Chemical- and radiation-induced haemorrhagic cystitis: current treatments and challenges.

• To review the published data on predisposing risk factors for cancer treatment-induced haemorrhagic cystitis (HC) and the evidence for the different preventive and therapeutic measures that have been used in order to help clinicians optimally define and manage this potentially serious condition. • Despite recognition that HC can be a significant complication of cancer treatment, there is currently a lack of UK-led guidelines available on how it should optimally be defined and managed. • A systematic literature review was undertaken to evaluate the evidence for preventative measures and treatment options in the management of cancer treatment-induced HC. • There is a wide range of reported incidence due to several factors including variability in study design and quality, the type of causal agent, the grading of bleeding, and discrepancies in definition criteria. • The most frequently reported causal factors are radiotherapy to the pelvic area, where HC has been reported in up to 20% of patients, and treatment with cyclophosphamide and bacillus Calmette-Guérin, where the incidence has been reported as up to 30%. • Mesna (2-mercaptoethane sodium sulphonate), hyperhydration and bladder irrigation have been the most frequently used prophylactic measures to prevent treatment-related cystitis, but are not always effective. • Cranberry juice is widely cited as a preventative measure and sodium pentosanpolysulphate as a treatment, although the evidence for both is very limited. • The best evidence exists for intravesical hyaluronic acid as an effective preventative and active treatment, and for hyperbaric oxygen as an equally effective treatment option. • The lack of robust data and variability in treatment strategies used highlights the need for further research, as well as best practice guidance and consensus on the management of HC.

Radiological treatment of a spontaneously ruptured inferior adrenal artery aneurysm.

BACKGROUND: A 70-year-old man with a history of hypertension presented with severe epigastric discomfort that radiated to his back. CT revealed cystic kidney disease and a large retroperitoneal hemorrhage, and CT angiography identified an active bleeding point in the region of the left adrenal gland. Selective left renal angiography identified a small inferior adrenal artery aneurysm with active hemorrhage. The patient underwent successful transcatheter embolization with microcoils and polyvinyl alcohol microparticles to control the bleeding. INVESTIGATIONS: Blood tests, urinalysis, electrocardiography, triphasic CT with CT angiography. DIAGNOSIS: Ruptured left inferior adrenal artery aneurysm. MANAGEMENT: Access to the inferior adrenal artery was achieved with a microcatheter, followed by transcatheter embolization using a combination of polyvinyl alcohol microparticles distally and microcoils proximally to the aneurysm.

Does laser ablation prostatectomy lead to oncological compromise?

OBJECTIVE: To assess the incidence and outcome of incidental prostate cancer detected at transurethral resection of the prostate (TURP), and to evaluate whether laser ablation prostatectomy would miss significant cancer by failing to provide tissue for histopathological analysis. PATIENTS AND METHODS: Information on TURP-detected prostate cancer was gathered from 1996 to 2006, from The South-west Cancer Intelligence Service, hospital-operating and coding records, histopathology databases and The British Association of Urological Surgeons Cancer Registry. We recorded the total number of prostate cancers diagnosed per year, number of TURPs performed, Gleason scores and patients outcomes. RESULTS: TURP-detected prostate cancer has declined since the relatively high rates (22%) recorded locally in 1996-97. Between 2001 and 2006, a mean (range) of 124 (111-135) prostate cancers were detected per year. Incidental cancers accounted for only 1.5-5.6% of all newly diagnosed prostate cancers per year. Incidental cancers had a mean (sem) Gleason score of 5.7 (0.3) compared to 8.0 (0.3) in known cancers (P < 0.01) undergoing TURP. Of newly diagnosed patients, 82% were allocated to active surveillance, whilst 18% were started on hormone therapy, with no prostate cancer-related deaths over a mean (sem, range) follow-up of 49.7 (2.4, 11-81) months. CONCLUSIONS: TURP mainly samples transitional-zone tissue where tumours are relatively uncommon, and have a good prognosis. Our series of incidental TURP-detected cancers showed an incidence in keeping with published data, and favourable histological and clinical outcomes. We suggest the lack of tissue should not discourage the use of laser prostatectomy surgery.

Laparoscopic deroofing of a renal cyst: the hidden invasion.

Cysts of the kidney usually originate from the renal parenchyma after tubule obstruction; rarely pyelocalyceal cysts occur, originating from transitional urothelium. Neoplasia is a rare but possible complication. A 45-year-old man was found to have a cyst related to the right kidney. Computed tomography demonstrated minimal calcification in the wall (Bosniak II). Symptom-relieving percutaneous drainage yielded clear fluid; resultant cytology was negative. After rapid reaccumulation, laparoscopic deroofing was performed. No communication within the renal pelvis was detected however histology revealed transitional cell carcinoma. An open radical nephroureterectomy was performed; adjuvant chemotherapy was given. Three previous cases of malignancy in a pyelocalyceal cyst have been reported. This is the first reported after laparoscopic deroofing of a cyst. Despite widespread use of the Bosniak renal cyst classification, the management of category II cysts remains contentious. This case should serve as a warning to clinicians that seemingly benign cysts of the kidney may harbor underlying neoplasia. Intraoperative frozen section should be considered in all cases where preoperative imaging suggests Bosniak II classification.

Small-bowel obstruction: coronal reformations from isotropic voxels at 16-section multi-detector row CT.

PURPOSE: To retrospectively assess the added value of coronal reformations of the abdomen and pelvis from isotropic voxels by using 16-section multi-detector row computed tomography (CT) for the diagnosis of small-bowel obstruction (SBO). MATERIALS AND METHODS: This HIPAA-compliant study was approved by the institutional review board of this medical center with a waiver of informed consent. One hundred consecutive patients (40 men and 60 women; mean age, 55 years) suspected of having SBO and abdominal pain underwent 16-section multi-detector row CT with coronal reformations. Twenty-nine patients had a final diagnosis of SBO, and 71 patients did not. Three independent readers blinded to the diagnosis interpreted the CT scout scan, then transverse scans alone, and then transverse plus coronal scans for the presence of SBO and abnormal wall enhancement. Confidence was scored with a 1-5 scale (1 = absent, 5 = present). RESULTS: Mean sensitivity and specificity of CT scout alone, transverse CT alone, and transverse plus coronal CT for the diagnosis of SBO were 88% and 86%, 87% and 87%, and 87% and 90%, respectively (not significant). In patients without SBO, transverse plus coronal CT enhanced confidence in the exclusion of SBO (P = .01). In patients with SBO, transverse plus coronal CT enhanced confidence in the diagnosis of SBO and identification of abnormal wall enhancement (P = .01). CONCLUSION: Transverse 16-section multi-detector row CT data sets are an excellent test for the diagnosis of SBO, while the addition of coronal reformations obtained from these isotropic data sets adds confidence to the diagnosis and exclusion of SBO.

Management of acute epididymitis: are European guidelines being followed?

OBJECTIVE: Acute epididymitis is increasing in men aged 35 years or under due to sexually-transmitted Chlamydia trachomatis. This study examines whether Urological surgeons are following European guidelines for the management of acute epididymitis in these patients. METHODS: A postal questionnaire survey was conducted of specialists in Urology in two regions of the UK. RESULTS: Of 79 completed replies, 41 (52%) take a detailed sexual history but only 34 (43%) refer patients to a Genitourinary medicine clinic. Quinolones are the most commonly prescribed first-line antibiotic by 56 (71%) respondents, principally ciprofloxacin. CONCLUSIONS: The current management of acute epididymitis in young men must be improved. Ciprofloxacin is not the optimal antimicrobial for the treatment of urogenital chlamydial infection. We recommend that all such patients be referred to local Genitourinary medicine services for contact-tracing and treatment of their sexual partners.