Is there a role for the development of a supra-regional network for the management of penile cancer in the Republic of Ireland?

INTRODUCTION: There is an average of 25 cases of penile cancer in the Republic of Ireland each year. Due to the low volume of cases, the National Institute for Clinical Excellence recommends that treatment is centralised to allow the best standardised treatment for primary tumours and nodal disease. OBJECTIVES: To determine whether outcomes for patients with penile cancer differed significantly between secondary and tertiary referral centres in the Republic of Ireland. METHODS: Between 2001 and 2014, 36 patients were treated in the Mercy University Hospital (MUH) with penile cancer. Twenty patients were treated primarily in MUH and 16 patients underwent initial management in a secondary referral centre (SRC) with subsequent referral to the MUH. A retrospective matched case-control study was performed on this patient cohort. RESULTS: There were no significant differences in length of follow-up or risk factors for the development of penile cancer between both groups (p = 0.6 and p = 0.5 respectively) Ultimately, the incidence of high risk disease, nodal metasases, high grade disease and pelvic lymph node dissection were significantly greater in patients that were initially managed in a SRC (p = 0.02, p = 0.03, p = 0.004 and p = 0.028 respectively). Patients undergoing initial treatment in a SRC had a non-significantly reduced rate of cancer specific survival (88 Vs 66%, MUH Vs SRCs, p = 0.495) and recurrence free survival (85 Vs 46%, MUH Vs SRCs, p = 0.24). CONCLUSION: Our findings suggest that managing penile cancer in special interest centres may improve oncological outcome.

Management of bladder cancer.

Bladder cancer is the fourth most common cancer in men and is increasing in incidence in women as well. Bladder cancer has a broad range of behavior and presentations, with different prognoses and treatments. Laboratory research has made strides in elucidating pathways of this cancer, and identifying novel therapeutic targets. This short review provides a summary of the current knowledge of the management of bladder cancer.

Dynamic sentinel node biopsy for penile cancer: an initial experience in an Irish Hospital.

BACKGROUND: The presence of nodal metastases is the single most important prognostic factor in penile cancer. However, reliable assessment of nodal status in clinically node-negative (cN0) patients poses a challenge. Approximately 20% of these patients harbour occult nodal metastases. Currently available non-invasive radiological investigations are unreliable in excluding micrometastatic disease. AIM: Dynamic sentinel node biopsy (DSNB) is a minimally invasive procedure for assessing lymph node involvement. We report our initial experience with DSNB in assessing the status of regional lymph nodes in cN0 penile cancer patients. METHODS: DSNB was performed in penile cancer patients with at least one cN0 groin. All patients undergoing DSNB at our institution were included. Lymphoscintigraphic images were obtained from all patients, after intradermal, peritumoral injection of a Technetium-99m nanocolloid. The sentinel nodes were defined as the nodes identified on lymphoscintigraphy, which were also radioactive intraoperatively using a gamma probe. RESULTS: In total, 18 groins from 11 patients underwent DSNB. Of these, 11 patients underwent bilateral DSNB and 4 had unilateral DSNB. The mean (range) age of patients at the time of presentation of their primary tumour was 63 (39-78) years. A mean of 1.2 nodes per groin was retrieved. One lymph node was positive in one patient, who subsequently underwent a bilateral inguinal lymph node dissection. Overall, the median (range) follow-up was 12.8 (2.7-31.3) months with no local or regional recurrences. CONCLUSION: Further cases and longer follow-up will define the accuracy of this technique in the Irish population.

Prevention of postsplenectomy sepsis: how much do patients know?

INTRODUCTION: Asplenia causes a deficiency in immunity with a long-term risk of fulminant infection, associated with significant mortality. Patient compliance requires an understanding of risks of infection and its prevention. The impact of patient education has been little studied. MATERIALS AND METHODS: To ascertain the degree of knowledge held by patients who have undergone splenectomy, a comprehensive survey was designed. This also aimed to determine which group of health professionals was most successful in conveying information to patients. Patients who had undergone total splenectomy were interviewed by telephone, using a standardised list of questions to assess their understanding of the post-operation risks. RESULTS: Of 40 consecutive patients, 32.5% had a good knowledge of the risks of asplenia and their prevention, 52.5% had a fair knowledge and 15% a poor knowledge. Haematologists were most successful in initially conveying information to patients, and general practitioners also played a critical role in patient education. In this survey, it appears that surgeons were not effective at educating patients. CONCLUSION: Patient education postsplenectomy is poor. Measures to prevent infection in the asplenic patient are not being adequately implemented.

Exploration of the acute scrotum: a retrospective analysis of 100 consecutive cases.

BACKGROUND: Acute scrotal pain is a common urological emergency. Urgent exploration is the standard means of management, as no investigation can confidently exclude torsion of testis from the differential diagnoses. In our department, all patients up to the age of 40 years, presenting with acute scrotal pain undergo emergency scrotal exploration. AIM: This study assesses the outcome of such a policy in one unit. METHODS: The notes of 100 consecutive males who underwent exploration of scrotum have been reviewed. RESULTS: Testicular torsion was diagnosed in 33% of patients, with torsion of the appendix testis being the next most common entity. In the group with testicular torsion 12% required orchidectomy, and all had presented at least 24 hours after the onset of pain. The perioperative morbidity of scrotal exploration was very low. CONCLUSION: These data justify the policy of emergency exploration for all cases of acute scrotal pain up to the age of 40 years.

One-stage Fowler-Stephens orchidopexy for impalpable undescended testis.

BACKGROUND: The Fowler-Stephens orchidopexy (FSO) is a well-described treatment for high maldescended testes where the limiting factor for successful placement in the scrotum is short testicular vessels. The operation involves division of these vessels. The testicular blood supply is then dependent on collaterals from the vasal artery. AIMS: To assess the long-term outcome of patients who underwent this procedure in our institution. METHODS: The medical records of 20 patients who underwent 22 FSO from 1978 to 1999 by one urologist (HB) were reviewed. Outcome was assessed in terms of testicular position and size. RESULTS: Age at operation ranged from 2 to 14 years (mean 5.8 years). All patients had a one-stage FSO and in two of them the procedure was bilateral. In five patients, FSO was preceded by a diagnostic laparoscopy. Mean follow up was 22 months (range 0-121 months). Overall, results were considered good in 18 of 22 testes (82%). CONCLUSION: Our results for the one-stage FSO are comparable with other procedures for the management of high maldescended testis.

Renal replacement and male sexuality.

End-stage renal disease (ESRD) and dialysis have negative impact on lifestyle. Renal transplantation improves many facets of daily life. Male sexuality is a significant predictor of quality of life. This brief review summarizes the impacts of ESRD and renal replacement on a range of sexual domains as presented at the European Association of Urology meeting in Vienna.

The Distribution of PSA Age-Specific Profiles in Healthy Irish Men between 20 and 70.

Background. Ireland is estimated to have the highest European incidence rate of prostate cancer (Pca) in 2006 which will increase by 275% by 2025. This study aimed to determine PSA cutoff values in different age groups of healthy male patients without Pca. Methods. 660 men in a pilot men's health programme, aged 18-67, had PSA assayed. Men were grouped into 8 age groups at 5-year intervals: 30-34, 35-39, 40-44, 45-49, 50-54, 55-59, 60-64, and 64-70. Results. Linear regression demonstrates a PSA velocity of 0.024 ng/ml/year. The 95% confidence interval demonstrates a near flat line of PSA values from age 20 to 50 and rises after. When transformed logarithmically, PSA correlates highly with expected values from the normal distribution (0.98). A fractional polynomial quantile regression model was used to predict median and 95th percentile for PSA as follows: 30-34 (0.73, 1.57), 35-39 (0.71, 1.65), 40-44 (0.73, 1.85), 45-49 (0.78, 2.17), 50-54 (0.88, 2.63), 55-59 (1.01, 3.25), 60-64 (1.20, 4.02), and 64-70 (1.43, 4.96). Conclusions. PSA levels are similar to other racial groups but not as high as US Caucasians until 65 years. These data define the predicted PSA for the Irish population and provide a reference for future screening programmes.

Controversies in ilioinguinal lymphadenectomy.

Patients with penile cancer who are proven to have negative inguinal lymph nodes have an excellent prognosis. Furthermore, patients with small-volume inguinal node involvement can often be cured by surgery alone. Lymphadenectomy has clear survival benefits for patients when applied to those with lymph node metastasis. However, the current morbidity of the standard technique of lymphadenectomy is an impediment to its universal application, and innovative strategies to reduce the morbidity of staging/treatment that do not compromise oncologic control must be developed and standardized. The optimal integration of multimodality therapy to improve survival in advanced disease will occur only through collaborative studies between centers with significant patient volume, which would be facilitated through the development of regional referral centers.

Sexual function in patients with benign prostatic hyperplasia.

Sexual health has significant impact on quality of life among men with benign prostatic hyperplasia (BPH). The degree of sexual dysfunction matches the severity of lower urinary tract symptoms (LUTS). Treatment of BPH affects not only LUTS, but sexual function as well. Medical, surgical, and minimally invasive therapies differ in their effect on erectile function, ejaculation, and sexual satisfaction. Choice of treatment modality takes into account baseline sexual function and patient expectations. This review outlines the relationship between LUTS and sexual function and how they change with the currently available treatments.

Longevity of the Marshall-Marchetti-Krantz procedure.

BACKGROUND AND AIMS: The Marshall-Marchetti-Krantz procedure (MMK) is a vesico-urethral suspension, for the correction of urethral hypermobility in women with stress urinary incontinence. This study aims to describe the long-term outcome of the procedure. MATERIAL AND METHODS: 40 women with stress incontinence underwent the MMK. All operations were performed by one surgeon. Analysis of patients' notes yielded the early continence rate and perioperative morbidity. Long-term outcome was measured by means of a postal questionnaire with telephone contact to ensure maximum uptake. RESULTS: The immediate continence rate was 82%. Continence rates at up to 22 years follow-up (mean 8.5 years) is 61%. All failures occurred within 2 years of the operation. CONCLUSION: Patients still continent two years after the MMK will maintain continence in the long-term.

Priming prostate carcinoma cells for increased apoptosis is associated with up-regulation of the caspases.

BACKGROUND: The potential to prime prostatic carcinoma cell lines for apoptosis represents an exciting strategy for the treatment of patients with this disease. The ability and the underlying molecular mechanisms involved in sensitizing both androgen-sensitive and androgen-insensitive cell types to a range of apoptotic-inducing agents are investigated by the authors. METHODS: Primary and secondary cell lines were pretreated with diethyl-maleate (DEM) prior to the induction of apoptosis by Fas antibody (1 microg/mL), cycloheximide (1 microg/mL), etoposide (62.5 microM), and radiation (5 grays). It was demonstrated previously that DEM (50 microM) increases the sensitivity to apoptosis induced by these agents. The effects of DEM on both protein and RNA expression was determined by Western blot analysis and a ribonuclease protection assay, respectively. The effects of DEM on intracellular glutathione (GSH) levels and its intracellular distribution also were assessed. RESULTS: DEM did not affect the expression of the caspases at the transcriptional level but was associated with increased procaspase-3 and caspase-8 protein levels. DEM preincubation restored sensitivity to Fas antibody and radiation-induced apoptosis in cells from the LNCaP-bcl-2 transfectant cell line that, normally, are resistant to these apoptotic stimuli. It is that DEM chemically depletes intracellular thiol levels. Although no depletion in total intracellular thiol GSH was observed at these concentrations of DEM, trafficking of GSH from the nucleus to the cytosol was demonstrated. CONCLUSIONS: Identification of the caspases as a potential target for chemical manipulation may serve as an effective, adjuvant-based approach in the treatment of patients with prostate carcinoma and, in particular, for immunotherapy and radiation-based strategies that rely on the activation of these death-effector proteases.