Female urethral stricture: a contemporary series.

PURPOSE: To report the etiology, presenting symptoms and outcomes of the different treatments performed in female patients with recurrent urethral stricture. MATERIALS AND METHODS: Twenty-six patients with refractory LUTS were diagnosed with a urethral stricture. The symptoms, the treatment performed and the outcomes were prospectively recorded. Sixteen patients were treated with a urethroplasty using a buccal mucosal graft (BMG) in 14 cases (54 %) and a vaginal flap in 2 (8 %). Urethral dilatation, optical urethrotomy and meatoplasty were performed in 8 (31 %), 1 (3.8 %) and 1 (3.8 %) patients, respectively. RESULTS: Strictures were idiopathic in 11 patients (42 %). Previous urethral instrumentation and traumatic vaginal delivery were the commonest causes of urethral stricture (42 and 15 %, respectively). The most frequent symptoms were reduced flow (93 %), detrusor overactivity (50 %) and UTIs (42 %). The stricture was cured in 93 % of patients treated with a BMG urethroplasty and in all the patients in which a vaginal flap urethroplasty was performed. In the same group, the improvement in urethral pain was observed in the 67 and the 88 % of patients were cured from recurrent UTIs. All the patients treated with urethral dilatation needed further dilatations; hence, the cure of the stricture was achieved in none of them. Improvement in urethral pain, UTIs and detrusor activity was not recorded in the latter group. CONCLUSION: Urethroplasty in its various forms has demonstrated in the present series the highest cure rate for the treatment of recurrent urethral stricture.

Correlation of estimated and measured glomerular filtration rate in patients with interposed bowel in the urinary tract.

OBJECTIVE: Isotope glomerular filtration rate (GFR) measurement is invasive, time-consuming and expensive. Estimated glomerular filtration rate (eGFR) is used as a surrogate, but has not been validated in patients whose lower urinary tract (LUT) is replaced with bowel. This study aimed to evaluate the correlation between the Modification of Diet of Renal Disease (MDRD) eGFR andchromium-51 ethylenediamine tetra-acetic acid (Cr-EDTA) GFR in patients with LUT reconstruction/diversion. MATERIAL AND METHODS: A retrospective chart review was undertaken of 75 consecutive patients with LUT reconstruction/diversion attending scheduled follow-up in a single institutional setting. Cr-EDTA GFR, serum creatinine and eGFR were compared. Routine patient demographics, type of bowel reconstruction/diversionand time since surgery were noted. RESULTS: The correlation between Cr-EDTA GFR and creatinine was poor (r (2) = 0.411) and the limits of agreement between variables were wide (-118 to +102, p = 0.053). The correlation between Cr-EDTA GFR and eGFR was slightly better (r (2) = 0.536), and the limits of agreement narrowed to -39 to +37 (p = 0.0003). The correlation was improved (r (2) = 0.623) when separating patients with renal failure (eGFR ≤ 60 ml/min per 1.73 m(2), n = 21), but the agreement between variables was poor (-20 to +16 ml/min per 1.73 m(2), p = 0.424).Study limitations include the heterogeneous/complex patient population and types of bowel interposition, and asynchronous eGFR and Cr-EDTA GFR measurement (although no clinical events were recorded between measures). These reflect the reality in which eGFR is often used. CONCLUSIONS: There is poor correlation between eGFR and Cr-EDTA GFR in patients with LUT reconstruction/diversion with bowel. eGFR should be used with caution as a surrogate marker for isotope GFR in these patients. Larger prospective studies controlling for the study limitations identified are indicated.

Transdermal estradiol improves bone density when used as single agent therapy for prostate cancer.

PURPOSE: Current androgen deprivation therapies for men with prostate cancer cause accelerated osteoporosis and a significant risk of osteoporotic fracture. We have recently shown that transdermal estradiol is an effective alternative for such patients. Here we report the impact of transdermal estradiol therapy on the bone mineral density of men with prostate cancer. MATERIALS AND METHODS: A total of 20 patients with newly diagnosed locally advanced or metastatic prostate cancer were treated with transdermal estradiol patches. Bone mineral density of the lumbar spine and the proximal femur was measured with dual-energy x-ray absorptiometry, and correlated with computerized tomography and isotope bone scan findings at 6-month intervals. RESULTS: In all measured regions bone mineral density increased with time. By 1 year mean bone mineral density +/- SEM had increased by 3.60% +/- 1.6% in the lumbar spine (p = 0.055), 2.19% +/- 1.03% in the femoral neck (p = 0.055), 3.76% +/- 1.35% in the Ward's region (p = 0.008) and 1.90% +/- 0.85% in the total hip (p = 0.031), respectively. Of 12 osteoporotic sites 4 had improvement based on World Health Organization grading. All other sites improved toward a better classification. CONCLUSIONS: Transdermal estradiol protects against bone loss in men with prostate cancer and may improve bone density in those at risk for osteoporotic fracture.

Transdermal estradiol therapy for advanced prostate cancer--forward to the past?

PURPOSE: Current hormonal therapies for prostate cancer are associated with significant morbidities, including symptoms of andropause and osteoporosis. Oral estrogens prevented many of these problems but were abandoned due to cardiovascular toxicity attributed to hepatic effect. In contrast, parenteral estrogens prevent first pass hepatic metabolism and substantially reduce cardiovascular risk, and long-term transdermal estradiol therapy is believed to be cardioprotective. We report preliminary results of a pilot study using transdermal estradiol therapy to treat men with advanced prostate cancer. MATERIALS AND METHODS: A total of 20 patients with advanced prostate cancer were enrolled in a before and after study that examined the impact of estradiol patches on hormones, disease, thrombophilia, vascular flow, osteoporosis and quality of life. RESULTS: Median followup is 15 months. Estradiol levels greater than 1,000 pmol./l. were achieved using 2 patches and higher levels were obtained by increasing the number of patches. All patients achieved castrate levels of testosterone within 3 weeks and had biochemical evidence of disease regression. One patient died of disease at 14 months and 1 cardiovascular complication occurred. Thrombophilic activation was avoided and vascular flow improved. Bone mineral density was significantly increased. Mild or moderate gynecomastia occurred in 80% of patients but no patient had hot flushes. All other functional and symptomatic quality of life domains improved. CONCLUSIONS: Transdermal estradiol therapy produced an effective tumor response. Cardiovascular toxicity was substantially reduced compared with that expected of oral estrogen, and other morbidity (gynecomastia) was negligible. Transdermal estradiol therapy prevented andropause symptoms, improved quality of life scores and increased bone density. Transdermal estradiol costs a tenth of current therapy cost, with the potential for considerable economic savings over conventional hormone therapies.

A probability based system for combining simple office parameters as a predictor of bladder outflow obstruction.

PURPOSE: We explored the relationships of office assessment of lower urinary tract symptoms, transrectal ultrasound measurement and the bladder outlet obstruction index, as derived from pressure flow studies. We also developed and validated a multivariate analysis for predicting the bladder outlet obstruction index. MATERIALS AND METHODS: We evaluated 384 men with lower urinary tract symptoms using the International Prostate Symptom Score, maximum urine flow, post-void residual urine, transrectal ultrasound and urodynamic studies. Data were analyzed by multiple linear regression with continuous variables. A simple algorithm, that is the predicted bladder outlet obstruction index, was created using the best fit variables identified from a derivation set and assessed in a separate validation set. The predicted index was applied to predict the probability of actual obstruction according to office parameters. RESULTS: Maximum urine flow and total prostate volume predicted the bladder outlet obstruction index most completely (adjusted R2 = 0.50, F 75.9, p <0.0001), while other variables were not helpful. These variables were used to create the predicted bladder outlet obstruction index algorithm, antilog10 (2.21 - 0.50 log maximum urine flow + 0.18 log total prostate volume) - 50. In the 42% of patients with a predicted index of greater than 40 there was a 92% risk or positive predictive value of equivocal or worse obstruction, whereas a predicted index of less than 20 in 23% indicated a 4% risk of significant obstruction. CONCLUSIONS: The bladder outlet obstruction index can be predicted from maximum urine flow and prostate volume. Development of the predicted bladder outlet obstruction index algorithm enables the mathematical prediction of obstruction from these simple measures. Using the predicted bladder outlet obstruction index clinicians can determine the risk of obstruction in individuals. In 65% of patients we predicted equivocal or worse obstruction with greater than 90% confidence.