Radical prostatectomy outcome when performed with PSA above 20 ng/ml.

Many centres currently do not offer radical prostatectomy (RP) to men with high-risk localised prostate cancer due to concerns regarding poor outcome, despite evidence to the contrary. We identified 18 men undergoing RP with serum PSA >20 ng/ml (high-risk by National Comprehensive Cancer Network definition) and minimum follow-up of 12 years (mean 13.5). Mean preoperative PSA was 37.0 ng/ml (Range 21.1-94.0). Prostatectomy pathology reported extracapsular disease in 16 (88.9%), positive surgical margins in 15 (83%) and positive pelvic lymph nodes in 5 (27.8%). Overall and cancer-specific survival at 5 and 10-years was 83.3%, 88.2%, 72% and 76.5% respectively. With complete follow-up 11 (61.1%) are alive, and 5 (27.8%) avoided any adjuvant therapy. Complete continence (defined as no involuntary urine leakage and no use of pads) was achieved in 60%, with partial continence in the remainder. We conclude that surgery for this aggressive variant of localised prostate cancer can result in satisfactory outcome.

Is simple nephrectomy truly simple? Comparison with the radical alternative.

BACKGROUND: The Oxford English dictionary defines the term "simple" as "easily done" and "uncomplicated". We tested the validity of this terminology in relation to open nephrectomy surgery. METHODS: Retrospective review of 215 patients undergoing open, simple (n = 89) or radical (n = 126) nephrectomy in a single university-affiliated institution between 1998 and 2002. Operative time (OT), estimated blood loss (EBL), operative complications (OC) and length of stay in hospital (LOS) were analysed. Statistical analysis employed Fisher's exact test and Stata Release 8.2. RESULTS: Simple nephrectomy was associated with shorter OT (mean 126 vs. 144 min; p = 0.002), reduced EBL (mean 729 vs. 859 cc; p = 0.472), lower OC (9 vs. 17%; 0.087), and more brief LOS (mean 6 vs. 8 days; p < 0.001). CONCLUSIONS: All parameters suggest favourable outcome for the simple nephrectomy group, supporting the use of this terminology. This implies "simple" nephrectomies are truly easier to perform with less complication than their radical counterpart.

Malignant priapism: a case report.

BACKGROUND: Metastatic involvement of the penis is most commonly from a primary malignant genitourinary tumour. It is a rare phenomenon usually reflecting disseminated malignancy associated with a poor prognosis. Metastasis to the penis mimicking priapism is extremely rare, particularly in the absence of disseminated disease. MATERIALS AND METHODS: We describe a case of painful priapism caused by a high-grade urothelial malignancy without disseminated disease. CONCLUSION: Life expectancy is estimated at less than 1 year in these patients. Our patient remains in clinical and radiologic remission over 36 months from his original radical surgery.

Recombinant activated factor VII to control life-threatening haemorrhagic radiation cystitis.

INTRODUCTION: The use of recombinant activated factor VII has been described for many clinical scenarios, but the value of this therapeutic agent for life-threatening haemorrhagic cystitis remains novel. METHOD: We describe a case of persistent life-threatening haemorrhagic radiation cystitis, and discuss current knowledge of this therapy including potential complications. RESULT: Control of haemorrhage was successfully achieved only after use of this agent. CONCLUSION: This therapy deserves mention in any future management algorithm devised for this condition.

Artificial hydroureteronephrosis to facilitate MR urography during pregnancy.

INTRODUCTION: Insertion of a percutaneous nephrostomy (PCN) catheter decompresses the upper urinary tract, thereby removing the hydroureteronephrosis upon which magnetic resonance (MR) urography is dependent for diagnosing the precise level and cause of ureteric obstruction. METHOD: We present the case of a young woman who required PCN insertion during pregnancy. RESULT: Only when unenhanced T2-weighted MR urography was repeated after the creation of an artificial hydronephrosis by an injection of sterile saline via the PCN catheter was the diagnosis of stone in the mid-ureter later made possible. CONCLUSION: This case highlights an easy solution to a limitation with the use of MR urography during pregnancy, when a physiological hydroureteronephrosis has been relieved by the insertion of a PCN catheter.

Interventions for preventing post-operative atrial fibrillation in patients undergoing heart surgery.

BACKGROUND: Post-operative atrial fibrillation is a common complication of cardiac surgery and has been associated with increased incidence of other complications including post-operative stroke, increased hospital length of stay and increased cost of hospitalisation. Prevention of atrial fibrillation is a reasonable clinical goal and, consequently, many randomised trials have evaluated the effectiveness of pharmacological and non-pharmacological interventions. We systematically reviewed the literature and prepared meta-analyses to better understand the role and effects of various prophylactic therapies against post-operative atrial fibrillation. OBJECTIVES: To assess the effects of pharmacological and non-pharmacological interventions for preventing post-cardiac surgery atrial fibrillation. SEARCH STRATEGY: We searched CENTRAL, MEDLINE, EMBASE and CINAHL from earliest achievable date to June 2003. We hand searched references from reports and earlier reviews. We searched abstract books and CD-ROMs from annual scientific meetings of American College of Cardiology, American Heart Association, North American Society of Pacing and Electrophysiology and European Heart Organization between 1997-2003. No language restrictions were applied. SELECTION CRITERIA: Randomised controlled trials comparing pharmacological interventions or non-pharmacological interventions with control treatment, placebo or usual care for the prevention of post-operative atrial fibrillation in post-coronary artery bypass grafting or combined CABG and valvular surgery. DATA COLLECTION AND ANALYSIS: Two reviewers assessed trial quality and extracted data. Study authors were contacted for additional information. MAIN RESULTS: Fifty eight studies were included with a total of 8565 participants. Interventions included were amiodarone, beta blockers, solatol and pacing. Results favoured treatment for post-operative atrial fibrillation. The data for stroke favoured treatment by a non-significant effect size of 0.81, 95% confidence interval 0.51 to 1.28. Similarly, a positive indication for length of stay was derived but it too was not significant with a weighted mean difference of -0.66, 95% confidence interval -0.95 to -0.37. A positive result for cost of hospitalisation in favour of treatment was achieved, but the statistic is not significant due to low power and large standard deviations: a weighted mean difference of -2717, 95% confidence interval 7518 to 2084. Beta-blockers had the greatest magnitude of effect across 28 trials (4074 patients) with an odds ratio (random) of 0.35, 95% confidence interval 0.26 to 0.49. Across all treatment, the odds ratio favoured treatment with a ratio (random) of 0.43, 95% confidence interval 0.37 to 0.51. REVIEWERS' CONCLUSIONS: Intervention is favoured across the three pharmacological interventions studied and the one non-pharmacological intervention, pacing. The length of stay data favoured treatment (-0.66, 95% confidence interval -0.95 to -0.37).

Should patients with a pre-operative prostate-specific antigen greater than 15 ng/ml be offered radical prostatectomy?

BACKGROUND: Patients with prostate cancer with a pre-operative prostate-specific antigen (PSA) >15 ng/ml who undergo radical retropubic prostatectomy (RRP) generally do not have a good outcome, yet may have organ-confined cancer and should be offered the option of surgery. AIM: To assess the outcome of patients who underwent RRP with a pre-operative PSA >15 ng/ml. METHODS: Thirty-four patients, mean pre-operative PSA: 25.46 ng/ml (15.03-76.6) and mean Gleason score: 6.4 (5-9) were assessed. RESULTS: Two groups were identified. Group I: 41% (14/34) have no biochemical recurrence to mean follow up of 58 months (30-106). Mean PSA: 18.8 ng/ml (15.03-25.84). Mean Gleason score: 6.1 (5-7). Clinical stage: T1c in 80%. No patient had seminal vesicle or lymph node involvement. Group II: 59% (20/34) have biochemical recurrence or died (3) from their disease to mean follow up of 66 months (36-98). Mean PSA: 28.9 ng/ml (15.28-76.6). Mean Gleason score: 6.7 (5-9). Clinical stage: T1c in 25%. Eleven patients had seminal vesicle (8) involvement or positive lymph nodes (3) or both (2). CONCLUSION: RRP seems feasible in patients whose pre-operative PSA is between 15 and 25 ng/ml with stage T1c, Gleason score < or = 7 and negative lymph node frozen section.

Thoracoscopic management of primary spontaneous pneumothorax.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) is the preferred option for the surgical management of primary spontaneous pneumothorax (PSP). AIMS: To evaluate the role of thoracoscopic blebectomy with and without chemical pleurodesis. METHODS: A retrospective study was performed on 113 consecutive cases carried out in one unit. RESULTS; One hundred and thirteen VATS procedures were performed on 108 patients. The mean age was 23 years (range 14-45). The male to female ratio was 82:26. Recurrent pneumothorax was the indication for surgery in 80%. Conversion to an open procedure was required in 10 cases (9%), most commonly due to severe adhesions. Successful endoscopic blebectomy was performed in 98 cases (87%), 48 of which had an additional chemical pleurodesis. Follow-up is currently to a mean of 28 months. Recurrence has occurred in eight cases, including only three in the group managed with additional chemical pleurodesis (6.25%). CONCLUSION: VATS with blebectomy and chemical pleurodesis is a safe and effective procedure in the management of PSP.