Effects of psychological stress on male fertility.

Psychological stress can be defined as any uncomfortable 'emotional experience' accompanied by predictable biochemical, physiological and behavioural changes or responses. Many clinical studies looking at the effects of psychological stress on male fertility have shown that stress is associated with reduced paternity and abnormal semen parameters. Enough scientific evidence exists to suggest that psychological stress could severely affect spermatogenesis, mainly as a result of varying testosterone secretion. The hypothalamic-pituitary-adrenal axis has a direct inhibitory action on the hypothalamic-pituitary-gonadal (HPG) axis and Leydig cells in the testes. The newly discovered hormone, gonadotropin-inhibitory hormone (GnIH), also has an inhibitory effect on the HPG axis. Inhibition of the HPG axis results in a fall in testosterone levels, which causes changes in Sertoli cells and the blood-testis barrier, leading to the arrest of spermatogenesis. Germ cells also become vulnerable to gonadotoxins and oxidation. However, the extent and severity of the effects of psychological stress on human testes is difficult to study and data mostly come from animal models. Despite this limitation, stress as a causative factor in male infertility cannot be ignored and patients should be made aware of its effects on testicular function and fertility and helped to manage them.

Management of non-muscle-invasive (superficial) bladder cancer.

Non-muscle-invasive (superficial) bladder cancer (NMIBC) represents 80% of incident cases of bladder cancer, and is characterized by a generally good prognosis, with a tendency to remain localized. Only 10%-20% of cases progress to invasion and/or metastasis. The biggest problem in management is the potential for local recurrence, and this will occur with relatively predictable prognostic determinants. Gene expression and other cell surface determinant are associated with outcome. In most cases, successful management is predicated on careful history taking and physical assessment, meticulous endoscopic assessment, and transurethral resection of bladder tumor tissue where indicated. Histology determines the potential for recurrence. Options of treatment include repeat resection, immunologic therapy via intravesical instillation, and the use of intravescally administered cytotoxic agents, including mitomycin C, doxorubicin, gemcitabine, and selected investigational compounds. Of importance, as some cases have the potential to invade and metastasize, timing of cystectomy for recurrent, high-risk tumors is important to avoid unnecessary morbidity and mortality.

Radical prostatectomy--too soon to abandon the perineal approach?

Perineal radical prostatectomy (PRP) is one of the oldest surgical procedures for prostate cancer, but its use has declined over the past 30 years. New studies show that PRP is not only minimally invasive but beneficial from an economic perspective and should not yet be abandoned in the treatment of early prostate cancer.

Clinical management of chronic testicular pain.

AIM: To review the causes and principles and recent concepts in the management of testicular pain. INTRODUCTION: Chronic testicular pain is a common presenting symptom in genitourinary surgery. Due to increased awareness of testicular cancer and in men's health more cases are likely to be referred. MATERIAL AND METHODS: A literature search was made for abstracts, original papers and review articles in the Cochrane Database, Medline and medical textbooks using the words 'testicular pain' and orchialgia to find the causes and mechanisms of testicular pain. The management and algorithm have been structured on evidence-based management strategies. RESULTS: The management of chronic testicular pain remains essentially based on clinical assessment. In recent years there have been advances in the non-surgical management of testicular pain mainly because of the emergence of pain relief as a specialty. However, in some cases pain control is a problem and may ultimately conclude with orchiectomy. CONCLUSIONS: The management of chronic testicular pain includes a careful assessment of testicular and extratesticular causes. Relief of symptoms is not always possible and gaining an insight into the patient's concerns and empathizing with their condition is paramount in helping them cope with their symptoms. Surgery should not be undertaken lightly for there is no guarantee that there will always be resolution of symptoms and the patient should be counseled accordingly.

Tamsulosin MR and OCAS (modified release and oral controlled absorption system): current therapeutic uses.

BACKGROUND: Although tamsulosin is mainly used to treat lower urinary tract symptoms secondary to benign prostatic hyperplasia, with better understanding of functional anatomy and distribution of alpha(1) receptors, it is also indicated in other conditions of genito-urinary tract in both men and women. OBJECTIVE: To detail the therapeutic use and clinical effects of tamsulosin. METHODS: The scope of the review was related to tamsulosin and its therapeutic application in conditions of genitourinary tract. Publications were searched from Pubmed and Medline from 1975 to 2007 using the search words tamsulosin, lower urinary tract symptoms, alpha receptors and blockers. CONCLUSIONS: The management of benign prostatic hyperplasia was transurethral resection of prostate until simpler and alternative treatments were tried in the last two decades, particularly alpha(1) adrenoceptor-blocking agents. Tamsulosin is a potent, third-generation selective alpha(1A) adrenoceptor-blocking agent.

Management of post-radical prostatectomy anastomotic stricture by endoscopic transurethral balloon dilatation.

OBJECTIVE: Anastomotic strictures are seen more commonly with increasing treatment of prostate cancer by means of radical prostatectomy. In view of the proximity to the sphincter, anastomotic strictures need careful management to avoid making the patient incontinent. We describe our experience with a novel method. MATERIAL AND METHODS: Nine patients who had developed anastomotic strictures were treated with endoscopic transurethral balloon dilatation. A catheter was left in place for 24 h postoperatively. RESULTS: Eight patients were treated successfully and remained well after a median follow-up period of 33 months. There were no complications and all patients remained continent. CONCLUSION: This is a safe and effective procedure that should be used as a first-line treatment for the management of anastomotic strictures, with transurethral incision being reserved for non-responders.

Assessing the size and stage of testicular germ cell tumours: 1984-2003.

OBJECTIVE: To assess the size and stage of testicular tumours on presentation in the period 1984-2002. PATIENTS AND METHODS: Demographic details and information on staging on 550 patients treated at St. Bartholomew's and the Royal London Hospital in the period 1984-2002 were collected prospectively in the departmental database. Information on testicular size was obtained by reviewing the histopathology records, and the maximum dimension of the tumour as measured in the gross specimen was taken as the size of the testicular tumour. RESULTS: The period 1984-2002 was divided into three intervals, i.e. 1984-95, 1996-98 and 1999-2002. The mean testicular tumour size in the three intervals decreased from 4 cm (162 tumours) to 3.2 cm (85) and 2.5 cm (72; P = 0.002, Student's t-test). The proportion of tumours of <2 cm on presentation also increased, from 11% to 14% and 23% in the three intervals, respectively, while the proportion of patients with stage 1 disease increased from 57%, to 63% and 77%, respectively. CONCLUSIONS: The size of testicular tumours on presentation has shown a consistent decline in the last two decades, the mean size now being 2.5 cm. That 23% are now <2 cm raises the possibility of testis-preserving surgery in this young group of patients, who have an excellent prognosis, and therefore in the long-term issues such as psychological morbidity and natural fertility assume greater importance. There is a need for a randomized controlled trial to evaluate these issues.

Assessment of tumor invasion of the vena caval wall in renal cell carcinoma cases by magnetic resonance imaging.

PURPOSE: We evaluated the role of magnetic resonance imaging (MRI) in patients with renal cancer and inferior vena caval involvement with reference to its ability to characterize the extent and nature of inferior vena caval tumor extension and wall invasion. MATERIALS AND METHODS: The study included 12 consecutive patients with renal cancer and inferior vena caval involvement. All patients underwent imaging on a 1.5 Tesla MRI unit. Coronal, axial T1 and axial T2-weighted images were performed in all cases, while in 6 3-dimensional gadolinium enhanced magnetic resonance angiography and venography were also performed. Images were assessed for the extent and nature of tumor extension, that is tumor versus thrombus, and invasion of the inferior vena caval wall. Imaging results were compared with operative findings. RESULTS: On MRI the extent and nature of the inferior vena caval tumor was correctly defined in all cases. The sensitivity, specificity and accuracy of inferior vena caval wall invasion were 100%, 89% and 92%, respectively. CONCLUSIONS: In patients with renal cancer and inferior vena caval involvement MRI defines the tumor level in the inferior vena cava. It is also a sensitive technique for detecting vessel wall invasion and provides important preoperative information for surgical planning.