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Priapism is defined as a full or partial erection lasting greater than 4 h due to a fault in the normal detumescence mechanism of the penis. We describe the case of a confused 73-year-old gentleman presenting with painless priapism, a 2 cm non-tethered lesion in the scrotum and a vague palpable pelvic mass. On the presumption that this was a case of high-flow non-ischaemic priapism secondary to pelvic malignancy, the urology registrar attempted corporal body aspiration. Clear fluid was aspirated and the penis became flaccid instantly. A CT scan performed to determine the presence of a pelvic mass, revealed a penile prosthesis and artificial reservoir. While iatrogenic penile prosthesis malfunctions are well established in the literature, a case managed as an acute priapism is yet to be reported. This case teaches us the importance of taking an adequate medical history and clinical examination prior to formulating a diagnosis and administering treatment.
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Prótese de Pênis , Priapismo , Urologia , Idoso , Humanos , Masculino , Ereção Peniana , Pênis/patologia , Priapismo/diagnóstico por imagem , Priapismo/etiologiaRESUMO
INTRODUCTION: Different techniques are used in open partial nephrectomy (OPN) for localized renal cancer, with variable impact on renal function. Regional renal ischemia technique by using different clamps and without the need to occlude renal vessels is gaining popularity. In our study, we present the largest international series; and the first in the United Kingdom; describing OPN using soft bowel clamp. We study the impact of this regional ischemia innovative technique on renal function, postoperative complications and oncological outcomes. MATERIALS AND METHODS: We retrospectively analyzed the first 100 OPN cases done between 2001 and 2011. All available data on the hospital databases were analyzed; recording patient demographics, tumor characteristics, operative procedure details, histopathology results and long term follow up. RESULTS: A direct comparison with other studies that have used different clamps to achieve regional ischemia was performed. Our technique has the advantage of being used for interpolar and hilar/central tumors. Our mean tumor size was higher at 4.1 cm. Our positive margin rate for malignant tumors was comparable with other studies, same for mean operative time and hospital stay. None had significant deterioration in renal function that required renal replacement therapy. Median blood loss was 400 mL. Our series has the advantage of showing the long term follow up data. CONCLUSION: We believe the technique we have developed using soft bowel clamp to produce regional renal ischemia is practical and successful. It can be applied safely in all OPN cases, with excellent oncological outcome and clinically acceptable renal function preservation.
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Isquemia , Neoplasias Renais/cirurgia , Rim/irrigação sanguínea , Rim/cirurgia , Nefrectomia/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Artéria Renal/fisiopatologia , Estudos Retrospectivos , Instrumentos Cirúrgicos , Resultado do Tratamento , Reino Unido , Adulto JovemRESUMO
Background: A variety of surgical and nonsurgical management options for small renal masses (SRMs) now exist. Surgery in the form of partial nephrectomy (PN) has three different approaches. It is unclear which PN approach, if any, offers superior clinical outcomes. Aim: The aim of this study is to compare outcomes in patients with SRMs <4 cm undergoing PN through the open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN), or robotic partial nephrectomy (RPN) approach and to establish the advantages and disadvantages of the various approaches. Methods: A systematic literature search was conducted for studies comparing at least two of the above techniques. Eighteen studies and 17,013 patients were included in our study. A network meta-analysis with a frequentist framework was performed. OPN was used as the baseline comparator. The prespecified primary outcome was R0 resection rates. Secondary outcomes included operating time, ischemia time, blood loss, transfusion rates, urine leak rates, significant morbidity, length of stay, and recurrence. Results: There was no significant difference between the techniques in terms of R0 rates, tumor recurrence, urine leak rates, renal function, and >3a Clavien-Dindo complications. LPN had a longer ischemic time and operating time. OPN had a longer length of stay and higher average intraoperative blood loss. RPN had lower blood transfusion rates. Discussion: All approaches are acceptable from an oncological perspective. The minimally invasive approaches (i.e., RPN and LPN) offer advantages in terms of morbidity; however, LPN may increase ischemic time and operative duration. Variations between perioperative outcomes may influence the choice of approach on a case-by-case and institutional basis.
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Neoplasias Renais , Nefrectomia , Nefrectomia/métodos , Humanos , Neoplasias Renais/cirurgia , Neoplasias Renais/patologia , Metanálise em Rede , Resultado do Tratamento , Procedimentos Cirúrgicos Robóticos/métodos , Laparoscopia/métodosRESUMO
INTRODUCTION: Ireland's population is living longer, and the prevalence of any LUTS is estimated to be 63-83% in adult men, increasing with age. Ireland has one of the lowest urologists per population ratio in Europe, at approximately 1:127,027. The patients waiting the longest are those with routine benign conditions such as men with LUTS. The impact on quality of life for men experiencing LUTS can be profound. METHODS: Sláintecare funded an ANP post in TUH to develop an integrated referral pathway for male LUTS and develop a secondary care nurse-led clinic for LUTS and tackle the ever increasing new and return waiting lists. The initial focus of this role was on reducing pre-existing outpatient (OP) waiting lists. This is a review of the first 12-month outcomes of this ANP post. RESULTS: A total of 410 new patients were assessed over the 12-month period. The mean waiting time from referral to review was 24 months; however, some referrals dated back to 2014. Four hundred forty-two return patients were reviewed in the 12-month period. All these patients were waiting longer than 18 months for a return appointment. In absence of the ANP-led clinic, there was no capacity for any of these patients to be reviewed in the general urology clinics. Overall outcomes were as follows: 38% were given advice and education and discharged. Treatment was initiated in 42% and follow-up arranged. Physical review was deemed necessary for 11% of patients. Only 6% of patients reviewed required referral back to consultants' clinic. CONCLUSION: This study demonstrates the safety, efficacy and financial advantage of an ANP-led clinic for adult men presenting with lower urinary tract symptoms previously triaged by a consultant urologist.
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Sintomas do Trato Urinário Inferior , Profissionais de Enfermagem , Adulto , Humanos , Masculino , Qualidade de Vida , Sintomas do Trato Urinário Inferior/etiologia , Sintomas do Trato Urinário Inferior/terapia , Instituições de Assistência Ambulatorial , Encaminhamento e ConsultaRESUMO
Background: Upper tract urothelial carcinoma (UTUC) is the malignant transformation of urothelial cells, from the renal calyces to the ureteral orifices. While the benefits of minimally invasive nephroureterectomy over their open counterpart have been established, the optimal technique remains a debate. We aimed to assess current evidence in the literature and compare outcomes between robotic-assisted (RANU) and laparoscopic nephroureterectomy (LNU). Methods: A systematic review of the literature was performed for studies comparing RANU and LNU for bladder cancer. Outcome measurements were recurrence rates (local and distal), positive margins, positive lymph node yield and perioperative outcomes. Meta-analysis was performed using Review Manager 5. Results: Our results demonstrate a significantly higher mortality rate in patients undergoing laparoscopic nephroureterectomy when compared with the robotic-assisted approach for the treatment of UTUC (1.8% vs. 1.1%, p = 0.008); however, these results were inconsistent on sensitivity analysis and should therefore be interpreted with caution. No significant difference was observed for other outcomes. Conclusion: The ideal approach to minimally invasive radical nephroureterectomy remains undetermined. Future research, ideally prospective randomised studies, should focus on long-term outcomes, in particular recurrence, recurrence-free survival, overall survival and the correlation between surgical technique and survival.
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PURPOSE: To develop an image-based technique capable of detection and grading of prostate cancer, which combines features extracted from multiparametric MRI into a single parameter map of cancer probability. MATERIALS AND METHODS: A combination of features extracted from diffusion tensor MRI and dynamic contrast enhanced MRI was used to characterize biopsy samples from 29 patients. Support vector machines were used to separate the cancerous samples from normal biopsy samples and to compute a measure of cancer probability, presented in the form of a cancer colormap. The classification results were compared with the biopsy results and the classifier was tuned to provide the largest area under the receiver operating characteristic (ROC) curve. Based solely on the tuning of the classifier on the biopsy data, cancer colormaps were also created for whole-mount histopathology slices from four radical prostatectomy patients. RESULTS: An area under ROC curve of 0.96 was obtained on the biopsy dataset and was validated by a "leave-one-patient-out" procedure. The proposed measure of cancer probability shows a positive correlation with Gleason score. The cancer colormaps created for the histopathology patients do display the dominant tumors. The colormap accuracy increases with measured tumor area and Gleason score. CONCLUSION: Dynamic contrast enhanced imaging and diffusion tensor imaging, when used within the framework of supervised classification, can play a role in characterizing prostate cancer.
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Algoritmos , Imagem de Difusão por Ressonância Magnética/métodos , Gadolínio DTPA , Interpretação de Imagem Assistida por Computador/métodos , Neoplasias da Próstata/patologia , Técnica de Subtração , Idoso , Meios de Contraste , Humanos , Aumento da Imagem/métodos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeRESUMO
OBJECTIVE: ⢠To determine the influence of tumour and prostate gland volumes on the underestimation of prostate cancer Gleason score in diagnostic core biopsies. PATIENTS AND METHODS: ⢠Patients undergoing radical prostatectomy with matched diagnostic biopsies were identified from a prospectively recorded database. ⢠Tumour volumes were measured in serial whole-mount sections with image analysis software as part of routine histological assessment. ⢠Differences in various metrics of tumour and prostate volume between upgraded tumours and tumours concordant for the lower or higher grade were analysed. RESULTS: ⢠In all, 684 consecutive patients with Gleason score 6 or 7 prostate cancer on diagnostic biopsy were identified. ⢠Of 298 patients diagnosed with Gleason 6 tumour on biopsy, 201 (67.4%) were upgraded to Gleason 7 or higher on final pathology. Similarly, of 262 patients diagnosed with Gleason 3 + 4 = 7 prostate cancer on initial biopsy, 60 (22.9%) were upgraded to Gleason score 4 + 3 = 7 or higher. ⢠Tumours upgraded from Gleason 6 to 7 had a significantly lower index tumour volume (1.73 vs 2 mL, P= 0.029), higher calculated prostate volume (41.6 vs 39 mL, P= 0.017) and lower relative percentage of tumour to benign glandular tissue (4.3% vs 5.9%, P= 0.001) than tumours concordant for the higher grade. ⢠Similarly, tumours that were Gleason score 3 + 4 on biopsy and upgraded on final pathology to 4 + 3 were significantly smaller as measured by both total tumour volume (2.3 vs 3.3 mL, P= 0.005) and index tumour volume (2.2 vs 3, P= 0.027) and occupied a smaller percentage of the gland volume (6.3% vs 8.9%, P= 0.017) compared with tumours concordant for the higher grade. ⢠On multivariate analysis, lower prostate weight (hazard ratio 0.97, 95% confidence interval 0.96-0.99, P < 0.001) and larger total tumour volume (hazard ratio 1.87, 95% confidence interval 1.4-2.6, P < 0.001) independently predicted an upgrade in Gleason score from 6 to 7. In tumours upgraded from biopsy Gleason 3 + 4, only higher index tumour volume (hazard ratio 3.1, 95% confidence interval 1.01-9.3, P= 0.048) was a significant predictor of upgrading on multivariate analysis. CONCLUSIONS: ⢠Under-graded tumours are significantly smaller than tumours concordant for the higher grade, indicating that incomplete tumour sampling plays a significant role in Gleason score assignment error. ⢠Surrogate measures of tumour volume may predict those at greatest risk of Gleason score upgrade.
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Neoplasias da Próstata/patologia , Carga Tumoral , Adulto , Idoso , Biópsia , Humanos , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Reprodutibilidade dos Testes , Estudos Retrospectivos , Viés de SeleçãoRESUMO
UNLABELLED: Study Type - Diagnostic (exploratory cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Due to sampling error, the Gleason score of clinically localized prostate cancer is frequently underestimated at the time of initial biopsy. Given that this may lead to inappropriate surveillance of patients with high-risk disease, there is considerable interest in identifying predictors of significant undergrading. Recently PSAD has been proposed to be an accurate predictor of subsequent upgrading in patients diagnosed with Gleason 6 disease on biopsy. We examined the predictive characteristics of PSAD in patients with low- and intermediate-risk disease on biopsy subsequently treated with radical prostatectomy. We found that although PSAD was a significant predictor of upgrade of biopsy Gleason 6 and 3 + 4 = 7 tumours, it failed to predict upgrading in patients with Gleason 7 tumours taken as a whole. When we explored reasons for this discrepancy, we found that the amount of PSA produced per unit tumour volume decreased with increasing Gleason score, thereby diminishing the predictive value of PSAD. OBJECTIVES: To analyse the performance of PSA density (PSAD) as a predictor of Gleason score upgrade in a large cohort stratified by Gleason score. We and others have shown that an upgrade in Gleason score between initial prostate biopsy and final radical prostatectomy (RP) pathology is a significant risk factor for recurrence after local therapy. PATIENTS AND METHODS: Patients undergoing RP with matching biopsy information were identified from two prospective databases. Patients were analysed according to the concordance between biopsy and final pathology Gleason score in three paired groups: 6/>6, 3 + 4/>3 + 4, 7/>7. Receiver-operating characteristic (ROC) curves were generated stratified by Gleason score, and the area under the curve (AUC) calculated. Logistic regression models were fitted to identify significant predictors of tumour upgrade. RESULTS: From 1516 patients, 435 (29%) had an upgrade in Gleason score. ROC analysis showed a decline in AUC with increasing biopsy Gleason score, from 0.64 for biopsy Gleason score 6, to 0.57 for Gleason score 7. In logistic regression models containing pretreatment variables, e.g. clinical stage and number of positive cores, for Gleason score 6 and 3 + 4, PSAD was the strongest predictor of subsequent tumour upgrade (odds ratio [OR] 1.46, 95% confidence interval [95% CI] 1.18-1.83, P= 0.001 and OR 1.37, 95% CI 1.14-1.67, P= 0.002, respectively). Surprisingly, in tumours upgraded from Gleason score 7 to >7, PSAD was not predictive even on univariable analysis, whereas clinical stage and number of positive cores were significant independent predictors. To explore the relationship between serum PSA and Gleason score, tumour volume was calculated in 669 patients. There was a strong association between Gleason score and tumour volume, with the median volume of Gleason score 7 and Gleason score >7 tumours being approximately twice and four-times that of Gleason score 6 tumours, respectively (P < 0.001). In contrast, the median serum PSA level per millilitre tumour volume decreased significantly with increasing grade, from 5.4 ng/mL for Gleason score 6 to 2.1 ng/mL for >7 (P < 0.001). CONCLUSIONS: There is a strong correlation between Gleason score and tumour volume in well/intermediate differentiated tumours, and as they produce relatively high amounts of PSA per unit volume of cancer, high PSAD is the strongest single predictor of tumour undergrading. However, as higher grade tumours produce less PSA per unit volume, PSAD loses its predictive ability, and other clinical markers of tumour volume such as palpable disease and numbers of positive cores become more predictive.
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Antígeno Prostático Específico/sangue , Próstata/patologia , Prostatectomia , Neoplasias da Próstata/patologia , Biópsia por Agulha , Humanos , Masculino , Gradação de Tumores , Neoplasias da Próstata/cirurgia , Carga TumoralRESUMO
UNLABELLED: What's known on the subject? and What does the study add? Positive surgical margins (PSMs) after radical prostatectomy are common, although their impact on the risk of disease recurrence is unknown. We examined the impact of PSMs on the risk of 'significant' biochemical recurrence stratified by their risk of occult metastatic disease. We find that only in intermediate-risk disease does the presence of a PSM have a significant impact on the risk of recurrence, and this represents a failure of technique. By contrast, for high- and low-risk disease, the risk of recurrence is driven by intrinsic tumour biology, and the presence of a PSM has little impact on outcome. OBJECTIVE: To determine the impact of surgical margin status on the risk of significant biochemical recurrence (prostate-specific antigen [PSA] doubling time <3, <6 or <9 months) after prostatectomy. MATERIALS AND METHODS: Patients undergoing radical prostatectomy with complete clinical and pathological data and detailed PSA follow-up were identified from two prospectively recorded databases. Patients were stratified according to their risk of occult systemic disease (low risk: PSA < 10 ng/dL, pT2 stage and Gleason score ≤6; intermediate risk: PSA 10-20 ng/dL, pT2 stage and/or Gleason score 7; high: PSA > 20 ng/dL or pT3-4 stage or Gleason score 8-10) and the impact of a positive surgical margin (PSM) within each stratum determined by univariable and multivariable analysis. RESULTS: Of 1514 patients identified, 276 (18.2%), 761 (50.3%) and 477 (31.5%) were classified as having low-, intermediate- and high-risk disease respectively. A total of 370 (24.4%) patients had a PSM and with a median follow-up of 22.2 months, and 165 (7%) patients had a biochemical recurrence. Sufficient PSA data was available to calculate PSA doubling times in 151/165 patients (91.5%). The PSM rate rose significantly, from 11% in low-risk to 43% in high-risk disease (P < 0.001), with similar positive associations noted with tumour grade, stage and serum PSA (P < 0.001). Patients with low-risk disease had essentially identical risks of significant biochemical recurrence over the study period, regardless of surgical margin status. By contrast, in patients with both intermediate- and high-risk disease, a PSM was a strong predictor of significant biochemical recurrence on univariable analysis. On multivariable analysis, howver, PSM predicted significant disease recurrence in intermediate-risk disease only. CONCLUSIONS: PSM is a risk factor for significant biochemical recurrence only in intermediate risk disease.
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Recidiva Local de Neoplasia/sangue , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/sangue , Neoplasias da Próstata/patologia , Adulto , Idoso , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/epidemiologia , Estudos Prospectivos , Prostatectomia , Neoplasias da Próstata/epidemiologia , Neoplasias da Próstata/cirurgia , Medição de Risco , Fatores de RiscoRESUMO
Men require prostate cancer (Pca) knowledge to practice health-seeking behaviours. Nine hundred seventy-nine men participated in a Pca screening programme comprising IPSS, bother score and health belief questionnaire. Men with private insurance had greater knowledge. Forty-nine percent (481) assessed their health status as average. Seventy-five percent (735) visited the GP at least once per year. The majority (576) felt well informed about health matters. Fifty-five percent (542) knew the prostate location but only 319 (33%) could identify it on a diagram. Forty-one percent (401) could not name a symptom. Few knew risk factors but 98% would attend a Pca screening clinic and sought more information. Men lack knowledge to pursue healthier behaviours and should be targeted possibly through a men's health initiative.
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Conhecimentos, Atitudes e Prática em Saúde , Programas de Rastreamento , Educação de Pacientes como Assunto , Neoplasias da Próstata/prevenção & controle , Adulto , Idoso , Tomada de Decisões , Acessibilidade aos Serviços de Saúde , Humanos , Irlanda , Masculino , Pessoa de Meia-Idade , Modelos Teóricos , Projetos Piloto , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/sangue , Fatores de Risco , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: â¢To determine the effect of an upgrade in Gleason score between initial prostate biopsy and final prostatectomy specimen on the risk of postoperative biochemical recurrence. PATIENTS AND METHODS: â¢A total of 1629 patients with paired biopsy and radical prostatectomy histology were identified from two prospectively recorded prostate cancer databases. â¢Information on key clinical and pathological characteristics as well as prostate-specific antigen follow-up was recorded. â¢Patients who experienced an upgrade in their Gleason score were compared with corresponding patients with concordant tumours of the lower and higher grade. â¢Kaplan-Meier curves and multivariate models were generated to examine the impact of Gleason score upgrade on the risk of postoperative biochemical recurrence. RESULTS: â¢Overall, 466 patients (28.6%) experienced an upgrade in their Gleason score post radical prostatectomy, in 88.4% of cases involving a change in a single Gleason score point. â¢Patients upgraded from Gleason 6 (3 + 3) to Gleason 7 (3 + 4) had pathological characteristics that were very similar to Gleason 7 (3 + 4) concordant tumours, with an identical risk of biochemical recurrence. In contrast, patients upgraded from Gleason score 6 (3 + 3) to Gleason 7 (4 + 3) had tumours with pathological characteristics intermediate between the two concordant groups, which was mirrored by their risk of biochemical recurrence. â¢Patients with Gleason 7 tumours who experienced a change in the predominant pattern from 3 + 4 to 4 + 3 had tumours that resembled Gleason 7 (4 + 3) concordant tumours, with a similar risk of biochemical recurrence. In contrast, patients upgraded from Gleason 7 to Gleason >7 had tumours with intermediate pathological characteristics, and a risk of biochemical recurrence that was significantly different to concordant tumours of the lower and higher grade. â¢In multivariate models, a change in Gleason score was an independent predictor of biochemical recurrence in the preoperative setting only. â¢Although a difference in Gleason score was an independent predictor of recurrence in concordant tumours in models based on postoperative variables, an upgrade in Gleason score in discordant tumours was not, with differences in co-segregated adverse pathological characteristics being more predictive. CONCLUSIONS: â¢Patients experiencing an upgrade in their Gleason score between biopsy and final specimen exhibit significantly more aggressive pathological features than corresponding concordant tumours, and a higher risk of biochemical recurrence post radical prostatectomy. â¢As Gleason score can be more accurately assessed preoperatively than other prognostic tumour features, continued effort is required to identify those most at risk of upgrading, and to refine biopsy strategies to reduce sampling error.
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Recidiva Local de Neoplasia/epidemiologia , Prostatectomia , Neoplasias da Próstata/patologia , Neoplasias da Próstata/cirurgia , Adulto , Idoso , Humanos , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Recidiva Local de Neoplasia/sangue , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/sangue , Estudos Retrospectivos , RiscoRESUMO
PURPOSE: Urological service provision has changed dramatically with the advent of the SARS-CoV-2, necessitating restructuring and reorganization. The aim of this study was to review the reorganization of our unit, map the change in volume of departmental activities and discuss potential solutions. METHODS: Departmental activities over the months of April and May 2020 and 2019 were analysed. Details of admissions, operations, diagnostic procedures, outpatient reviews, morbidities and mortalities were recorded. Operations were performed on two sites, with elective operation transferred to an offsite, COVID-free hospital. RESULTS: Seventy-four emergency operations were performed onsite, with 85 elective operations outsourced. A total of 159 operations were performed, compared with 280 in the same period in 2019. Five (5.0%) of 101 admitted patients to the COVID hospital contracted COVID-19. No patients outsourced to the COVID-free hospital were infected there. Outpatient referrals to urology service decreased from 928 to 481. There was a 66% decrease in new cancer diagnoses. A virtual review clinic was established, with remaining outpatients reviewed through a telephone clinic platform. CONCLUSION: Compared with 2019, we performed fewer operations and outpatient procedures, had fewer admissions and diagnosed fewer patients with new cancers. However, outsourcing elective operation to designated non-COVID hospitals prevented the infection of any patient with COVID-19 in the post-operative period. The use of virtual clinic and telephone clinic has had some success in replacing traditional outpatient visits. The overall significant decrease in operative volume will likely precipitate a mismatch between demand and service provision in the coming months, unless capacity is increased.
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COVID-19/epidemiologia , Urologia/métodos , Feminino , Humanos , Controle de Infecções , Irlanda/epidemiologia , Masculino , SARS-CoV-2/isolamento & purificação , Centros de Atenção Terciária , Doenças Urológicas/patologia , Doenças Urológicas/terapia , Urologia/normas , Unidade Hospitalar de Urologia/organização & administração , Unidade Hospitalar de Urologia/normasRESUMO
BACKGROUND: With among the lowest urologist per population ratios in Europe, the demand for urology specialist review in Ireland far exceeds supply. Lower urinary tract symptoms (LUTS) account for a significant number of referrals. The traditional paradigm of every patient being reviewed in a consultant-led clinic is unsustainable. New models of care with nurse-led clinics represent an opportunity to optimise limited resources. METHODS: Existing long-waiting male LUTS referrals were triaged to a specialist nurse-led LUTS clinic. After urology CNS assessment, charts were reviewed by a consultant urologist and a plan formulated. Relevant data were prospectively collected and analysed. RESULTS: Fifty-eight new male patients with LUTS were seen over a 6-month period with an average waiting time of 15.8 months. Patients were assessed with uroflowmetry, IPSS and DRE. Mean age was 64, IPSS 14.5, Qmax 18.3 ml/s and PVR 89 ml. Thirty patients (52%) were discharged directly with lifestyle modification and medical therapy. Twenty-eight patients (48%) required one or more further investigations and subsequent review; 11 had flexible cystoscopy, 4 had urodynamics, 5 had prostate MRI, and 2 patients were listed for surgery (TURP and circumcision). The remaining 10 patients were for review post trial of lifestyle modifications and/or medical treatment. After review/investigations, 4 more patients were discharged. A total of 32 patients (55%) were discharged or listed for surgery after initial assessment. This total increased to 62% after a second review/investigations. CONCLUSION: Introduction of a CNS-led LUTS clinic has significantly reduced the number of patients requiring follow-up in general urology clinics, representing a quality improvement in service provision.
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Sintomas do Trato Urinário Inferior , Hiperplasia Prostática , Urologia , Hospitais Universitários , Humanos , Sintomas do Trato Urinário Inferior/terapia , Masculino , Pessoa de Meia-Idade , Papel do Profissional de Enfermagem , Projetos Piloto , Hiperplasia Prostática/complicações , Carga de TrabalhoRESUMO
Eradication of a urinary tract infection (UTI) appears to be related to a number of innate host defence mechanisms and their interactions with invading bacteria. Recurrent UTIs (rUTIs) pose a difficult problem in that these bacteria use both host and bacterial factors to evade elimination. Neutrophil bactericidal function is depressed, both systemically and in urine, in patients with a history of recurrent UTI. Taurine is a semi-essential amino acid and is successful in preserving neutrophil bactericidal function in urine. Taurine may preserve neutrophil function at the urothelium and thus aid UTI resolution. Adult female (6 weeks old) C57Bl/6 mice were randomised into three groups: a saline gavage only control group, a saline gavage + E. coli group, and a taurine gavage + E. coli group [21 g/70 kg taurine in 0.9% normal saline (N/S) for 5 days]. Whilst taurine gavage pre-treatment resulted in increased serum neutrophils respiratory burst activity, at the urothelial-endothelial interface it caused higher colony forming units in the urine and a higher incidence of E. coli invasion in the bladder wall with no evidence of increased bladder wall neutrophils infiltration on MPO assay of histological assessment. Histologically there was also evidence of reduced bladder inflammation and urothelial cell apoptosis. In conclusion, taurine effectively increases neutrophils activity but given its anti-inflammatory properties, at the expense of decreased urothelial-endothelial activation thus preventing clearance of active E. coli infection in the bladder. Despite the negative results, this study demonstrates the importance of modulating interactions at the urothelial interface.
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Infecções por Escherichia coli/fisiopatologia , Neutrófilos/efeitos dos fármacos , Taurina/farmacologia , Bexiga Urinária/microbiologia , Bexiga Urinária/fisiopatologia , Infecções Urinárias , Animais , Modelos Animais de Doenças , Escherichia coli , Feminino , Camundongos , Camundongos Endogâmicos C57BL , Infiltração de Neutrófilos , Neutrófilos/imunologia , Taurina/efeitos adversos , Taurina/imunologia , Infecções Urinárias/tratamento farmacológico , Infecções Urinárias/fisiopatologia , Urotélio/imunologiaRESUMO
Androgen deprivation treatment in prostate cancer patients is well established; however, resistance to such treatment manifests itself by progression to castration-resistant prostate cancer (CRPC). Despite significant advances in treatment options for patients with CRPC, their prognosis remains poor. Resistance results from multiple processes that facilitate cancer cell growth and survival. Mechanisms underlying the shift to castrate resistance have been attributed to a complex interplay of clonal selection, reactivation of the androgen receptor axis despite castrate levels of serum testosterone, stress-induced prosurvival genes and cytoprotective chaperone networks and alternative mitogenic growth factor pathways. This article discusses several pathways involved in the development of CRPC, with a particular focus on those mechanisms that have led to the development of new targeted therapies.
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Neoplasias da Próstata/terapia , Antagonistas de Androgênios/uso terapêutico , Inibidores da Angiogênese/uso terapêutico , Neoplasias Ósseas/tratamento farmacológico , Neoplasias Ósseas/prevenção & controle , Neoplasias Ósseas/secundário , Humanos , Imunoterapia Ativa , Masculino , Chaperonas Moleculares/biossíntese , Terapia de Alvo Molecular , Neovascularização Patológica , Orquiectomia , Neoplasias da Próstata/irrigação sanguínea , Neoplasias da Próstata/patologia , Testosterona/sangue , Falha de TratamentoRESUMO
INTRODUCTION: Since the advent of prostate-specific antigen (PSA)-based testing, transrectal ultrasound (TRUS)-guided prostate biopsy has become a standard part of the diagnostic pathway for prostate cancer (PCa). Rectal bleeding is one of the common side effects of this transrectal route. While rectal bleeding is usually mild and self-limiting, it can be life-threatening. In this article, we examine rectal bleeding post-TRUS-guided prostate biopsy and explore the literature to evaluate techniques and strategies aimed at preventing and managing this common and important complication. METHODS: A PubMed literature search was carried out using the keywords "transrectal-prostate-biopsy-bleed." A search of the bibliography of reviewed studies was also conducted. Additionally, papers in non-PubMed-listed journals of which the authors were aware were appraised. RESULTS: Numerous modifiable risk factors for this bleeding complication exist, particularly anticoagulants/antiplatelets and the number of core biopsies taken. Successfully described corrective measures for such rectal bleeding include tamponade (digital/packs/catheter/tampon/condom), endoscopic sclerotherapy/banding/clipping, radiological embolization, and surgical intervention. CONCLUSIONS: We advocate early consultation with the colorectal/gastroenterology and interventional radiology services and a progressive, stepwise approach to the management of post-biopsy rectal bleeding, starting with resuscitation and conservative tamponade measures, moving to endoscopic hemostasis ± radiological embolization ± transanal surgical methods. Given the infrequent but serious nature of major rectal bleeding after TRUS biopsy, we recommend the establishment of centralized databases or registries forthwith to prospectively capture such data. To the best of our knowledge, this is the first comprehensive look specifically at the management of post-TRUS biopsy rectal bleeding.
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Young patients with diabetes but without established vascular disease have altered conduit and resistance artery reactivity. Early endothelial dysfunction is an initial step in atherogenesis: reductions in nitric oxide (NO) production in these vascular beds are implicated. The study aim was two-fold: first, to detect baseline abnormalities in cardiac function, conduit vessels and the microcirculation using applanation tonometry, brachial artery ultrasound and laser Doppler fluximetry, respectively; and second, to investigate any modification in these parameters with the use of pravastatin. Nine young men with diabetes and normoalbuminuria were randomised in a double-blind cross-over fashion to placebo or pravastatin (40 mg) treatment for two weeks. They underwent scans on three separate occasions. Control patients (n=12) underwent a baseline scan but were not given any drug treatment. It was found that patients with diabetes had significantly higher systolic and diastolic blood pressures, heart rate and Buckberg index (propensity to myocardial ischaemia). Brachial artery reactivity and microcirculatory dilation were both reduced. Levels of von Willebrand Factor, a marker of endothelial damage, were also elevated. Pravastatin treatment restored these sub-clinical abnormalities towards normal levels. In conclusion, pravastatin improves vascular abnormalities in young male patients with diabetes through alterations in microcirculation and conduit vessel function, with secondary myocardial effects. This may be of benefit in preventing end-organ injury.
Assuntos
Diabetes Mellitus Tipo 1/complicações , Angiopatias Diabéticas/prevenção & controle , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Pravastatina/uso terapêutico , Adulto , Pressão Sanguínea/efeitos dos fármacos , Artéria Braquial/fisiologia , Método Duplo-Cego , Frequência Cardíaca/efeitos dos fármacos , Humanos , Masculino , Projetos Piloto , Volume Sistólico/efeitos dos fármacos , Vasodilatação/efeitos dos fármacosRESUMO
CONTEXT: Urothelial carcinoma in situ (CIS) has a high propensity for progression. It is usually reported within the heterogeneous context of non-muscle-invasive bladder cancer (NMIBC) but warrants special consideration. OBJECTIVE: To review the contemporary literature on the diagnosis and management of CIS. EVIDENCE ACQUISITION: A systematic search using broad terms to capture the diagnosis and treatment of CIS was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria. Full-text original articles, reviews, and editorials from 1966 to 2014 in English were included. References from selected articles, relevant guidelines, and conference abstracts were searched. Abstracts were excluded. EVIDENCE SYNTHESIS: A total of 1887 articles were identified, of which 120 were used in this review. Most reports were retrospective and heterogeneous in caseload. There is a lack of standardised classification of CIS. Many studies consider CIS in the context of NMIBC without a clear separation of the subset with CIS. Recent prospective phase 2 and 3 studies have improved the evidence base. CONCLUSIONS: We are beginning to understand that CIS has a spectrum of biologic potential. Bacillus Calmette-Guérin immunotherapy appears superior to other intravesical agents and may alter the natural history of CIS. New imaging modalities, agents, and treatment strategies have emerged in recent years with the aim of better identification of CIS, more bladder-preserving treatments, and prevention of surgical overtreatment. PATIENT SUMMARY: Improvements in imaging techniques combined with new bladder-preserving treatments will continue to have an impact on the outcomes of bladder carcinoma in situ.
Assuntos
Adjuvantes Imunológicos/uso terapêutico , Carcinoma in Situ/terapia , Carcinoma de Células de Transição/terapia , Sistema Urinário/patologia , Neoplasias Urológicas/diagnóstico , Neoplasias Urológicas/terapia , Administração Intravesical , Carcinoma in Situ/diagnóstico , Carcinoma de Células de Transição/diagnóstico , Humanos , Imagem Multimodal , Resultado do Tratamento , Sistema Urinário/efeitos dos fármacos , Neoplasias Urológicas/patologiaRESUMO
PURPOSE: Ultrasound-based solutions for diagnosis and prognosis of prostate cancer are highly desirable. The authors have devised a method for detecting prostate cancer using a vibroelastography (VE) system developed in our group and a tissue classification approach based on texture analysis of VE images. METHODS: The VE method applies wide-band mechanical vibrations to the tissue. Here, the authors report on the use of this system for cancer detection and show that the texture of VE images characterized by the first and the second order statistics of the pixel intensities form a promising set of features for tissue typing to detect prostate cancer. The system was used to image patients prior to radical surgery. The removed specimens were sectioned and studied by an experienced histopathologist. The authors registered the whole-mount histology sections to the ultrasound images using an automatic registration algorithm. This enabled the quantitative evaluation of the performance of the authors' imaging method in cancer detection in an unbiased manner. The authors used support vector machine (SVM) classification to measure the cancer detection performance of the VE method. Regions of tissue of size 5 × 5 mm, labeled as cancer and noncancer based on automatic registration to histology slides, were classified using SVM. RESULTS: The authors report an area under ROC of 0.81 ± 0.10 in cancer detection on 1066 tissue regions from 203 images. All cancer tumors in all zones were included in this analysis and were classified versus the noncancer tissue in the peripheral zone. This outcome was obtained in leave-one-patient-out validation. CONCLUSIONS: The developed 3D prostate vibroelastography system and the proposed multiparametric approach based on statistical texture parameters from the VE images result in a promising cancer detection method.
Assuntos
Técnicas de Imagem por Elasticidade/métodos , Imageamento Tridimensional/métodos , Imagem Multimodal/métodos , Neoplasias da Próstata/diagnóstico por imagem , Neoplasias da Próstata/fisiopatologia , Vibração , Algoritmos , Área Sob a Curva , Humanos , Masculino , Próstata/diagnóstico por imagem , Próstata/patologia , Próstata/fisiopatologia , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/cirurgia , Curva ROC , Máquina de Vetores de SuporteRESUMO
INTRODUCTION: Prostate cancer recurrence following primary radiation is common. If the recurrence remains localized to the prostate gland, surgical removal may result in long-term local control or cure. Despite the well-established oncological outcomes, salvage prostatectomy is infrequently performed or reported. We present our experience with salvage prostatectomy at a Canadian centre. METHODS: We identified all patients undergoing salvage prostatectomy at the Vancouver General Hospital between 1995 and 2010 from a prospectively recorded and maintained prostate cancer database. Details regarding initial presentation, delivery of radiotherapy, clinical features at the time of recurrence, as well as oncological and functional outcomes, were collected. Information regarding postoperative morbidity was collected prospectively and confirmed by retrospective chart review. RESULTS: Over a 15-year period, salvage prostatectomy was successfully completed in 21 patients. With a median follow-up period of 68 months (range: 2-122), 9 (43%) patients experienced a biochemical recurrence, with most failing within the first 2 years of surgery. There were 3 deaths in the cohort, all from prostate cancer, giving a prostate cancer specific and overall survival of 86%. The main postoperative morbidity was bladder neck contracture, occurring in 40%. One patient each developed a recto-urethral fistula and osteitis pubis. Physician-recorded data regarding continence was available in 13 (62%). Of these 13 patients, 10 (85%) men were recorded as dry or using 1 pad per day. CONCLUSIONS: This is the first Canadian centre to report that salvage prostatectomy can be performed with favourable oncological and functional outcomes.