prostate (TUVP), a new electrosurgical modality, with the standard treatment, transurethral resection of the prostate (TURP). DESIGN: A multicentre randomised controlled trial of pragmatic design with associated economic evaluation using cost minimisation. SETTING: Patients were recruited from four centres in south-east England. PARTICIPANTS: Men requiring surgery for lower urinary tract symptoms deemed to be due to benign prostatic hypertrophy. INTERVENTIONS: TURP was performed and subsequent management conducted according to the usual practice of the clinical team. TUVP was performed with the most promising available equipment using a technique described in the literature. Postoperative management after TUVP was left to the ward team, who were not necessarily informed to which treatment arm the patient had been allocated. For the purpose of the study, patients were assessed clinically, by questionnaire and investigation at baseline, 2 months and 6 months after randomisation. A long-term follow-up postal questionnaire was sent to each patient at 2 years. For the economic evaluation, direct costs from the NHS viewpoint were collected. MAIN OUTCOME MEASURES: A reduction of at least 5 from the International Prostate Symptom Score (IPSS) was taken as a satisfactory outcome. The IPSS quality of life (QoL) question provided disease-specific information about QoL. Secondary outcome measures included urinary flow rate, post-void urinary volume, prostate volume and pressure-flow urodynamics. Questionnaires used included SF-36, EuroQol and a sexual function section based on the International Continence Society 'Benign Prostatic Hyperplasia' (ICS-BPH) questionnaire. Measurement of full blood count and urea and electrolytes was made at baseline and at 24 hours. Adverse events were recorded during the hospital stay and at follow-up visits. RESULTS: TURP and TUVP were both effective in producing a clinically important reduction in IPSS and positive change in the IPSS QoL question. The success rate for relief of symptoms was 85% for TURP and 74% for TUVP. Neither the success of the treatment nor the change in aggregated IPSS was significantly different between the groups. The improvement was sustained to 24 months after treatment with no significant difference between the groups. The effectiveness of both treatments was also equivalent when assessed through improvement in objective measures of urinary tract function, reduction in prostate size and the change in health questions of SF-36. The absolute incidence of adverse events was similar between the two groups. The incidence of severe or prolonged bleeding was less with TUVP, as evidenced by the need for blood transfusion and the drop in haemoglobin level 24 hours postoperatively. TURP and TUVP are broadly equivalent in direct NHS resource use. This study did not show any significant difference in inpatient stay or use of outpatient resources between the groups. The disposable electrodes used for TUVP are more expensive than reusable TURP electrodes. CONCLUSIONS: TURP and TUVP are equivalently effective in improving the symptoms of benign prostatic enlargement over at least 2 years. TUVP is associated with less morbidity due to haemorrhage than TURP. Replacement of TURP by TUVP would not produce a significant cost benefit to the NHS unless a reduction hospital inpatient stay of at least 1 day could be secured. Further research is necessary to determine why patients stay in hospital after transurethral surgery to the prostate and how a reduction in the length of stay can be achieved. A much larger observational study/audit is required to assess the incidence of infrequently occurring adverse events after TUVP. Longer term follow-up is also needed.

Modular integrated fluidized bed bioreactor technology.

We describe the design and demonstrate the application of a modular integrated fluidized bed bioreactor system. Basically the system is a reactor vessel equipped with an extending cylinder and a liquid distributor plate. Instead of an external recirculation loop, as used in existing fluidized bed systems, a low shear stress impeller is used as the recirculation pump. The system has several unique features, such as modular exchangeable elements, efficient oxygenation and the option of operating as a stirred tank-, a packed bed- or a fluidized bed reactor. An example of a fluidized bed run using CHO-K1 cells is shown. Under standard culture conditions a 100-fold increase in cell density (up to 1.2 x 10(8) cells/ml) was achieved.

The surgical risk of suprapubic catheter insertion and long-term sequelae.

INTRODUCTION: Suprapubic catheter (SPC) insertion is a common urological procedure, which is often referred to as safe and simple even in inexperienced hands. There is, however, very little published evidence on the safety of this procedure. Our study aimed to provide evidence on the associated morbidity and mortality and provide guidance for practising clinicians. PATIENTS AND METHODS: A total of 219 patients who underwent SPC insertion under cystoscopic guidance at two urology institutions between 1994 and 2002 were identified and their case notes reviewed. RESULTS: The intra-operative complication rate was 10% and the 30-day complications rate was 19%. Mortality rate was 1.8%. Long-term complications included recurrent UTIs (21%), catheter blockage (25%) resulting in multiple accident and emergency attendance (43%). Despite this, the satisfaction rate was high (72%) and most patients (89%) prefer the SPC over the urethral catheter. CONCLUSIONS: SPC bladder drainage results in a high patient satisfaction rate. Patients and clinicians should be aware of the potential complications associated with SPC insertion.

An appendicular mass mimicking a bladder tumour.

We present a case of an appendicular mass mimicking symptoms of a bladder tumour in a 27-year-old female. The patient initially presented with a 5-month history of intermittent lower abdominal pain associated with dysuria, anorexia and weight loss. Cystoscopy revealed an erythematous urothelium with the appearance of a solid mass bulging into the bladder posteriorly. Urothelial biopsies were negative and computerised tomography showed a soft tissue mass extending from the right superior aspect of the bladder and abutting the distal ileum. At laparoscopy an appendiceal mass adherent to the bladder was found. The symptoms later resolved and she is well at follow-up.

Pressure changes in canine gall-bladder associated with emptying.

1. For decades it has been supposed that emptying of the gall-bladder follows a rise in gall-bladder pressure of some 10-15 mmHg and relaxation of the sphincter of Oddi. 2. This subject has been re-examined in dogs chronically fitted with fistulas, using a model which does not entail interference with either the bile duct or sphincter of Oddi. 3. The pressure in the gall-bladder was recorded continuously under fasting conditions, after feeding and after intravenous infusion of the octapeptide of cholecystokinin (CCK-OP) in six dogs. 4. Gall-bladder pressure showed a modest sustained rise of 2-3 mmHg following ingestion of food and intravenous infusions of CCK-OP (125 ng kg-1 h-1). 5. During half of the experiments a transient rise of 3-10 mmHg lasting 2-3 min was observed after feeding and following infusion of I.V. CCK-OP (125 ng kg-1 h-1). Emptying of the gall-bladder, measured by bilirubin output from the biliary fistula, started shortly before the peak rise in pressure occurred. 6. We conclude that a significant rise in gall-bladder pressure is not a prerequisite for emptying and that the pressure changes occurring physiologically are smaller than have been reported previously. 7. We believe that the larger pressure changes recorded in the past may have been produced because of resistance to bile flow introduced by the models employed. 8. Emptying of the gall-bladder, in the dog, appears to have occurred within 40 min of the ingestion of food, suggesting that the cephalic and gastric phases of this process are quantitatively more important than has been thought previously.

Adenomatous polyposis: an association with carcinoma of the thyroid.

A review of the St Mark's Hospital Polyposis Registry has revealed an association between adenomatous polyposis (familial polyposis coli) and thyroid carcinoma. Even though full clinical information was unavailable on all patients in the registry, it is evident that young women (below 35 years of age) are at particular risk of developing thyroid cancer, mainly of a papillary type, their chances of being affected being approximately 160 times that of normal individuals. All patients with adenomatous polyposis should thus have regular thyroid examination.

Exenteration as palliation for patients with advanced pelvic malignancy.

OBJECTIVE: To examine the place of pelvic exenteration in the palliation of advanced and recurrent pelvic tumours. PATIENTS AND METHODS: The notes of patients referred for palliative exenteration were reviewed retrospectively. Fourteen patients (three men, mean age 52 years, and 11 women, mean age 61 years) with a variety of pelvic tumours associated with severe symptoms, had a laparotomy with a view to pelvic exenteration and 10 underwent total or anterior exenteration. RESULTS: Eight patients achieved excellent or good palliation based on survival and quality of life assessment, and two received no benefit. Four of eight patients were alive and apparently free of tumour at a mean of 17 months after surgery. Four were alive, symptom-free but with evidence of malignancy at a mean of 19 months. Two patients who received no benefit died at 2 and 7 months after surgery. The planned exenteration was abandoned in four patients; three of these four patients were dead at a mean of 13 months and one was alive at 12 months. CONCLUSION: Our results confirm that with careful selection and appropriate multi-specialty care, aggressive pelvic surgery is of value in the palliation of some tumours.

Sequential renography in acute urinary tract obstruction due to stone disease.

A group of 76 patients with urographically proven acute calculus obstruction was studied prospectively using 99mTc-DTPA renography to see if kidneys at risk of irreversible renal damage could be identified. There was a statistically significant relationship between the presence of obstruction on renography and the subsequent requirement for intervention, but not with the degree of obstruction (partial or severe). Stones over 5 mm in size are highly likely to cause obstruction, a drop in relative renal function and require intervention. In all, 14 patients sustained a drop in relative renal function of greater than 7% on renography and 12 of these returned to normal limits when their calculi had been passed or removed. The 2 kidneys whose function remained impaired had fallen below 25% of overall renal function and both patients had received prior treatment for their calculi. No patient who presented de novo suffered any permanent loss of ipsilateral renal function. The results confirm that the criteria for intervention were well founded and emphasise the importance of achieving a stone-free state after primary treatment. Renography is recommended for stones over 5 mm in size, those in the middle and upper ureter and for those patients discharged with a stone in situ.

Transurethral electrovaporization of the prostate: is it any better than conventional transurethral resection of the prostate?

OBJECTIVE: To evaluate transurethral electrovaporization of the prostate (TUVP), compared with transurethral resection of the prostate (TURP), as a treatment for men with symptomatic benign prostatic enlargement (BPE). PATIENTS AND METHODS: In all, 235 men with symptomatic BPE in four hospitals in the South-East of England were randomized to TUVP (115) and TURP (120). Patients were assessed using the International Prostate Symptom Score (IPSS), the Short Form-36 (SF-36), EuroQol and sexual function questionnaire, uroflowmetry, ultrasonographic measurement of residual urine volume, pressure-flow urodynamics and transrectal ultrasonography. RESULTS: There was no statistically significant difference in the objective and subjective outcome after TURP and TUVP. The latter was associated with a lower transfusion rate than TURP but this did not result in an overall reduction in complications. There was no difference in the length of hospital stay. Overall, the two operations produced equivalent results and equivalent complication rates. CONCLUSION: TUVP is an effective treatment for symptomatic BPE, with results equivalent to TURP. TUVP has not led to the expected reduction in early postoperative morbidity or shorter hospital stays.

Regeneration of transgenic plants of Prunus armeniaca containing the coat protein gene of Plum Pox Virus.

A system was developed which allows the transfer of foreign genes into apricot cultivars. We report the transformation and regeneration of Prunus armeniaca plants with Agrobacterium tumefaciens strain LBA 4404 containing various binary plasmids, pBinGUSint, carrying the marker gene ß-glucuronidase (GUS) and pBinPPVm, carrying the coat protein gene of Plum Pox Virus (PPV). The marker gene GUS was used for optical evaluation of the efficiency of the transformation system. The coat protein gene of PPV was used to introduce coat protein mediated resistance against one of the most important pathogens of stone fruit trees in Europe and the whole Mediterranean area. This is the first report of the successful integration of a viral coat protein gene into a fruit tree species, opening a new perspective on the control of the disease.