Prospective comparison of the novel visual prostate symptom score (VPSS) versus the international prostate symptom score (IPSS), and assessment of patient pain perception with regard to transrectal ultrasound guided prostate biopsy.

OBJECTIVE: To compare the International Prostate Symptom Score (IPSS) and novel Visual Prostate Symptom Score (VPSS) in patients with lower urinary tract symptoms (LUTS), to correlate scores with uroflowmetry and prostate volume and assess patient perceptions regarding pain prior to, and after prostate biopsy. MATERIALS AND METHODS: Patients with LUTS who had an indication for transrectal ultrasound (TRUS) biopsy were included. Patients completed the IPSS-, VPSS- and prostate biopsy pain assessment questionnaires. Assessment included uroflowmetry, post- void residual volume and prostate volume (measured with TRUS). RESULTS: One hundred men were included. There were statistically significant correlations between the VPSS score and IPSS score (correlation coefficient (r) = 0.802); VPSS and Qmax (r = -0.311); VPSS and. Qave (r = -0.344); prostate volume with VPSS (r = 0.194) and Qmax (r = -0.260). The VPSS was quicker to complete than the IPSS (mean 100 vs. 165 seconds). The mean anticipated pain score before biopsy was 2.8 (range 0-6), and after biopsy (experienced pain) it was 1.8 (range 0-5). The pain during biopsy was less than expected in 67% of patients. CONCLUSION: In men with LUTS scheduled to undergo prostate biopsy, the VPSS score correlated positively with the IPSS score. Men with limited education take less time to complete the VPSS. Patient's perception of expected pain or discomfort during TRUSguided prostate biopsy was significantly higher than the pain actually experienced during biopsy. Men with lower education level had significantly higher expectation of pain prior to biopsy, but similar pain during biopsy.

Retroperitoneoscopic live donor nephrectomy: review of the first 50 cases at Tygerberg Hospital, Cape Town, South Africa.

BACKGROUND: Changing from an open to a laparoscopic live renal donor programme poses challenges and may affect donor and graft outcomes. OBJECTIVES: To evaluate donor safety and graft outcomes for the first 50 retroperitoneoscopic live donor nephrectomies performed at Tygerberg Hospital, Cape Town, South Africa. METHODS: The procedures were performed by a single surgeon from 8 April 2008 to 3 April 2012. Operative and anatomical data were prospectively collected. A flank approach with lateral and posterior placements was used. Vascular control was achieved with Hem-o-lok clips in the majority of cases. RESULTS: The mean age of the donors was 31.5 years (range 18 - 50), 28 (56.0%) were male, and the left kidney was harvested in 28 (56.0%) of cases. The mean operating time was 149.8 minutes (range 75 - 250), mean warm ischaemic time (WIT) 181.3 seconds (107 - 630), mean blood loss 139.7 ml (5 - 700) and mean hospital stay 3.2 days (2 - 5). Mean WIT was significantly longer for right-sided than left-sided nephrectomy (213 v. 162 seconds). In two right-sided cases the renal vein was too short and vena profunda femoris was used to create length. No donor received a blood transfusion. Comparing the last 25 with the first 25 cases showed a significant decrease in mean WIT (158 v. 204 seconds) and operating time (128 v. 172 minutes). No major complications occurred. CONCLUSION: Our initial 50 retroperitoneoscopic live donor nephrectomies were performed without major complications. Donor safety was maintained during the early learning curve of the transition to minimal-access donor nephrectomy.

Stents and stone disease.

The use of stents in renal stone disease is relatively new. The main advantage is reduced pressure in the renal collecting system during times of infected obstructed collecting systems, surgery or obstructing stones. As much pain relieve theses stents offer when indicated, equally much morbidity is caused when stent materials interface with the human urothelium in terms of symptoms, perforations and the "forgotten stent". This review aim to summarize some of the most important considerations when stents are used in stone disease.

Urinary tract infection associated with conditions causing urinary tract obstruction and stasis, excluding urolithiasis and neuropathic bladder.

PURPOSE: The aim of this study was to examine urinary tract infection (UTI) associated with conditions causing urinary tract obstruction and stasis, excluding urolithiasis and neuropathic bladder dysfunction. METHODS: An electronic literature search was performed using the key words urinary tract infection (UTI), benign prostatic hyperplasia (BPH), hydronephrosis, obstruction, reflux, diverticulum, urethra, and stricture. In total, 520 abstracts were reviewed, 210 articles were studied in detail, and 36 were included as references. RESULTS: It is one of the axioms of Urological practice that urinary tract obstruction and stasis predispose to UTI. Experimental studies indicate that, whereas transurethral inoculates of bacteria are rapidly eliminated from the normal bladder, urethral obstruction leads to cystitis, pyelonephritis, and bacteremia. BPH is, next to urolithiasis, the most common cause of urinary tract obstruction predisposing to UTI. Urethral stricture remains a common cause of UTI in many parts of the world. Urinary stasis in diverticula of the urethra or bladder predisposes to UTI. Experimental studies have shown that, whereas the normal kidney is relatively resistant to infection by organisms injected intravenously, ureteric obstruction predisposes to pyelonephritis. It also causes renal dysfunction which impairs the excretion of antibiotics in the urine, making eradication of bacteria difficult. CONCLUSIONS: In patients with UTI and urinary tract obstruction, targeted antibiotic treatment according to urine culture should be complemented with urgent drainage (bladder catheterization, percutaneous nephrostomy or ureteric stenting) followed by definitive surgery to remove the cause of obstruction or stasis once infection is under control.

Treatment of male urethral strictures - possible reasons for the use of repeated dilatation or internal urethrotomy rather than urethroplasty.

OBJECTIVE: To investigate the possible reasons for repeated urethral dilatation or optical internal urethrotomy rather than urethroplasty in the treatment of male urethral strictures. PATIENTS AND METHODS: Men referred to the stricture clinic of our institution during the period April 2007 - March 2008 were reviewed and the operative urological procedures performed in the same period were analysed. Statistical analysis was performed using Student's t-test and Fisher's exact test (p<0.05 statistically significant). RESULTS: The mean age of the 125 men was 49.9 years (range 12.8 - 93.4 years). Previous stricture treatment had been given 1 - 2, 3 - 4 and 5 - 6 times in 52%, 32% and 12% of patients, respectively (4% had not undergone treatment). In these groups, previous treatment was dilatation in 70%, 76% and 72%, urethrotomy in 26%, 15% and 28%, and urethroplasty in 4%, 9% and 0, respectively. The group with 5 - 6 compared with 1 - 2 previous treatments was significantly older (mean age 60.2 v. 46.6 years) and had a significantly greater proportion with underlying co-morbidities (80% v. 52%). The group that had undergone urethroplasty compared with 5 - 6 repeated dilatations or urethrotomies was significantly younger (mean age 48.2 v. 60.2 years) with a lower prevalence of co-morbidities (47% v. 80%). During the study period urethroplasty was performed in 16 (2%) of 821 inpatients, whereas 55 men were seen who had undergone ≥3 previous procedures, indicating that urethroplasty was performed in less than one-third of cases in which it would have been the optimal treatment. Owing to limited theatre time, procedures indicated for malignancy, urolithiasis, renal failure and congenital anomalies were performed more often than urethroplasty. CONCLUSIONS: Factors that possibly influenced the decision to perform repeated urethrotomy or dilatation instead of urethroplasty were limited theatre time, increased patient age and the presence of underlying co-morbidities.

Clamp ablation of the testes compared to bilateral orchiectomy as androgen deprivation therapy for advanced prostate cancer.

PURPOSE: Burdizzo clamp ablation of the testes (CAT) may provide an incisionless, cost-effective form of androgen deprivation therapy (ADT) in men with adenocarcinoma of the prostate (ACP) who find bilateral orchiectomy (BO) unacceptable or can not afford medical ADT. The aim of this study was to compare CAT with BO as primary ADT in men with ACP. MATERIALS AND METHODS: Written, informed consent was obtained from men with locally advanced or metastatic ACP. Patients were prospectively randomized to BO (n = 9) or CAT (n = 10) under local anaesthesia, and were evaluated 3 and 7 days, 6 weeks and 3 months post-procedure. The protocol was approved by the local institutional ethics committee. Statistical analysis was performed using Student's, Mann-Whitney's and Fisher's tests. RESULTS: Mean duration of the procedure was significantly longer for BO than CAT (16.9 vs. 10.9 minutes). Mean pain scores during and after the procedure did not differ significantly. Serum testosterone decreased significantly on days 3 and 7 after CAT, but increased at 6 weeks, and was significantly higher than after BO. Serum luteinizing hormone increased significantly from day 3 after BO and from day 7 after CAT. Serum prostate specific antigen decreased significantly after BO, but not after CAT. Minor complications were more common after BO (89%) than CAT (40%). In the 9 men who did not achieve castrate levels of testosterone after CAT, BO was performed. CONCLUSIONS: CAT was quicker to perform and had a lower complication rate, but was not as effective as BO in achieving castrate serum testosterone levels.

Comprehensive analysis of the cytokine-rich chromosome 5q31.1 region suggests a role for IL-4 gene variants in prostate cancer risk.

Although inflammation is emerging as a candidate prostate cancer risk factor, the T-helper cytokine-rich [interleukins (IL)-5, 13 and 4] chromosomal region at 5q31.1 has been implicated in prostate cancer pathogenesis. In particular, IL-4 has been associated with prostate cancer progression, whereas the IL-4 -589C>T (rs2243250) promoter variant has been associated with differential gene expression. We genotyped rs2243250 and 11 tag single-nucleotide polymorphisms (SNPs) spanning 200 kb across the 5q31.1 region on 825 cases and 732 controls from the Risk Factors for Prostate Cancer Study. The minor alleles of rs2243250 and an IL-4 tagSNP rs2227284 were associated with a small increase in prostate cancer risk. Per allele odds ratios (ORs) are 1.32 [95% confidence interval (CI) 1.08-1.61, P = 0.006] and 1.26 (95% CI 1.07-1.48, P = 0.005), respectively. Although these associations were not replicated in an analysis of the Melbourne Collaborative Cohort Study, including 810 cases and 1733 controls, no clinicopathological characteristic was implicated for this divergence. Correlating rs2243250 genotypes to IL-4 gene transcript levels and circulating IL-4 plasma levels, we observe in contrast to previous reports, a non-significant trend toward the minor T-allele decreasing the likelihood of IL-4 activity. From our observed association between a low IL-4 producing promoter T-allele and prostate cancer risk, our study suggests an antitumor role for IL-4 in prostate cancer. Although we saw no association for IL-5 or IL-13 gene variants and prostate cancer risk, our findings call for further evaluation of IL-4 as a contributor to prostate cancer susceptibility.

Retroperitoneal LESS donor nephrectomy.

Donor nephrectomy with laparo-endoscopic single site (LESS) surgery has been reported via the transperitoneal approach. We describe a novel technique of retroperitoneal donor nephrectomy using a single surgical incision in the groin, below the abdominal skin crease or "bikini line". The LESS groin incision offers superior cosmesis, while the retroperitoneal approach has distinct advantages, such as the ability to identify the renal vessels early. The new procedure has been performed in two obese patients (body mass index 32 and 33 kg/m2, respectively). The operative times were 4 and 5 hours, warm ischemic times 135 and 315 seconds, blood loss 100 and 250 mL, and hospitalization 3 and 2 days, respectively. Retroperitoneal LESS donor nephrectomy through a single, inconspicuous groin incision is feasible and safe. Further evaluation of the technique in a larger patient cohort is indicated.

Development of a computer assisted gantry system for gaining rapid and accurate calyceal access during percutaneous nephrolithotomy.

PURPOSE: To design a simple, cost-effective system for gaining rapid and accurate calyceal access during percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: The design consists of a low-cost, light-weight, portable mechanical gantry with a needle guiding device. Using C-arm fluoroscopy, two images of the contrast-filled renal collecting system are obtained: at 0-degrees (perpendicular to the kidney) and 20-degrees. These images are relayed to a laptop computer containing the software and graphic user interface for selecting the targeted calyx. The software provides numerical settings for the 3 axes of the gantry, which are used to position the needle guiding device. The needle is advanced through the guide to the depth calculated by the software, thus puncturing the targeted calyx. Testing of the system was performed on 2 target types: 1) radiolucent plastic tubes the approximate size of a renal calyx (5 or 10 mm in diameter, 30 mm in length); and 2) foam-occluded, contrast-filled porcine kidneys. RESULTS: Tests using target type 1 with 10 mm diameter (n=14) and 5 mm diameter (n=7) tubes resulted in a 100% targeting success rate, with a mean procedure duration of 10 minutes. Tests using target type 2 (n=2) were both successful, with accurate puncturing of the selected renal calyx, and a mean procedure duration of 15 minutes. CONCLUSIONS: The mechanical gantry system described in this paper is low-cost, portable, light-weight, and simple to set up and operate. C-arm fluoroscopy is limited to two images, thus reducing radiation exposure significantly. Testing of the system showed an extremely high degree of accuracy in gaining precise access to a targeted renal calyx.

Bladder cancer in Africa.

Accurate epidemiological data about the incidence and mortality of bladder cancer are unavailable for most African countries. Transitional cell carcinoma (TCC) of the bladder is probably less common in rural African regions than in industrialized countries, due to lower levels of exposure to carcinogenic chemicals. In areas with endemic schistosomiasis (bilharzia) caused by parasitic schistosomes (blood flukes), most bladder cancer cases are comprised of squamous cell carcinoma (SCC). However, with increased urbanization, industrialization, and cigarette smoking in many African countries, there is an increasing incidence of TCC relative to SCC of the bladder. SCC of the bladder presents in patients who are on average 10 to 20 years younger than those with TCC. In Egypt and other North African countries, SCC is more common in men (the male to female ratio ranges from 3:1 to 5:1), probably because boys and men performing agricultural work are more exposed to schistosomiasis-infested water. In some sub-Saharan countries, SCC of the bladder is equally common in men and women, probably due to equal schistosomiasis exposure of girls and boys, and because women obtain household water and perform most agricultural tasks. Although SCC of the bladder often presents at a locally advanced stage, the tumors are usually well differentiated, with a relatively low incidence of lymphatic and hematogenous metastases. Patients with localized SCC are ideal candidates for cystectomy and orthotopic neobladder construction, because they are relatively young and healthy, and there is no risk of urethral recurrence, unlike with TCC. Unfortunately, many patients in Africa still present with advanced and inoperable bladder cancer, and many do not have access to healthcare facilities that can provide a cure and a good quality of life by means of radical cystectomy and neobladder construction.

Bicalutamide (Casodex) 150 mg plus standard care in early non-metastatic prostate cancer: results from Early Prostate Cancer Trial 24 at a median 7 years' follow-up.

Trial 24, one of three ongoing trials in the Early Prostate Cancer programme, is evaluating the efficacy and tolerability of bicalutamide (Casodex) 150 mg following standard care (radiotherapy, radical prostatectomy or watchful waiting) in patients with early, non-metastatic prostate cancer. At 7 years' median follow-up, addition of bicalutamide significantly improved objective progression-free survival (PFS) for patients with locally advanced disease, reducing the risk of progression by 34% versus standard care alone (hazard ratio 0.66; 95% confidence interval 0.55, 0.79; P<0.001). In localized disease, a significant difference in objective PFS was not found. There was no significant difference in overall survival.

Bicalutamide ('Casodex') 150 mg in addition to standard care in patients with nonmetastatic prostate cancer: updated results from a randomised double-blind phase III study (median follow-up 5.1 y) in the early prostate cancer programme.

Trial 24 is one of three placebo-controlled trials within the ongoing bicalutamide ('Casodex') Early Prostate Cancer (EPC) programme evaluating bicalutamide 150 mg/day in addition to radical prostatectomy, radiotherapy or watchful waiting for T1b-4, any N, M0 prostate cancer. In Trial 24, at 5.1 y median follow-up, the addition of bicalutamide significantly (P < 0.0001) improved objective progression-free survival (PFS) and prostate-specific antigen PFS compared with standard care alone. There was no significant difference in overall survival (P = 0.746). In the context of the whole EPC programme, long-term bicalutamide is not appropriate for localised disease, yet provides advantages in delaying disease progression in patients with locally advanced prostate cancer.

A true hermaphrodite with some unusual features.

A fifteen-month-old boy with ambiguous external genitalia was found to have a 46XX karyotype, an ovotestis in the right labioscrotal fold, and an absent left gonad. He also had a rudimentary uterus and fallopian tubes and a blind-ending vagina lined with squamous epithelium. These features are compared with those more commonly found in true hermaphroditism.

Luteinizing hormone, follicle-stimulating hormone, testosterone and dihydrotestosterone during testicular descent in the pig fetus.

To investigate the relationship between gonadotrophins, androgens and testicular descent in the pig fetus, serum concentrations of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), and serum concentrations and testicular content of testosterone (T) and 5 alpha-dihydrotestosterone (DHT) were determined by radioimmunoassay in 95 fetuses (48 males, 47 females) between Day 60 and Day 90 post coitum (p.c.). The testes were descended in 0% of fetuses at Day 60, 8% of fetuses at Day 70, 40% of fetuses at Day 80 and 87% of fetuses at Day 90 p.c. There was a significant increase in mean serum concentrations of LH in both male and female fetuses from Day 60 to Day 90, with a significant difference in mean serum concentrations of LH between male fetuses with a body mass < 350 g (4% of testes descended) and those with a body mass > 450 g (87% of testes descended), but not between male and female fetuses < 350 g or > 450 g in body mass. There was no significant difference in mean serum concentrations of FSH between male and female fetuses. Mean serum concentrations of T were significantly higher in male fetuses at Day 60 than in those at Days 70-90, with no significant difference in serum concentrations of DHT from Day 60 to Day 90 p.c. Testicular content of T and DHT showed a non-linear increase from Day 60 to Day 90 p.c. Although the serum concentration of T is elevated before, and decreased during, the period of descent, the testicular content of T and DHT increases during the period of descent, indicating that serum concentrations of LH and FSH may have an indirect effect on descent by stimulating testicular androgen synthesis.

Surgical complications of radical cystectomy in a teaching hospital.

We reviewed the surgical complications in 112 consecutive patients who had undergone radical cystectomy for bladder cancer at Tygerberg Hospital between 1978 and 1989. The cystectomies were performed by a total of 16 surgeons, of whom 1 (A) performed 30 and assisted at 2, 1 (B) performed 26 and assisted at 4, 2 (C + D) performed 27 and assisted at 16, and 12 (E-P) performed 29 and assisted at 46. Pre-operative radiotherapy was given in 37% of cases and intravesical chemotherapy in 25%. Major coexisting medical problems were present in 60%. The overall peri-operative mortality rate was 11%, but the rate was significantly lower (3%) in the group of patients operated on by surgeon A than in those operated on by surgeons E-P (21%). Major early postoperative complications occurred in 17% of the patients and major late complications in 25%. There were no significant differences between the different surgical groups in early and late complication rates. Peri-operative mortality and major early complications were significantly increased in patients aged over 71 years compared with those aged under 60 years. Peri-operative mortality was significantly increased in patients who had not received pre-operative radiotherapy compared with those who had done so. The presence of major coexistent medical problems did not significantly affect the rates of peri-operative mortality or major early or late surgical complications. Peri-operative mortality was lower in patients with T0-1 tumours than in those with T2-4 tumours, but the stage did not affect the incidence of major early or late surgical complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Infiltrating transitional cell carcinoma of the bladder--treatment results.

This is a review of the treatment results of 100 consecutive patients with infiltrating transitional cell carcinoma of the bladder who underwent cystectomy at Tygerberg Hospital between 1978 and 1989. Radiotherapy was given pre-operatively in 39% and postoperatively in 15%, and systemic chemotherapy was used postoperatively in 12% of the patients. Follow-up was available in 81% of patients, with a mean of 40.8 months (range 1-145 months). The estimated overall 5-year survival rate was approximately 70%, which compares favourably with the 5-year survival rate reported in other series of transitional cell bladder carcinoma treated with radical cystectomy (30-82%). There was a statistically significant decrease in overall 5-year survival in patients with more locally advanced tumours, and in patients with a higher pathological stage relative to clinical tumour stage (upstaging) than in those with a lower pathological stage relative to clinical tumour stage (downstaging). There was no statistically significant difference in overall survival between patient groups aged < 60 and > 70 years, between patients with and without pre-operative radiotherapy, between groups with different tumour grades, between those with and without carcinoma in situ, and between those with and without pelvic lymph node metastases.

Outpatient treatment for male urethral strictures--dilatation versus internal urethrotomy.

Male patients with proven urethral strictures (total 210) were prospectively randomised to undergo either dilatation (106 patients) or internal urethrotomy (104 patients) as an outpatient procedure under local anaesthesia. The incidence of complications or failure during the performance of the procedure did not differ significantly between the two treatment groups. Complications or failure in performing urethral dilatation were significantly more common in patients who presented with retention or complications compared with symptoms only, and in those with a positive compared with negative urine cultures. Complications or failure in performing internal urethrotomy were significantly more common in patients with a positive than with a negative urine culture, and long (> 2 cm) rather than short (< 2 cm) strictures, whereas the difference approached significance for patients with multiple rather than single strictures (P = 0.06). Failure alone in the performance of internal urethrotomy was significantly more common in patients with trauma compared with urethritis as aetiology, and in those without previous stricture treatment. With a mean follow-up of 15 months the cumulative percentage of recurrent urethral strictures did not differ significantly between the two treatment groups. We conclude that urethral dilatation and optical internal urethrotomy under local anaesthesia are equally successful as initial outpatient treatment. With regard to successful performance of the procedure itself, multiple, longer (> 2 cm), post-traumatic, and previously untreated strictures are better managed with dilatation, whereas patients with complications or retention are better managed with internal urethrotomy. A positive urine culture is associated with a higher complication and failure rate in the performance of both procedures.

Vesicosuspension for female stress incontinence and cystocele using pubic bone anchors.

OBJECTIVE: The purpose of this study was to evaluate the results of vesicosuspension for female stress incontinence and cystocele using fixation with pubic bone anchors in a cohort of patients operated on by a single surgeon. METHODS: Using a standard questionnaire, an independent female interviewer not employed by the surgeon's practice contacted 100 consecutive patients with stress incontinence and/or cystocele who had undergone vesicosuspension using suprapubic fixation with bone anchors between October 1996 and July 1997. The patients' responses were recorded on a computerised database and analysed. All procedures were performed by a single surgeon (A.J.V.). The duration of the operation was normally 45 minutes, the patient was mobilised on day 3 postoperatively, and the catheter removed on day 7. RESULTS: The mean age of the 100 women was 50.4 years (range 26-84 years) and the mean follow-up was 11 months (range 1.4-19 months). Previous operations for incontinence had been performed in 44 patients. Preoperatively 56 patients had to wear protective pads, using an average of 4.4 pads per day, and 36 had to change underwear because of urine leakage. Postoperatively 14 patients had to wear protective pads, using an average of 3.5 pads per day, while 11 had to change their underwear because of urine leakage. Only 3 patients used a catheter to empty the bladder, 2 used medication for incontinence, and none had had a subsequent operation for urine leakage. Postoperatively 16 patients reported having problems with pain in the pelvis, and 6 had pain during intercourse, but there were no cases of osteitis pubis. Subjective improvement reported by the patients was 93% on average, and overall patient satisfaction with the procedure was 8.6 on a scale of 0-10. In total, 89 patients said they would be prepared to undergo the operation again, while 92 would recommend it to a friend. CONCLUSION: The use of pubic bone anchors for colposuspension is safe and reliable, with results comparable to those of other methods, and the added advantages of faster mobilisation and few short-term complications.

Prostate carcinoma--the value of T stage and grade in predicting metastases and prognosis. A cost-effective approach to clinical staging.

In order to evaluate the initial T stage and tumour grade as predictors of metastatic disease and prognosis in adenocarcinoma of the prostate, 963 patients were reviewed. Of the patients, 41% presented with metastatic disease. Stage T4 tumours were associated with a consistently poor prognosis, and 70% of such patients had demonstrable distant metastases. No patient with TOf local disease had metastases or died of prostate cancer during follow-up. The incidence of metastases was also low in stages T1 and T2. High tumour grade correlated strongly with more advanced disease. Using this information a more cost-effective approach to the staging of prostate carcinoma is proposed.