Carbon dioxide laser treatment of penile intraepithelial neoplasia.

INTRODUCTION & OBJECTIVE: The non-invasive nature of penile intraepithelial neoplasia (PeIN) allows for curative penile sparing therapy and is recommended, in their guidelines, by the European Association of Urology (EAU). Treatment options include topical chemotherapy, immunotherapy, laser treatment, photodynamic therapy and surgical excision. Our primary aim was to evaluate the outcome of carbon dioxide (CO2) laser treatment of penile intraepithelial neoplasia. METHODS: A retrospective review of 47 patients who underwent CO2 laser ablation of PeIN, from May 2008 to June 2015, in our tertiary referral centre was performed. All patients underwent acetic acid mapping and had their lesions ablated with a Lumenis Shaplan CO2 laser device. Patients had regular follow up and further suspicious areas underwent re-biopsy. RESULTS: Forty-seven men had primary PeIN. After laser treatment, 8 men (17%) had a recurrence and the average time to recurrence was 19.4 months. Seven of the eight patients with recurrences, pathologically had further PeIN and one patient developed G1 pT1 disease. These patients underwent further laser treatment, glans resurfacing or local excision. No patients required penectomy. The average length of follow-up was 29 months (rg: 1-76). Penile cancer-specific survival was 100% and overall survival 98%. No patients required re-admission or developed other long-term complications, such as meatal stenosis from their treatment. CONCLUSION: Carbon dioxide laser treatment for penile intra-epithelial neoplasia is effective due to its 100% response rate, low progression rate and lower recurrence rate compared with topical agents. The laser has minimal morbidity with cosmetically acceptable outcomes compared to more invasive resurfacing surgeries.

Routine urine cytology has no role in hematuria investigations.

PURPOSE: Urine cytology has been a long-standing first line investigation for hematuria and is recommended in current major guidelines. We determined the contribution of urine cytology in hematuria investigations and its cost implications. MATERIALS AND METHODS: Data were prospectively collected for 2,778 consecutive patients investigated for hematuria at a United Kingdom teaching hospital from January 1999 to September 2007 with final analysis in October 2010. All patients underwent standard hematuria investigations including urine cytology, flexible cystoscopy and renal tract ultrasound with excretory urogram or computerized tomography urogram performed in those with visible hematuria without a diagnosis after first line tests. Patients with positive urine cytology as the only finding underwent further cystoscopy, retrograde studies or ureteroscopy with biopsy under general anesthesia. Outcomes in terms of eventual diagnosis were cross-referenced with initial urine cytology results (classified as malignant, suspicious, atypical, benign or unsatisfactory). Costs of urine cytology were calculated. RESULTS: Of the patients 124 (4.5%) had malignant cells and 260 (9.4%) had atypical/suspicious results. For urothelial cancer cytology demonstrated 45.5% sensitivity and 89.5% specificity. Two patients with urine cytology as the only positive finding had urothelial malignancy on further investigation. For the entire cohort the cost of cytology was £111,120. CONCLUSIONS: Routine urine cytology is costly and of limited clinical value as a first line investigation for all patients with hematuria, and should be omitted from guidelines.

Beware: the inguinoscrotal hernia with urological origins.

Cases of herniated bladder diverticulae causing inguinoscrotal hernias are rare, and there are 19 described in the English literature. We describe the case of a 64-year-old Caucasian man with a huge bladder diverticulum that herniated into his scrotum. The original diagnosis was that of inguinoscrotal hernia containing bowel contents. Radiological investigations revealed a urological cause, and he underwent a successful diverticulectomy. It is important to recognize that inguinoscrotal hernias can have urological origins, 1-4% being the reported figure. Clinical examination can lead to a general surgical diagnosis before further radiological investigations confirm the nature of the hernia. They prove difficult to both diagnose and surgically correct.

Half of visible and half of recurrent visible hematuria cases have underlying pathology: prospective large cohort study with long-term followup.

PURPOSE: Visible hematuria has a cancer yield of up to 24.2%. A large proportion of cases will have no etiology. In this study we determined the incidence of pathology (benign and malignant) in patients with visible hematuria and those with persistent and recurrent visible hematuria, and evaluated the policy for investigations. MATERIALS AND METHODS: Data were prospectively collected for 1,804 patients with visible hematuria at a United Kingdom teaching hospital from January 1999 to September 2007. In October 2010 the comprehensive hospital electronic database was checked for every individual patient to ensure no urological pathology was missed. All patients underwent standard hematuria investigations, including renal tract ultrasound and excretory urography or contrast enhanced computer tomography urogram, flexible cystoscopy and urine cytology. RESULTS: The male-to-female ratio was 4.8:1. Median age ± SD was 67 ± 17.0 years (range 21 to 109). Median followup was 6.6 ± 2.5 years (range 1.5 to 11.6). No urological pathology was found in 965 (53.5%) patients. Malignant urological disease was found in 386 (21.4%) patients, of whom 329 had bladder tumors. There were 32 patients with persistent visible hematuria and no malignancy. Repeat investigation was performed in 69 patients reporting recurrence. Of these patients 35 received a significant urological diagnosis, including 12 (17.4%) urological malignancies, while 34 (49.3%) still had no diagnosis. Limitations include the possibility of missing pathology. CONCLUSIONS: Almost 50% of patients presenting with visible hematuria will have a diagnosis. Therefore, all cases of visible hematuria require full standard investigations. Patients with no diagnosis can be discharged from followup. Recurrent visible hematuria after full initial negative findings requires repeat full standard investigations because 11.6% will have malignant pathology.

Natural history of upper limb arterio-venous fistulae for chronic hemodialysis.

PURPOSE: Arterio-venous fistulae (AVF) for hemodialysis are prone to problems, ultimately leading to failure of the fistulae. Our aim was to determine the site and time to first stenosis and time to and factors influencing AVF failure for radio-cephalic (RC), brachio-cephalic (BC), and transposed brachio-basilic (BB) AVF. METHODS: Retrospective analysis of native AVF constructed within a single vascular unit between January 2002-December 2008. Patients followed up to the end points of death, AVF failure or end of study period. Data collected included: age, sex, AVF type, time and site of first stenosis and time to failure. The relationship between fistula type, stenosis, and failure were examined. RESULTS: In total, 398 native AVF were included in the study (91 RC, 208 BC, and 99 BB), with a mean age of 66 years. A total of 215 (54%) AVF developed a flow limiting stenosis, and over time 151 (40%) AVF failed. Stenoses developed significantly earlier in RC AVF (median 113 days) compared to BC (median 277 days), compared to BB (median days 414), P=.029. There was no statistically significant difference in time to failure (RC median 1344 days; BC median 1576 days; BB median 1159 days), P=.673. The presence of stenosis was the only variable found to have a significant impact on AVF failure in multivariate analysis. CONCLUSIONS: Type of upper limb fistula did not impact on failure rates. Flow limiting stenoses impacted on fistula failure.

Metastatic Crohn's disease of the penis: two cases.

Metastatic Crohn's disease is a rare inflammatory process that is non-contiguous from the bowel. It can affect the penis and is variable in presentation and onset in relation to bowel symptoms. It has been treated with oral, topical, systemic, and surgical therapies. We describe our experience with two cases of penile metastatic Crohn's disease and their management in comparison with other cases described in the literature. Both our patients were of the lymphoedematous type and had sexual and voiding dysfunction. They were treated with topical and intra-lesional steroids and circumcision after unsuccessful systemic treatments.