Bipolar plasmakinetic transurethral resection of the prostate vs. transurethral enucleation and resection of the prostate: pre- and postoperative comparisons of parameters used in assessing benign prostatic enlargement.

INTRODUCTION: Transurethral enucleation and resection of the prostate (TUERP) may offer a better treatment for benign prostatic enlargement. We compared the perioperative parameters and outcome following bipolar plasmakinetic transurethral resection of the prostate (TURP) and TUERP. METHODS: Data from two independent institutions were reviewed retrospectively. 50 and 45 consecutive patients were enrolled in the TURP and TUERP groups, respectively. Pre- and postoperative parameters, including prostatic specific antigen (PSA), prostate volume (PV), International Prostate Symptom Score (IPSS), quality of life (QOL) score, uroflowmetry and prostate volume (PV), were compared. RESULTS: Age at surgery, preoperative PSA (5.8 +/- 4.0 versus 7.6 +/- 5.9 ng/ml) and PV (55.8 +/- 31.6 versus 53.2 +/- 26.8 g) showed no significant difference (p-value greater than 0.05). However, postoperative PSA (2.8 +/- 3.0 versus 0.8 +/- 0.4 ng/ml; p-value less than 0.05) and PV (15.2 +/- 7.7 versus 10.5 +/- 5.4 g; p-value less than 0.01) differed significantly between the TURP and TUERP groups, respectively. There were no significant differences in IPSS, QOL and Qmax between the two groups during follow-up (p-value is 0.62, 0.68 and 0.13, respectively). However, for the TUERP group, the postoperative post-void residual urine volume (PVR) was significantly better (13.8 +/- 19.5 versus 25.2 +/- 18.7 ml; p-value less than 0.01). CONCLUSION: The TUERP technique achieved more complete resection than TURP, with a smaller post procedure PV and lower PSA and PVR after surgery. This may predict better long-term results for patients who had TUERP.

Contemporary results of endopyelotomy for ureteropelvic junction obstruction.

INTRODUCTION: Endopyelotomy is an accepted treatment option for ureteropelvic junction obstruction (UPJO). In this study, we reviewed our 7-year experience with antegrade endopyelotomy for UPJO. MATERIALS AND METHODS: We reviewed the records of 35 consecutive antegrade endopyelotomy for UPJO between 1996 and 2002. Patients were included if they had shown radiographic evidence of UPJO on diuresis urography or intravenous urogram with signs and symptoms or deterioration of renal function. RESULTS: A total of 34 consecutive patients underwent 35 antegrade endopyelotomy procedures in 35 renal units. One patient had bilateral endopyelotomy for bilateral UPJO. Eighteen renal units (51%) had concomitant renal calculi that required percutaneous nephrolithotomy, including 8 renal units with pelvi-ureteric junction stones. Twenty-four renal units (69%) had moderate degree of hydronephrosis whilst 11 renal units (31%) had severe hydronephrosis. The mean operating time for antegrade endopyelotomy was 94 +/- 28 minutes and the mean hospital stay was 4.7 +/- 2.8 days. No patients had conversion to open pyeloplasty and no patient required perioperative blood transfusion. The mean followup was 33 +/- 23 months and the overall success rate following endopyelotomy was 83% (n = 29 renal units). The success rate for primary UPJO was 81%, whilst the success rate for secondary UPJO was 84%. Four renal units (11%) required ancillary procedures for failed endopyelotomy. Two patients required repeat endopyelotomy, and 2 patients needed open pyeloplasty. Two patients were lost to follow-up. CONCLUSION: Endopyelotomy remains a viable approach for UPJO compared to open reconstruction. Careful patient selection can optimise the surgical outcome and minimise endopyelotomy failures.

Predictors of androgen independence in metastatic prostate cancer.

OBJECTIVE: To assess the factors that influence the onset of androgen independence (AI, which heralds a dismal outcome) in patients with metastatic prostate carcinoma. PATIENTS AND METHODS: The records of 361 consecutive patients with prostate carcinoma diagnosed and treated in the authors' institution from 1 January 1996 to 31 December 1999 were reviewed retrospectively; 92 with metastatic prostate carcinoma were assessed (median age 71.0 years, range 42-93). Patients were included if they developed metastatic disease from prostate cancer at the time of diagnosis. The nadir for prostate specific antigen (PSA) level was defined as the date of the lowest PSA level after hormonal therapy, and AI was defined as the date of the third consecutive PSA increase above the nadir value by any threshold. RESULTS: The median Gleason sum was 8 and the modal Gleason score 4 + 5. The median (range) pretreatment PSA level was 274.0 (1.3-2179) ng/mL. Of the 92 men, 57 (62%) attained a nadir PSA, including 23 with a nadir of < 2 ng/mL; 32 (35%) progressed to AI within 2 years and 27% reached a nadir PSA but did not develop AI. The mean (sd) time from diagnosis to the nadir PSA was 13.7 (11.8) months, while the mean time from diagnosis to progression to AI was 30.3 (15.6) months. Univariate analysis showed that a nadir PSA level after treatment of >/= 1 ng/mL (P = 0.0128) was an early predictor of progression to AI; a nadir PSA level of >/= 2 ng/mL (P = 0.0216) was a predictor of poor overall survival. CONCLUSION: Failure to attain a nadir PSA of < 1 ng/mL after treatment predicts progression to AI and a nadir PSA of > 2 ng/mL predicts poorer overall survival. The development of skeletal events predicts the onset of AI but occurs late in the disease and is unsuitable as an early prognostic marker.

Routine vascular control using the Hem-o-lok clip in laparoscopic nephrectomy: animal study and clinical application.

BACKGROUND AND PURPOSE: During laparoscopic nephrectomy (LPN), a stapling device is often used for vascular control, especially of the renal vein. Herein, we report our experience using a polymer clip (Hem-o-lok) for routine control of the vessels during LPN in the animal and clinical setting. PATIENTS AND METHODS: Fifty ablative and fifteen live-donor nephrectomies were performed in domestic pigs. Hem-o-lok clips (10 mm; Weck Closure System, Research Triangle Park, NC) were routinely used for vascular control. In addition, from January 2001 to July 2002, 46 patients underwent hand-assisted laparoscopic (HAL) (N=40) or laparoscopic (N=6) nephrectomy for renal disease or donor nephrectomy. Venous control was achieved solely by the Hem-o-lok clips where at least two clips were applied on the patient side. Arterial control was obtained by the Hem-o-lok clips either alone or in combination with the metal clips. The technical difficulty in obtaining vascular control, transfusion requirement, and clinical outcome were evaluated. RESULTS: In the animal study (total 65 nephrectomies), individual vascular control was obtained by the Hem-o-lok clip in all cases except two, where vascular injury during dissection necessitated endoscopic stapling of renal hilum or open conversion. The warm ischemic time for animal donor kidney harvest was uniformly <2 minutes. In the clinical study, arterial control was obtained mostly by a combination of Hem-o-lok and metal clips. Venous control using the Hem-o-lok was successful in all 46 cases without any slipping of clips or uncontrolled bleeding. The mean operating time was 148 minutes. No open conversion was required. The transfusion rate was 6.5% (N=3), with none of the transfusions being related to inadequacy of vascular control using the Hem-o-lok. Major complications included deep vein thrombosis and postoperative retroperitoneal hemorrhage (same patient) and acute respiratory distress syndrome (N = 1). The mean postoperative stay was 5.2 days (range 1-20 days). CONCLUSION: The Hem-o-lok is a reliable and economical device for vascular control in laparoscopic renal surgery.

A twelve-year review of radical cystectomies in Singapore General Hospital.

INTRODUCTION: Bladder carcinoma is the tenth most common cancer affecting men in Singapore. This study reviews the complication rates and long-term outcome after radical cystectomy for bladder carcinoma. PATIENTS AND METHODS: A retrospective case-record review of 90 consecutive radical cystectomies in the Department of Urology at the Singapore General Hospital from 1 January 1989 to 31 December 2000 was performed. Patients were included if they were operated for muscle-invasive tumour, high-grade tumour with carcinoma in-situ (CIS), recurring multifocal high-grade tumour, CIS unresponsive to intravesical therapy, or endoscopically uncontrollable tumour. Patients were excluded if they had metastatic disease or non-bladder primary carcinomas. RESULTS: The patients were predominantly male (M:F, 80:10) and Chinese (Chinese:Malay:Indian:Others, 70:10:3:7) with a mean age of 64.1 +/- 9.9 years (range, 39 to 83 years). Fifty-one patients underwent ileal conduit creation, 36 had ileal neobladder creation, 2 had ureterosigmoidostomies and 1 had Mainz II pouch creation following radical cystectomy. Perioperative mortality was 2.2% (n = 2). Early complications constituted 39% (n = 35), whilst late complications constituted 14% (n = 13) of cases. The mean follow-up was 27.1 +/- 29.7 months (range, 1 to 137 months). The mean time to recurrence was 26.0 +/- 29.5 months (range, 3 to 137 months). The overall survival was 70%, 43% and 37% at 1, 3 and 5 years, respectively. The disease-free survival was 64%, 35% and 32% at 1, 3 and 5 years, respectively. CONCLUSION: The results of our radical cystectomies for bladder carcinoma are comparable to other established urology units although the morbidity remained significant.