A multicentre assessment of prostate MRI quality and compliance with UK and international standards.

AIM: To assess prostate magnetic resonance imaging (MRI) image quality and compliance with technical standards between centres in the South West region of the UK. MATERIALS AND METHODS: Fifteen imaging sites in the region submitted seven consecutive anonymised MRI studies. These were assessed by two experienced radiologists in consensus. Overall, subjective image quality for T2-weighted imaging (T2W), diffusion weighted imaging (DWI), and dynamic contrast enhancement (DCE) was scored on a five-point Likert scale. Five additional quality parameters were also assessed visually, including image noise, motion, artefact, and distortion. The degree of compliance by each site with 21 published technical standards was also assessed. RESULTS: Ninety-four MRI examinations were reviewed from across all sites (mean 6.3 scans per site, range 5-7). Mean compliance with technical standards was 63% (range 38-86%). Forty-seven percent of sites did not perform DCE. One site used a 3 T scanner. The percentage of patients with overall quality scores of ≥3 (diagnostically acceptable) were 68% for T2W, 81% for DWI, and 60% for both T2W and DWI. Ninety-three percent of the 45 patients who underwent DCE had diagnostically acceptable studies. By scanner age, the percentage of patients with diagnostically acceptable T2W scores was 53% for scanners ≥7 years and 80% when <7 years (p=0.006). Comparing individual sites, the mean overall quality scores were 2.9 (range 2.2-4.2) for T2W, 3.2 (1.8-4.7) for DWI, and 3.4 (2.5-4.7) for DCE. CONCLUSION: There is wide variation in compliance with recognised technical standards and image quality across sites. If MRI is to replace biopsy in selected low-risk patients, improvements in image quality may be required.

Changes in collagen metabolism in prostate cancer: a host response that may alter progression.

PURPOSE: The interaction of cancer cells and the extracellular matrix is essential for cancer progression. However, little is known about the influence of cancer on the metabolism of collagen, which is the major constituent of the extracellular matrix. We studied changes in collagen metabolism in prostate cancer with increasing Gleason score and correlated them with clinical parameters and patient survival. MATERIALS AND METHODS: Collagen content and clinical parameters in 3 types of prostatic tissue were compared, including the foci of prostatic cancer, unaffected tissue from the same cancerous prostates and prostatic tissue from patients with no evidence of cancer. In addition, to assess collagen metabolism tissue obtained prospectively from 45 patients undergoing prostatic biopsy was assessed for collagen content, the type and extent of collagen cross-linking, serine proteinase, matrix metalloproteinase and the C-terminal propeptide of type I collagen. RESULTS: With increasing Gleason sum of the cancer collagen content at the focus decreased, while that of surrounding unaffected tissue from the same prostate increased to levels significantly above that from controls with no cancer. Markers of collagen synthesis in the prostate biopsy material were significantly increased in the presence of prostate cancer. CONCLUSIONS: In prostate cancer there are changes in collagen metabolism not only in the cancer focus but also in nearby histologically benign prostatic tissue. These observed changes are related to the Gleason score of the tumor and may represent a host response. Collagen content in the surrounding unaffected tissue may be a predictor of patient survival.

Medical treatment of erectile dysfunction.

There has been a tremendous increase in demand for the treatment of erectile dysfunction in the last 10 years. This has occurred partly because of a greater understanding and awareness by both the general public and clinicians, and also because there now exists a range of effective treatments. The choice of treatments is increasing rapidly and novel delivery systems which may be more patient-friendly than intracavernosal injections are now becoming available. We review the published data on effectiveness and safety of the currently available treatments and discuss recent advances in oral therapy, as these drugs are likely to become available in the near future.

The andropause: fact or fiction?

The so-called andropause is an ill-defined collection of symptoms in a group of men who may have low but may also have normal androgen levels. Unlike the proven benefits of hormone replacement therapy in women, the effects of testosterone supplementation in men are equivocal. It may increase sexual interest, but rarely to a level thought adequate by the patient. It has no proven beneficial effect on erectile dysfunction and other possible beneficial effects on haemopoesis, bone metabolism, lipids and fibrinolysis have yet to be demonstrated. With the availability of the testosterone patch, sustained increases in the serum testosterone levels will be readily achieved and could theoretically significantly affect the behaviour of subclinical prostate cancer. At the present time, testosterone replacement therapy in hypogonadal men is of proven clinical benefit; this is not the case, however, for eugonadal men with symptoms attributed to the andropause. The symptoms of the andropause fatigue can readily be explained by stress and there is no scientifically valid, placebo-controlled study that shows any benefit for testosterone supplements in this not uncommon group of patients.

Surgical care and outcome for patients in their nineties.

BACKGROUND: Surgical care of the elderly poses special problems. Very little has been published on the management of patients aged 90 years and over. METHODS: This study reviewed a consecutive series of patients aged 90 years and over, admitted to hospital over 2 years under five general surgeons and two urologists. There were 129 patients (68 per cent women) aged 90-104 (median 92) years and a total of 141 admissions, 45 elective and 96 emergency. Gastrointestinal conditions were commonest (40 per cent of admissions), followed by undiagnosed abdominal pain (16 per cent), hernia (16 per cent), arterial disease (13 per cent) and urological problems (7 per cent). RESULTS: Operation was required after 66 per cent of admissions (37 of 45 elective admissions and 56 (58 per cent) of 96 emergencies). In contrast to other studies of the very elderly, some patients were American Society of Anesthesiologists (ASA) grade 1, none of whom died after operation; no patient with ASA grade 5 was submitted to operation. Fifteen patients (12 per cent) died in hospital, three of 31 and seven of 50 respectively after elective and emergency surgery. CONCLUSION: Very elderly patients can be managed with a reasonable expectation of good outcome after admission for surgical care.

Fifteen years experience of penile prosthesis insertion.

INTRODUCTION AND OBJECTIVES: To review the outcome and patient satisfaction of penile prosthesis insertion over a 15 y period. PATIENTS/MATERIALS AND METHODS: We reviewed the notes of 172 patients who underwent penile prosthesis insertion between January 1980 and May 1995. From the notes information was determined on age of the patient, type of prosthesis, surgical approach and length of stay. Also noted were risk factors for erectile dysfunction and the aetiology. Twenty patients were known to have died or moved away. To assess the impact the operation had on quality of life, 152 questionnaires were sent of which 103 were returned (67%). The questionnaire gained information about sexual activity, before and after the operation and the overall satisfaction of the patient and his partner and whether they felt the operation was a success. RESULTS: Overall 149 patients were known to have had malleable prostheses inserted and 23 had inflatables. The commonest organic groups were vascular disease, diabetes and Peyronies disease. Fifteen patients had two procedures. Four patients required revision of the prosthesis due to erosion, and there was one death due to pulmonary embolism. One hundred and three completed questionnaires have been returned to date the median time since operation was 4 y, the range being six months to 16 y and 78% thought the operation was a success. CONCLUSIONS: The insertion of malleable prostheses is associated with low complication rates, good patient satisfaction and improved quality of life for the couple. Concealment was not a major problem.