Is pre-operative imaging essential prior to ureteric stone surgery?

INTRODUCTION: The aim of this study was to identify patients not requiring ureteric stone surgery based on pre-operative imaging (within 24 hours) prior to embarking on semirigid ureteroscopy (R-URS) for urolithiasis. METHODS: The imaging of all consecutive patients on whom R-URS for urolithiasis was performed over a 12-month period was reviewed. All patients had undergone a plain x-ray of the kidney, ureters and bladder (KUB), abdominal non-contrast computed tomography (NCCT-KUB) or both on the day of surgery. RESULTS: A total of 96 patients were identified for the study. Stone sizes ranged from 3 mm to 20 mm. Thirteen patients (14%) were cancelled as no stone(s) were identified on pre-operative imaging. Of the patients cancelled, 8 (62%) required NCCT-KUB to confirm spontaneous stone passage. CONCLUSIONS: One in seven patients were stone free on the day of surgery. This negates the need for unnecessary anaesthetic and instrumentation of the urinary tract, with the associated morbidity. Up-to-date imaging prior to embarking on elective ureteric stone surgery is highly recommended.

The laparoscopic nephrectomy learning curve: a single centre's development of a de novo practice.

OBJECTIVE: There has been a dramatic increase in the interest and practice of laparoscopic urology, with nephrectomy having become the commonest laparoscopic urological procedure. Compared with open nephrectomy, it results in reduced morbidity and shorter convalescence times while maintaining oncological safety. However, while these results predominately stem from institutions with well developed laparoscopic programmes, little is known about the results in centres that have newly adopted this technique. The introduction of a laparoscopic urological service at the Royal Hallamshire Hospital provided an opportunity to study these factors. METHODS: Since the appointment in October 2000 of a urological surgeon (N Oakley) to develop the laparoscopic service, there have been over 200 laparoscopic procedures including 121 nephrectomies performed at this centre. Full details were collected for each of these cases, and in addition, compared with retrospective data for 50 open nephrectomies performed during the same time period. RESULTS: With increased operator experience the median operative duration, complication, transfusion, and conversion rates significantly improved. While a learning curve was evident, the overall operative complication (9%) and conversion rates (6%) were low, in addition to patient morbidity (16.5%) and mortality (0%) rates, showing that this learning curve had no deleterious effects upon patient care. The median hospital stay was four days, which reduced to three with experience and was significantly shorter than for open nephrectomy at this institution (p = 0.001). CONCLUSIONS: The development of a successful laparoscopic programme can be achieved with a comparatively short learning curve and without detriment to the patient provided the necessary steps are observed.

Randomised prospective trial of contact laser prostatectomy (CLAP) versus visual laser coagulation of the prostate (VLAP) for the treatment of benign prostatic hyperplasia. 2-year follow-up.

OBJECTIVE: To determine the long-term efficacy and complications of visual laser coagulation/ ablation, VLAP (side-firing fibre) and direct contact laser ablation, CLAP (sapphire-tipped fibre) of the prostate in the treatment of benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: Patients with clinical BPH, obstructed at voiding cystometry, were recruited and randomised to undergo either CLAP (21 patients) or VLAP (17 patients). At baseline, 1, 6, 12 and 24 months, patients underwent clinical evaluation, International Prostate Symptom Score (IPSS), uroflowmetry, post-void residual urine volume, and pressure/flow urodynamics. RESULTS: The mean operating time for CLAP was 37.7 min and 24.5 min for VLAP. There was minimal morbidity with only 5 men requiring bladder irrigation after CLAP, 1 of whom had a blood transfusion. No patient required irrigation after VLAP. The mean catheterisation time after CLAP was 4.5 days (range 1-31 days) and 13.2 days (range 7-70 days) after VLAP. IPSS and Qmax improved significantly and maintained at 2 years. After CLAP, the IPSS decreased from 20.9 to 13.5 at 2 years while Qmax rose from 10 to 15.5 ml/s at 2 years. After VLAP, the IPSS decreased from 21.8 to 13.3 at 2 years while Qmax rose from 10 to 15. 9 ml/s. There was no difference between CLAP and VLAP. Pressure/flow urodynamics at 6 months showed reduced bladder outflow obstruction. CONCLUSIONS: CLAP and VLAP offer the same improvement in flow rates and symptoms at 2years. Both procedures lead to minimal morbidity, but the excellent haemostasis that is achieved at VLAP makes it of more use in treating patients at high risk of haemorrhage after surgery.

A pilot study for a randomized controlled trial comparing the efficacy, safety and cost-effectiveness of surgical treatments of the prostate.

OBJECTIVE: To assess the numbers of men in outpatients and subsequently undergoing transurethral resection of the prostate (TURP) who were referred during 1993-94 and 1996-97, thereby assessing the feasibility of a subsequent study of treatment efficacy in men with bladder outlet obstruction secondary to benign prostatic hyperplasia, prospectively randomized to the surgical treatment options, i.e. TURP, laser ablation of the prostate, transurethral needle ablation and T3 thermotherapy, to investigate treatment outcome, cost-efficacy and cost-benefit. PATIENTS AND METHODS: All patients considered and consenting for prostate surgery were reviewed prospectively with a view to inclusion in the proposed trial. The diagnosis was based on two estimates of flow rate from voids of >150 mL and from symptoms assessed using the International Prostate Symptom Score. All patients had TURP explained by a urological surgeon and nursing staff, and subsequently had further consultation with research staff. RESULTS: Patients seen in clinic as new referrals increased by 11% between the periods assessed, although the numbers undergoing TURP decreased by 19%. Of the 383 patients screened, who were on the waiting list for TURP, only 13 elected to enter the trial. Of the 383 men, 267 (67%) ultimately had prostate surgery, with 39 (10%) electing to continue with watchful waiting and 34 (9%) continuing with pharmacotherapy. CONCLUSION: Although more men with benign prostatic disease and lower urinary tract symptoms are being seen in clinics, the reduced proportion of patients continuing to surgical intervention will lead to increasing difficulty in carrying out randomized controlled clinical trials assessing surgical options. With ever more therapeutic options available, patients find it difficult to make decisions in both the clinical situation and when asked to enter a trial. Fully informed decisions by both the surgeon and the patient will only be possible when objective data are available from trials that investigate outcome, cost-efficacy and cost-benefit. This study suggests that when presented with more information and counselling, fewer men decide to undergo prostate surgery for symptomatic BPH.

Safety and efficacy of transurethral needle ablation of the prostate for symptomatic outlet obstruction.

OBJECTIVES: To examine, in an observational study, the safety and efficacy of transurethral needle ablation (TUNA) of the prostate as a treatment for symptomatic benign prostatic enlargement. PATIENTS AND METHODS: This prospective study included 71 symptomatic men with unequivocal obstruction on pressure-flow urodynamics. The variables measured at baseline and up to 12 months after treatment included the American Urological Association (AUA)-7 symptom index and an added quality-of-life question, the AUA BPH-Impact Index, a sexual function score, transrectal ultrasonography of the prostate, a frequency-volume chart, free-flow uroflowmetry, post-void residual urine volume (PVR) and pressure-flow urodynamics. Transurethral resection of the prostate (TURP) was offered if the symptoms failed to resolve at any time during the follow-up period. TUNA was performed under local anaesthetic and sedation in 63 (89%) men and as a day-case procedure in 10 (14%). Five patients were on warfarin which was not discontinued. RESULTS: There were no serious treatment-related adverse events. Eight of the initial nine patients who were not routinely catheterized after treatment with TUNA developed acute urinary retention. Although some haematuria occurred in all patients, only one (1.4%) developed catheter blockage by clot. There were no problems with bleeding in those patients on warfarin at the time of treatment. The mean (95% confidence interval, CI) AUA-7 index fell from 23 (1.7) to 10.6 (1.8) (P < 0.001, Mann-Whitney U-test) at 12 months, 29 men (41%) had an AUA-7 index of < or = 7. The maximum (95% CI) urinary flow rate increased from 9.0 (0.8) to 11.3 (1.1) mL/s (P < 0.001) and this was accompanied by a small but significant reduction in PVR of 70 (14) mL to 35 (8) mL (P < 0.001 Mann-Whitney U-test). There was a significant reduction in both maximal voiding pressure and detrusor pressure at peak flow at 3 months (Mann-Whitney U-test, both P < 0.001) and at 12 months (P < 0.001, Wilcoxon matched-pairs signed-ranks test). However, 78% of the 45 men undergoing repeat pressure-flow studies at 12 months were unequivocally obstructed according to the Abrams-Griffiths nomogram. The mean (95% CI) prostatic volume fell from 49.0 (4.8) mL at baseline to 40.8 (4.9) mL at 3 months, but this change was not statistically significant (P = 0.011, Mann-Whitney U-test). Two men reported erectile dysfunction, one experienced ejaculatory problems and seven reported an improvement in erectile function after TUNA. During the study, 22 men (31%) underwent TURP. CONCLUSIONS: TUNA is a safe treatment which can be performed as an out-patient procedure under local anaesthesia and sedation in the vast majority of patients. There was no evidence of serious adverse events and no significant adverse effect on sexual function. The symptomatic improvement was sustained at 12 months in most (54%) patients, with modest improvements in peak flow rate, PVR and voiding pressures, indicating that TUNA may result in prolonged symptomatic improvement in a proportion of patients suffering from bladder outlet obstruction. A randomized controlled study against established therapies is now essential to clearly delineate its place in the management of such patients.

A prospective audit of the use of a prostate clinic.

OBJECTIVE: To assess the efficiency of a prostate clinic and to determine the treatment outcomes and the proportion of patients who could potentially be managed by their General Practitioners (GPs). PATIENTS AND METHODS: Referral letters from GPs were screened by the consultant urologists and appropriate patients seen in the next available prostate clinic. The initial assessment consisted of an International Prostate Symptom Score and a medical history, uroflowmetry, ultrasonographically determined post-void urine volumes, renal function tests and measurement of prostate specific antigen, in addition to a physical examination and a digital rectal examination. Further investigations were requested as required. RESULTS: Over a period of 18 months, 403 patients were seen, 90% of them within 12 weeks from the time of referral. Uroflowmetry was performed in 96% of patients and further urodynamics in 22%. Bladder outlet obstruction was diagnosed in 246 (61%) patients and primary detrusor instability was detected in 20 (5%) patients. Fourteen per cent of patients were returned to the care of the GP following their first visit. The audit identified a potential group of patients (52%) who could be managed by their GP. Seven per cent underwent prostate surgery for the relief of bladder outlet obstruction. CONCLUSION: The prostate clinic significantly reduced the delay for patients to be seen at the hospital and facilitated rapid assessment and investigation, much of which was carried out by a nurse practitioner during the first visit (in most cases). Several patients were identified who could be managed in the community.

Steroid abuse in athletes, prostatic enlargement and bladder outflow obstruction--is there a relationship?

OBJECTIVE: To evaluate the effects of exogenous androgenic-anabolic steroids on the human prostate gland. SUBJECT AND METHODS: A white male athlete, who was routinely using anabolic steroids, volunteered for the study. He was studied during a 15-week period of steroid self-administration. Both objective and subjective parameters were measured, including: prostatic volume (transrectal ultrasound), digital rectal examination, urine flow rate, serum acid phosphatase and prostate specific antigen, symptom scoring for bladder outflow obstruction and other associated symptoms. RESULTS: During the period of steroid self-administration, prostatic volume increased and urine flow rate decreased. The man also noticed an increase in nocturnal urinary frequency, libido and aggression. CONCLUSION: In this pilot study, the administration of exogenous androgenic-anabolic steroids has been demonstrated to have profound effects on the human prostate gland, including an increase in prostatic volume, reduction in urine flow rate and an alteration in voiding patterns. These findings warrant further investigation.

Torsion of the testis: a new technique for fixation.

There are many methods of testicular fixation following torsion. We describe a simple technique of simultaneous bilateral fixation to the median scrotal septum.

Mitomycin-C in superficial bladder cancer. Is long-term maintenance therapy worthwhile after initial treatment?

A total of 72 patients with recurrent superficial transitional cell carcinoma of the bladder (TCC) were treated with 40 mg intravesical instillations of mitomycin-C (MMC) weekly for 10 weeks, followed by monthly maintenance doses. With a mean follow-up period of 41 months, 30 patients (42%) had a complete and sustained response after the initial treatment course, and a further 14 (19%) achieved a complete response on maintenance therapy. Sixteen patients (22%) continued to have recurrent tumours and the remaining 12 (17%) developed recurrent tumours after an initial complete response. Of these, 4 patients with carcinoma in situ (CIS) showed symptomatic improvement, but the histological changes persisted and all of those with tumours > 2 cm in size did not respond. We conclude that maintenance treatment with MMC is beneficial in superficial bladder cancer but is of limited value in the presence of bulky tumours or CIS.

Effect of repeated intraperitoneal chemotherapy with epirubicin on the hepatic transport of bile acids and their enterohepatic circulation.

The effect of repeated intraperitoneal perfusion with epirubicin on the clearance of 14C-taurocholate by the liver and the enterohepatic circulation of the synthetic bile acid 75-SeHCAT were investigated using a rat model. After six treatments there was no significant difference in the transport rate constants (plasma to liver, liver to bile and liver to plasma) between and within the saline and epirubicin groups. Similarly, there were no differences detected between the groups for the parameters derived from these transport rate constants. Thus the initial plasma clearance after six perfusions was 39 +/- 9, and 36 +/- 11 ml/min/kg in the epirubicin and saline groups respectively. The excretory efficiency of the liver at this stage was identical: 67 +/- 10% in the epirubicin treated animals and 67 +/- 6% in the saline controls. A deterioration in the SeHCAT retention was observed after repeated intraperitoneal perfusion in both groups. This was significant only in the cytotoxic group, between the first and sixth epirubicin perfusion: 59 +/- 9% vs 48 +/- 9% at 24 h (P = 0.03), 31 +/- 8% vs 22 +/- 5% at 48 h (P = 0.019) and was not cumulative beyond this stage. These findings indicate that repeated intraperitoneal perfusion chemotherapy with epirubicin does not impair bile acid clearance by the hepatocyte. The decrease in the retention of SeHCAT is unlikely to be the result of epirubicin-induced ileal mucosal damage since the reduction was not cumulative beyond 48 h of administration of the compound.

Upper tract tumours following cystectomy for bladder cancer. Is routine intravenous urography worthwhile?

The incidence and presentation of upper tract tumours were studied in 180 patients who had previously undergone cystectomy for transitional cell carcinoma of the bladder. Intravenous urography was performed routinely 3 months after cystectomy, 1 year later and at 3-yearly intervals thereafter. Ten patients developed upper tract tumours; 1 presented with loin pain and the remainder with haematuria. Six patients underwent nephroureterectomy and 5 of them lived for at least 4 years; 4 were inoperable and only 1 survived longer than 6 months. In this series, all patients with upper tract tumours presented with symptoms and routine intravenous urography failed to detect any asymptomatic lesions. Routine radiological assessment of the upper tracts to detect tumours is not justified following cystectomy.

Acute retention of urine: is trial without catheter justified?

Following an episode of acute retention of urine in men it is commonplace for urinary catheters to be removed to see if micturition is re-established. Many patients will require definitive treatment, however and, to assess which patients do benefit from a trial without catheter, the outcome of this practice was analysed against the relevant features of the history in 100 men. The majority of patients both with and without previous symptoms suggestive of outflow obstruction had further retentions. Trial without catheter was of value in three groups of patients: those with urinary tract infection without previous obstructive symptoms, those with gross constipation and those recently commenced on drugs with anticholinergic properties. With these exceptions, definitive treatment was necessary in 93% of the remainder. Most of those in whom micturition was re-established are still under active review and may yet come to surgery, in view of poor flow rates. With the exceptions detailed above it is concluded that trial without catheter is not justified in acute retention of urine and definitive treatment should be instituted at an early stage.

Fractionated urinary cytology in the follow-up of bladder cancer.

Cytological examination of voided urine is an established investigation in urological practice. In a pilot study of 50 patients with histologically proven transitional cell carcinoma of the bladder, urine cytology was undertaken on samples from the initial, mid-stream and terminal parts of the void. Analysis showed that although the cell density varied between the samples in some cases, no part of the void was consistently richer in benign or malignant cells and similar cell types were seen in every sample from any given patient. It was concluded that fractionated cytology did not improve the diagnostic accuracy of urinary cytology and that any sample of urine was suitable for cytological purposes.

Indications for conservative management of acute scrotal pain in children.

Forty-three boys who presented with acute scrotal pain were studied retrospectively. Of these, 40 had torsion of scrotal contents. Torsion of testicular appendages, a self limiting condition, tended to present later than testicular torsion (P = 0.002). The testis was saved in all 11 cases of testicular torsion explored within 12h of the onset of pain but orchidectomy was required in four who presented later. In 11 cases, a torted testicular appendage diagnosed as a tender nodule was found on examining the upper pole of the testis. The remaining 14 cases of torted appendage were diagnosed at operation because testicular torsion could not be excluded due to scrotal swelling. Most (12) of this operated group were not seen until 3 days after the onset of pain. This study suggested that urgent operation was unnecessary in those in whom a tender nodule was found (pathognomonic of a torted appendage) and in those presenting after more than 24h of pain with scrotal erythema and oedema. The likely diagnosis in the latter case is a torted appendage and in cases of torsion of the testis there is no prospect of salvage at this stage. These guidelines were applied to a group of 20 boys studied prospectively. In eight, all with less than 24h of pain, immediate exploration was undertaken and testicular torsion was confirmed in six. The remaining 12 fulfilled the criteria for conservative management and were observed. All had normal testes at late review. Careful clinical assessment in boys with scrotal pain indicates which cases may be treated by non-operative management without fear of losing a salvageable testis.

An outbreak of Clostridium difficile associated diarrhoea in urological practice: a potential consequence of excessive antibiotic prophylaxis?

During an outbreak of Clostridium difficile associated diarrhoea, 17 patients on a urological ward developed symptoms in a 17-day period. Of these patients, 15 had received antibiotics during their admission. In order to eradicate the infection, it was necessary to close the unit for 1 month. Antibiotic associated diarrhoea is a serious complication of the prophylactic and therapeutic use of such agents and, because of the common use of antimicrobials on urological units, there is potential for similar epidemics.