Change from transrectal to transperineal ultrasound-guided prostate biopsy under local anaesthetic eliminates sepsis as a complication.

Transrectal ultrasound-guided (TRUS) biopsy of the prostate is associated with increased risk of post-procedural sepsis with associated morbidity, mortality, re-admission to hospital, and increased healthcare costs. In the study institution, active surveillance of post-procedural infection complications is performed by clinical nurse specialists for prostate cancer under the guidance of the infection prevention and control team. To protect hospital services for acute medical admissions related to the coronavirus disease 2019 (COVID-19) pandemic, TRUS biopsy services were reduced nationally, with exceptions only for those patients at high risk of prostate cancer. In the study institution, this change prompted a complete move to transperineal (TP) prostate biopsy performed in outpatients under local anaesthetic. TP biopsies eliminated the risk of post-procedural sepsis and, consequently, sepsis-related admission while maintaining a service for prostate cancer diagnosis during the COVID-19 pandemic.

Iatrogenic Bowel Injury at Exchange of Supra-Pubic Catheter

Suprapubic catheter insertion and exchange is a common urological procedure, but it is not without risks and complications. While bowel perforation is a recognised complication at suprapubic catheter insertion, it is not commonly reported at suprapubic catheter exchange. We report our experience of recognition, diagnosis and subsequent successful management of the most important complication related to suprapubic catheters.

Multidisciplinary emergent removal of a metal penoscrotal constriction device.

Strangulation of the genital organs is a rare presentation to the emergency department which requires urgent intervention to avoid long term complications. Penoscrotal constriction devices are either used for autoerotic stimulus or to increase sexual performance by maintaining an erection for a longer period. We report a case of a man who presented with penile strangulation following the application of a titanium penoscrotal constriction ring during sexual intercourse seven hours previously. The Fire Brigade department attended with an electric operated angle grinder to facilitate removal of the ring as standard medical equipment (orthopaedic saws, bolt and bone cutters) were insufficient. Fully functional recovery was achieved.

Concomitant loss of EAF2/U19 and Pten synergistically promotes prostate carcinogenesis in the mouse model.

Multiple genetic alterations are associated with prostate carcinogenesis. Tumor-suppressor genes phosphatase and tensin homolog deleted on chromosome 10 (Pten) and androgen upregulated gene 19 (U19), which encodes ELL-associated factor 2 (EAF2), are frequently inactivated or downregulated in advanced prostate cancers. Previous studies showed that EAF2 knockout caused tumors in multiple organs and prostatic intraepithelial neoplasia (PIN) in mice. However, EAF2-knockout mice did not develop prostate cancer even at 2 years of age. To further define the roles of EAF2 in prostate carcinogenesis, we crossed the Pten+/- and EAF2+/- mice in the C57/BL6 background to generate EAF2-/-Pten+/-, Pten+/-, EAF2-/- and wild-type mice. The prostates from virgin male mice with the above four genotypes were analyzed at 7 weeks, 19 weeks and 12 months of age. Concomitant loss of EAF2 function and inactivation of one Pten allele induced spontaneous prostate cancer in 33% of the mice. Prostatic tissues from intact EAF2-/- Pten+/- mice exhibited higher levels of phospho-Akt, -p44/42 and microvessel density. Moreover, phospho-Akt remained high after castration. Consistently, there was a synergistic increase in prostate epithelial proliferation in both intact and castrated EAF2-/-Pten+/- mice. Using laser-capture microdissection coupled with real-time reverse transcription-PCR, we confirmed that co-downregulation of EAF2 and Pten occurred in >50% clinical prostate cancer specimens with Gleason scores of 8-9 (n=11), which is associated with poor prognosis. The above findings together demonstrated synergistic functional interactions and clinical relevance of concurrent EAF2 and Pten downregulation in prostate carcinogenesis.

A rare benign renal tumour presenting as polycythaemia in a teenage girl.

We present the case of a 15-year-old girl who presented with polycythemia. CT abdomen revealed an enhancing mass in the upper pole of her left kidney with features suggestive of renal cell carcinoma. She underwent a laparoscopic radical nephrectomy. Histology demonstrated a well circumscribed, focally encapsulated, round blue cell tumour showing areas of microcalcifications and numerous psammoma bodies. Imunostaining showed diffuse positive staining for CD 57. This was consistent with a diagnosis of metanephric adenoma a rare benign epithelial renal tumour.

Should patients with symptomatic BPH have a trial of medical therapy by their general practitioner prior to referral for urological assessment?

The British Association of Urological Surgeons (BAUS) has recently recommended guidelines for the management of Lower Urinary Tract Sypmtoms by GPs outlining the indications for urological referral. We wished to assess the prescription of medical therapy by GPs in the referrals to our LUTS pre-assessment clinic. 115 consecutive patients were reviewed prospectively, over a three month period. Each patient was assessed for International Prostatic Symptom Score (IPSS) and Bother Score, uroflowometry with post void residual and whether medical therapy had been commenced (D-Blocker or 5-D-Reductase inhibitor). The majority of patients (75%) were classified with moderate symptoms. Only 10% of those with moderate symptoms and 5% of those with severe symptoms were commenced on medical therapy by their GP as recommended by the BAUS guidelines. Only 30 patients (26%) had completed an IPSS form with their GP. The majority of patients referred to our service for assessment of LUTS have at least moderate symptom severity and are not prescribed medical therapy by their GP. Further primary care education with greater emphasis on the BAUS LUTS algorithm prior to referral to an urologist should be encouraged.

The type of urethroplasty for a pelvic fracture urethral distraction defect cannot be predicted preoperatively.

PURPOSE: Pelvic fracture urethral distraction defects (PFUDDs) are generally treated surgically by a so-called progression approach consisting of 4 steps to achieve a tension-free bulboprostatic anastomosis. Implicitly the need for each step in turn is predictable according to the length of the defect on preoperative x-ray. MATERIALS AND METHODS: In 62 evaluable patients with PFUDD the length of the radiological defect was compared with the surgical steps that subsequently proved necessary to achieve a tension-free bulboprostatic anastomosis. RESULTS: Except at the extremes of length there was no association between defect length and the scale of the surgery performed. CONCLUSIONS: Surgeons preparing to repair an apparently short PFUDD cannot assume that simple repair is all that is necessary.

Measuring aggression in older adults: a latent variable modeling approach.

This cross-sectional measurement study demonstrates a technique for combining information from several aggression scales into one aggression score using latent variable modeling. Participants included male patients (n = 49) with a DSM-IV diagnosis of dementia at The Veterans Affairs Medical Center Outpatient Geriatric Psychiatry Clinic. Data from seven aggression scales were used to indicate the latent aggression variable. Results provided evidence that a unidimensional latent variable model of aggression adequately represented the data. Reliability of the aggression latent variable was estimated as 0.90, whereas reliability of the separate scales estimated with this sample were less than 0.84. Our findings suggest that combining multiple scales into one aggression score using latent variable modeling results in comprehensive and reliable aggression scores that offer researchers several advantages over current methods for measuring aggression.

Renal transplantation in patients with an augmentation cystoplasty.

OBJECTIVE: To retrospectively review our experience over a 10-year period of renal transplantation in patients with augmented bladders and thus assess the safety of this procedure. PATIENTS AND METHODS: Ten transplant recipients who had previously undergone augmentation cystoplasty were reviewed; a cadaveric kidney was transplant in each case. The donor ureter was anastomosed to the augment bladder in six patients, in three to the native ureter and in one the donor renal pelvis was anastomosed to the native ureter. RESULTS: No patients died and nine of the 10 grafts were functioning at a mean follow-up of 27 months. The mean (SD) serum creatinine level at the follow-up was 100.8 (27.25) mmol/L. Four patients had 10 episodes of urosepsis requiring hospital admission, with only one graft lost. CONCLUSION: Renal transplantation can be performed safely in patients with an augmentation cystoplasty.

A randomized prospective trial of low-dose OKT3 induction therapy to prevent rejection and minimize side effects in recipients of kidney transplants.

BACKGROUND: We attempted to minimize the undesired side effects and maximize the benefit of OKT3 induction therapy in renal transplantation. METHODS: One hundred and one recipients of kidney-only transplants were randomized to three groups. Each received low-dose 2.5-mg OKT3 induction for 7-14 days, but different premedication on days 0, 1, and 2. Group I was given 250 mg i.v. methylprednisolone at 1 and 6 hr, and group II received another 500 mg at 1 hr before initial OKT3. Group III received Atgam 15 mg/kg on day 0 and began OKT3 on day 1. A CD3+ T-cell cut-off of 50/mm3 was used to guide therapy. Maintenance therapy included cyclosporine and steroids for each patient. However, groups I and II were also given mycophenolate mofetil, and group III received azathioprine as a third agent. All rejections were biopsy confirmed and Banff scored. RESULTS: No differences in demographic or transplant characteristics were noted between groups I, II, and III, and mean follow-up was 25.7 (1-38) months. There was no significant difference in actuarial patient (90%, 91%, 94%) or graft survival (83%, 88%, 84%) at 3 years between the respective groups. Mean creatinine values and infectious complications were similar for each group. No patient experienced acute rejection during induction, and eight patients required dose escalation to sustain suppression of CD3 counts. The incidence of acute rejection at 6 and 12 months was significantly (P=0.004) greater in group III (38.2, 44.1%) than in either group I (15.1, 18.1%) or group II (14.7, 17.6%); relative risk 1.988 (95% CI 1.012-3.906). Formation of anti-OKT3 antibody was significantly (P=0.006) greater in group III (26.5%) than in group I (6%) or group II (2.9%). Group I recipients enjoyed significantly (P=0.001) fewer (2.17) OKT3 side effects on days 0, 1, and 2 than group II (3.03) or group III (2.49), and contained the largest number (61%) of recipients who experienced no side effects. Group I also exhibited the most suppressed profile of OKT3-induced release of tumor necrosis factor-alpha (P=0.006), interferon-gamma (P=NS), and interleukin-6 (P=0.01) on days 0 and 1. CONCLUSIONS: Low-dose 2.5-mg OKT3 with pretreatment of split-dose steroids on days 0, 1, and 2 provides the most effective method for OKT3 induction, which minimizes side effects for most patients. Subsequent maintenance therapy with cyclosporine, mycophenolate mofetil, and steroids provides effective rejection prophylaxis without increased complications for up to 3 years. Predepletion of T cells before exposure to OKT3 does not prevent cytokine release.

Identification and characterization of three subtypes of radiation response in normal human urothelial cultures exposed to ionizing radiation.

In an attempt to assess genetic variation underlying the variation in human responses to radiation exposure, measurements of apoptosis, necrosis and induction of key proteins were made in primary explant cultures of human normal urothelium and correlated with growth post- exposure to a range of doses of (60)Co. These data were validated by similar experiments using CBA/H and C57/BL6 mouse strains, known to exhibit genetically determined differences in response to radiation. The data for human tissues show a wide variation in response with three broad categories being identifiable. The commonest had a hypersensitive response involving considerable apoptosis in the low dose region, followed by 'induction' of a survival response at higher doses involving the persistence of abnormal cells. The pattern of gene expression was consistent with suppression of apoptosis. The second category showed no induction of survival and considerable necrosis was seen in the progeny. The rarest category showed an extremely hypersensitive low dose response and despite induction of a survival response, the sensitivity to higher doses was very severe. Considerable apoptosis and necrosis were seen in these cultures. In the mouse experiments, strain CBA/H (mice known to exhibit genetic instability post-irradiation) had lower levels of delayed cell death and apoptosis than C57/BL6 mice (which exhibit significantly less instability). It is concluded that there is a variation in response to radiation between human patient cultures which is detectable in this system and which is consistent with a pattern of radiation- induced delayed death/apoptosis correlating with long-term genomic stability. The mouse experiments demonstrate the importance of genetic factors in determining these responses.

Acute colonic pseudo-obstruction (Ogilvie's syndrome) after renal transplantation.

BACKGROUND: Acute colonic pseudo-obstruction (Ogilvie's syndrome) in the immunosuppressed patient is associated with increased morbidity and mortality. Renal transplant recipients possess several comorbidities that increase the risk of acute pseudo-obstruction of the colon. The aims of this study were to present our experience with this syndrome and to evaluate the potentiating factors in these patients. A review of the literature for pseudo-obstruction following renal transplantation is presented. METHODS: Seven patients who developed Ogilvie's syndrome were identified in a retrospective review of 550 kidney-only transplants. Pretransplant data, potential risk factors, presentation, management, and outcome details were retrieved. The medical literature was reviewed using Medline. RESULTS: Seventy-eight patients with Ogilvie's syndrome in the early posttransplant period have been reported. The associated morbidity and mortality was heightened in this immunocompromised population. Obese transplant recipients (body mass index >30 kg/m2) were at significantly increased risk for developing this syndrome. CONCLUSION: A broad armamentarium of treatment options is available, but the key to successful resolution lies in early recognition.