Comparison of lower urinary tract symptoms between women with detrusor overactivity and impaired contractility, and detrusor overactivity and preserved contractility.

PURPOSE: We compared symptoms in women with detrusor overactivity with impaired contractility and women with detrusor overactivity who had preserved contractility. MATERIALS AND METHODS: The study included 359 consecutive women with detrusor overactivity who underwent multichannel urodynamics at our department between 2009 and 2011. The women were divided into 2 groups, including 151 (42%) with detrusor overactivity and impaired contractility, and 208 (58%) with detrusor overactivity and preserved contractility. We compared the 2 groups. RESULTS: Women with detrusor overactivity and impaired contractility were older (mean ± SD age 73.2 ± 17.3 vs 54.1 ± 20.7 years) with a higher frequency of diabetes mellitus (49% vs 31%, each p <0.001). The prevalence of previous urinary retention and recurrent cystitis was significantly higher in women with impaired contractility (7% vs 1%, p <0.01 and 22% vs 7%, p <0.001, respectively). Mean post-void residual urine was greater in the group with impaired contractility (89 ± 42 vs 21 ± 18 ml) and the mean maximal flow rate was lower (11 ± 6 vs 23 ± 5 ml per second, each p <0.001). The frequency of storage symptoms was similar in the 2 groups. However, voiding symptoms were more common in women with impaired contractility, including a slow stream in 69% vs 42%, an intermittent stream in 72% vs 26%, hesitancy in 35% vs 22%, straining in 84% vs 26%, terminal dribbling in 73% vs 42% and incomplete emptying in 71% vs 49% (p <0.001). CONCLUSIONS: Women with detrusor overactivity and impaired contractility are older than women with detrusor overactivity and preserved detrusor contractility. Urinary retention and recurrent cystitis are more frequent in women with detrusor overactivity and impaired contractility, and voiding symptoms are significantly more common.

Hyperbaric oxygen therapy for hemorrhagic radiation cystitis.

BACKGROUND: Hemorrhagic radiation cystitis (HRC) is a significant clinical problem that occurs after pelvic radiation therapy and is often refractory. OBJECTIVES: To evaluate the efficacy and safety of hyperbaric oxygen therapy (HBO) for HRC. METHODS: Daily 90 minute sessions of HBO at 2 ATM 100% oxygen were given to 32 HRC patients with ASTRO grades 3-4 hematuria. RESULTS: The median age was 72.5 (48-88 years). The median time interval between radiation therapy and HBO was 4 years (1-26 years). The patients received a median of 30 HBO sessions (3-53). Hematuria resolved in 27 patients (84%) and persisted in 5. Cystectomy was required in two, and ileal-conduit and bilateral percutaneous nephrostomies were performed in one and two patients, respectively. With a median follow-up of 12 months (5-74 months), the hematuria cleared completely in 16 patients (59%) and mild hematuria requiring no further treatment recurred in 10 others. Another patient with ASTRO grade 4 hematuria needed bladder irrigation and blood transfusions. Complications included eardrum perforation in four patients and transient vertigo and mild hemoptysis in one case each. None of them required HBO discontinuation. CONCLUSIONS: HBO controlled bleeding in 84% of the patients. A durable freedom from significant hematuria was achieved in 96% of the patients. HBO seems to be an effective and safe modality in patients with HRC.

Decreased amplitude of detrusor overactivity by repetitive swallowing.

PURPOSE: We determined whether swallowing has an effect on the degree of urinary urgency and on the amplitude of detrusor contraction during filling cystometry in patients with detrusor overactivity. MATERIALS AND METHODS: Included in study were 20 consecutive patients with detrusor overactivity. During urodynamics the mean peak pressure of each contraction was documented and compared. At the beginning of wave 2 patients were asked to perform 5 repetitive swallows. After each wave patients were asked to grade the severity of urgency on a visual analog scale. RESULTS: The mean ± SD peak of the detrusor contraction was 39 ± 15 vs 95 ± 26 cm H(2)O with vs without swallowing (p <0.01). All patients reported that during swallowing the degree of urgency decreased. The mean visual analog scale score for urgency was significantly lower during repetitive swallowing than without swallowing (mean 3.4 ± 1.5 vs 7.7 ± 2.2, p <0.01). CONCLUSIONS: The repetitive swallowing maneuver inhibits urinary urgency and detrusor overactivity. The maneuver can be used during bladder training program or when micturition is not desirable.

[Part-time residency training in Israel].

Full-time work has long been perceived as a cornerstone of medical residency, the consensus being that a resident must apply the bulk of his time and attention to his professional training. Demographic and cultural changes that have taken place over the last several years, specifically the rise in the number of female doctors and the importance of leisure time to the younger generation, have intensified the need to find new and innovative ways to deal with the plight of the resident population. One idea, already in effect in many Western countries, is the institution of part-time residency programs. The possibility of fulfilling residency requirements on a part-time basis is intended to assist medical residents in integrating their professional development with their personal and family life, without compromising the quality of their training. A number of research studies conducted over the last several years in countries that allow part-time residency, among them the United States, England and Switzerland, aimed to examine the quality of part-time training. The various studies evinced a high level of satisfaction from the program both by the residents themselves and their supervisors, and in many aspects those doing residency part-time received higher appraisals than their full-time colleagues. Some of the residents polled noted that they would have totally foregone the practice of medicine had there not been an option to complete residency part-time. In light of the experience throughout the world and the changing landscape in Israel, the Scientific Council of the Israeli Medical Association decided to examine the issue and its various aspects, and weighed all the considerations in favor and against part-time residency. Recently, the Scientific Council approved the launch of a pilot program to allow part-time residency in several fields that were carefully selected according to specific criteria. Once the Ministry of Health completes the LegisLation process, part-time residency will officially begin in Israel.

Evolution from active surveillance to focal therapy in the management of prostate cancer.

Organ-preserving therapies are widely accepted in many facets of medicine and, more recently, in oncology. For example, partial nephrectomy is now accepted as a preferred alternative over radical nephrectomy for small (up to 4 cm or T1) tumors. Focal therapy (FT) is another organ-preserving strategy applying energy (cryotherapy, laser ablation and/or high-intensity focused ultrasound) to destroy tumors while leaving the majority of the organ, surrounding tissue and structures unscathed and functional. Owing to the perceived multifocality of prostate cancer (PCa) technology limitations, in the past PCa was not considered suitable for FT. However, with the rise of active surveillance for the management of low-risk PCa in carefully selected patients, FT is emerging as an alternative. This is owing to technology improvements in imaging and energy-delivery systems to ablate tissue, as well as the realization that many men and clinicians still desire tumor control. With the postulated ability to ablate tumors with minimal morbidity, FT may have found a role in the management of PCa; the aim of FT a being long-term cancer control without the morbidity associated with radical therapies. Data for FT in PCa have been derived from case series and small Phase I trials, with larger cohort studies with longer follow-up having only just commenced. More data from large trials on the safety and efficacy of FT are required before this approach can be recommended in men with PCa. Importantly, studies must confirm that no viable cancer cells remain in the region of ablation. FT might eventually prove to be a 'middle ground' between active surveillance and radical treatment, combining minimal morbidity with cancer control and the potential for retreatment.

[Pelvic floor medicine--innovative versus conservative approach].

UNLABELLED: Female pelvic floor medicine treats a variety of conditions including urinary and anal incontinence, pelvic floor prolapse, overactive bladder, periurethral lesions and chronic pelvic pain. A third of the women are expected to experience one of these conditions, and one out of 9 women will have a pelvic floor surgery. Pelvic floor dysfunction impairs patients' quality of life and results in social embarrassment and psychological distress. Aging of the population and requirements for a better and an active life in old age resulted in an increased demand for medical treatment. Since pelvic floor organs are anatomically and physiologically connected and because many women have several pelvic floor diseases, treatment should be obtained by several medical disciplines: female-urologist, urogynecologist, colorectal surgeon and rehabilitation pelvic floor physiotherapist. This review presents the problematic aspects of treating women with pelvic floor dysfunction. Comparisons between conservative and innovative approaches will be discussed. CONCLUSIONS: Integrated multidisciplinary pelvic floor service represents the innovative approach. The service includes all the medical disciplines that treat women with pelvic floor problems and could provide a "one stop shop". This kind of service should provide quick, economical and effective treatment. The collaboration between different disciplines should save compound bureaucracy and prevent unnecessary tests and procedures. Complex cases can be managed more easily, clinically and surgically, without referrals. Centralized service encourages usage of clinical protocols and guidelines and potentially reduces the risk of medico-legal claims. The quality of the treatment and the patients' satisfaction should be improved.

[Interstitial cystitis/painful bladder syndrome: a comprehensive review of the current literature].

Interstitial cystitis/painful bladder syndrome (IC/PBS) presents as a pelvic pain condition associated with urinary urgency and frequency. These symptoms significantly impair the patient's quality of life. The prevalence of IC/PBS is 0.5% in the general western population and is nine times more frequent in women. The average age for presentation is 42 years. The etiology is as yet not obvious. The current acceptable theory is injury or dysfunction of the glycosaminoglycan layer that covers the urothelium. Abnormal diffusion of toxins from the urine to the submucosa leads to neurogenic inflammation, pain and fibrosis. The definition of the syndrome is not yet solid and was changed several times since it was first described more than one hundred years ago. Since the diagnosis of IC/PBS is quite complex and furthermore, the awareness is low, the average time from presentation to diagnosis is 7 years. Early treatment provides better outcomes. Many types of methods were described but most of them were not evaluated in well designed randomized controlled studies. Currently, there is no one single treatment that provides good outcomes to every patient. Therefore, the treatment of patients with IC/PBS is challenging and requires a multidisciplinary approach. in this manuscript we review the current literature and describe the problematic diagnosis and the challenging treatment of IC/PBS. Our main objective is to educate and provide awareness of this entity to the general physician. Hopefully, this will result in early diagnosis, saving unnecessary tests and pain to the patients.

[Is the rate of medical publication from Israel similar to other countries? A comparative study of three medical specialties].

UNLABELLED: Academic careers of individual doctors are commonly evaluated by examining the number and quality of authored publications. Similarly, the extent and quality of medical research may be assessed nationwide by measuring the number of publications originating from the country of interest over time. This in turn, may indicate on the quality of medicine practiced. To evaluate the extent and quality of IsraeLi publications we measured the rate and quality of medical publications originating from Israel for two decades in the fields of urology, cardiology and orthopedics, and compared the data to those of other countries. METHODS: Leading journals in urology, cardiology, and orthopedics were selected. A Medline search (http://www.ncbi.ntm.nih.gov/sites/entrez] was conducted for all the publications originating in Israel between the years 1990-2009 in the selected journals. Data from Israel was compared to those from Italy, France, Germany, Egypt and Turkey. The change in rate of publications was tested using Linear regression. The quality of publications was calculated by multiplying the number of publications by the relevant impact factor. RESULTS: While the urology publications rate in Israel increased by 32.7% in the second study decade as compared with the first, the urology publication rates during the same time period from Italy, France, Germany, Egypt and Turkey were 199%, 115%, 184%, 180% and 227% respectively. The regression coefficient for the urology publication rate was 0.51 for Israel, and 0.78, 0.95, 0.78, 0.87 and 0.97 for the other countries, respectively. The regression coefficient for the change in the quality of publications from Israel was 0.31 and 0.81, 0.75, 0.92, 0.73, and 0.92 for the other countries, respectively. In cardiology, the Israeli publication rate increased by 26% during the second study decade, whereas in the other countries the increments were 46%, 35%, 76%, 80% and 309% respectively. The regression coefficient for Israeli pubLication rate was 0.45, and 0.78, 0.54, 0.62, 0.13 and 0.75 for the other countries, respectively. The regression coefficient of the quality of publications in Israel was 0.3 as opposed to 0.47, 0.36, 0.48, 0.01, and 0.78 respectively. The Israeli publications in orthopedics increased by 9.3% during the second decade compared with the first. At the same time, other countries increased the publication rate in orthopedics by 69%, 121%, 173%, 140% and 296% respectively. The regression coefficient for the publication rate in orthopedics was 0.02 for Israel, and 0.62, 0.64, 0.78, 0.34 and 0.71 for the other countries, respectively. The regression coefficient of the quality of publications in Israel was 0.05 as opposed to 0.67, 0.62, 0.75, 0.31, and 0.66 in the other countries, respectively. CONCLUSIONS: Israel lags behind Italy, France, Germany, Egypt and Turkey with regard to the increase of both the number and the quality of medical publications in urology and orthopedics. While the rate and quality of IsraeLi publications in cardiology surpasses those from Egypt, they lag in the number of publications in this medical field behind those of all the rest of the countries examined. In a world of rapid progress and expansion of medical research, Israel has been stagnant in publications in 3 medical specialties, rendering it inferior to other nations.

Association between tamsulosin and intraoperative "floppy-iris" syndrome.

Intraoperative "floppy-iris" syndrome is a novel entity that was initially described in 2005 by Chang and Campbell who encountered it during cataract surgery. The manifestations include a triad of the following intraoperative findings: (a) flaccid iris stroma leading to fluttering and bellowing of the iris, (b) prolapse of the iris through the surgical incisions, and (c) progressive pupil constriction. IFIS has been associated with increased surgical difficulty and, as a result, with increased morbidity including retinal detachment and loss of vision. Since the initial publication of IFIS in 2005, there have been several reports of a possible association between the use of tamsulosin for symptomatic prostate hyperplasia and IFIS. Consequently, in 2005 the U.S. Food and Drug Administration issued an alert recommending ophthalmic examination prior to treatment with tamsulosin. In this review we present evidence of the association between tamsulosin and IFIS. We conducted a Medline search using the key words tamsulosin or alpha-blockers and retrieved English written reports and data on the prevalence of treatment with alpha-blockers in general and specifically tamsulosin among patients undergoing cataract surgery, the prevalence of IFIS among treated versus non-treated patients, and the resulting surgical complications. Of the 19 publications on this topic only 7 were patient series providing data on IFIS and treatment with tamsulosin. The prevalence of men receiving tamsulosin for BPH among the patients operated for cataract was 1-3%, the occurrence of IFIS was reported in 2-3% of the patients, and 57-100% of the patients receiving tamsulosin had at least one manifestation of IFIS. The occurrence of IFIS among men receiving other alpha-blockers or in non-treated patients was rare. An association between preoperative treatment with tamsulosin and IFIS is probable. This observation warrants further research to establish causality. Meanwhile, it seems prudent to perform an ophthalmic examination prior to prescribing tamsulosin.

[Palliative surgery for locally advanced prostate cancer].

Local progression of prostate cancer occurs when the tumor grows beyond the prostatic capsule and invades adjacent structures such as the urinary bladder, rectum, pelvic side-wall and ureters. This is an important clinical event that can in itself cause significant morbidity, impaired quality of life and even mortality. Patients with this condition may experience urinary symptoms due to bladder outlet obstruction by the tumor mass, ureteral obstruction and renal failure, hematuria due to invasion of the tumor into the bladder, and pelvic pain, constipation or tenesmus, as a result of rectal involvement. In the absence of metastasis, some patients with Locally advanced prostate cancer (LAPC) may survive for Longer than 5 years. Therefore, effective and durable palliation is necessary to reduce morbidity and maintain patient quality of life. ALthough the majority of the patients with LAPC cannot be cured by any currently available modality, effective palliation is an independent clinical endpoint. This article presents the LAPC syndrome and treatment options.

Intracavernosal saline infusion decreases intraoperative blood loss during radical retropubic prostatectomy.

OBJECTIVE: Radical retropubic prostatectomy (RRP) is associated with intraoperative blood loss. We studied whether regional hemodilution using intracavernosal saline infusion has an impact on blood loss during RRP. METHODS: This is a prospective, randomized controlled study. There were 16 patients treated with intracavernosal saline infusion, and 17 did not receive infusion and served as the control group. Patients who received neoadjuvant therapy and those who underwent pelvic lymph node dissection or salvage RRP were excluded. Both corpora were infused in a pressure of 80-cm water. Clinical, pathologic, and laboratory parameters were evaluated and compared. Intraoperative actual blood loss was calculated. RESULTS: Blood loss was significantly higher in the control group (1,036 +/- 176 vs. 482 +/- 184 ml; P < 0.001). Postoperatively, 3 control patients received 2 packed-cell units each. There were no differences between the 2 groups in regard to patient's age, comorbidities, body mass index, American Society of Anesthesiologists score, prostate-specific antigen level, clinical or pathologic stage, Gleason score, prostate specimen weight, and operating time. Localized penile edema developed in 6 patients (37.5%) that resolved spontaneously 48 hours postoperatively. None of the patients had symptoms or signs of systemic fluid overload. CONCLUSION: Our result indicates that localized hemodilution using intracavernosal saline infusion is feasible, safe, and significantly decreases blood loss during RRP.

Ultrashort intracorporeally maneuverable cryoprobes for laparoscopic renal cryoablation in the porcine model.

AIM: To determine the feasibility and efficacy of laparoscopic renal cryosurgery using a novel ultrathin ultrashort intracorporeal cryoprobe in a porcine model. MATERIAL AND METHODS: Novel cryoprobes 4 cm in length and 1.5 mm in diameter were manipulated intracorporeally after insertion via a designated 15 mm laparoscopic port. Renal cryoablative lesions were induced laparoscopically in four 40 kg female piglets. We correlated between intraoperative temperature, ice ball geometry, intraoperative ultrasonographic properties, and histology. RESULTS: Laparoscopic manipulation of the cryoprobes was straightforward. No port site bleeding occurred during insertion, freezing, thawing or upon removal of the probes. The 0 degrees C, -20 degrees C, and -40 degrees C isotherms were measured at 6, 8, and 12 mm from the probe circumferentially. Ice-ball volume stabilization as determined by ultrasound occurred after 10 min of activation. Lower temperatures were reached after 10 min of probe activation as compared with 5 min (ice ball diameter 30 mm, DeltaT = 13-21 degrees C). Using a second 10-min-long freeze cycle resulted in a 14-22 degrees C lower temperature within the ice ball compared to a single cycle. Full coagulative necrosis was noted in the areas between the inserted probes with an additional 1-2 mm circumferential rim of severe tubular damage and apoptosis. CONCLUSIONS: Our novel cryoprobe can be used effectively and conveniently in laparoscopic renal cryosurgery. Considering the size of the cryogenic lesion, using a cluster of probes may be advisable.

Does prostate biopsy Gleason score accurately express the biologic features of prostate cancer?

PURPOSE: To correlate Gleason grading in prostate biopsies with the final Gleason score in radical prostatectomy specimens, and to investigate predictors for concordance and preoperative undergrading. MATERIALS AND METHODS: The charts of 303 patients who underwent radical retropubic prostatectomy between 1992 and 2002 were retrospectively reviewed. Prostate biopsy and surgical specimen Gleason scores and correlative clinical data were recorded, and a multivariate analysis model was applied. RESULTS: Data were available in 293 cases (97%). The preoperative biopsy predicted the prostatectomy Gleason score accurately in 51% and undergraded them in 41% of the patients. Accuracy rates were significantly higher for Gleason scores 7-10 compared to low Gleason scores (2-4), concordance 90% and 6%, respectively (P < 0.01). Moreover, accuracy rates were higher in patients with prostate-specific antigen (PSA) higher than 10 ng/ml (85% vs. 40%; P < 0.01) and prostate glands smaller than 55 g (68% vs. 38%; P < 0.01). In 233 patients, the biopsy Gleason score did not include 4 or 5 components. Upgrading to 4 or 5 in 1 of the components was noted in 32 patients (14%). Multivariate analysis revealed that upgrading is associated with preoperative serum PSA (odds ratio 1.05; P < 0.05) and the percentage of positive cores in the biopsy (odds ratio 1.47; P < 0.001). CONCLUSIONS: Biopsy Gleason scores of 2-4, low PSA, and a low percentage of positive cores in the biopsy can predict the biopsy driven biologically significant undergrading of 1 of the components of the Gleason score that may adversely affect therapeutic decisions.

[Percutaneous diagnostic biopsy of solid renal masses in adults].

Most solid renal masses are presumed to represent renal cell carcinoma. Percutaneous biopsies of renal cell carcinoma have been discouraged because traditionally it was believed that surgery provides tissue diagnosis, staging, and grading as well as definitive treatment. Percutaneous renal mass biopsy was shown to be inaccurate and finally, beside rare complications such as bleeding and pneumothorax, biopsy may facilitate tumor seeding along the needle tract. In recent years, due to an increased use of cross-sectional imaging, more renal masses are being detected. The size of renal masses in contemporary series is smaller than in historical cohorts. On the basis of our findings and according to reports by others, approximately 20% of small renal masses are benign. We reviewed the indications, techniques, success rates, accuracy and complications of percutaneous biopsy of solid renal masses in adults in order to debate whether it is currently indicated to reconsider the role of renal mass biopsy in the diagnostic flowchart of small renal masses workup. Such a modification, if proven to be justified, may spare a substantial number of patients the risk and morbidity of nephrectomy or partial nephrectomy.

[Management of prostate cancer with indolent biological potential: from watchful waiting to active surveillance].

Prostate cancer is the most common malignancy among elderly men. Due to its indolent course and the fact that the majority of contemporary patients are diagnosed early, disease progression to metastasis often occurs many years after the initial diagnosis. Elderly men who have concurrent severe illnesses may not experience progression to metastasis during their lifetime. Therefore, it is reasonable to withhold active therapy in some patients avoiding the associated risks, and impact on patient quality of life. Watchful waiting (WW) is an adequate approach in such cases, and has been shown to be associated with a similar overall survival when compared with radical prostatectomy. However, the disease-specific survival was better in patients who had undergone surgery. Prostate cancer patients often find it hard to persist on a WW policy. This is due to their expectation to be treated, to fight, and win the battle over cancer. Consequently, many patients who start on WW drop out and seek active treatment within several years, mostly when PSA elevation is noted. Active surveillance for prostate cancer is a novel approach consisting of avoiding the risks of therapy, while allowing the early detection of those who are prone to progress. In these high-risk individuals delayed active treatment is offered. Active surveillance consists of periodic monitoring of the PSA serum level, digital rectal exam and repeated prostate biopsies. Threshold values for these parameters are pre-defined and active therapy is instituted when such threshold values are met. Preliminary results of active surveillance show that more patients remain on a surveillance regimen as compared with the traditional WW; it is possible to offer curative treatment to individuals who were defined as having high risk by active surveillance parameters, and the disease-specific mortality is similar to that with WW. Active surveillance for prostate cancer is a novel and fascinating approach that may improve our ability to distinguish between patients who have a higher risk and need active therapy, and others in whom the risk for progression remains low and avoiding the risks of therapy is warranted.

[Multivariate analysis on radical retropubic prostatectomy associated blood loss: importance of prostate size, pelvic lymph-node dissection and percentage of carcinoma].

BACKGROUND: Radical retropubic prostatectomy (RRP) has been associated with blood loss requiring blood transfusion. AIM: To define risk factors for blood transfusion. STUDY DESIGN AND METHODS: The charts of 303 patients who underwent RRP between the years 1992 and 2002 were prospectively reviewed. Blood loss, blood requirements and correlative clinical data were recorded and a multivariate analysis model was applied. RESULTS: Data was available in 293 cases (97%). A total of 122 patients were transfused (42%) with a median of 2 units of packed cells. Median estimated blood loss was 766 ml (range 150-2800). Blood loss declined progressively during the study period (1220 ml in 1992 to 826 ml in 2002). Multivariate analysis reveals that estimated blood loss and transfusion rate are related to performance of pelvic lymph node dissection, prostate size and percentage of cancer in the prostatectomy specimen. CONCLUSION: Our series indicates that blood preparation may be spared in patients who are not candidates for pelvic lymph node dissection with prostate smaller than 57 gr. and with less than 77% in the biopsy specimen (equivalent to < 66% of cancer in the prostatectomy specimen).

[Comparative morbidity for different accesses in percutaneous nephrolithotripsy].

BACKGROUND: Over the last decades percutaneous nephrolithotripsy (PCNL) has been developed as an alternative for open renal operations in the treatment of complex renal stones. Currently, different approaches are used for the collecting system. OBJECTIVES: To estimate the overall morbidity of different approaches to the collecting system during PCNL; to compare the complication rates for PCNL through the upper pole of the kidney with lower pole access and multiple access approaches. METHODS: We retrospectively reviewed 174 patients (178 renal units) who underwent PCNL. They formed three groups according to surgical access: upper pole (n = 107), lower pole (n = 51) and multiple (n = 20). Inter-group data on procedure related complications were compared. RESULTS: Postoperative fever was more frequent in the upper pole group (34%) compared to the other two groups (25% each, p < 0.49). There was a higher rate of pulmonary complications in the upper pole and multiple access groups (21% and 20%, respectively) compared with the lower pole group (2%, p=0.007). The rate of bleeding and need for blood transfusion was significantly higher in the multiple access group than in the other groups (20% vs 5% and 6%, respectively, p < 0.05). CONCLUSIONS: The upper and multiple access approaches were associated with a higher overall incidence of pleural effusion compared with the lower pole access. The incidence of bleeding and transfusion rates were similar using the upper and lower pole accesses but higher in the multiple access group. Provision of an enhanced surgical field and greater maneuverability together with 'the treatable nature of the associated complications favor an upper pole access, especially for removing a large stone burden.

PSA elevation during prostate cryosurgery and subsequent decline.

PURPOSE: To determine the immediate effect of prostate cryosurgery on PSA and the subsequent decline. METHODS AND MATERIALS: PSA level was measured in 14 patients who underwent cryosurgery for prostate cancer. Blood samples were taken immediately before and after cryosurgery and 1, 2, 4, 6 weeks and 3 months postoperatively. A confidence interval for the elevation from baseline to maximal PSA was calculated. PSA decline was assessed in patients with a nadir PSA < or =0.5 ng/mL. Patients with a postoperative nadir PSA >0.5 ng/mL were considered to harbor viable cancer and were excluded from the decline analysis. The observed PSA levels during the postoperative period were compared with the expected levels that were calculated according to the maximal PSA level and a serum half-life of 2.5 days. Student t-test was used to compare expected and observed PSA levels. RESULTS: PSA increased from an average of 9.23 ng/mL preoperatively to a maximum average of 155 ng/mL (maximal PSA ranges: 18.9-490.5 ng/mL). The 95% CI for the increase in PSA from baseline level was 63.4 to 224.14. PSA nadir < or =0.5 ng/mL was achieved in 10 patients. The observed PSA decline course was slower than expected according to its half-life. Average observed and expected PSA levels at 2,4 and 6 weeks after cryosurgery were 10.4 versus 3.57 ng/mL (P = 0.005), 0.65 versus 0.07 (P = 0.007) and 0.09 versus 0.001 (P = 0.03), respectively. CONCLUSION: PSA levels increase steeply following cryosurgery, and decline slower than expected according to the serum half-life.

Retropubic radical prostatectomy: associated blood loss and transfusion requirements--a two-decade perspective review.

Bleeding during retropubic radical prostatectomy arises from venous structures in the majority of cases. Since its introduction two decades ago, the nerve-sparing procedure with surgical control of the dorsal venous complex has led to a reduction in blood loss and blood transfusion rate. The reducton in blood loss is a result of better understanding of the prostatic blood vessel anatomy, extensive surgical experience over time, and reduction in transfusion triggers with an acceptance of lower postoperative hemoglobin values. Increased blood loss during RRP is associated with poorer outcomes most probably due to surgical difficulties. But as for now, there are no decisive risk factors for clinically significant bleeding during RRP although newer technologies for hemostasis of the dorsal vein complex are being utilized.

Ureteral stents: morbidity and impact on quality of life.

BACKGROUND: Stents offer a simple and effective drainage method for the upper urinary tract. However, ureteral stents are associated with frequent side effects, including irritative voiding symptoms and hematuria. OBJECTIVES: To determine the side effects associated with ureteral stents and their impact on sexual function and quality of life. METHODS: Symptom questionnaires were administered to 135 consecutive patients with unilateral ureteral stents. The questionnaire addressed irritative voiding symptoms, flank pain, hematuria, fever, loss of labor days, anxiety, sleep impairment, decreased libido, erectile dysfunction, dyspareunia, painful ejaculation, and a subjective overall impact on quality of life. The items were graded from 1 (minimal or no symptoms) to 5 (maximal symptoms). The patients were seen and questionnaires filled at 2 weekly intervals following stent insertion until stent extraction. Following removal of the stent, stent patency, impaction and migration rates were determined. Admissions to hospital and ancillary procedures to retreive stents were noted. RESULTS: The findings presented refer to questionnaire items scoring 3 or more. Dysuria, urinary frequency and urgency were reported by 40%, 50% and 55% of the patients, respectively. Flank pain, gross hematuria or fever was reported by 32%, 42% and 15% respectively. Among working patients, 45% lost at least 2 labor days during the first 14 days, and 32% were still absent from work by day 30. A total of 435 labor days were lost in the first month. Anxiety and sleep disturbance were reported by 24% and 20% respectively, and 45% of patients reported impairment in their quality of life. Decreased libido was reported by 45%, and sexual dysfunction by 42% of men and 86% of women. Stent removal necessitated ureteroscpoy in 14 patients (10.5%), due to upward migration in 11 (8.2%) and incrustration and impaction in 3. Spontaneous stent expulsion occurred in one patient. Forty-six stents (34%) were obstructed at the time of removal. Obstructed stents were associated with a longer mean dwell time as compared to the whole population, 75 versus 62 days respectively (P = 0.04). CONCLUSIONS: Ureteral stents are associated with frequent side effects and significant impact on patient quality of life. Our findings should be considered when deciding on ureteral stent insertion and dwell time.