The use of tamsulozin as adjunctive treatment after ESWL in patients with distal ureteral stone: do we really need it? Results from a randomised study.

Our study aimed to define the position of tamsulosin as adjunctive therapy in patients with stones of the distal ureter who had undergone extracorporeal shock wave lithotripsy (ESWL). In total, 61 consecutive patients (38 men and 23 women) with single distal radiopaque ureteral stone of > or =6 mm of diameter were enrolled. After ESWL patients were randomized in two groups. Non-steroidal anti-inflammatory drug (supp. diclofenac 50 mg) was given to both groups upon demand. In group B, all patients (30) received additionally tamsulozin 0.4 mg every day. Follow-up visits were performed 1, 2, 3 and 4 weeks after ESWL. Evaluation included a KUB plain film and an ultrasound examination. Efficacy was evaluated in terms of success rate, stone-free rate, expulsion time of the fragments and use of diclofenac. Two patients from the tamsulosin group experienced dizziness and one was withdrawn. The success rate was 58.06 and 66.66% for the control and the tamsulosin group, respectively, while the corresponding values for stone-free rate were 51.6 and 63.33%, respectively. The mean expulsion time of the fragments was 13.22 days for group A and 12.95 days for group B. These results did not achieve statistically significant difference (P > 0.05). The mean diclofenac dose was 118.9 mg in group A and 56.9 mg in group B. This difference was statistically significant (P = 0.02). Despite the relatively small number of patients, our data indicate that the use of tamsulosin after ESWL in this specific subgroup of patients does not result in improved success and stone-free rate and expulsion time. In contrast, a significantly reduced need for analgesics was found.

Ten years' experience with the submucosally embedded in situ appendix in continent cutaneous diversion.

OBJECTIVE: To reevaluate the submucosally embedded in situ appendix as continence mechanism in a large single institutional series of ileocecal urinary reservoirs. MATERIAL AND METHODS: Between November 1990 and June 1999 an ileocecal reservoir with appendico-umbilical stoma was created in 118 patients (84 men, 34 women) aged 3.9-82.7 (mean 56.8) years as a primary urinary diversion or after failure of previous reconstruction. The most common indication for urinary diversion was bladder replacement after anterior exenteration for pelvic malignancies (n = 98), followed by functional or morphological bladder loss due to various benign conditions. The patients were followed prospectively according to a standard protocol. RESULTS: There were no perioperative deaths. In 3 patients necrosis of the appendix resulted in total incontinence with subsequent replacement by an intussuscepted ileal nipple. Impaired catheterization due to stomal stenosis was observed in 19 patients with recurrence in 6 and a total of 25 minor revisions. With a mean follow-up of 60 months all patients are continent day and night. CONCLUSION: Over 10 years, the submucosally embedded in situ appendix has survived as a continence mechanism in the original technique reliably providing continence in ileocecal reservoirs.

Complicated urinary tract infections.

The term complicated urinary tract infection is usually used to convey an infection that occurs in a patient with a structural or functional abnormality impeding urine flow, or in a host with altered defences. The distinction between complicated and uncomplicated infections is important because, when complicating factors are present, antimicrobial resistance is more common and the response to therapy is often disappointing, even with agents active against the causative microbial pathogen. In addition, severe complications frequently occur which may lead to urosepsis, renal scarring or even end-stage disease. Drug treatment of complicated urinary tract infections often must be complemented with endoscopic and/or surgical intervention. Only a few well designed treatment studies have been published and therefore sources for definitive therapeutic guidelines remain inadequate.

Intravesical therapy of superficial bladder cancer.

Transurethral resection (TUR) of the superficial transitional cell carcinoma (TCC) of the bladder is known to be insufficient in controlling the disease because of the unacceptable rates of recurrence, progression and ultimate cystectomy. Adjuvant intravesical chemo-and/or immunotherapy is administered in an effort to enhance the efficacy of surgery alone. The initial tumor stage and grade, the multifocality of this cancer and the history of previous recurrences remain the determinant factors in survival. It is important to decide exactly which patients are at risk, and, therefore, do need treatment. Knowledge of the natural history of the disease will facilitate this decision making, although the natural history of TCC is largely unpredictable owing to tumor heterogeneity. Several cytotoxic and immune modifying agents have been used intravesically in different treatment schedules. However, despite their effectiveness, no consensus exists about the optimal antineoplastic regimen. The selection of the latter is a subject of continuous investigation. Intravesical treatment with cytotoxic drugs has been demonstrated to achieve an acceptable reduction in short- and intermediate-term recurrence rates, but has no proven ability in preventing disease progression to muscle-invasive cancer or prolonging survival. On the other hand, bacillus Calmette-Guerin (BCG) currently appears to be the most effective agent for intravesical use, especially in patients with high grade and stage neoplasms but the optimum strain, dosage and duration schedule have not been determined. Clinical trials have shown that BCG provides long-term protection from tumor recurrence, while there is evidence that it may favorably alter the progression rate of the disease with prolongation of survival. Toxicity of intravesical chemo- and immunotherapy still remains a major problem and attempts at reducing the dosage, and, thus, toxicity without affecting efficacy are underway. This review endeavors to present updated information on intravesical chemotherapy in treating superficial bladder cancer, the expanding role of intravesical immunotherapy, the recent work comparing various immunotherapeutic regimens with chemotherapeutic intravesical therapies, and the progress made towards achieving optimal treatment regimens.

Experience with the Mainz modification of ureterosigmoidostomy.

BACKGROUND: The purpose of this study was to report experience with the revived surgical concept of ureterosigmoidostomy in its low pressure modification and to discuss its value within the current spectrum of urinary diversion. METHODS: Between February 1992 and September 1997 modified ureterosigmoidostomy (rectosigmoid pouch; Mainz pouch II) was performed in 34 patients aged 1.9-76.9 (mean 55.8) years as a primary urinary diversion after radical cystectomy for bladder cancer (n = 30) and benign conditions (bladder exstrophy, three patients; intractable urinary incontinence, one). All patients were followed prospectively according to a standard protocol including assessment of continence, renal function and acid-base balance. RESULTS: There were no perioperative deaths. In one patient dislocation of a ureteral stent in the early postoperative course required insertion of a percutaneous nephrostomy. All patients were continent during the day. One patient experienced night-time incontinence but rejected a conversion procedure. In one case ureterosigmoidostomy was replaced by an ileal conduit after several episodes of septicaemia. One nephrectomy was performed for ureterointestinal obstruction. Mild hyperchloraemic acidosis was seen in two patients. CONCLUSION: Bowel frequency and urge incontinence, the major weaknesses of classical ureterosigmoidostomy, can be overcome by detubularization of the rectum. As the modified procedure is quick, safe and easy to perform with highly satisfactory results, the rectosigmoid pouch has potential in reconstructive urology.

Milk of calcium cysts masquerading as renal calculi.

Milk of calcium renal cysts contain a colloidal suspension of calcium crystals. By routine radiography and sonography in supine position this rare condition may be misinterpreted as renal lithiasis for which an unnecessary surgical intervention may be performed as it happened in our two cases that are presented here. Postoperatively, the characteristic finding of half-moon contour on upright abdominal plain views was lacking in one case, but in both cases computed tomography revealed the typical calcific suspension layering. However, upright plain views and computed tomography are not routinely performed in patients in whom a renal stone has initially been considered. This entity should be considered in the differential diagnosis of renal paracalyceal calcifications of obscured origin.

Complications related to different continence mechanisms in ileocecal reservoirs.

PURPOSE: We compared the incidence, treatment and outcome of complications related to different continence mechanisms in a single institutional series of continent urinary diversions using an ileocecal reservoir. MATERIALS AND METHODS: From November 1990 through October 1996 in 193 consecutive cases an ileocecal pouch (Mainz I) was used as a low pressure, high capacity reservoir. A submucosally embedded in situ appendix was used in 96 patients (mean age 57.2 years, mean followup 35.6 months) and an ileal intussusception valve was used in 106 (mean age 58.4, mean followup 33.1 months). Without exception the stoma was placed in the umbilicus. RESULTS: In 172 patients (85.2%) no stoma related complication was observed. In 17 patients (17.7%) with appendix stoma 23 reinterventions were performed, for appendico-umbilical stenosis in all but 2 cases (15.6%), occurring after a mean of 20.4 months. Two complete appendix necroses required replacement by ileal nipple. Stomal stenoses could be corrected as minor outpatient procedures. In 13 of 106 patients (12.3%) with intussuscepted ileal nipple a second operation became necessary after a mean interval of 9.6 months (partial/complete necrosis of nipple in 4 cases, dislocation of nipple from ileocecal valve in 3, detachment from fascia in 4 and stomal stenosis in 2). Whereas no calculi were observed in the appendix group, stones had to be removed from 3 patients (2.8%) with ileal nipple. CONCLUSIONS: In situ appendix and intussuscepted ileal valve techniques are satisfactory in providing ileocecal reservoir continence. Besides the known advantages of the appendix as the primary reconstructive approach, the treatment of subsequent complications is simple. Therefore, whenever an appropriate appendix is encountered it should be the intestinal segment of choice in forming a continence mechanism.

Post-intercourse versus daily ciprofloxacin prophylaxis for recurrent urinary tract infections in premenopausal women.

PURPOSE: We evaluated and compared the efficacy of post-intercourse and daily oral ciprofloxacin prophylaxis against recurrent lower urinary tract infections in 135 sexually active premenopausal women. MATERIALS AND METHODS: Post-intercourse (group 1, 70 patients) and daily (group 2, 65 patients) prophylactic regimens of 125 mg. ciprofloxacin were started following a curative, conventional treatment of the initial acute urinary tract infection. Prophylaxis was maintained for 12 months and during this period patients were followed clinically and bacteriologically with urine and introital samples. Patients were subsequently followed for an additional year after the end of preventive treatment. RESULTS: While 3.67 urinary tract infections per patient in group 1 and 3.74 in group 2 occurred during an identical mean time of 12.2 months before start of the corresponding prophylactic regimen, only 0.043 infection per patient in group 1 and 0.031 in group 2 developed during prophylaxis (p < 0.0001). Before prophylaxis 86% of the vaginal vestibule cultures yielded gram-negative Enterobacteriaceae, equally distributed between both treatment arms, compared to 5.6% and 2.5% during postcoital and daily prophylaxis, respectively. The overall improvement in the incidence of the urinary infections per patient and the rate of introital colonization with enteric gram-negative bacteria was maintained after the end of prophylaxis, with a mean incidence of infections of 0.44 per patient (occurring in 34% of the total patient population), while 36% of all women had abnormal introital colonization. CONCLUSIONS: Long-term post-intercourse prophylaxis with ciprofloxacin proved to be equally effective as daily prophylaxis, and the major advantage of the former therapy was use of only a third of the amount of drug consumed in daily prophylaxis.

Intravesical bacillus Calmette-Guérin versus epirubicin in the prophylaxis of recurrent and/or multiple superficial bladder tumours.

A prospective, randomized trial was conducted to evaluate and compare the effects of modified adjuvant intravesical bacillus Calmette-Guérin (BCG) and epirubicin regimens in patients with superficial bladder cancer. One hundred thirty-two individuals with recurrent and/or multiple neoplasms, i.e. at high risk for tumour recurrence and progression, were enrolled. After complete transurethral resection of their tumours, the patients received a 6-week course of BCG instillations or an early 4-week course of epirubicin instillations as their initial therapy. Those with stage Ta and grade 1 neoplasms who remained free of recurrences received maintenance therapy consisting of single quarterly instillations. However, for those with stage T1 cancer of any grade or stage Ta of grade 2 or 3 neoplasms who also remained free of recurrences, the treatment schedules were modified: they received, instead of single maintenance doses, 3 weekly instillations of epirubicin at months 3 and 6 of follow-up, or a 3-week course of BCG at month 6 of follow-up. The recurrence-free rates did not differ significantly between the two study groups (44% for epirubicin versus 55% for BCG), for an identical median follow-up of 43 months. However, in terms of relative risk of recurrences, disease-free intervals and recurrence rate per 100 patient-months, a significant benefit in favour of BCG when compared with epirubicin was demonstrated in patients who had stage T1 or grade 3 neoplasms.

Nonfunctional adrenal cortical carcinoma. Report of a case and review of the literature.

Nonfunctional carcinomas of the adrenal gland are quite rare. By presenting a 47-year-old woman with such a tumour, a review of the literature is made, with special emphasis on the epidemiology and histologic criteria in predicting malignant behaviour. In addition, the clinical, pathological and radiographic findings, as well as the treatment modalities of this neoplasm are discussed.

BCG versus epirubicin in the prophylaxis of multiple superficial bladder tumours: results of a prospective randomized study using modified treatment schemes.

A prospective randomized trial on 94 eligible patients evaluated and compared the efficacy of adjuvant intravesical epirubicin and bacillus Calmette-Guérin (BCG) after complete resection of multifocal superficial bladder cancer. BCG treatment schedule consisted of an induction 6-week course of instillations (150 mg Pasteur BCG per instillation) and single maintenance doses to patients who remained free of recurrences at follow-up examinations for a total treatment period of 2 years. These initial responders received additionally a separate 4-week course of therapy 6 months after the start of treatment. Chemoprophylaxis included an early (on the second postoperative day) instillation followed by 4 weekly treatments with epirubicin (50 mg per instillation) and then by 10 monthly treatments for the initial responders during the first year of follow-up and at every follow-up examination for a total treatment period of 2 years. The overall treatment results did not differ significantly between the 2 arms (54% of patients of the epirubicin group remained free of recurrences compared to 65% of those treated with BCG) for an identical mean follow-up of 35.1 months. However, a significant benefit in favour of BCG when compared with epirubicin was shown in patients who had stage T1 and grade 3 tumours and in terms of relative risk of recurrences, disease-free interval and recurrence rate per 100 patient-months. Both drugs were proved to be safe with manageable toxicity.

Neomycin-induced perception deafness following bladder irrigation in patients with end-stage renal disease.

OBJECTIVE: To report a serious side-effect of intravesical instillations of neomycin in patients with end-stage renal disease. PATIENTS AND METHODS: Three patients (two men and a woman, aged 51.71 and 54 respectively) with end-stage renal disease who had undergone bladder irrigation with neomycin sulphate solution suffered complete irreversible deafness, which was assessed by audiogram. RESULTS: All three patients developed complete perception deafness after 3, 4 and 10 months, with characteristic changes in the audiogram. The severe progressive hearing loss was maximal in the high-frequency range. A high-pitched tinnitus was the first sign of impending hearing difficulty and two patients developed a spontaneous nystagmus. CONCLUSION: In view of the doubtful efficacy and, most importantly, the risk of severe disabling side-effects such as ototoxicity, we recommend the avoidance of intravesical instillation with neomycin whenever possible.

Multiple (five) synchronous primary malignant neoplasms of dissimilar histogenesis including a malignant fibrous histiocytoma of the bladder.

A unique case was recently encountered involving the synchronous presentation of five primary malignancies of different histology. Malignant neoplasms of the colon, kidney, prostate and bladder were treated surgically. Bladder was affected by two separate tumours: a transitional cell carcinoma and a malignant fibrous histiocytoma. The latter constitutes an extremely rare malignant lesion of the organ. The pathologic characteristics, histogenesis, differential diagnosis and treatment considerations of this soft tissue sarcoma, and the incidence, terminology and incriminating factors of multiple primary malignant neoplasms, as well as their association with the genitourinary system are reviewed.

Silver staining nucleolar organizer region in prostate cytology.

Amongst males, the prevalence of prostate cancer is third in frequency with a rising incidence. As the population grows older, the number of latent cancer of the prostate increases. Therefore, diagnostic tools for an early detection of this malignancy are necessary. Silver staining of nucleolus organizer regions (AgNOR) is a new technique in tumour analysis. It is especially valuable as an addition to classical prostate cytology. A report on 90 cases of transrectal prostate aspiration biopsies is presented. 81 of these had a histological evaluation (biopsy gun) at the same time. The air-dried slides were stained according to Ploton et al. [10]. The AgNORs were counted and measured by means of an interactive image analysis system. Patients without malignancy were reliably classified as negative both by routine cytology as well as by AgNOR analysis. The sensitivity in routine tumor diagnosis was ca. 87%. In contrast, the AgNOR index revealed a sensitivity of 96% and a specificity of 97%. Thus, AgNOR staining improves differential diagnosis in inconclusive cases. Our data suggests that the inexpensive AgNOR analysis improves differentiation between carcinomatous and benign prostatic cells. It is a useful tool, in addition to routine prostatic cytology.

Stamey endoscopic vesical neck suspension in female urinary stress incontinence: results and changes in various urodynamic parameters.

A total of 32 female patients with urinary stress incontinence who underwent a Stamey endoscopic bladder neck suspension were clinically and urodynamically studied pre- and postoperatively. Complete cure was obtained in 78% of the patients and improvement in 6%, the overall success rate being 84% for a mean follow-up of 11.1 months (range 6-19). Complications occurred in 22% of the patients. Comparison of the pre- and postoperative urodynamic data revealed that the maximum urine flow rate, functional urethral length and maximum urethral closure pressure were changed significantly after operation. In addition, when studying the abdominal pressure transmission to the entire urethra during stress, there was a significant conversion of negative to positive pressure transmission after surgical repositioning of the urethra.

Tumor-forming eosinophilic cystitis in children. Case report and review of literature.

Eosinophilic cystitis is an unusual bladder lesion of unclear etiology first described in 1960. It usually causes irritative voiding symptoms and hematuria and in its rare tumor-like appearance the disease may mimic an invasive bladder neoplasm. In the report herein, a case of an 11-year-old boy with a tumor-forming eosinophilic cystitis is presented which was mistaken for an infiltrative vesical malignancy until the histopathological study was completed. The principal clinical findings, differential diagnosis, etiology, pathogenesis and treatment modalities of this inflammatory disease are discussed.