Focal renal infarction: an unusual cause of haematuria in a patient with sickle cell trait.

A 29-year-old woman with sickle cell trait developed persistent haematuria. Intravenous urography, ultrasound, cystoscopy and selective renal angiography revealed focal renal infarction, but in the absence of papillary necrosis. There are no prior reports of focal renal infarction as a cause of haematuria in patients with sickle cell trait.

Urinary tract stones--Part I: role of radiological imaging in diagnosis and treatment planning.

The modern management of urolithiasis requires a multi-disciplinary approach. Imaging plays a central role in both diagnosis and planning therapy of renal and ureteric calculi. This article reviews the current status of diagnosis and management of stone disease, and the contribution of radiological imaging in accurately triaging a given case to the most appropriate therapy.

Urinary tract stones--Part II: current status of treatment.

The majority of renal and ureteric stones are now managed by minimally invasive techniques, for example nephrostomy, ureteral stents, extracorporeal shockwave lithotripsy or percutaneous nephrolithotomy. A multi-disciplinary approach is necessary, and this review examines the status of modern stone therapy and the contribution of the radiology department.

Are transrectal ultrasonically guided biopsies required for the accurate diagnosis of carcinoma of the prostate? Can digitally guided systematic biopsies offer an acceptable alternative?

OBJECTIVE: To compare the diagnostic yield of ultrasonically guided and digitally guided systematic biopsies of the prostate. PATIENTS AND METHODS: Fifty two patients with suspected but unproven carcinoma of the prostate underwent simultaneous transrectal ultrasonography (TRUS)-guided and digitally guided systematic biopsies of the prostate. A mean of 12 cores was obtained from each patient. On average more cores were obtained with TRUS guidance (mean 6.7) than with digital guidance (mean 5.3). RESULTS: Cancer was detected in 19 patients and the diagnosis was made by both techniques in 16. Two patients had tumour detected only with TRUS guidance and one only with digital guidance. No complications occurred. CONCLUSION: This study indicates that there is no significant difference between TRUS guidance and digital guidance to direct systematic biopsies of the prostate. The use of routine TRUS in screening programmes is now in doubt.

Urological day case surgery in elderly and medically unfit patients using sedoanalgesia: what are the limits?

OBJECTIVE: To assess how elderly and medically unfit patients cope with day case surgery in a urological unit using sedoanalgesia. PATIENTS AND METHODS: One hundred patients (mean age 78 years, range 59-97) either over the age of 75 years, or with an American Society of Anesthesiologists (ASA) status of 3 or 4 (58 patients) were studied before and after surgery to assess their medical condition, home circumstances and how they coped with their first day after the operation. RESULTS: Ninety patients found the procedure good or acceptable and 86 thought having their operation and going home on the same day was a good idea. CONCLUSION: Elderly and medically unfit patients can be treated safely with no serious complications using sedoanalgesia in a well organized Day Unit equipped with full monitoring facilities.

From hospital to production line: the price of modern surgical bed management?

A global analysis of surgical bed dynamics in a District General Hospital over a typical 18 working day period is presented. All surgical specialties are represented. A total of 2,484 bed days were studied. Bed occupancy was 92 per cent. Seven per cent of bed capacity was occupied by acute medical patients. The operation cancellation rate was 7 per cent. Fifteen per cent of beds were closed for financial reasons. The study of admission and the stay and discharge policies of different specialties indicated that potential cost improvements could be made by the introduction of more day surgery, day of surgery admission, efficient discharge, ring fencing of beds and improved hospital data collection. While these recommendations are financially desirable, their impact on patients and staff remains to be seen.

Radical excision of sacrococcygeal tumours.

Large sacrococcygeal tumours are rare and remain a difficult management problem. Chordomas are one of the most common tumours in this region and may account for 30-40 per cent of postrectal tumours. Four patients aged between 22 and 66 years, three with chordomas and one with a schwannoma, are described. Each was managed by a combined general and neurosurgical approach. Major radical excision of the tumour involving high amputation of the sacrum and lower sacral nerve root division was performed. These large lesions can be radically excised with limited postoperative morbidity and excellent preservation of neurological function, including sphincter control, provided that one S2 nerve root is left intact.

Temporary prostatic stenting and androgen suppression: a new minimally invasive approach to malignant prostatic retention.

Urinary retention secondary to carcinoma of the prostate is usually treated by 'channel' transurethral resection of the prostate either performed alone or in combination with hormone manipulation. The combination of temporary prostatic stenting and androgen suppression may reduce the morbidity and mortality associated with this treatment. We report on our initial experience using the combination of a temporary prostatic stent with the oral anti-androgen Flutamide in 10 patients with urinary retention or severe bladder outflow obstruction secondary to prostatic carcinoma. Eight of the ten patients successfully voided and maintained normal voiding after stent removal. There were two treatment failures requiring prostatic resection. We believe the cost of stenting and medication is entirely justified by patient preference and clearance of hospital beds.

Laser prostatectomy: our initial experience of a technique in evolution.

Recently great interest has been generated in alternatives to transurethral resection for benign prostatic hyperplasia. Lasers are currently being assessed, but marketing has for the moment outstripped basic science. A cystoscopic approach was used delivering Nd:YAG or KTP laser energy via forward and sidefiring fibers and contact tip devices in 51 patients. The sidefiring device is intended to coagulate a volume of prostate that subsequently sloughs, leaving a cavity. Treatment of the apical and middle lobe tissue using this technique was unsatisfactory. A further disadvantage was the interval between treatment and improvement in urine flow, which was approximately 6 weeks. The use of temporary prostatic stents has helped to overcome this delay in treatment effect. Encouraging early results have been achieved using forward-firing fibers to treat apical and middle lobe tissue. The use of contact tip devices to perform bloodless prostatotomies in combination with sidefire or bare fiber has also proved useful. Laser prostatectomy is an exciting field with considerable potential but remains in the developmental stage.

Sedation for day-case urology: an assessment of patient recovery profiles after midazolam and flumazenil.

The specific antagonist flumazenil has been shown to reverse the central actions of benzodiazepines. Its use, in day-case procedures performed under benzodiazepine sedation, offers the potential for enhanced patient recovery. However, concern has been expressed over the possibility of resedation given the short elimination half-life of flumazenil. A randomised, double-blind, placebo controlled trial was therefore designed to assess patient recovery profiles after flumazenil. A total of 44 adults were entered into the trial. Recovery was assessed by means of a battery of psychomotor tests performed pre- and postoperatively. Psychomotor function in patients receiving flumazenil returned to, or near to, baseline levels within 15 min of administration--an improvement maintained throughout the 6 h test period. Patients receiving placebo did not recover fully until the 2 h test point--significant differences between the two groups existing at 15 min and 1 h. In this study, flumazenil effectively reversed midazolam-induced sedation without evidence of resedation. The implications for day-case surgery are discussed.

Sedoanalgesia in urology: a safe, cost-effective alternative to general anaesthesia. A review of 1020 cases.

Sedoanalgesia is a technique developed to provide safe and satisfactory operating conditions for a wide range of patients independent of age and overall level of fitness (although its use in children remains to be established). It is suitable for both endoscopic and open procedures, day-cases and in-patients. When used in day-case surgery it significantly improves overall efficiency. It is recognised that day-case surgery is an important and cost-effective element in surgical care. With increasing restraints being imposed upon hospital finances, patient beds and staffing levels, any strategies designed to improve efficiency in this sphere of surgical activity are to be welcomed. That 93% of patients prefer sedoanalgesia to conventional general anaesthesia attests to its high degree of acceptability. The technique of sedoanalgesia, its applications and potential impact for urology are detailed.

Day-case surgery: enhanced recovery with flumazenil.

In an open, randomized, parallel group study of 84 adult patients undergoing elective day-case urological surgery the specific benzodiazepine antagonist flumazenil was shown to reverse effectively subjective postoperative sedation due to midazolam and enabled 83% of patients to recover and be ready for potential discharge within 15 min of surgery (control group 24% p less than 0.001). The significantly shorter recovery time has benefits in terms of increased patient cooperation and reduced demands on postoperative nursing care. The implications of these findings for day-case surgery are discussed.