Indwelling ureteral stents: evaluation of quality of life to aid outcome analysis.

BACKGROUND: Ureteral stents cause various side effects. We have evaluated health-related quality of life (HRQoL) in patients with stents using validated questionnaires and developed a new stent symptom (intervention)-specific questionnaire (SSQ). PATIENTS AND METHODS: Along with structured literature review and in-depth interviews, prospective sub-studies were carried out using generic (SF-36 [N = 30], EuroQol [N = 40], and Functional Status Questionnaire FSQ [N = 20]) and symptom-specific (IPSS [N = 30] and International Continence Society ICS [N = 30]) questionnaires both with a stent in situ and after removal. The results of these studies formed the foundation for a new SSQ that was pilot tested (N = 10) and field tested (N = 20) in order to develop a final draft of the questionnaire that is formally validated. RESULTS: The qualitative research identified a range of problems. Urinary symptoms, pain, work performance, and general health were the most important. Most patients (80%) experienced bothersome urinary symptoms and stent-related pain. Storage symptoms and incontinence were significant urinary symptoms affecting quality of life. As many as 40% of patients experienced sexual dysfunction. The stent had a significant impact on patients' general health. None of the existing measures evaluated the complete impact. The SSQ includes five sections covering urinary symptoms, pain, sexual matters, general health, and work performance. The preliminary results showed it to be valid, reliable (alpha > 0.7) and responsive to the change in scores (p < 0.05) after stent removal. CONCLUSIONS: Indwelling ureteral stents are associated with significant morbidity, resulting in a reduced HRQoL in 80% of patients. The SSQ is a reliable intervention-specific instrument that would be useful as an outcome measure to evaluate the impact of stents.

The use of ultrasound in automated prostatectomy.

A new way of applying transurethral ultrasound scanning in the common surgical procedure of the transurethral resection of the prostate is described. The scanning is incorporated as part of a robotic procedure for surgery, so that the overall time spent in an operation can be further shortened, and a safe and accurate operation can be achieved. The prostate dimensions obtained pre-operatively by the transrectal method and those obtained operatively are compared. A robotic system, which was developed specifically to remove prostatic adenoma automatically, is discussed. The system, called a motorized frame, is briefly described, together with its predecessor, a manual frame, in relation to ultrasound measurements. Sizing of the prostate pre-operatively using transrectal ultrasound methods is discussed, using both the manual and the motorized frame. The shortcomings of transrectal ultrasound for use in a robotic procedure are highlighted.

A computer-assisted training/monitoring system for TURP structure and design.

A generic framework for a computer-assisted system for both soft tissue endoscopic surgery and surgical training is being researched and developed. The concept demonstrator is a specific system for transurethral prostatic resection (TURP). The main novelty of the research is that it is not confined to an in vitro trainer system. An in vivo monitoring version of the system, for use in the operating theater, is also being researched. This paper presents the framework's structure and design using the United Modeling Language. It also discusses and justifies the underlying information technologies chosen to implement this approach. Object-oriented concepts and well-proven mathematical tools have been adopted as the foundation of this research and development. The rationale for having chosen such tools is presented. The objectives are to arrive at a system which is modular, general, and reusable.

The Angelchik antireflux device: a 5-year experience.

A total of 44 patients had an Angelchik antireflux prosthesis inserted over a 5-year period. Of these, 41 were available for review and were assessed by interview using a modified Visick grading. Of the 23 patients followed up for a minimum of 3 years 74% had an excellent or satisfactory outcome; 92% of patients with symptoms of reflux obtained relief, but less than 50% of those patients presenting with dysphagia had a satisfactory outcome. The incidence of mild postoperative dysphagia increased the longer the period of follow-up. The main cause of a Visick 3 or 4 result was prosthesis migration. We have modified our technique of insertion to reduce these complications, and in a more recent series have achieved a Visick Grade 1 or 2 in up to 92% of patients. We conclude that dysphagia is a relative contraindication to the insertion of the Angelchik prosthesis. Our recent results encourage the use of the prosthesis provided steps are taken to reduce the incidence of migration and pericapsular fibrous tissue formation.

Is follow up of patients after surgery for breast cancer worthwhile?

The effectiveness of routine outpatient follow up in detecting recurrent disease after 'curative' surgery for breast cancer has been evaluated in a retrospective study of 148 patients. In all, 32 patients developed recurrent cancer. In 3 cases, asymptomatic disease was discovered by routine X-rays. In 25 cases, the patient noticed local disease or complained of symptoms due to distant spread, and over half of these returned to the clinic before the next routine appointment. In only 4 cases was routine examination by a doctor solely responsible for the discovery of recurrent disease. It is concluded that routine follow up made little contribution to the welfare of these patients.

The development of a surgeon robot for prostatectomies.

The removal of prostatic tissue through transurethral resection of the prostate (TURP) is an operation that can require considerable skill from a surgeon as well as being a lengthy procedure. The potential for using robotic techniques was investigated in a preliminary feasibility study using a standard six axis 'Puma' robot. This led to the construction of a manually operated 'safety frame' which has been shown to be effective through clinical trials on 30 patients. A special-purpose robot, based on the design of the manual frame, has now been constructed. Some of the safety issues are discussed which make this procedure an ideal candidate for a robotic device.

Our experience with retroperitoneal and transperitoneal laparoscopic pyeloplasty for pelvi-ureteric junction obstruction.

OBJECTIVE: Laparoscopic dismembered pyeloplasty has been quoted to have equivalent success rates to the traditional open procedure in the treatment of pelvi-ureteric junction obstruction (PUJO). The aim of this study was to report our experience with laparoscopic pyeloplasty. PATIENTS AND METHODS: All patients with PUJO are entered into a database to record patient, operative and post-operative details. Over an eleven-year period, 176 procedures were performed. Eighty-three procedures were dismembered laparoscopic pyeloplasties, of which two retroperitoneal procedures were converted to open. The first 17 procedures were performed via the retroperitoneal approach and the following 66 via the transperitoneal route. Thirty-one procedures were open pyeloplasty. RESULTS: The retroperitoneal group had a mean follow up of 35 (16-66) months. Five patients (33%) developed recurrent symptoms with evidence of obstruction seen on the renogram within 4 months and required further surgery. The transperitoneal group had a mean follow up of 15 (3-38) months. Five patients were classified as failures (mean time to failure 4.6 months) resulting in a success rate of 92% for the transperitoneal route. Both groups had a mean post-operative hospital stay of 3.6 days. Open pyeloplasty at our institution has a success rate of 88% at a mean follow up of 85 months (range 3-260 months) and a mean length of post-operative stay of 6 days. CONCLUSION: Overall our success rate following laparoscopic pyeloplasty is 88%. However, our preferred approach is transperitoneal, which is associated with a success rate of 92%. This is equivalent, if not better than that seen following open pyeloplasty with the additional benefits of reduced hospital stay and time to recovery. There are many possible explanations for this difference in success rates between approaches, however equivalent results are reported in the literature and therefore the learning curve is likely to be the major factor in this series.

Urological outcome in female patients with spinal cord injury: the effectiveness of intermittent catheterisation.

A review of 52 female patients with spinal cord injury is presented. Twenty five of 38 patients seen within 3 months of their injury were discharged on a clean intermittent catheterisation regime. Of the 14 patients seen at an interval of 3 months or greater after the injury, only 3 practised clean intermittent catheterisation but 8 had a long-term indwelling urethral catheter as the method of management. At 49 months median follow-up, only 14 (50%) continue on the programme of intermittent catheterisation and 9 (32%) are dry. This lack of success was due to incontinence, despite drug therapy in 17 patients. Recurrent symptomatic urinary tract infection occurred in 10 (36%). Thirteen of the 14 patients (92%) on long-term indwelling urethral catheter developed complications. Five patients voided normally. Automatic bladder emptying was employed in only 2 patients but was associated with the development of a non-functioning kidney in 1 and severe incontinence in another. Upper tract changes occurred in 7 patients (13%) including 3 on indwelling catheter drainage and 2 on intermittent catheterisation. Four patients have had implantation of the Brindley intradural sacral anterior root stimulator because of recurrent symptomatic urinary tract infections and incontinence in all 4. Post-operatively the incidence of infection has been reduced. Improvement in the degree of incontinence is related to the completion of posterior root section. Those patients who have no alternative to long-term catheter drainage are managed by the suprapubic route to avoid urethral incompetence. This is combined with catheter clamping for 2 hours daily to maintain bladder capacity and anti-cholinergic therapy to reduce detrusor contractility.(ABSTRACT TRUNCATED AT 250 WORDS)

A randomized trial comparing lithoclast with an electrokinetic lithotripter in the management of ureteric stones.

OBJECTIVE: To compare two in situ ballistic lithotripters, the lithoclast and the electrokinetic lithotripter (EKL), both of which can be used through the newer small-bore ureteroscopes, for their ease of use, robustness, fragmentation time, adequacy of fragmentation and stone-free rate. PATIENTS AND METHODS: Forty-six consecutive patients with ureteric stones refractory to treatment by extracorporeal shock wave lithotripsy were randomized to undergo fragmentation using the lithoclast (23 patients) or the EKL (23 patients). One patient was excluded from analysis in the EKL group. The adequacy of fragmentation was recorded, with the degree and significance of proximal migration for each device. After treatment patients were assessed by plain X-ray and the stone-free rate was determined. RESULTS: The mean (median) initial stone burdens in the lithoclast and EKL groups were 69 (50) mm2 and 72 (52) mm2, respectively. The respective mean (median) procedure duration and fragmentation time were 54 (50) min and 90 (49) s in the lithoclast group, and 50 (42.5) min and 87 (52.5) s in the EKL group; the differences were not statistically significant. In four (14%) patients of each group there was significant proximal migration of the stones. The stones were completely fragmented in 17 of 23 (74%) patients in the lithoclast group and 19 of 22 (86%) in the EKL group. There was no fragmentation in one patient in each group. In the lithoclast and EKL groups, 20 of 23 (87%) and 17 of 22 (77%) were rendered stone-free, respectively (P > 0.5). The equipment failed on two occasions in each group. CONCLUSION: In this randomized trial there was no significant difference in the stone-free rate, procedure duration, fragmentation time, proximal stone migration rate and equipment failure between these in situ ballistic lithotripters.

Citric acid (solution R) irrigation in the treatment of refractory infection (struvite) stone disease: is it useful?

OBJECTIVE: Citric acid, in varying concentrations, has been used in the dissolution treatment of struvite renal calculi. Solution R (Uro-trainer), which contains 6% citric acid, is a solution licensed for use in the management of struvite stone disease in the UK. We report our experience. METHODS: 23 kidneys in 22 patients (10 male and 12 female patients, mean age 45, range 15-60 years) underwent solution R irrigation following debulking of the stone with percutaneous nephrolithotomy (n = 20), ureteroscopy and shock wave lithotripsy (n = 2) combined with open procedures (n = 4) between 1994 and 1998. The original stone configuration consisted of 14 staghorn, 4 partial staghorn and 5 large burden stones. Irrigation was performed through a nephrostomy tube (n = 20) or in a retrograde fashion (n = 3) using a closed infusion pump system (40 ml/h). The response to treatment was checked using a nephrostogram and/or plain X-ray. RESULTS: In 6 (26%) kidneys, after an average duration of 2 (1-5) days, irrigation had to be abandoned due to loin pain, leak or sepsis. The average duration of irrigation was 6.4 (1-20) days. At the end of irrigation, a total of 4 (17.4%) kidneys had complete radiographic clearance, while the stone was reduced to calyceal dust in 3 (13%). Partial response was seen in 11 (47.8%) and no response in 5 (21.8%) kidneys. Following additional alternative intervention(s) in 6 (26%) kidneys (4 with partial and 2 with no response) further clearance was achieved in 3 (13%) and calyceal dust status in 3 (13%). The response was better if the stone was reduced to less than 10mm prior to irrigation. At the mean follow-up of 2.44 (1-4) years, of 13 kidneys with stone clearance or calyceal dust, 9 suffered recurrence or re-growth, 5 of which required further interventions. Only 4 (17.4%) of 23 kidneys remained stone free. CONCLUSIONS: In patients with complex stone disease, adjuvant solution R irrigation can reduce the stone burden. There is a considerable potential for side effects necessitating close monitoring for sepsis and electrolyte abnormalities. However, the overall success rate for solution R is limited.

Hand-assisted laparoscopic nephrectomy: complications related to the hand-port site.

OBJECTIVE: To evaluate the early results of hand-assisted radical nephrectomy and nephroureterectomy in our institution. PATIENTS AND METHODS: The records of 13 patients with malignant disease of the kidney who underwent hand-assisted laparoscopic radical nephrectomy and nephroureterectomy were reviewed retrospectively. Clinical outcomes were compared with a series of 16 patients who underwent similar procedures via a standard laparoscopic approach. RESULTS: There were three major hand-port wound complications in those who underwent hand-assisted procedures, while one other patient required conversion because of technical failure of the device. The operative duration, length of hospital stay, estimated blood loss, transfusion rate, analgesic requirement, conversion rates, and minor complications were similar between the hand-assisted and standard laparoscopy groups. CONCLUSION: There was little difference between hand-assisted and standard laparoscopy in operative duration or recovery, but there were problems with wound complications which may be related to the hand-assisted approach. We have consequently abandoned the technique in favour of a standard laparoscopic approach.

Flexible ureteroscopes: a user's guide.

OBJECTIVE: To compare, quantitatively and qualitatively, four small-diameter flexible ureteroscopes. MATERIALS AND METHODS: Four flexible ureteroscopes from different manufacturers, i.e. the DUR-8 (ACMI, Southborough, MA, USA), Olympus UPF-3 (Keymed, Southend-on-Sea, UK), Storz 11274AA (Karl Storz GmbH, Tuttlingen, Germany) and the Wolf 9 F (Henke Sass Wolf GmbH, Tuttlingen, Germany), were assessed quantitatively by measuring the active tip deflection and irrigation flow rate with laser fibres (200 micro m, 365 micro m), an electrohydraulic lithotripter (1.9 F) and grasping forceps (3 F) in position. They were then assessed subjectively by two endourologists who scored them, using a visual analogue scale (maximum 10), for insertion, deflection mechanism, manoeuvrability, rigidity, image quality and overall satisfaction. RESULTS: All the endoscopes are < 9 F at the tip, although the length of the smallest diameter (bevelled tip vs section of shaft) was variable. Tip deflection was 87-100% of the manufacturers' specifications and decreased by similar percentages with instruments in the working channel. The irrigation flow rate was comparable for instruments with a 3.6 F working channel (72-88 mL/min with an empty working channel), although much greater for the Wolf, which has a 4 F channel (116 mL/min). Direction and image size were nearly identical, as was the field of view, apart from the Wolf (60 degrees vs 90 degrees ). There was agreement in the user assessment for three instruments, with overall satisfaction scores being Storz (4), ACMI (7.5) and Olympus (8.6), but disagreement in scores for Wolf (1.9 vs 5.3). CONCLUSIONS: Whilst there were considerable similarities in the objective assessment among the instruments, the user assessment showed qualitative variability. Thus it is important to try the different instruments before selecting one. Additional variables to consider include durability, cost and service/warranty, which vary considerably among instruments.

Measurement of surgical diathermy current during trans-urethral resection of the prostate gland.

A system is described that has been developed to measure the surgical diathermy current passing through the patient during each cut of a trans-urethral resection of the prostate gland (TURP), with 1.5% glycine solution as irrigant. The immediate aim was to distinguish capsular tissue of the male prostate gland from the hyperplastic adenomatous tissue within it. The ultimate aim was to prevent resection into the surgical capsule which can easily result in excessive blood loss and absorption of irrigant. The system was used in a conventional theatre setting with a commercial diathermy system (Eschmann TD 411-S) of known output characteristics. Measurements were made in 12 patients during resection with a standard loop, involving typically 75 cuts in each patient (60 in adenoma and 15 in capsule). In 8 of these patients this was followed by roller ball placement on typically 10 sites each of capsule or residual adenoma at very low diathermy settings. The results showed great variability both between patients, and between different cuts in the same patient, with no consistent difference between tissues identified under direct vision as adenoma and surgical capsule. Physical reasons are suggested for the observed variability, and it is concluded that it is not possible to use this technique to guide tissue resection in the prostate.

Flexible ureterorenoscopy for the treatment of refractory upper urinary tract stones.

OBJECTIVE: To report our experience of using flexible ureterorenoscopy for upper urinary tract stones. PATIENTS AND METHODS: Thirty-seven patients (13 females, 24 males, mean age 48 years, range 10-76) with upper urinary tract stones not responding to other treatments had their residual symptomatic stones treated through a 9.3 F flexible ureterorenoscope. Electrohydraulic lithotripsy (EHL) was used to fragment the stones and a basket or a grasper used to retrieve the fragments. RESULTS: Twenty-three patients were completely freed of stone and a further five had asymptomatic residual fragments of < 5 mm. Of 15 patients with ureteric stones, 14 were rendered stone-free at the end of the procedure and 14 of the 22 patients with kidney stones were treated successfully; 80% of the lower calyceal stones were treated successfully and a firm decision was possible on the further management of the remaining stones. There were no major complications. CONCLUSION: Flexible ureterorenoscopy should be considered in patients with symptomatic upper ureteric or renal stones refractory to other treatments, but the instrumentation is expensive and delicate, and its use should be reserved for such cases.

Re-auditing a regional lithotripsy service.

OBJECTIVE: To assess, in a repeat audit of a regional lithotripsy service, whether changes implemented after a regional audit in 1994 (which showed disappointing results from shock wave lithotripsy, attributable to both poor patient selection and an inadequate fixed-site lithotripter) have had any effect. PATIENTS AND METHODS: A data-collection sheet was devised to gather information on the site, size and number of stones treated, together with information on the lithotripsy treatment and outcome. Patients selected for the audit were the first 50 new patients treated with lithotripsy at each centre in 1999. As only one hospital has a fixed-site lithotripsy machine, the results of mobile lithotripsy were grouped by machine for analysis. RESULTS: There was an overall improvement in patient selection from the previous audits. Few stones of > 16 mm or < 4 mm were treated. Two units treated more ureteric stones, thought to reflect first the influence of a fixed-site lithotripter, and second a willingness to insert a ureteric stent and await the next mobile lithotripter visit. The stone free rates were all disappointingly low (16.7-26.7%) but the results improved when fragments of < 4 mm were included as "successful" giving an "overall success rate" of 45.9-66.7%. The unit with a fixed-site lithotripter appeared to perform better (two-thirds successful) than the mobile machines (Modulith SLX, 51%; Modulith SLK, 46%). One centre visited by both mobile machines had a success rate of 65% but a high rate of auxiliary procedures (35% vs 16-19% vs the fixed-site). CONCLUSION: Although these results show some improvement in patient selection for our regional lithotripsy service, stone-free and success rates are poorer than those reported elsewhere. This may reflect the modern lithotripsy machines that allow day-case treatment with minimal analgesia, and confirms reports by other authors who encourage a re-examination of success rates of shock wave lithotripsy.

Laparoscopic lymph node sampling in locally advanced prostate cancer.

OBJECTIVE: To assess the role of laparoscopic lymph node sampling in patients with locally advanced prostate cancer before radical radiotherapy, and to show that the procedure is safe when carried out by urologists with the appropriate training. PATIENTS AND METHODS: Patients were selected prospectively using a combination of prostate-specific antigen (PSA) level, clinical stage and Gleason grade, which predicted a > 20% risk of lymph node metastases. Between October 1998 and March 2001, 50 patients (mean age 65 years, range 54-78) underwent laparoscopic pelvic lymphadenectomy. Age, presenting PSA level, Gleason grade, clinical stage, operative time, length of stay, and any adverse events were recorded. The histology reports were reviewed for the presence of nodal metastases. The selection criteria were compared between the groups with and with no nodal metastases. RESULTS: The mean (range) PSA level of the men was 36.8 (4.4-184) ng/mL and the Gleason grade 6.8 (4-9); 58% had stage T3 disease and 12 patients (24%) had lymph node metastases. There were no statistically significant differences in PSA, Gleason grade or clinical stage between those with positive or negative nodes. The mean operative duration was 110 min, although this decreased from 133 min for the first 10 cases; one case was converted to an open procedure. The median (range) postoperative stay was 1 (1-12) days. There were two major (5%) and seven (17%) minor complications. CONCLUSIONS: This study confirms that laparoscopic lymph nodes can be sampled safely by urologists with experience in laparoscopic surgery. Patients with a significant risk of metastases can be selected preoperatively using a combination of PSA, clinical stage and Gleason grade. Lymph node sampling in this group is necessary, as there is no other method of reliably identifying the subgroup of patients with metastatic disease in which radical conformal radiotherapy cannot be justified.

Response of the benign hypertrophied prostate to treatment with an LHRH analogue.

Twenty patients with outflow tract obstruction secondary to benign prostatic hypertrophy were treated with an LHRH analogue, buserelin, for up to 6 months. Despite maintaining castrate levels of testosterone and achieving a significant reduction in tissue levels of dihydrotestosterone, no significant improvement was seen in flow rate or residual volume.

Histamine and duodenal ulceration in renal transplant recipients.

Six of 25 renal transplant recipients had a duodenal ulcer at endoscopy. Histamine concentration and the activity of histamine methyltransferase, the degrading enzyme of histamine, were measured in gastric mucosal biopsies obtained at endoscopy and compared with patients with duodenal ulcer but not undergoing transplant and with patients with an apparently normal stomach and duodenum. Histamine concentrations in the corpus (no ulcer, median: 151 nmol/g; DU, median: 122 nmol/g) and in the antrum (no ulcer, median: 118 nmol/g; with DU, median: 113 nmol/g) of renal transplant patients, irrespective of ulcer diagnosis, and in patients with a chronic duodenal ulcer (median corpus histamine: 137 nmol/g and median antral histamine: 126 nmol/g) were not different from one another but significantly lower than the corresponding values in normal subjects (median corpus histamine: 241 nmol/g, p less than 0.01, and median antral histamine: 178 nmol/g, p less than 0.05). Histamine concentration in the corpus was significantly higher than in the antrum in all three groups of patients (p less than 0.05). There were no significant differences in histamine methyltransferase activity in any of the groups studied. Mucosal histamine and histamine methyltransferase activity were significantly correlated in the corpus (p less than 0.05) and antrum (p less than 0.02). Plasma concentration of histamine after transplant was higher in the patients who subsequently were discovered to have a duodenal ulcer (p less than 0.05). The occurrence of ulcer after transplantation was not related to the serum creatinine level. The uniform depletion of gastric histamine and increase in circulatory histamine after renal transplantation may be a factor in the pathogenesis of duodenal ulcer disease in this clinical situation.

The "plain film" bladder shadow in outflow obstruction: as accurate a discriminant of residual urine as ultrasound.

The height, width and area of the bladder shadow on post-micturition plain abdominal radiography was compared with the residual urine obtained at endoscopy from 58 men presenting with pure bladder outflow obstruction. Each parameter of the bladder shadow correlated significantly with the residual urine in patients in whom this shadow was visible. Post-micturition plain abdominal radiography is considerably cheaper than ultrasound and appears to be equally effective in the determination of residual urine. Its use as the sole imaging technique in the routine management of bladder outflow obstruction is recommended.