Prospective study comparing video-endoscopic radical inguinal lymph node dissection (VEILND) with open radical ILND (OILND) for penile cancer over an 8-year period.

OBJECTIVE: To compare the complications and oncological outcomes between video-endoscopic inguinal lymph node dissection (VEILND) and open ILND (OILND) in men with carcinoma of the penis. PATIENTS AND METHODS: A prospectively collected institutional database was used to determine the outcomes in 42 consecutive patients undergoing ILND between 2008 and 2015 in a centre for treating penile cancer. Before 2013 all procedures were OILNDs. Since 2013 we have performed VEILND on all patients in need of ILND. The wound-related and non-wound-related complications, length of stay, and oncological safety between OILND and VEILND groups were compared. The mean duration of follow-up was 71 months for OILND and 16 months for the VEILND groups. RESULTS: In the study period 42 patients underwent 68 ILNDs (OILND 35, VEILND 33). The patients' demographics, primary stage and grade, and indications were comparable in both groups. There were no intraoperative complications in either group. The wound complication rate was significantly lower in the VEILND group at 6% compared to 68% in the OILND group. Lymphocoele rates were similar in both the groups (27% and 20%). The VEILND group had a better or the same lymph node yield, mean number of positive lymph nodes, and lymph node density confirming oncological safety. There were no groin recurrences in either group of patients. VEILND significantly reduced the mean length of stay by 4.8 days (P < 0.001). CONCLUSION: VEILND is an oncologically safe procedure with considerably low morbidity and reduced length of stay, at a mean (range) follow-up of 16 (4-35) months.

Is routine urine cytology useful in the haematuria clinic?

INTRODUCTION: The objective of this study was to determine the value of routine urine cytology in the initial evaluation of patients presenting to a one-stop haematuria clinic. PATIENTS AND METHODS: A total of 1000 consecutive patients who attended the haematuria clinic between June 2003 and November 2004 were studied prospectively. A standard protocol was used to investigate these patients. This included urine cytology, upper tract imaging and flexible cystoscopy. RESULTS: Overall, 986 samples of urine were sent for cytology. In 126 patients, the report was abnormal; of these, 71 patients were found to have bladder transitional cell carcinoma by flexible cystoscopy and a further 3 had upper tract transitional cell carcinoma diagnosed radiologically. The remaining 52 patients with abnormal cytology were not found to have cancer on further investigations. The total cost for urine cytology and additional investigations was pound50,535. CONCLUSIONS: In this study of the initial evaluation of patients with haematuria, no case of urothelial malignancy was diagnosed on the basis of urine cytology alone. Therefore, urine cytology need not be used routinely in the initial diagnostic work-up for haematuria.

Identification of degradome components associated with prostate cancer progression by expression analysis of human prostatic tissues.

Extracellular proteases of the matrix metalloproteinase (MMP) and serine protease families participate in many aspects of tumour growth and metastasis. Using quantitative real-time RT-PCR analysis, we have undertaken a comprehensive survey of the expression of these enzymes and of their natural inhibitors in 44 cases of human prostate cancer and 23 benign prostate specimens. We found increased expression of MMP10, 15, 24, 25 and 26, urokinase plasminogen activator-receptor (uPAR) and plasminogen activator inhibitor-1 (PAI1), and the newly characterised serine proteases hepsin and matriptase-1 (MTSP1) in malignant tissue compared to benign prostate tissue. In contrast, there was significantly decreased expression of MMP2 and MMP23, maspin, and the protease inhibitors tissue inhibitor of metalloproteinase 3 (TIMP3), TIMP4 and RECK (reversion-inducing cysteine-rich protein with Kazal motifs) in the cancer specimens. The expression of MMP15 and MMP26 correlated positively with Gleason score, whereas TIMP3, TIMP4 and RECK expression correlated negatively with Gleason score. The cellular localisation of the expression of the deregulated genes was evaluated using primary malignant epithelial and stromal cell cultures derived from radical prostatectomy specimens. MMP10 and 25, hepsin, MTSP1 and maspin showed predominantly epithelial expression, whereas TIMP 3 and 4, RECK, MMP2 and 23, uPAR and PAI1 were produced primarily by stromal cells. These data provide the first comprehensive and quantitative analysis of the expression and localisation of MMPs and their inhibitors in human prostate cancer, leading to the identification of several genes involved in proteolysis as potential prognostic indicators, in particular hepsin, MTSP1, MMP26, PAI1, uPAR, MMP15, TIMP3, TIMP4, maspin and RECK.

Banking of fresh-frozen prostate tissue: methods, validation and use.

OBJECTIVE: To describe the establishment, methods, validation and use of a bank of fresh-frozen human prostate tissue. MATERIALS AND METHODS: On obtaining informed patient consent, protocols were followed for banking prostate tissue from any type of prostatectomy or cystoprostatectomy. A pseudobanking procedure was devised to determine the accuracy of assessing the histopathological status of the banked tissue. RNA was extracted, its quality assessed and used for quantitative real-time reverse transcription-polymerase chain reaction for the serine protease hepsin. RESULTS: To date prostate tissue from 112 patients has been banked, with pseudobanking in 58. The histopathological assessment showed pseudobanked tissue matched adjacent unbanked tissue in 98% of cases for benign vs malignant diagnoses, and in 92% of carcinomas for the Gleason score. Hepsin expression was significantly higher in malignant than in benign tissues (P < 0.0001). CONCLUSION: We established a validated method for banking human fresh-frozen prostate tissue and applied it successfully. Hepsin expression can be used to differentiate malignant and benign prostate tissue, and as an indicator of tissue heterogeneity.

Differential expression of the ccn3 (nov) proto-oncogene in human prostate cell lines and tissues.

AIMS: To investigate the expression of the human ccn3 (hccn3; nov) proto-oncogene, a member of the CCN family of proteins, in prostate epithelial cells and prostate tissue samples. METHODS: Normal adult prostate luminal epithelial cells immortalised by SV40 large T (PNT1A and PNT1B), metastatic tumours (LNCaP, DU-145, and PC-3), and prostate tissue samples from patients with benign prostatic hyperplasia (BPH) and prostatic adenocarcinoma were used. hccn3 (nov) mRNA was measured by the reverse transcription polymerase chain reaction (RT-PCR) and hCCN3 (NOV) protein expression was determined by immunochemistry. RESULTS: hccn3 (nov) RNA values were higher in PC-3 cells than in the other prostate cell lines. The immortalised normal cell lines either did not express hccn3 (nov) RNA (PNT1B) or expressed very low amounts (PNT1A). BPH samples expressed variable amounts of hccn3 (nov) RNA. With the use of immunocytochemistry, all cell lines except PNT1A and PNT1B were shown to contain hCCN3 (NOV) protein. hCCN3 (NOV) was localised mainly in the epithelial compartment of BPH and adenocarcinoma samples, and there was evidence of luminal secretion. CONCLUSION: The overexpression of hccn3 (nov) RNA in cancer cell lines compared with other cell lines and its epithelial localisation in human prostate samples are consistent with a role for hCCN3 (NOV) in prostatic tumorigenesis.

Surgical technique for the conservative management of distal urethral melanoma.

Urethral melanoma is very rare and pathological diagnosis is important. The prognosis remains poor irrespective of the treatment modality. Rare cases of long-term survival have been reported, one of them following conservative management. An initial attempt at conservative resection is worth considering to offer a better quality of life to the patient for as long as possible. We describe a technique of organ-sparing resection in the management of urethral melanoma along with the follow-up protocol that we adapted.

Imaging assessment of uncomplicated bladder outflow obstruction.

To assess the impact of the use of plain X-ray films and ultrasound examinations on clinical decision-making in patients referred with symptoms of bladder outflow obstruction. Patients with symptoms of bladder outflow obstruction were recruited prospectively. After clinical assessment they underwent standard investigations of plain X-ray of the kidneys, ureters and bladder, and upper and lower urinary tract ultrasound. A management decision was made on the basis of all results. These decisions were then reviewed with specific reference to radiological findings to assess the role of imaging in the decision-making process. A total of 320 men were recruited for the study. X-ray of the kidneys, ureters and bladder detected 10 upper tract calculi, none of which has required active intervention to date. Four bladder calculi were detected. Two of these were also seen on ultrasound scan: one was small and insignificant, the other had caused microscopic haematuria, necessitating cystoscopy regardless of the X-ray findings. Upper tract ultrasound revealed abnormalities and anatomical variants which did not affect management. Four patients had upper tract dilatation but these had already had surgery planned on the basis of other investigations, including residual urine volume determination by lower tract ultrasound. Lower urinary tract ultrasound should be the only routine imaging used in the initial assessment of patients with bladder outflow obstruction, with consequent implications of reduced patient stress and reduced investigation cost.

Maximisation of the erectile response in the investigation of impotence.

UNLABELLED: The aim of this study was to assess whether redosing with a combination of intracavernosal (IC) vasoactive agents could produce a complete erectile response, thereby providing a reliable and reproducible method of dynamic investigation of erectile dysfunction. Forty-one impotent men were redosed with a combination intracavernosal agents until a constant penile rigidity was achieved. They were then shown audiovisual sexual stimulation (VES) by means of a videotape. The erectile responses were monitored continuously by RigiScan (Dacomed). RESULTS: Despite a constant rigidity with intracavernous injection (ICI), 16 men (39%) still had an improved response with VES that was clinically detectable. CONCLUSION: Dynamic investigation of erectile dysfunction with a combination and redosing of IC agents may still lead to an incomplete erectile response. This may potentially lead to patients being incorrectly labelled and confirms the limitations of follow-up studies using dynamic tests of erectile function.

Morning vs evening dosing with doxazosin in benign prostatic hyperplasia: efficacy and safety.

Three hundred and fifty-three patients with symptomatic benign prostatic hyperplasia were randomized to doxazosin or placebo, with morning or evening dosing, to compare the effect of dosing time on the efficacy and safety of doxazosin treatment. After 24 weeks of treatment, the mean International Prostate Symptom Score had decreased by 6.8 units in the doxazosin group compared with 4.5 units in the placebo group (P=0.003). Improvements in Q(max) of 2.03 ml/s and 0.30 ml/s were seen for the doxazosin and the placebo groups, respectively (P<0.001). No differences in efficacy or safety between the morning- and evening-dosed subgroups were observed. Doxazosin was significantly more effective than placebo at improving symptoms of BPH and urinary flow rates at endpoint, and was well tolerated. The time of dosing did not appear to influence the efficacy or safety of doxazosin, suggesting that there is no need to restrict administration of doxazosin to the evening in BPH patients.

Reproducibility of penile arterial colour duplex ultrasonography.

OBJECTIVE: To assess the reproducibility of penile arterial colour duplex ultrasonography (CDU) in patients with impotence. PATIENTS AND METHODS: Fifty-eight patients underwent CDU of their penile arteries on two occasions 2 weeks apart. Group A (n = 34) received 60 mg of papaverine intracavernosally before CDU and group B (n = 24) received a combination of papaverine, prostaglandin E1 and phentolamine. The variables measured during CDU were peak systolic velocity (PSV) and the end diastolic velocity (EDV), with the systolic rise-time (SRT) also recorded in group B. RESULTS: In both groups of patients the reproducibility between the first and second recordings was poor for all variables. The mean variation in PSV was 31.5% and 40.2%, and in EDV was 44.9% and 50.1%, for groups A and B, respectively. For the SRT, measured only in group B, the mean variation was 25.7%. CONCLUSIONS: These results show that CDU is a poorly reproducible technique for assessing vascular status in patients with impotence. Therefore, it is not reliable in the long-term follow-up of patients and single measurements should be interpreted with caution.

Erectile function following transurethral prostatectomy.

OBJECTIVE: To determine the true incidence and possible aetiology of impotence following transurethral prostatectomy. PATIENTS AND METHODS: Over a 9-month-period 268 patients who were about to undergo transurethral prostatectomy were interviewed about their sexual function. Full details of each operation were recorded including size of prostate, operative time, grade of surgeon and the occurrence of capsular perforation. The interviews were repeated by letter or telephone 3 months after operation. RESULTS: Of the 268 men interviewed, 246 (91.8%) were suitable for inclusion in the study. Pre-operatively, 137 (55.7%) were fully potent, 43 (17.5%) could achieve a partial erection and 66 (26.8%) were impotent. Of the fully potent patients, 20 (14.6%) became partially potent and four (2.9%) became impotent post-operatively. Of those who were partially potent before operation, 16 (37.2%) became impotent post-operatively. Overall, the risk of impotence was 28.1% if the prostate capsule was breached at operation but only 10.0% if it was not (P < 0.01). CONCLUSION: In fully potent men the risk of impotence after transurethral prostatectomy is fairly low, but it is higher in men who already have a degree of erectile failure. The risk of impotence is related to the incidence of capsular perforation at the time of surgery.

Gangrenous cystitis: case report and review of the literature.

A case of gangrenous cystitis in a 67-year-old woman is reported. Associated etiological factors include invasive recurrent carcinoma of the cervix, radiotherapy and atherosclerosis. Primary infection was not a feature. The patient was treated with antibiotics, bladder drainage and total cystectomy with complete recovery. The etiology and management of this unusual condition are discussed.

The role of colour duplex ultrasonography in the diagnosis of vasculogenic impotence.

Colour duplex ultrasonography was used to obtain peak systolic velocity (PSV) readings from cavernosal arteries at rest and during papaverine-induced tumescence. Results from 31 men with vasculogenic impotence were compared with those from 17 men with non-vasculogenic impotence and a control group of 6 potent men. In the flaccid state no significant differences in PSV readings were found between the vasculogenic and control groups. Following the injection of papaverine, men from the vasculogenic group without venous leakage were alone in having significantly lower PSV readings compared with the potent controls. All 23 men with normal penile haemodynamics had a mean PSV greater than or equal to 20 cm/s during tumescence. This was also the case for 19 (61%) of the vasculogenic group, including 9 (69%) of the 13 patients with venous leakage. The remaining 12 men in the vasculogenic group (39%) had a mean PSV less than 20 cm/s, this being diagnostic of an inadequate arterial inflow. Colour duplex ultrasonography can identify patients who have marked arterial insufficiency as the major cause of their impotence and hence allows more rational selection for angiography and revascularisation. Lesser degrees of arterial deficit are difficult to characterise using mean PSV readings alone.

Urodynamic study of ileocystoplasty in the treatment of idiopathic detrusor instability.

Enterocystoplasty is being used with increasing frequency in the treatment of patients with idiopathic detrusor instability. We have performed a prospective clinical and urodynamic study of this procedure in 11 patients using both conventional (CMG) and ambulatory monitoring techniques (AM). Nine of 11 patients were satisfied with the symptomatic outcome, but 7 relied on clean intermittent self-catheterisation (CISC) to achieve a good result. Urodynamic studies demonstrated a significant increase in residual urine volume from 48 +/- 72 ml before to 347 +/- 298 ml after operation, but there was only a small and statistically insignificant increase in cystometric capacity. Detrusor instability, present before operation in all patients, could still be demonstrated in over half of them after operation. However, a significant decrease in the severity of instability was found after operation as assessed by an increased volume at first unstable contraction. The bladder volume before operation at which the first unstable contraction occurred was smaller in those who still had persistent instability after enterocystoplasty compared with those in whom instability could not be identified after operation. These results suggest that all patients about to undergo ileocystoplasty should be trained in the use of CISC. In selected patients with idiopathic detrusor instability refractory to other treatment, this procedure can yield satisfactory results.

An animal model of non-obstructive bladder instability.

Eight minipigs with proven normal bladder function have undergone a circumferential supratrigonal bladder transection. Urodynamic studies were performed before, and at various times up to eight months after operation. Over the same period biopsies were taken for physiological and histological studies. By three weeks after transection all animals had developed bladder instability, the abnormal contractions being maintained for the duration of the study. Concomitant with this change was the development, in vitro, of a non-specific detrusor smooth muscle supersensitivity similar to that which occurs in obstructed animals. By contrast with the latter group there was, however, no loss of cholinergic nerve from the transected bladder muscle. The transected (decentralised) minipig may be a useful model for the study of bladder instability not associated with outflow obstruction. The findings suggest that anatomical denervation is not a prerequisite for unstable contractions although a functional loss of nerve may be of importance. Supersensitivity, however, appears to occur in both obstructed and nonobstructed instability.