Home grown: the development and structure of urological training in the Caribbean.

Training in general surgery at the University of the West Indies commenced in Jamaica in 1972 and urology training followed just over a decade later. Since then, the 'Doctor of Medicine' diploma offered by the university has also expanded to include the Trinidadian campus. Most urologists in the English-speaking Caribbean are, in fact, graduates of this programme. Residents follow a two-part training plan and two years of core surgical training are followed by four years of urology training. Despite the tremendous regional impact of this training programme, there is a lack of awareness of its existence among the wider urology community. This article reviews the history, development and structure of urology training in the English-speaking Caribbean.

The current state of prostate cancer treatment in Trinidad and Tobago.

Prostate cancer mortality in the Caribbean region is among the highest in the world and prostate cancer is the most common cancer in Trinidad and Tobago. There is a two-tiered healthcare system in Trinidad and Tobago, and prostate cancer related issues account for a significant percentage of urologists' workload. Delivery of care is sometimes constrained by limited financial resources. Prostate-specific antigen testing is widely available but there is no national guideline. Treatment options available include active surveillance, radical prostatectomy, external beam radiotherapy and brachytherapy. Patients have access to androgen deprivation, chemotherapy and palliative care for the management of advanced disease. Generally, the infrastructure for treatment in Trinidad and Tobago is satisfactory but would benefit from further investments in technology and human resources.

A Clinicopathological Profile of Prostate Cancer in Trinidad and Tobago.

Aim. To conduct a clinicopathological review of all prostate biopsies performed in a tertiary referral centre in Trinidad and Tobago over a period of 30 months. Methods. The records of all patients who had prostate biopsies from January 2012 to July 2014 were reviewed. Clinical and pathologic data were compiled and subsequently analysed using SPSS version 20. Results. From January 2012 to July 2014, 617 transrectal ultrasound guided prostate biopsies were performed. Pathological data were found for 546 patients of whom 283 (51.8%) were confirmed carcinoma of the prostate. Moderately differentiated tumors (Gleason 7) were the most common group. Using the D'Amico risk classification, most cases were found to be high risk (63.1%). Afro-Trinidadians comprised 72.1% of the patients with prostate cancer. Afro-Trinidadians were also more likely to have high risk and high grade disease as well as high PSA values. Conclusion. This study demonstrates that over half of our biopsies are eventually positive for cancer and most cases were high risk. Afro-Trinidadians comprised a disproportionate number of those diagnosed with prostate cancer and had a greater risk of high risk disease.

Late delayed repair of fractured penis.

Early surgery has been recommended by most authors for fractured penis. Because of gross swelling of the penis, early surgery might have to be performed with an extensive degloving incision of the penis to enable better exposure. We report a case in which the man presented late with deformity and pain. Simple repair at that stage provided a good result in this patient; hence, it might be possible to repair a fractured penis at a later stage without degloving the penis. Additionally, this presentation could probably explain the pathogenesis of the "rolling sign" described by us earlier.

An orthotopic metastatic prostate cancer model in SCID mice via grafting of a transplantable human prostate tumor line.

Metastasis is the major cause of prostate cancer deaths and there is a need for clinically relevant in vivo models allowing elucidation of molecular and cellular mechanisms underlying metastatic behavior. Here we describe the development of a new in vivo model system for metastatic prostate cancer. Pieces of prostate cancer tissue from a patient were grafted in testosterone-supplemented male NOD-SCID mice at the subrenal capsule graft site permitting high tumor take rates. After five serial transplantations, the tumor tissues were grafted into mouse prostates. Resulting tumors and suspected metastatic lesions were subjected to histopathological and immunohistochemical analysis. Samples of metastatic tissue were regrafted in mouse anterior prostates and their growth and spread examined, leading to isolation from lymph nodes of a metastatic subline, PCa1-met. Orthotopic grafting of PCa1-met tissue in 47 hosts led in all cases to metastases to multiple organs (lymph nodes, lung, liver, kidney, spleen and, notably, bone). Histopathological analysis showed strong similarity between orthotopic grafts and their metastases. The latter were of human origin as indicated by immunostaining using antibodies against human mitochondria, androgen receptor, prostate-specific antigen and Ki-67. Spectral karyotyping showed few chromosomal alterations in the PCa1-met subline. This study indicates that transplantable subrenal capsule xenografts of human prostate cancer tissue in NOD-SCID mice can, as distinct from primary cancer tissue, be successfully grown in the orthotopic site. Orthotopic xenografts of the transplantable tumor lines and metastatic sublines can be used for studying various aspects of metastatic prostate cancer, including metastasis to bone.

Development and characterization of efficient xenograft models for benign and malignant human prostate tissue.

BACKGROUND: Various research groups have attempted to grow fresh, histologically intact human prostate cancer tissues in immunodeficient mice. Unfortunately, grafting of such tissues to the sub-cutaneous compartment was found to be associated with low engraftment rates. Furthermore, xenografts could only be established using high-grade, advanced stage, but not low- or moderate-grade prostate cancer tissues. METHODS: This paper describes methods for xenografting both benign and malignant human prostate tissue to severe combined immunodeficient (SCID) mice. We examine the efficiency and histopathologic consequences of grafting to the sub-cutaneous, sub-renal capsule, and prostatic orthotopic sites. RESULTS: Sub-renal capsule grafting was most efficient in terms of take rate (>90%) for both benign and malignant tissue. Orthotopic grafts consistently exhibited the best histopathologic differentiation, although good differentiation with continued expression of androgen receptors (AR) and PSA was also seen in the sub-renal capsule site. Sub-cutaneous grafting resulted in low take rates and the lowest level of histodifferentiation in surviving grafts. Grafted benign tissues in all sites appropriately expressed AR, PSA, cytokeratins 8, 18, and 14 as well as p63; carcinoma tissues did not express the basal cell markers. Grafting of tissues to castrated hosts did not affect the graft take rates (but was not practical in the case of the orthotopic site). Grafting followed by host castration resulted in epithelial regression with loss PSA and reduced AR expression at all three sites. CONCLUSIONS: These data suggest that sub-renal capsule and orthotopic grafting of human prostate tissue can be used for many basic scientific and translational studies.

Day case TURP - is it possible?

OBJECTIVE: To determine if day case transurethral resection prostatectomy (TURP) was possible, safe and gave excellent results. DESIGN AND METHODS: A prospective study was undertaken on 75 consecutive patients over an 18-month period. Patients' mean age was 65 years (range 51-76 years) and all had significant obstruction with an average American Urology Association (UA) score of 21 (range 14-28). They were admitted in the morning and a conventional TURP was performed before noon under spinal anaesthesia. Meticulous attention was paid to haemostasis. Intravenous frusemide was used both intra- and post-operatively and rapid irrigation with 0.9 percent saline was given post operatively. The patient was ambulated and discharged on the day of surgery. Follow-up was done by phone for the first 48 hours. RESULTS: The average operating time was 55 minutes (range 35-65 minutes) and 85.3 percent (67) were discharged on the day of surgery. The average duration of stay was 7.1 hours (range 6.5-9.2 hours), 6 were discharged <24 hours and 2 >24 hours. The mean prostatic weight was 30 g (range 12-45g). No transfusions were necessary, urinary tract infection occurred in 4 percent (3) post operative fever in 2.6 percent (2), chest pains in 1.4 percent (1) and re-catheterisation in 1.4 percent (1). There were no cases of clot retention or re-admission. Patient satisfaction was high (96 percent). CONCLUSIONS: Day-case TURP is possible and it is a safe, cost effective alternative to the standard TURP procedure.(Au)

The Goetz mini loin incision: a new minimally invasive technique for removal of kidney stones

A mere 2" incision in the line of the 12th rib, The Goetz Mini Loin Incision (GMLI) was developed in South Trinidad to provide a safe, cost effective access to the kidney for removal of renal calculi comparable to the standard options currently available such as open nephrolithotomy, percutaneous nephrolithotomy (PCNL) or extra corporeal shock wave lithotripsy (ESWL). It provides immediate access to the lower pole and midzone and also to the upper pole by gently rotating the kidney on its pedicle. Blunt nephrolithotomy followed by closure of the capsule ensures complete haemostasis without any vascular clamping. 23 of 30 mini loin nephrolithotomies were each completed within an hour with an average time of 54 minutes and the rest at an average time at 79 minutes. The shortest length of stay was <24 hours in 11 and the longest just over 3 nights in 5 patients, with the rest staying overnight. The GMLI is a minimally invasive and cost effective alternative to standard nephrolithotomy, PCNL and ESWL.(AU)

The incidence of prostate cancer-trends in two ethnic groups in Trinidad: a nine year study - abstract

Data on prostate cancer patients were obtained from the Pathology Department, General Hospital, San Fernando (before 1993) and, after 1993, prospectively collected for all admissions to that hospital for all patients with prostate cancer. Additonal data was collected from the hospital theatre registers and medical records. 365 prostate patients' data over the nine year period 1987-1995 were analysed for tends in the disease. In the population served by the hospital there are equal numbers of East Indians and Africans in the age range > 60 years. There was a rapid rise in the incidence of prostate cancer in males > 60 years starting in 1993, when PSA became widely available. This rise was maintained and seen mainly in the African population though there was a lesser rise among the East Indians. In most years, prostate cancer was more frequent in African than East Indian men. These data emphasize the value of PSA in detecting prostate cancer in both races but there is need for more education and systematic screening programmes to detect the asymptomatic male who can be offered curative therapy. The significantly higher frequency of prostate cancer in Africans (87.2 percent) than East Indians (12.8 percent) may be associated with differences with genetic and dietary factors and not with environment which is the same for both races. (AU))

Diabetes and sexual dysfunction

Diabetes mellitus is a very common illness and sexual dysfunction is common in diabetes due to diseased corpora cavernosa smooth muscles, damaged nerves and blood vessels to the penis. Both vacuum and injection therapies are good initial approaches following appropriate work up. Patient education should be stressed, since this determines the expectations of the patient and his partner which are critical in deciding which therapy is chosen and in optimizing its outcome. (AU)

A neurosurgical profile - abstract

Neurosurgical disease patterns, trends and workload in a hospital with 30 years' neurosurgical experience, serving a population of 1/3 milion were studied to assess, provide guidelines for more cost-effective patient care and to provide data for the development of neurosurgical facilities in developing areas. At the San Fernando General hospital, Trinidad, 1979-1988, there was a general increase in total hospital admissions (approximately 48,000/yr), neurosurgical admissions (73 to 161/yr), transfers to the neurosurgical unit (39 to 76/yr), new clinic patients (170 to 269/yr), consultations (181 to 351/yr), neuro-radiological procedures (44 to 105/yr), and surgical procedures (32 to 140 yr). There was an increase in bed occupancy rate (68 percent to 87 percent) and a reduction in the length of stay per patient (16 to 11 days), and in deaths (from a peak of 20 to 13/yr). There was a decrease in invasive studies with the advent of computerized axial tomographic scanning and magnetic resonance imaging, and myelograms showed a sharp rise due in part to newer water soluble contrast media. Surgical procedures showed a trend to more definite cranial surgery with a sharp rise in spinal surgery - laminectomy. There was and increase in the relative value score and factor which take case complesity into consideration. The commonest condition was head trauma followed by cervical spondylosis, brain tumours, seizures, spinal fractures, herniated lumbar disc, hydrocephalus and congenital anomalies and spinal tumours (AU)