De novo HLA sensitization and antibody mediated rejection following pregnancy in a heart transplant recipient.

Here we report a case wherein both donor-specific and third-party, paternal, HLA class II specific antibodies developed following a spontaneous miscarriage resulting in antibody-mediated rejection in a patient who had undergone an orthotopic cardiac transplant six years earlier.

An MRSA outbreak in a urology ward and its association with Nd:YAG coagulation laser treatment of the prostate.

An outbreak of methicillin resistant Staphylococcus aureus (MRSA) involving 88 patients in a general urology ward is described. Symptomatic bacteraemia and epididymo-orchitis occurred in 10 and 8% of patients respectively. Patients had a particularly high risk of acquiring serious MRSA infection after endoscopic neodymium yttrium aluminium garnet (Nd:YAG) laser treatment of the prostate. Appreciation of the mode of transmission of MRSA, a programme of continuing education for all medical and nursing staff, simple changes in ward protocol and advances in surgical laser technique contributed to the control of the outbreak.

Teflon injection in female stress incontinence. Effect on urethral pressure profile and flow rate.

Thirty-six females with genuine stress incontinence (GSI) were treated by bladder neck teflon injection. Urethral pressure profilometry (UPP) and uroflowmetry were performed both pre- and post-operatively on 18 patients. In 24 patients who were either completely cured or improved by this procedure, the mean urine flow rate was reduced by 23% and the mean functional profile length increased by 9% compared with pre-operative values. Although these findings appear to explain the mechanism by which teflon improves continence, these differences were not statistically significant. Fourteen of the 18 patients who had not responded to previous anti-incontinence procedures were successfully treated by teflon injection. The improved response rate in these patients was not statistically significant. It was not possible to predict with certainty those patients most likely to respond to teflon injection. However, in women with normal or near normal pelvic floor anatomy the procedure had an acceptable success rate. In view of the simplicity, lack of morbidity and the ease with which it can be performed and repeated, bladder neck teflon injection deserves consideration as an alternative, particularly where open surgery has failed.

The 'hitch-stitch' and drain technique for the prevention of inguinoscrotal haematoma following complicated inguinoscrotal surgery.

A method to prevent inguinoscrotal haematoma following hernia and hydrocele repair is presented. The technique was used in 34 consecutive patients, none of whom developed a significant postoperative haematoma or complications.

Primary vesical sensory urgency. A clinical trial of bromocriptine.

A randomised double blind crossover trial of Bromocriptine against an inert placebo was performed in 14 patients with primary sensory urgency. Bromocriptine was found to have no therapeutic advantage for these patients and the possible explanations for this finding are discussed.

Videoprostatectomy. Guidelines for choosing an effective microvideo operating system.

Videoprostatectomy is gaining increasing acceptance by urologists. Guidelines are suggested to assist in the selection of a suitable video operating system and to optimise both the quality of the video image and safety of operation.

Periurethral Teflon for stress urinary incontinence: medium-term results.

Medium-term results are presented for the periurethral injection of Teflon in the treatment of stress urinary incontinence. Follow-up data were obtained on 36 women by means of case note review and the completion of a postal questionnaire. Mean follow-up was 5.1 years. Subjective results showed 12 patients to be dry or much improved while the remaining 24 patients did not obtain significant benefit from the procedure. Repeat injections in 12 women resulted in only 3 obtaining useful improvement, while a subgroup of patients who had undergone previous procedures showed a better response. No significant complications were observed. Periurethral Teflon injection is a minor surgical procedure which can produce worthwhile improvement, although an initially good result may not be sustained with longer follow-up. This method may be advocated as treatment for poor risk patients who are unsuitable for surgery, particularly when previous attempts at formal surgical correction have been unsuccessful.

Vaginal ureterolithotomy.

The vaginal approach to the low ureteric calculus may provide an easy, rapid and safe solution to a difficult surgical problem. It is important to select the case with care and, provided basic surgical principles are followed, the complications should be minimal. 3 recent successful cases are described and a further 2 in which the technique failed due to proximal displacement of the stone. The importance of adequately immobilising the calculus prior to ureterotomy is emphasised.

Staghorn calculi of the kidneys. A. Clinical review.

A series of 91 staghorn calculi are reviewed. Possible aetiological factors are analysed. A high incidence of hypercalciuria was found, and the significance of this is discussed. The rates of complete stone clearance after conservative surgery are considered for different types of staghorn calculus and it is felt that local circulatory arrest with kidney cooling may be of value in removing stones due to Proteus. The place of elective nephrectomy in the management of staghorn calculi is discussed. Nephrectomy may be the treatment of choice in the management of large, unilateral stones in older patients.

An evaluation of urologist-operated ultrasound and its use in the urological out-patient clinic.

The value of urologist-operated real time ultrasound scanning was assessed in the urological out-patient clinic. In terms of accuracy, the urologists' ultrasound scans of the genito-urinary tract proved comparable with those of the radiologists. The techniques were quickly learned and scanning added little to the consultation time. Scanning during clinic time was shown to be both time-saving and cost-effective by allowing more rapid assessment of the patient and a speedier diagnosis. In economic terms considerable savings could be made by reducing the need for formal ultrasound referrals, since patients scanned at the out-patient clinic would be spared two further trips to hospital, one for the formal examination and another for the out-patient clinic review. Clinic turnover thus becomes more efficient and inconvenience to the patient and transport costs are lessened.

Multiple use of fibres in the visual laser ablation of the prostate.

OBJECTIVE: To investigate the possibility of re-using laser fibres for the visual laser ablation of the prostate (VLAP). PATIENTS AND METHODS: Thirty-four patients, each with a mean maximum urinary flow rate of < 14.0 mL/s and an American Urological Association symptom score of > 19, were evaluated. All underwent VLAP: laser energy, generated by a Neodymium:YAG system, was delivered with a side-firing fibre. The laser generator was fitted with a custom-built power meter that measured the energy delivered by the fibre. Fibres were re-used until the energy output fell below 60 W despite increases in laser generator power. Each patient was followed for at least 12 months. RESULTS: A total of seven fibres was used to treat the 34 patients; between one and nine patients were treated with each fibre. The outcome obtained with the first use of a fibre compared well with those obtained with each subsequent use. After 12 months, 25 patients (74%) expressed satisfaction with the results of their operation. Five patients (15%) had urinary tract infections. As each fibre costs about pound 650, multiple use saved a mean of pound 516 for each patient treated. CONCLUSION: This evaluation implies that there is no justification for the single use of laser fibres on the basis of efficacy, provided that a power meter is used to monitor the efficiency of the delivery device.

The surgical management of tuberculous lower ureteric stricture.

25 years' experience of the open surgical management of the lower ureteric stricture is reviewed. An extravesical anti-reflux tunnel procedure has been found to be simple and effective. There is still a place for the Boari procedure or psoas hitch, particularly in the management of a long stricture of when gross thickening of the ureter makes the formation of a tunnel of effective length impracticable.

A further assessment of bladder transection in the management of adult enuresis and allied conditions.

The use of bladder transection for the management of adult enuresis and allied conditions is reported. The beneficial effects of the operation, assessed by an improvement of symptoms and measured objectively by urodynamic investigation, have been found to be maintained during 4 years' experience of the procedure.

The use of generic measures of health-related quality of life in the assessment of outcome from transurethral resection of the prostate.

OBJECTIVES: To investigate the performance of the EuroQol (EQ) quality-of-life measure and the Nottingham Health Profile (NHP) in assessing the outcome of transurethral resection of the prostate (TURP) for lower urinary tract symptoms (LUTS) suggestive of benign prostatic obstruction (BPO), and to determine which men experience the greatest increase in health-related quality of life (HRQL) after TURP. PATIENTS AND METHODS: A prospective cohort study was undertaken over 12 months from Arpil 1992 of 314 men who completed the EQ, the NHP and a symptom inventory before undergoing elective TURP for probable BPO (Group 1). Identical postal questionnaires were used to follow up this group at 6 weeks, 6 months and 12 months post-operatively, with response rates of 79%, 74% and 69%, respectively. Overall, 92% of patients responded at either 6 or 12 months after surgery. A group of 51 men who had not undergone operation, also with LUTS and probable BPO, were similarly followed over 6 months, before eventually undergoing TURP (Group 2). These patients differed from Group 1 in being younger, less symptomatic and having a higher baseline quality-of-life score, but the inclusion of this group from a broadly similar diagnostic category allowed outcome to be assessed over time in the absence of surgery. RESULTS: There was a significant improvement in all LUTS 6 weeks after TURP; post-micturition dribbling and storage symptoms continued to improve for up to one year. The NHP revealed pre-operative morbidity in all dimensions of the profile. At 12 months after surgery there were significant improvements in the domains of social interaction, energy, pain, emotional reactions and sleep. The EQ profile also showed morbidity in all dimensions before surgery, with significant improvement at 12 months in usual activities, mood and pain/discomfort. The EQ self-rated health and composite quality-of-life score also showed improvement with TURP which continued for 12 months after surgery. The patients in Group 2 tended to deteriorate over the 6 months of follow-up using all measures, but the changes were not significant. The EQ composite quality-of-life score also discriminated between patients on the basis of age, number of symptoms and ASA grade, suggesting that these subgroups experienced differing amounts of benefit from surgery. CONCLUSION: TURP led to significant improvement in the indices of generic HRQL as measured using the NHP and EQ; this improvement continued for 12 months after surgery and mirrored the symptomatic improvement. The EQ confirmed clinical experience, in that men who were younger, fitter and most symptomatic experienced the greatest benefit from surgery. This has not been shown previously using a quality-of-life measure. Generic HRQL measures can be incorporated easily into clinical trials and both the measures used in this study have sufficient sensitivity to be used in this population. The EQ has the advantage of generating a composite quality-of-life score which is easy to interpret and can be used in cost-utility analysis. The addition of HRQL measures leads to a more robust appraisal of the results of surgical intervention. Ultimately, patient-based outcome from TURP will be assessed using a combination of psychometrically tested disease-specific and generic measures, together with symptom scoring.

A prospective, randomised study to compare goserelin acetate (Zoladex) versus cyproterone acetate (Cyprostat) versus a combination of the two in the treatment of metastatic prostatic carcinoma.

A prospective randomised study was performed to test the hypothesis that total androgen ablation, achieved by combining an LHRH analogue, goserelin acetate (Zoladex), with an antiandrogen, cyproterone acetate (Cyprostat), is more effective than conventional monotherapy in delaying the time to progression of metastatic prostatic cancer. 525 patients were recruited at 18 UK centres between May 1986 and January 1989, 175 patients being allocated to each arm. Patients were clinically and biochemically assessed at 1, 2, 3, 6, 9 and 12 months after initiation of therapy and then every 6 months until a maximum duration of 48 months. There was no statistically significant difference in terms of median time to progression between the combination treatment arm and either monotherapy arm, although there was a statistically significant difference between goserelin acetate alone and cyproterone acetate alone, in favour of goserelin acetate (p = 0.016). All treatment regimens were well tolerated and cyproterone acetate reduced both tumour flare reactions and hot flushes in patients receiving goserelin acetate. It is concluded that total androgen ablation using cyproterone acetate (300 mg/day) and goserelin acetate (3.6 mg every 28 days) confers no advantage in terms of time to progression, to conventional monotherapy, but can reduce certain side effects caused by LHRH analogue treatment alone.