A Gottschalk, DS Smith, DR Jobes, et al
Preemptive Epidural Analgesia and Recovery from Radical Prostatectomy : A Randomised Controlled Trial
JAMA 279 : 1076-1082, 1998
Pain perception can be decreased by inhibiting CN S sensitization before the painful stimulus is introduced. However, whether such preemptive analgesia has proven clinical efficacy is a matter of controversy. The authors compared postoperative pain and other outcome measures after radical prostatectomy in patients who either did or did not receive preemptive analgesia.
Ninety patients scheduled for radical prostatectomy to treat prostate cancer who had no neurological impairment, chronic painful condition or cardiovascular conditions were enrolled. Before general anesthesia was induced, all patients had an epidural catheter placed to allow postoperative analgesia. The patients were divided into a control group that did not receive any preopereative epidural analgesia and a group that received preoperative epidural analgesia with fentanyl and a group that received preoperative epidural bupivacaine. The drugs were administered throughout surgery in the two active treatment groups, and all patients, received aggressive postoperative epidural analgesia. Patients reported pain scores on a visual analog scale each day while hospitalized. They were also followed up for upto 9.5 weeks after surgery to assess general health, pain and activity levels.
Postoperative pain control after preoperative fentanyl and bupivacaine did not differ significantly and thus these two groups were combined for consideration. Compared with the placebo group patients who received preemptive analgesia had 33% less pain during hospitalisation, starting from the first day after surgery. None of the groups differed significantly in the time of attainment of discharge milestone, pulmonary infection or in complication rates. Patients receiving preemptive analgesia were significantly more active at 3.5 weeks but activity levels did not differ significantly in the two groups by 5.5 to 9.5 weeks; but by 9.5 weeks patients receiving preemptive analgesia had significantly lower pain scores than the placebo group: 86% of the former and 47% of the latter reporting no pain at all.
Preoperative epidural analgesia significantly reduced postoperative pain till well after discharge and helped patients resume normal activities earlier.
McConnell JD, for the Finasteride Long-Term Efficacy and Safety Study Group [ Univ of Texas, Dallas; Univ of Wisconsin, Madison; The Johns Hopkins Med Institutions, Baltimore, Md; et al]
The Effect of Finasteride on the Risk of Acute Urinary Retention and the Need for Surgical Treatment Among Men With Benign Prostatic Hyperplasia
N Engl J Med 338: 557-563, 1998
Men with benign prostatic hyperplasia [BPH] invariably present with urinary symptoms, often improving with the use of finasteride. Long term administration of 5 mgm per day of finasteride was evaluated in 3040 men over a period of 4 years. All had BPH of moderate to severe degree and were evaluated every 4 months. They were studied for urinary flow, symptomatology prostatic MRI and volume as well as serum prostate-specific antigen levels. The last were done for 1 year and later once in 8 months.
In this double-blind, randomized and placebo-controlled study data for 2760 was available at the end of 4 years. 10% in the placebo group and 5% in the finasteride sample needed prostatic surgery. Acute retention of urine was observed in 7% of controls and 3% on active therapy. Finasteride treated patients revealed symptomatic improvement as well as a better flow of urine: reduction in prostate volume was also observed.
This study suggests that finasteride is a useful agent in managing patients with B.P.H. and may help in delaying surgery.
Goldstein I, for the Slidenafil Study Group [ Boston Univ; Univ of California, San Francisco; Univ of Southern California, Los Angeles; et al]
Oral Slidenafil in the Treatment of Erectile Dysfunction
N Engl J Med 338: 1397-1404, 1998
Erectile dysfunction is a problem faced by aging males. Sidenafil [Viagra] prevents catabolism of cyclic -GMP. This leads to relaxation of smooth muscle in the corpus cavernosum leading erection on sexual stimulation but not in the absence of the latter. Being administered orally, it is more acceptable than injections or surgery. The drug, in this study was taken 1 hour before planned sexual activity. Organic, psychogenic or mixed causes constituted the 861 men studied. They were 18 years of age or older and had the problem for 6 months or longer. Of these 532 received 25, 50 or 100 mgm of the drug or a placebo on a random selection, for 24 weeks. Another group of 329 men randomly received 50 mgm of the drug or a placebo. They were allowed to double the dose or reduce it by 50% depending on the response during the 12 week period of study.
Better erection and its maintenance after penetration was observed when the dose was gradually increased from 25 mgm to 100 mgm. Flushing headache and gastrointestinal disturbances were noticed. The drug was generally well tolerated.
Barbalias GA, Nikiforidis G, Liatsikos EN [Univ of Patras, Greece]
a-Blockers for the Treatment of Chronic Prostatitis in Combination With Antibiotics
J Urol 159: 883-887, 1998
For this study three groups were created. Group 1 comprised 134 subjects with prostatodynia and abacterial prostatitis; group 2, 72 participants had prostatodynia and the third group, 64 individuals had bacterial prostatitis. Group 1 and 2 and half of the group three received a-blockers. Dose was built up gradually to reach a maximum of 5 mgm of terazocin or 7.5 mg of alfuzocin daily. All patients with bacterial prostatitis and 67 of the abacterial group with more than 10 white cells per high-power field in prostatic secretion were given antibiotics.
At the end of 22 months of follow-up marked symptomatic improvement was observed with a-blockers. In the abacterial group greater improvement was observed in those on a combination regime. In the group of bacterial as well as abacterial prostatitis recurrences were reduced.
a-blockers are thus useful in treatment of symptoms arising out of benign prostatic hyperplasia.
Rosenberg SA, Yang JC, White DE, et al [NIH, Bethesda, Md]
Durability of Complete Responses in Patients With Metastatic Cancer Treated with High-Dose interleukin - 2: identification of the Antigens Mediating Response
Ann Surg 228: 307-319, 1998
This article analyzes the characteristics of 9.3% patients with metastatic renal cell carcinoma and the 6.6% of patients with metastatic melanoma who were treated with high dose lL-2 and sustained a complete clinical response.
Three parameters correlated with a complete response –
1. Absence of prior immunotherapy.
2. The total amount of lL-2 administered.
3. The magnitude of lymphocyte rebound immediately after completion of therapy.
The rigid rebound of lymphocytes after completion of lL-2 therapy generally implies that the lymphocytes had become marginated along the endothelial surface, and biopsy findings suggest that this may be most remarkable in the tumor. If this is the case, identification of molecules responsible for adherence of lymphocytes to the endothelium and the possible synergism of this form of immunotherapy with antiangiogenesis approaches is tantalizing.
Yamanishi T, Yasuda K, Sakakibara R, et al [ Chiba Univ, Japan]
Pelvic Floor Electrical Stimulation in the Treatment of Stress Incontinence : An Investigational Study and a Placebo Controlled Double-blind Trial
J Urol 158: 2127-2131, 1997
Forty-four subjects [mean age, 63 years] with stress as well as mild urge incontinence comprising 6 men and 38 women were studied. A vaginal electrode was used for women and anal for men.
Maximal urethral closing pressure were used for evaluation. This was measured before, during a stimulation period of 15 minutes and after treatment. Figures of 44.4, 64.5 and 46.8 cm of water were noted respectively.
Electrical stimulation of the pelvic floor is thus a useful alternative to surgery. Evaluation at the end of 4 weeks revealed 45% cure and 60% improvement rates.
M.L. Lachat, U. Moehrlen, H.P. Bruetsch and P.R. Vogt [ Department of Cardiovascular Surgery and Urology, University Hospital, Zurich, Switzerland]
The Seldinger Technique for Difficult Transurethral Cathetarization : A Gentle Alternative to Suprapubic Puncture
Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1729-1730
Difficult or unsuccessful transurethral catheterization may lead to iatrogenic urethral lesions which can compromise an otherwise excellent surgical result, cause long term morbidity.
An endoluminal catheter technique, a less invasive alternative to suprapublic bladder drainage has been developed for such cases.
This modified Seldinger technique was used in 21 cases undergoing cardiovascular surgery in whom the transurethral catheter could not be passed. The urethra was lubricated and anaesthetized. An atraumatic 0.035 inch J guidewire, length 30 cm, was inserted through the external urethral meatus and moved gently forward into the urinary bladder. A central venous catheter or 6F balloon catheter [ paediatric Folysil 6F] with tip cut off was then advanced over the guidewire . The guidewire was then removed, urine was aspirated, and the catheter connected to the urimeter and fixed with drapes. No complications followed.
E C Samuelsson, FT Arne Victor and K F Svardsudd, (Uppsala and Ostersund, Sweden)
Five-year incidence and remission rates of female urinary incontinence in a Swedish population less than 65 years old.
Am J Obstet Gynecol, Sept.2000; 183: 568-74
Objective: The authors sought to determine the incidence and remission rates of urinary incontinence in a population-based sample of women.
Study Design: A total of 382 (87.6%) of 436 eligible women aged 20 to 59 years answered a questionnaire and underwent a gynecologic examination at baseline and were followed up approximately 5 years later.
Results: Urinary incontinence was present in 23.6% of women at baseline and in 27.5% at follow-up. The mean annual incidence rate of incontinence was 2.9%, and the mean annual incidence rate of incontinence weekly or more often was 0.5%. Women that were receiving estrogen at baseline were more likely than other women to have incontinence during follow-up. The mean annual remission rate among the 90 women who were incontinent at baseline was 5.9%. The annual net increase of incontinence in the study population was 0.82%.
Conclusion: Female urinary incontinence seems to be a dynamic condition with a relatively high rate of spontaneous remission, a fact of which physicians should be aware when assessing and planning prevention and treatment strategies.
Lt Klein, D Frager, A Subramanium et al
Use of Magnetic Resonance Urography.
Urology 52: 602-608, 1998.
Magnetic Resonance Urography is a new technique that uses heavily weighted T2 fast spin-echo pulse sequence coronal MR images with a rapid acquisition – relaxation enhancement to generate a high intensity signal outlining the collecting system, ureters and bladder without contrast or ionizing radiation.
The entire urinary tract can be visualized in patients with renal failure. It can detect renal cysts, carcinomas, ureteropelvic junction obstruction, diverticulum in the bladder and ejaculatory duct cyst.
MRI failed to detect non-obstructing stones visible on i.v. urograms in 2 patients in the series of 100 patients (including all the above pathologies)
MRI is a useful adjunct to other modalities, particularly in those patients for whom ionizing radiation or contrast agents are contraindicated. Improvements in resolution, technique and cost are necessary before routine MRU use is feasible.
CCA Nolte Ernsting, A Buker, GB Adam, et al
Gadolinium Enhanced Excretory Magnetic Resonance Urography After Low Dose Diuretic Injection: Comparison with Conventional Excretory Urography.
Radiology 209: 147-157, 1998.
T2 weighted MR urography yields ‘water’ images of the kidney. MRU must be performed with contrast to provide structural and functional information.
MRU was performed after i.v. injection of 5-10mg Furosemide followed by 0.1 mmol of gadopentetate dimeglumine/kg body wt. Urograms were obtained within 5-20 mins after injection of contrast.
The collecting system was well visualized and images were not affected by gas filled intestinal loops or peristalsis.
Compared with conventional excretory urography, bladder and ureter, visualization was significantly better with MRU. Procedure was well tolerated and acquisition time was less than 45 mins.
False positive rates were from 10-15%. MRU does not visualize small caliceal abnormalities as well as conventional urography.
Even with fat suppressed images, magnetic resonance images are of poorer quality to those obtained by conventional urography. In patients with renal failure ionizing radiation and contrast are not required.
CL Siegel, WD Middleton, SA Teffey et al (Washington Univ, St. Louis)
Sonography of the Female Urethra,
AJR 170:1269-1274, 1998.
Availability of small calibre, catheter based endoluminal sonographic transducers have enabled a more thorough sonographic evaluation of female urethra.
Sonography can provide important information on location and extent of diverticular neck.
Application of this technology in the general population with an otherwise low incidence of urethral diverticulum and other periurethral disease is probably not warranted at this time.
It may have a role to play in those cases when diverticulum and periurethral disease is suspected but not picked up on VCU (voiding cystourethrogram) or double balloon urethrography.
MA Goldbergm WW Mayo-Smith, et al (Harvard Med. School, Boston)
FDG PET Characterisation of Renal Masses: Preliminary Experience.
Clin. Radiol 52: 510-515, 1997.
Fluorine-18, 2-fluoro-2deoxy-D-glucose positron emission tomography (FDG PET).
It is promising in the assessment of indeterminate renal cysts. A positive result in the appropriate clinical setting obviates the need for cyst aspiration.
Negative findings in conjunction with negative cyst aspiration helps to confirm that the cyst is benign. Seminomas seem to image most intensely with the modality.
FDG PET may find a place in the diagnosis of indeterminate renal masses.
S.L. Brown, DM Hoffman, J.P., Spirnak, (Case Western Reserve Univ, Cleveland, Ohio)
Limitations of Routine Spiral Computerized Tomography in the Evaluation of Blunt Renal Trauma.
J Urol 160:1979-1981, 1998.
In 3 of 35 patients (8.6%) spiral computerized tomography failed to identify injuries to the collecting system. In all 3 cases, injuries were detected on repeating the study over a period of several days based on high clinical suspicion.
This delay between scans, gives the contrast material sufficient time to image the collecting system and it ensures accurate staging and appropriate treatment of the renal injury.
NA Armenakas, CP Duckett, JW McAnunch (Univ of California, San Francisco)
Indications for Non-operative Management of Renal Stab Wounds.
J Urol. 161: 768-771, 1999.
More than half of all stab wounds to the kidney can be selectively treated non-operatively. Non-operative approach was selected in 108 of 199 (54%) cases.
Patients without haemodynamic instability or clinical signs suggestive of peritonitis should undergo clinical, laboratory or radiological investigations (CT Scan or IVU) to stage the injury.
An overall renal salvage rate of 94.5% can be obtained. Adequate staging with a CT scan is imperative.
G.C. Velmahos, E Degiannis. (Univ of Southern California, Los Angeles, Univ of Witwatersrand, Johanersby, S. Africa) – The Management of Urinary Tract Injuries after Gunshot Wounds of the Anterior and Posterior Abdominal Wall.
Injury : 28, 535-538, 1997.
If radiological staging of the renal injury has been obtained preoperatively ( a rare occurrence) and shows an injury remote from the pedicle without urinary extravasation, then observation may be a reasonable option in a stable patient.
In patients with stable perirenal haematoma remote from the hilum noted at the time of exploration for associated intra-abdominal injury, non-operative management of the genitourinary tract is associated with few complications.
Meticulous exploration of all periureteral haemotomas in the absence of haematuria is needed.
AL Shalhav, JJ Soble, SY Nakada, et al (Cleveland Clinic Foundation, Ohio, Univ of Wisconsin,Madison et al)
Long-term Outcome of Caliceal Diverticuli following Percutaneous Endosurgical Management.
J Urol 160: 1635-1639, 1998.
Percutaneous renal surgery achieved a 93% stone free rate, an 85% symptom free rate and 76% diverticular obliteration rate.
Percutaneous procedures have the best results with respect to stone free and symptom free outcomes.
Best results are obtained by direct puncture of the diverticulum, incision of the diverticular neck and fulguration of the lining epithelium.
As with any percutaneous procedure there is a risk of bleeding and hydrothorax in these patients.
JG Valdivia Uria, J Valle Gerhold, JA Lopez, et al (Hosp. Clinico Universitario, Zaragoza Spain).
Techniques and Complications of Percutaneous Nephroscopy: Experience with 557 patients in the supine Position.
J Urol 160:1975-1978, 1998.
Method: Before the examination patient was placed in a supine position with a 3L serum bag positioned below the ipsilateral flank.
The patient was completely stretched out with the ipsilateral leg completely extended and oblique positioning avoided.
A flexible cystoscope was used to deliver a 5F catheter into the affected ureteral meatus. To visualize and expand the renal cavity contrast material was injected.
The skin was punctured 1cm above the serum bag and 2-5cm above the iliac bone, along the posterior axillary line. Calyx was punctured with 10 G needle inserted through the flank. Placing the guide wire was easy as the surgeon was working along the renal sagittal plane. The tract was dialated to 30fr and renal cavity dilated under fluoroscopic control.
Findings: Reasons for failure included caliceal puncture, loss of path guide wire, kinking, acute bleeding, extreme renal mobility, morbid obesity and technical failure of dilator.
– 2 patients in the series of 519 procedures needed general anaesthesia.
– 8 patients had bleeding 3 of these needed transfusions.
– No patients had pneumothorax, hydrothorax or colonic damage.
Conclusions: Percutaneous nephroscopy in supine position avoids injury to the colon. Patients remain comfortable during the procedure. Surgeons enjoy the simplicity of the procedure. Shorter operative time (85mins on an average).
The anterior approach is a very useful technique in high-risk patients who will not tolerate a general anaesthetic or a prone position and who is not a candidate for ESWL.
ME Jabbour, ER Goldfischer, KG Stravodimus, et al (Albert Einstein College of Medicine, New Hyde Park, NY)
Endopyelotomy for Horseshoe and Ectopic Kidneys.
J.Urol 160:694-697, 1998.
Percutaneous access to horseshoe kidneys is obtained by standard techniques. The authors use Laparoscopic assistance to achieve access to pelvic kidneys.
Placement of percutaneous nephrostomy under CT guidance may avoid inadvertent visceral injury and can potentially eliminate the need for Laparoscopy.
Open surgery is rarely the procedure of choice because percutaneous access can usually be achieved by endoscopy.
M Grasso, D Bagley, (New York Univ; Thomos Jefferson Univ, Philadelphia)
Small Diameter, Actively Deflectable, Flexible Ureteropyeloscopy
J Urol 160; 1648-1654, 1998.
Flexible ureteroscopy is an attractive alternative to rigid ureteroscopy, because upper tract access is more easily achieved.
Smaller scopes rarely require balloon dilatation of the intramural ureter and the entire intrarenal collecting system is visualised 95% of the time.
With small working instruments therapeutic endoscopy can be performed in most cases.
The smaller endoscopes are very fragile but with appropriate use and care upto 30 procedures can be performed between repairs.
RJ Leveillee, L Pinchuk, GJ Wilson, et al. (Univ of Miami, Fla; Univ of Toronto)
A New Self-Expanding Lined Stent-Graft in the Dog Ureter: Radiological, Gross, Histopathological and Scanning Electron Microscopic Findings:
J Urol 160: 1877-1882, 1998.
Ureteral structures or malignant ureteral obstructions are usually treated with indwelling stents or Nephrostomy tubes. Both these methods need periodic changing.
The wallstent has been used in benign prostatic hypertrophy (BPH) and in the urethra for malignant obstruction.
Epithelial in-growth and hyperplasia that might cause recurrent obstruction have always been problems with this device.
The experimental model showed a lined device has lower tissue reactivity when placed in a normal ureter. Delivery of the device requires a percutaneous Nephrostomy.
T Yagasiwa, PS Chandhoke, J Fan (Tokyo Women’s Med.Univ; University of Colorado, Denver)
Metabolic Risk Factors in Patients with First time and Recurrent Stone Formations as Determined by Comprehensive Metabolic Evaluation.
Urology 52: 750-755, 1998
Methods : A comprehensive metabolic evaluation was performed in 37 patients (14 men) with first time calcium stone formation (FSF) and 136 (83men), age, weight and family history matched patients with recurrent calcium stone formation.
Results: Recurrent stone formers had greater number of metabolic abnormalities than first time stone formers.
In women the frequency of hypocitraturia was significantly higher in Recurrent Stone Formers than in first time stone formers. Calcium oxalate supersaturation indices were similar in recurrent and first time stone formers. Potassium citrate therapy may be useful in preventing stone formation in patients with hypocitraturia.
JA Cadeddu, Y Ono, RU Clayman, et al (John Hopkins Med. Institutions, Baltimore, Md; Washington Univ, St. Louis; Univ of Soskatchawan, Soskatoon, Canada; et al)
Laparoscopic Nephrectomy for Renal Cell Cancer: Evaluation of Efficacy and Safety: A Multicentre Experience.
Urology 52; 773-777, 1998.
Introduction : Concerns with laparoscopic procedure include possibility of tumor spillage and trocar site implantation.
Methods: Multicentric study included 157 patients who had undergone Laparoscopic radical nephrectomy between Feb.1991 and June 1997. All were clinical stages T1-2, No, Mo.
Results: 9.6% had perioperative complications and there was 1 intraoperative death. 6 patients needed to be converted to open surgical procedure for difficult dissection or bleeding. There was no case of implantation at Trocar site. 5 yr actuarial disease free rate was 91%.
Conclusion : Laparoscopic Radical Nephrectomy can be safely performed in patients with Renal Cell Carcinoma.
Although longer follow-up is needed to determine the true 5 and 10 yr survival rates, early data indicate that the laparoscopic procedure is comparable to open surgery in rates of actuarial, long term freedom from disease and cancer specific survival.
IS Gill, AC Novick; JJ Soble, et al (Cleveland Clinic Found, Ohio)
Laparoscopic Renal Cryoablation : Initial Clinical Series.
Urology 52: 543-551, 1998.
Introduction : Select patients with small (<4cm) unilateral localised renal carcinoma can be successfully treated with Nephron sparing surgery, but the technique is associated with potential morbidity.
Method : 10 patients with 11 tumors were selected. Mean tumor size was 2.3 cm on C.T. Nephron sparing surgery was selected because tumor was small, it was a solitary functioning unit, there was renal dysfunction, or suspected renal metastasis.
Entire renal surface was exposed laparoscopically. Needle biopsy was performed with 15 G needle. Doppler probe passed through 12mm port to guide the biopsy.
Post-operative follow-up included biochemical, radiological, histological, CT and MRI. The ice ball was monitored so that it was felt to extend 1cm beyond the tumor.
Results : Minimal bleeding at puncture site when the probe was removed.
Mean surgical time 2.4 hrs. Blood loss 75ml. 9 of 10 patients discharged in 23 hrs. Convalescence 2 weeks. All kidneys functioned post operatively.
Conclusion: In carefully, selected patients short-term outcome suggests that renal cryoablation is a safe and feasible technique.
HN Winfield, BD Hamilton, EL Bravo, et al (Cleveland Clinic Found; Ohio)
Laparoscopic Adrenalectomy: The Preferred Choice ? A comparison to open adrenalectomy.
J Urol 160; 325-329, 1998
Laparoscopic adrenalectomy is an excellent treatment choice for patients with tumors of less than 6cm.
With this procedure patients are able to return to full diet earlier and can leave the hospital sooner. They have reduced anlagesic requirements.
H Wunderlich, et al (Freidrich Schiller Univ, Jena Germany)
Nephron Sparing Surgery for Renal Cell Carcinoma 4cm or less in diameter: Indicated or Under Treated ?
J Urol 159: 1465-1469, 1998.
Background : Radical Nephrectomy continues to be the standard treatment for localised unilateral renal cell carcinoma in patients with normal contralateral kidneys.
The use of radical nephrectomy was retrospectively studied with respect to size and metastasis of renal cell carcinoma.
Findings: The frequency of grade I renal cell carcinomas declined with increasing tumor diameter.
The opposite was noted for grade 3. Tumor size was associated with lymph node and distant metastasis.
Frequency of venous involvement increased along with increase in tumor size.
Conclusion : The metastatic potential and biology of small renal cell carcinomas have not been established.
To minimise the risk of recurrence Nephron sparing surgery might be limited to those with renal cell carcinomas of 20mm or less.
KS Hafez, AC Novick, BP Butler (Cleveland Clinic Foundation, Ohio)
Management of Small Solitary Unilateral Renal Cell Carcinoma: Impact of Central Versus Peripheral Tumor Location.
J. Urol 159: 1156-1160, 1998.
Conclusion : No significant biological differences are evident between central and peripheral small solitary unilateral renal cell carcinomas.
Nephron sparing surgery was technically more complicated among central renal cell carcinomas.
Intraoperative ultrasonography may be a more important adjunct when approaching patients with central tumors.
H Miyake, H Nakamura, I Hara, et al (Kobe Univ;Japan; Kumamoto Univ, Japan)
Multifocal Renal Cell Carcinoma: Evidence for a Common Clonal Origin.
Clin Cancer Res. 4: 2491, 1998.
The controversy surrounding the use of Nephron sparing surgery for renal cell carcinoma has revolved around the observed 7% to 25% incidence of relatively small satellite tumors discovered at autopsy or upon careful examination of radical nephrectomy specimens from patients with clinically evident renal cell carcinoma.
In this study, the authors studied 10 cases of renal cell carcinoma that were accompanied by smaller satellite tumors for LOH (Loss of Heterozygosity) at chromosome arms 3p, 6q, 8p, 9p, 9q and 14q. All tumors were less than 5cm. Primary and satellite lesions in 8 of 10 cases exhibited identical patterns of LOH.
Similarity of LOH patterns in the main satellite tumors indicated that satellite tumors are the result of intrarenal metastasis rather than new separate primaries. In any series the satellite lesions are generally small and occurring within 2 cm of the index tumor. The satellite tumors measure 2-4mm. Many satellite lesions may be resected during a “radical partial nephrectomy” or may never reach the clinical horizon.
K Tsuda, T Murakami, T Kim, et al (Osaka Univ, Japan)
Helical CT: Angiography of Living Renal Donors: Comparison with 3D Fourier Transformation Phase Contrast MRA.
J Comput Assist Tomogr 22: 186-193, 1998.
Introduction: In the radiological evaluation of living renal donors, renal ultrasonography, iv urography and renal conventional angiography are routinely performed. Transplantation may be made difficult by presence of accessory vessels and prehilar branches. The choice of kidney would then be affected.
Helical CT angiography is less invasive and less costly than conventional angiography. MR angiography is also less invasive and less expensive. Some researches have recommended use of 3-dimensional fourier transformation phase contrast magnetic resonance angiography.
Conclusions : For evaluating the arterial anatomy of living renal donors, helical C.T. angiography is superior to 3-D fourier transformation phase contrast MR angiography. Helical CT angiography is emerging as the investigation of choice for evaluating living renal donors. In addition to imaging vessels one can also study the parenchyma and the collecting system.
The study demonstrates a modest advantage of CT over MR angiography.
AC Gulanikar, PP Daily, NK Kilambi, et al (Univ of Mississipi Jackson)
Prospective Pretransplant Ultrasound Screening in 206 Patients for Acquired Renal Cysts and Renal Cell Carcinoma.
Transplantation 66: 1669-1672, 1998.
The fastest emerging population coming to dialysis comprises patients over 60 yrs of age. The long-term survival of patients in this category is generally poor. Hence there is little enthusiasm for screening all end-stage renal disease patients for acquired renal cystic disease and renal cell carcinoma.
The exception to the rule is patients who are healthy enough to be considered for renal transplantation.
A prevalence of renal cell carcinoma at 3.4% (much higher than the prevalence in the general population) is certainly high enough to warrant routine pretransplant screening. This is especially true in the light of the uncertainties regarding biologic activity of renal cell carcinoma in immunosuppressed hosts.
VJ Bhagat, RL Gordon, RW Osorio, et al (Univ of Cal. San Francisco)
Ureteral Obstruction and Leaks After Renal Transplantation: Outcome of Percutaneous Antegrade Ureteral Stent Placement in 44 Patients.
Radiology 209: 159-167, 1998.
The study attests to the efficacy of initial, minimally invasive approach to the treatment of ureteral complications after renal transplantation.
Treatment of leak at the ureteroneocystostomy site was highly successful provided a stent could be placed in the bladder and any associated perinephric fluid collection could be drained.
Early ureteral obstruction (within 3 months) can be more easily treated than later obstruction.
Percutaneous nephrostomy and stent placement must be tried before open surgery and revision.
F Desgrandchamps, P Paulhac, S Fornairon, et al (Saint Louis Hosptial, Paris; Broussais Hosp, Paris)
Artificial Ureteral Replacement for Ureteral Necrosis After Renal Transplantation Report of 3 Cases.
J. Urol 159: 1830-1832, 1998.
Introduction : The standard treatment procedure is repeat ureteroneocystostomy and uretero-ureterostomy with the recipient ureter.
Methods: 3 patients with ureteral necrosis following cadaveric transplantation were included in the study. The treatment was done after standard endoscopic treatment failed.
The tract was created percutaneously under flouroscopic guidance and was progressively dilated.
A ureteral silicon PTFE bonded tube was placed in the pyelocaliceal renal graft cavities. Then tacked down subcutaneously to the suprapubic area. The tube was inserted into the bladder by a short suprapubic incision.
M Alcalay, P K Thompson, and T B Boone (Houstan, Texas)
Ball urethroplasty combined with Marshall-Marchetti-Krantz urethropexy versus suburethral sling in patients with intrinsic sphincter deficiency and urethral hypermobility.
Am J Obstet Gynecol, Dec.2000, 813: 1348-54
Objective : It was our goal to compare the efficacy of a suburethral fascial sling with that of a combination of Marshall-Marchetti-Krantz urethropexy and Ball urethroplasty in patients with intrinsic sphincter deficiency and urethral hypermobility.
Study Design : This study consisted of a retrospective observational evaluation of patients from 2 separate practice sites. Preoperative and postoperative data were collected from patients medical records. The long-term results were based on a mailed questionnaire addressing bladder symptoms and quality-of-life issues.
Results : Among a total of 48 patients, 37(77.1%) responded in the group undergoing Marshall-Marchetti-Krantz urethropexy combined with Ball urethroplasty, and 30 out of 35 (85.7%) patients replied in the suburethral fascial sling group. The mean length of follow-up was 2.7 years (range, 1-5 years). The patients were similar in age, hormonal status, parity, and previous bladder neck surgery. Similar cure and improvement were demonstrated in both groups (86.6% in the suburethral fascia group and 89.2% in the group with the Marshall-Marchetti-Krantz procedure combined with Ball urethroplasty). No significant differences were found in urinary incontinence types, irritable bladder symptoms, voiding difficulties, or quality-of-life measures.
Conclusion : The suburethral fascial sling and a procedure consisting of Marshall-Marchetti-Krantz urethropexy combined with Ball urethroplasty have similar results in patients with intrinsic sphincter and urethral hypermobility.
Chapman GB, Elstein AS, Kuzel TM, et al (Rutgers Univ, New Brunswick, NJ: Univ of Illinois at Chicago; VA Chicago Health Care System; et al)
Prostate Cancer Patients Utilities for Health States: How it Looks Depends on Where You Stand
Med Decis Making 18: 278-286, 1998
For patients with prostatic cancer, quality of life issues and patient preferences significantly influence the choice of treatment. Decisions regarding treatment have to balance the trade-off between a longer life with greater health impairment or a shorter life with less impairment (the time-trade-off dilemma (TTO)).
This article examines 2 different TTO methods of assessing these preferences.
1) A personal version, in which 31 men with prostatic cancer were asked to imagine their health was poor and to indicate how much life expectancy they would give up to improve their health and
2) An impersonal version in which 28 men with prostatic cancer were asked to imagine 2 friends, one with poor health but a longer life expectancy and another with better health but a shorter life expectancy and to indicate which of the hypothetical friends he would rather be.
Patients were divided into 3 different hypothetical states of health based on 5 aspects of prostate cancer (pain, mood, sexual function, bladder and bowel function and fatigue).
These hypothetical states were further subdivided into (A) low, (B) moderate and (C) high states depending upon the levels of dysfunction.
The effectiveness of the personal and impersonal methods was compared by determining how well patients could distinguish between the levels of dysfunction and by measuring how willing they were to trade time for improved health.
In the impersonal version patients were more likely to trade off life expectancy for improved quality of life.
The use of the impersonal TTO method gave a more valid assessment of the patients willingness to trade off longevity for improved quality of life.
Demark-Wahnefried W, Schildkraut JM, Iselin CE, et al (Duke Univ, Durham, NC; North Carolina Division of Health Promotion, Raleigh; Univ of North Carolina, Chapel Hill; et al)
Treatment Options, Selection, and Satisfaction Among African American and White Men With Prostate Carcinoma in North Carolina
Cancer 83: 320-330, 1998
In North Carolina the mortality rate for prostatic carcinoma in 2.5 times higher in African Americans than in whites.
The authors examine the reasons for this difference.
231 patients (117 African Americans and 114 whites) between 50-74 years, diagnosed as carcinoma of prostate were studied. Equal proportions had local (34.6%), regional (42.9%) or distant (22.5%) disease.
About 10 months after the diagnosis the patients were interviewed by telephone to determine their socio demographic characteristics, treatment options discussed with physicians, factors that influenced choice of treatment, and satisfaction with treatment.
Socio demographic variables had no significant association with treatment. Younger patients were more likely to have discussed prostatectomy as were patients with only one co-morbid condition. However, the stage at diagnosis played an important role in the choice and receipt of treatment.
Local and regional disease are more likely to have considered surgery, radiation and observation. Those with distant disease were more likely to have undergone orchiectomy. Both groups said that their physicians recommendation had the most influence on their choice of treatment. Most patients in both groups were satisfied with the information they received from their physicians.
Those with distant disease were less satisfied regarding their treatment options. Those who selected hormonal therapy were significantly less satisfied than those who chose radiation or prostatectomy.
The only factor consistently affecting the outcome of the treatment was the stage of the disease at diagnosis.
Thus, factors other than treatment choices, such as potential biologic differences must account for the differences in the mortality rate of prostate cancer seen in African American and white patients.
DAmico AV, Desjardin A, Chen M-H, et al (Harvard Med School, Boston; Worcester Polytechnic Inst, Mass; Univ of Millersville, Pa; et al)
Analyzing Outcome-Based Staging for Clinically Localized Adenocarcinoma of the Prostate
Cancer 83: 2172-2180, 1998
The value of clinical staging of carcinoma prostate based on PSA, and the calculated carcinoma volume construct (cVCa) has been assessed.
The ability of the cVCa-PSA clinical staging system to predict time to post-treatment PSA failure in 441 patients (post surgery) and 465 (post radiation) was compared with that of the AJCC (American Joint Commission on Cancer Staging) clinical and pathological staging system.
In a Cox regression multivariate analysis both staging systems significantly predicted time to postoperative PSA failure. However only the cVCa-PSA staging predicts time to postradiation PSA failure.
Further the cVCa-PSA staging predicted time to postoperative PSA failure in a clinically more useful fashion, identifying surgically treated patients with pathologic AJCC T2 disease with poor outcomes and those with AJCC T2b, c disease treated by radiation with good outcomes.
Kattan MW, Eastham JA, Stapleton AMF, et al (Baylor College of Medicine, Houston)
A Preoperative Nomogram for Disease Recurrence Following Radical Prostatectomy for Prostate Cancer
J Natl Cancer Inst 90: 766-771, 1998
No single modality of treatment can be universally recommended for clinically localized prostate cancer. Several risk factors can be used to predict recurrence risk. The authors have developed a nomogram to predict the probability of treatment failure.
The nomogram was developed with Cox proportional hazards regression analysis to model the clinical data and outcome of 983 men with clinically localized prostate cancer who would undergo radical prostatectomy. Clinical data included PSA levels, biopsy Gleason scores and clinical stage.
Treatment failure was defined as clinical evidence of recurrence, rising PSA levels or initiation of adjuvant therapy.
Validation of the nomogram was performed on a separate sample of 168 men with clinically localized prostate cancer.
Treatment failure occurred in 196 of the 983 men with a median follow up of 30 months. The 5-year probability of freedom from failure was 73%. The nomogram predictions were accurate and discriminating.
This nomogram may be useful in selecting therapy and identifying patients at high risk who may benefit from more aggressive adjuvant therapy.
Tewari A, Narayan P (Univ of Florida, Gainesville)
Novel Staging Tool for Localized Prostate Cancer: A Pilot Study Using Genetic Adaptive Neural Networks
J Urol 160: 430-436, 1998
Artificial intelligence-based neural networks are available for applications in medicine. These networks are more accurate than statistical methods for analyzing clinical data. They can be used as a staging tool for localized prostate cancer.
Data was obtained from 1200 prostate cancer patients (localized to the organ). Preoperative staging included serum PSA, systematic biopsy and Gleason staging. After radical prostatectomy and lymphadenectomy, 27% were found to have positive margins, 8% had seminal vesicle involvement, and 7% had lymph node disease.
The neural network had a sensitivity ranging from 81% to 100% and a specificity ranging from 72% to 75% for various predictions of margin seminal vesicle and lymph node involvement. For all three characteristics the negative predictive values were high (92%-100%). It missed only 8% of positive margins, and 2% of lymph nodal involvement.
None of those with seminal vesicle involvement were missed. Neural networks may be a useful tool in the initial staging of extracapsular extension in localized prostate cancer.
D Amico AV, Desjardin A, Chung A, et al (Harvard Med School, Boston)
Assessment of Outcome Prediction Models for Patients With Localized Prostate Carcinoma Managed With Radical Prostatectomy or External Beam Radiation Therapy
Cancer 82: 1887-1896, 1998
Current staging systems do not provide reliable information on which to base management decisions for individual patients. The ability of all known clinical staging systems to predict time to PSA failure after therapy for clinically localized prostate cancer has been investigated.
1441 patients (localized prostate cancer) from 3 centers treated with radical prostatectomy or external beam radiation therapy were enrolled in this study. Akaikes Information Criterion (AIC) and Schwartz Bayesian Criterion (SBC) estimates, comparative measures, were determined for each staging system.
Both the staging system based on the risk score and that based on the calculated volume of prostatic cancer (cVCa) and PSA optimized prediction of time to PSA failure after treatment. However the cVCa-PSA system provide an outcome satisfaction that was more clinically useful.
Further research is currently underway to verify these findings.
Rassweiler J, Frede T, Henkel TO (Univ of Heidelberg, Germany)
Nephrectomy: A Comparative Study Between the Transperitoneal and Retroperitoneal Laparoscopic Versus the Open Approach
Eur Urol 33: 489-496, 1998
This article compares the 3 approaches to a nephrectomy.
The clinical results of 18 transperitoneal laparoscopic nephrectomies (TLN) for benign renal disease were compared with those of 17 retroperitoneal laparoscopic nephrectomies (RLN) and 19 open nephrectomies (Nx). The indications for the 3 groups were comparable.
The mean operating time was 206.5 min (TLN) 211.2 min (RLN) and 117 min (Nx). Analgesia requirements per patient was 2, 1 and 4 days respectively. The convalescent period was 21 days (RLN) 24 days (TLN) and 40 days (Nx).
Laparoscopic nephrectomy is superior to open nephrectomy in benign renal disease. In addition RLN is better than TLN.
Edelstein CL, Ling H, Schrier RW (Univ of Colorado, Denver)
The Nature of Renal Cell Injury
Kidney Int 51: 1341-1351, 1997
Acute renal failure (ARF) carries a high mortality rate (50%). A better understanding of the pathogenesis could help one to prevent the need for haemodialysis, shorten the course of ARF and improve survival.
This article proposes that the mechanism for the decreased glomerular filtration rate (GRF) in ischemic ARF involves increased distal tubular obstruction and tubuloglomerular feed back.
GFR : When the GFR is < 10 ml / min, there is often complete recovery of renal function in those patients who survive, which suggests minimal histologic abnormalities and that the cell injury is sublethal and reversible. Previously it was suggested that there was irreversible proximal tubular cell death.
Pathophysiology : During the hypoxia and ischemia intracellular calcium and the calcium dependant enzymes calpain, phospholipase A2 and nitric oxide synthase play a role. Calpain and nitric oxide have an action on the cytoskeleton and cell adhesion. In ischemic renal failure, the tubular injury leads to a profound fall in the GFR, increased tubuloglomerular feedback and increased distal tubular obstruction.
In ischemic ARF, the nature of renal injury includes tubular death from irreversible apoptosis or necrosis and sublethal injury that causes reversible dysfunction.
A. Minervini, L. Lilas, G. Morelli, C. Traversi, S. Battaglia, R. Cristofani and R. Minervini (Department of Urology, University of Pisa, and Institute of Clinical Physiology, National Research Council, Pisa, Italy, and Department of Urology, Greenwich District Hospital, London, UK)
Regional Lymph Node Dissection in the Treatment of Renal Cell Carcinoma: Is It Useful in Patients With No Suspected Adenopathy Before or During Surgery?
BJU Intl. August 2001 Vol. 88 (3) Pg. 169-172
167 cases of renal cell carcinomas (RCC) with no detectable metastases who underwent radical nephrectomy have been reviewed. 108 underwent radical nephrectomy alone and 59 had radical nephrectomy with regional lymph node dissection (LND) limited to the anterior, posterior and lateral sides of the ipsilateral great vessel, from the level of the renal pedicle to the inferior mesenteric artery.
Of these 59, 49 had no evidence of metastases before or during surgery. The probability of survival was estimated by the Kaplan-Meier method, using the log-rank test to estimate differences among levels of the analysed variables.
The overall 5-year survival rate was 79% (5 years). In the radical nephrectomy group alone also it was 79% and for the LND group it was 78%. Of the 49 patients with no suspicion of lymph node metastases one (2%) was found to have histologically confirmed positive nodes.
This suggests that there is no clinical benefit in terms of overall outcome in undertaking LND in the absence of enlarged nodes detected before or during surgery.
M. H. Ather, J. Paryani, A. Memon and M. N. Sulaiman (Department of Surgery, The Aga Khan University, Karachi, Pakistan)
A 10-Year Experience of Managing Ureteric Calculi: Changing Trends Towards Endourological Intervention – Is There A Role For Open Surgery?
BJU Intl. August 2001 Vol. 88 (3) Pg. 173-177
This is a 12-year retrospective study of all primary ureteric stones treated by ESWL, endoscopy, intracorporeal shock wave lithotripsy (ISWL) administered via ureteroscopy, or open surgery.
1195 patients have been reviewed, 44% underwent ESWL, 37% by ureteroscopy and ISWL and 20% by open surgery. At a follow-up of 3 months, the stone-free rates for ESWL alone was 95%, for ureteroscopy 85% and for open surgery 97% giving an efficiency quotient of 73%, 64% and 94% respectively.
The overall complication rate for ESWL and for open surgery was 13% each and for ISWL 32%, but the complications of open surgery were often serious and life-threatening.
With recent advances in endourology, the indications for open surgery have decreased considerably, from 26% to 8%. However, the remaining indications for open ureterolithotomy include failure of less invasive modalities, the presence of anatomical abnormalities, a concomitant open procedure, and impacted calculi.
D. Dubey, A. Kumar, R. Kapoor, A. Srivastava and A. Mandhani (Department of Urology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India)
Acute Urinary Retention: Defining the Need and Timing for Pressure-Flow Studies
BJU Intl. August 2001 Vol. 88 (3) Pg. 178-182
This study was undertaken to investigate the utility of late pressure-flow studies in predicting the outcome of prostatectomy for acute urinary retention.
58 patients with acute urinary retention were prospectively assessed using the International Prostate Symptom Score and pressure-flow studies at a median of 24 days (13-60 days) after the episode of retention, and before TURP. Bladder outlet obstruction and bladder contractility were graded using a modified adaptation of Schafers passive urethral linear resistance relation.
56 patients (97%) generated a voluntary detrusor activity, with a mean detrusor pressure at maximum flow of 72.7 cmH2O (5-144), and 43 patients (75%) were deemed to be obstructed. 8 patients (16%) failed to void after prostatectomy and required clean intermittent catheterization. There were statistically significant differences between successful and unsuccessful patients in mean (SD) age, at 66.30 (6.9) vs 78.8 (2.6) years detrusor instability (49% vs 0%), inability to void during pressure study (8% vs 75%), and maximal detrusor pressure in the voiding phase, at 80 (36.0) vs 19 (11.2) cmH2O.
In patients with acute retention of urine, pressure-flow studies undertaken after a period of adequate bladder rest (> 3 weeks) are useful for predicting the surgical outcome.
P. Dasgupta, S. D. Sharma, C. Womack, H. N. Blackford and P. Dennis (Departments of Urology and Pathology, Peterborough Hospitals NHS Trust, Edith Cavell Hospital, Peterborough, UK)
Cimetidine in Painful Bladder Syndrome: A Histopathological Study
BJU Intl. August 2001 Vol. 88 (3) Pg. 183-186
This study attempts to determine the mechanism of action of cimetidine on painful bladder syndrome/interstitial cystitis.
14 patients with refractory bladder pain and irritant urinary symptoms were treated with cimetidine. The response to treatment was assessed by an analogue score and outpatient follow-up.
Bladder biopsies from 8 patients were stained with haematoxylin-eosin and a polyclonal antibody to gastrin with counterstaining using toluidine blue, to detect mast cell granules containing histamine. Biopsies from normal areas of the bladder from an age-matched control group with transitional cell carcinoma of the bladder were stained similarly.
However, stomach and colon were used as positive controls for gastrin and toluidine blue, respectively. The clinical response to cimetidine was compared with the histology in a blinded fashion. 8 of the 14 patients responded well to cimetidine; none of the biopsies showed evidence of carcinoma in situ.
None of the bladder biopsies showed gastrin-like immunoreactivity, apart from some non-specific urothelial staining. Numerous mast cells with crimson granules and pale nuclei were visible in 3 patients and fewer in three others; their presence or absence did not correlate with the symptomatic response.
Cimetidine is useful for bladder pain but the presence or absence of gastrin or histamine-like immunoreactivity does not explain its therapeutic benefit.
S. D. Woodhams, T. J. Greenwell, T. Smalley and A. R. Mundy (Institute of Urology and Nephrology, London, UK)
Factors Causing Variation in Urinary N-Nitrosamine Levels in Enterocystoplasties
BJU Intl. August 2001 Vol. 88 (3) Pg. 187-191
N-nitrosamines in the urine have been implicated in the development of cancer of the bladder. This study studies the pattern of N-nitrosamine levels (long term or diurnal variation in enterocystoplasty cases).
36 cases of enterocystoplasty and 6 normal controls have been studied. Urine samples were collected 4 hourly for 24 hours and N-nitrosamine levels assessed using a modification of the Pignatelli method. An additional sample of urine was assessed by microscopy, culture and sensitivity.
In an additional sample of 16 enterocystoplasty cases the urine was examined at 3 monthly intervals. No variations in N-nitrosamine levels was identified. The mean N-nitrosamine levels were higher in cystoplasty cases than in the controls.
The levels were higher in infected than in non infected urine. Those on prophylactic antibiotics had significantly lower values than those not taking antibiotics.
N. S. Morris and D. J. Stickler (Cardiff School of Biosciences, Cardiff University, Wales, UK)
Does Drinking Cranberry Juice Produce Urine Inhibitory to the Development of Crystalline, Catheter-Blocking Proteus mirabilis Bioflims?
BJU Intl. August 2001 Vol. 88 (3) Pg. 192-197
Urine was collected from groups of volunteers who had drunk up to 2 x 500 mL of cranberry juice or water within an 8-hour period. Laboratory models of the catheterized bladder were supplied with urine from these groups and inoculated with P. mirabilis. After incubation for 24-48 hours, the extent of encrustation was determined by chemical analysis for calcium and magnesium. It was also visualized by scanning electron microscopy.
The encrustation in the normal group (control) was identical to that in the group consuming 500 ml of cranberry juice. However, there was significantly less encrustation in the group that drank 2 x 500 mL of water than in the group that drank 2 x 500 mL of cranberry juice, though both these groups showed less encrustation than in the control group.
It was also found that increasing fluid intake significantly reduced encrustation. In this in vitro, study cranberry juice did not produce urine inhibitory to the development of encrustation on catheters (P. mirabilis films).
P. J. Westenend, J. A. Stoop and J. G. M. Hendriks (Pathologisch Laboratorium voor Dordrecht eo, Dordrecht, The Netherlands)
Human Papillomaviruses 6/11, 16/18 and 31/33/51 Are Not Associated With Squamous Cell Carcinoma of the Urinary Bladder
BJU Intl. August 2001 Vol. 88 (3) Pg. 198-201
This study assesses the risk of human papillomavirus (HPV) mainly HPV type 16, 18, 31 and 33 in squamous cell carcinoma (SCC) of the urinary bladder.
16 SCC of the urinary bladder were evaluated using non-isotopic in situ hybridization with a sensitive detection system for the presence of high risk HPV 16/18 or 31/33/51, and for HPV 6/11, a low-risk type commonly found in condylomata.
No high-risk HPV was found in any of the SCC of the bladder evaluated. Previous reports identified 9 HPV-positive SCC out of a total of 105, including the present series. In 4 of these positive cases, HPV types were found that are considered a high risk for anogenital carcinomas.
From these results, it can be concluded that HPV has no major role in the pathogenesis of SCC of the urinary bladder.
R. Rftterud, A. Berner, R. Holm, E. Skovlund and S. D. Fossa (Department of Pathology, Clinical Research Office, and Department of Medical Oncology and Radiotherapy, The Norwegian Radium Hospital, Montebello, Norway)
p53, p21 and mdm2 Expression Vs The Response To Radiotherapy in Transitional Cell Carcinoma of the Bladder
BJU Intl. August 2001 Vol. 88 (3) Pg. 202-208
This is retrospective study to identify possible molecular markers predictive of radioresponsiveness in patients with transitional cell carcinoma (TCC) of the bladder.
Patients with T2-T4a TCC treated with preoperative radiotherapy and cystectomy were included in this study if their cystectomy specimen was pT3b (in 42) and pT0 (in 17). Radiotherapy was given either as 2 Gy x 23 over 4-5 weeks with cystectomy 4-5 weeks later (in 23) or as 4 Gy x 5 during 1 week with cystectomy after 1 week (in 36).
Protein expression of p53, mdm2 and p21 (CDKN1 A/WAF1/C1P1/SD11) was assessed by immunohistochemistry in biopsies taken before radiotherapy. There was no difference in protein expression when comparing all patients with pT0 and pT3b.
However for patients receiving 46 Gy, increased p53 expression (but not p21 or mdm2) predicted the absence of residual tumour. Six of seven patients with > 50% p53 expression had pT0 in the cystectomy specimen whereas 10 of 12 patients with £ 5% expression had pT3b. Over-expression of p53 correlated with longer overall and cancer specific survival.
The expression of p21 or mdm2 did not predict radioresponsiveness in patients with TCC of the bladder. The role of p53 remains unclear.
M.D. Shelley, H. Kynaston, J. Court, T. J. Wilt, B. Coles, K. Burgon and M. D. Mason (Cochrane Prostatic Diseases and Urological Cancer Subgroup, Velindre NHS Trust, and Urology Department, University Hospital of Wales Healthcare Trust, Cardiff, Wales, UK, and Department of Veterans Affairs, Medical Centre, Minneapolis, MN, USA)
A Systematic Review of Intravesical Bacillus Calmette-Guerin Plus Transurethral Resection Vs Transurethral Resection Alone in Ta and T1 Bladder Cancer
BJU Intl. August 2001 Vol. 88 (3) Pg. 209-216
This study assesses in a systematic review, the effectiveness of intravesical bacillus Calmette-Guerin (BCG) in preventing tumour recurrence in patients with medium/high risk Ta and T1 bladder cancer.
An electronic database search of Medline, Embase, DARE, the Cochrane Library, Cancerlit, Healthstar and BIDS was undertaken, plus hand searching of the Proceedings of ASCO, for randomized controlled trials, comparing transurethral resection (TUR) alone or TUR with intravesical BCG in patients with Ta and T1 bladder cancer.
The search identified 26 publications of which 6 trials were considered acceptable, representing 585 eligible patients, 281 in the TUR-alone group and 304 in the TUR+BCG group. The major clinical outcome chosen was local tumour recurrence.
The weighted mean log hazard ratio for the first recurrence, taken across all six trials was -0.83 (95% confidence interval -0.57 to -1.08 P<0.001), which is equivalent to a 56% reduction in the hazard, attributable to BCG. The Peto odds ratio for patients recurring at 12 months was 0.3 (95% confidence interval of 0.21-0.43, P<0.001), significantly favouring BCG therapy. Manageable toxicities associated with intravesical BCG were cystitis (67%), haematuria (23%), fever (25%) and urinary frequency (71%). There were no deaths.
TUR+BCG provides a significantly better prophylaxis of tumour recurrence in Ta and T1 bladder cancer than TUR alone.
J. T. Hsieh, H. E. Huang, J. Chen, H. C. Chang and S. P. Liu (Department of Urology, National Taiwan University Hospital, Taipei, Taiwan)
Modified Plication of the Tunica Albuginea in Treating Congenital Penile Curvature
BJU Intl. August 2001 Vol. 88 (3) Pg. 236-240
The authors describe a modified plication technique and compare it with the Nesbit procedure for treating congenital penile curvature.
An artificial erection was induced by normal saline injection in the areas where plication was planned. Bucks fascia was opened longitudinally and dissected a short distance toward the midline to free the neurovascular bundles. Allis clamps were used to clamp the tunica albuginea and “bumps” created. 2 interrupted U-shaped 2/0 polyglactin sutures were placed underneath each Allis clamp to secure the bump. The results were analysed retrospectively and compared with the results of the Nesbit procedure.
The mean follow up was 25 months (12-47) for the Nesbit procedure and 15 months (8-26) for the authors procedure.
In the Nesbit procedure 8 out of 11 cases had satisfactory cosmetic and functional results. 3 complained of penile shortening and one had erectile dysfunction.
In the authors procedure 10 out of 11 reported satisfactory cosmetic and functional result, one complained of penile shortening, two were concerned about the indurations of the penis but none had erectile dysfunction.
This modified plication technique is easier to perform and gives better results than the Nesbit procedure.
L. F. A. Wymenga, K. Groenier, J. Schuurman, J. H. B. Boomsma, R. Oude Elferink and H. J. A. Mensink (Departments of Urology, Nuclear Medicine, Radiology and Clinical Chemistry, Martini Hospital, and the Departments of General Practice and Urology, University Hospital, Groningen, The Netherlands)
Pretreatment Levels of Urinary Deoxypyridinoline As A Potential Marker in Patients with Prostate Cancer With or Without Bone Metastasis
BJU Intl. August 2001 Vol. 88 (3) Pg. 231-235
This study evaluates the predictive role of the bone markers alkaline phosphatase (ALP) and urinary deoxypyridinoline (DPD), as indicators of bone turnover, at baseline in patients with prostate cancer.
Urinary DPD, serum ALP and serum PSA (prostate-specific antigen) were evaluated in 23 patients with benign prostatic hyperplasia (BPH), 115 patients with prostate cancer (21 had osseous metastasis) and in 16 age-matched control subjects.
Patients of prostatic cancer with bone metastasis had higher levels of urinary DPD, serum PSA and ALP than those with BPH or prostate cancer with no bone metastases.
Receiver operating curve analysis for PSA, ALP and DPD showed a significant discriminating ability for positive and negative bone scans. However, from logistic regression of the combinations, only serum ALP was a significant independent predictor of bone metastasis in patients with prostate cancer.
L. F. A. Wymenga, J. H. B. Boomsma, K. Groenier, D. A. Piers and H. J. A. Mensink (Departments of Urology and Radiology, Martini Hospital, and the Departments of General Practice, Nuclear Medicine and Urology, University Hospital, Groningen, The Netherlands)
Routine Bone Scans in Patients With Prostate Cancer Related to Serum Prostate-Specific Antigen and Alkaline Phosphatase
BJU Intl. August 2001 Vol. 88 (3) Pg. 226-230
This study evaluates the need for a bone scan as a routine staging procedure in patients with newly diagnosed prostate cancer in relation to serum prostate-specific antigen (PSA) and alkaline phosphatase (ALP) levels.
The results of bone scans were related retrospectively to levels of serum PSA and ALP in 363 patients with prostate cancer.
Of 363 cases, 111 had positive bone scans. In 19 of 144 (13%, missed diagnosis) patients with a PSA level of < 20 ng/mL the bone scan was positive. On the other hand in 125 patients (49%, false-positives) with a PSA level of > 20 ng/mL the bone scan was negative.
A threshold level of 100 U/L for ALP gave a better balance for the number of false-positives and missed diagnosis. ALP values correlated better with an abnormal bone scan than did PSA levels; ALP levels of > 90 U/L indicated a 60% chance for the presence of bone metastases.
In prostate cancer patients bone scintigraphy should be advised if there is bone pain or ALP levels are > 90 U/L. PSA levels do not correlate with presence of skeletal metastases.
S. W. Melchior, J. Noteboom, R. Gillitzer, P. H. Lange, B. A. Blumenstein and R. L. Vessella (Department of Urology, University of Washington, Seattle, Urologische Klinik, Johannes-Gutenberg-University, Mainz, and American College of Surgeons, Chicago, IL, USA)
The Percentage of Free Prostate-Specific Antigen does not Predict Extracapsular Disease in Patients with Clinically Localized Prostate Cancer Before Radical Prostatectomy
BJU Intl. August 2001 Vol. 88 (3) Pg. 221-225
Univariate and multivariate logistic regression was used to analyse data from 171 untreated patients who underwent radical prostatectomy. Variables included the total PSA (tPSA), free PSA (fPSA), f/tPSA, biopsy Gleason score, clinical stage and patient age.
In 115 patients with pathologically organ-confined tumours (pT2N0), the mean (SD) tPSA value was 6.9 (5.6) ng/mL; in 56 patients with extracapsular disease (pT3pN0/N+) it was 10.2 (7.6) ng/mL; the respective f/tPSA values were 14.9 (8.1)% and 14.2 (12.9)%.
In the univariate and multivariate analysis, tPSA and biopsy Gleason score were highly significant in predicting extracapsular disease, but the f/tPSA was not. There was no significant difference between the mean f/tPSA and the final Gleason scores.
Knowing the f/tPSA provides no significant additional information in predicting extracapsular disease when the biopsy Gleason score and tPSA are known.
R. G. Hindley, A. H. Mostafid, R. D. Brierly, N. W. Harrison, P. J. Thomas and M. S. Fletcher (Department of Urology, Royal Sussex County Hospital, Brighton, East Sussex, UK)
The 2-Year Symptomatic and Urodynamic Results of a Prospective Randomized Trial of Interstitial Radiofrequency Therapy Vs Transurethral Resection of the Prostate
BJU Intl. August 2001 Vol. 88 (3) Pg. 217-220
Patients with lower urinary tract symptoms (LUTS) and urodynamic evidence of bladder outlet obstruction (BOO) were randomized to undergo IRFT or TURP and were followed up using the International Prostate Symptom Score (IPSS) and urodynamic assessment for 2 years.
At 2 years there was a clinically relevant reduction in IPSS in the IRFT group (20 to 9) and TURP groups (22 to 4). There was also a statistically significant reduction in the detrusor pressure at maximum urinary flow in both groups, but the reduction in the IRFT group was not sufficient to explain the observed symptomatic improvements solely from a reduction in BOO.
The authors conclude that IRFT can produce a sustained improvement in LUTS for at least 2 years. However such improvements are unlikely to be entirely the result of a reduction in BOO. This may be partly independent of any thermal effect and depend instead on neuromodulation of lower urinary tract nerves.
A. A. B. Adeyoju, D. Burke, C. Atkinson, C. Mckie, A. J. Pollard and P. H. O’Reilly (Departments of Urology, and Radiology and Nuclear Medicine, Stepping Hill Hospital, Stockport, UK)
The Choice of Timing For Diuresis Renography: The F + O Method
BJU Intl. July 2001 Vol. 88 (1) Pg. 1-5
The authors investigated a method of diuresis renography, where the radiopharmaceutical and frusemide are given simultaneously (F+O), in contrast to conventional renography in which frusemide is injected 20 minutes after the radiopharmaceutical (F+20) or 15 min before (F-15), with particular interest in the effect of this change on assessing split renal function and interpreting upper urinary tract dynamics.
29 patients (18 F + 11M, mean age 47 years [21-86 years]) were assessed. Each patient had 2 renograms taken over a 48-hour period, either by the F+20 or F-15 and the F+O method. Data for split renal function and drainage curves were obtained and the results compared.
The split renal function assessments were identical (< 5% variation) in all but two patients. 90% gave identical drainage curves. Those that showed discrepancies had either hugely dilated upper tracts or had multiple complicating factors like impaired renal function or neuropathic bladder.
The authors conclude that the F+O method gives results similar to the conventional (F-15 or F+20) method. It reduces the time required for the procedure, but may not be useful in grossly dilated upper tracts.
H. Sells and R. Cox (Derriford Hospital, Plymouth, and Royal Cornwall Hospital, Truro, Cornwall, UK)
Undiagnosed Macroscopic Haematuria Revisited: A Follow-up of 146 Patients
BJU Intl. July 2001 Vol. 88 (1) Pg. 6-8
The authors have undertaken this study to determine the appropriate follow-up of undiagnosed haematuria.
They have studied the hospital records of 146 patients who presented with gross haematuria but had no detectable pathology on cystoscopy and upper urinary tract imaging. These patients were followed up for recurrent haematuria and for the development of further urologic problems either by telephone or through the family physician.
Of 146 cases, 98 were alive and well and no further urological problems. 33 had recurrent haematuria; 26 of these were further investigated but only one had a transitional cell carcinoma of the renal pelvis. The remaining 15 had died of non-urological causes.
These results confirm that further or repeat investigations are required only in patients who have recurrent bleeding.
O. Reichelt, H. Wunderlich, T. Weirich, A. Schlichter and J. Schubert (Department of Urology, Friedrich-Schiller-University Jena, Germany)
Computerized Contrast Angiosonography: A New Diagnostic Tool For The Urologist?
BJU Intl. July 2001 Vol. 88 (1) Pg. 9-14
The authors evaluated the diagnostic potential of echo-enhanced ultrasonography (US) for depicting the vascular pattern of renal cell carcinoma (RCC) and calculating the first pass effect using harmonic imaging against that obtained by triphasic helical computerized tomography (CT).
The imaging modes commonly used for diagnosing RCC are CT, MRI and US. CT has been the investigation of choice for staging the tumor despite its limitations.
US is a widely used portable non invasive first line modality for evaluating the kidney. It delineates the anatomy and the presence of abnormal masses. The addition of colour and more recently, power Doppler US has enhanced its diagnostic capability.
It can be used with or without an intravenous microbubble echo-enhancing agent. After depicting and defining the tumor-extent by B-mode US, the first pass effect/enhancement by the echo-enhancing agent within the lesion and that of a reference area of unaffected renal cortex, were recorded on-line by calculating the mean pixel intensity. Time intensity curves were constructed.
After applying the echo-enhancing agent all tumors were enhanced whereas the perfusion was decreased (in 48%), increased (in 16%) or similar (in 36%) compared with the cortical reference area. These results co-related well with CT-findings.
The authors conclude that US has considerable potential in diagnosing RCC.
P. Ulleryd, B. Zackrisson, G. Aus, S. Bergdahl, J. Hugosson and T. Sandberg (Departments of Infectious Diseases and Urology, Sahlgrenska University Hospital, Goteborg, Sweden)
Selective Urological Evaluation in Men with Febrile Urinary Tract Infection
BJU Intl. July 2001 Vol. 88 (1) Pg. 15-20
This article investigates the prevalence and clinical importance of urological abnormalities in men with community-acquired urinary tract infection (UTI).
It is a prospective study of 85 men (median age 63 years) who had an episode of febrile UTI. They were followed-up for one year. Investigations included an excretory urography (IVU), cysto-urethroscopy uroflowmetry, digital rectal examination and transabdominal ultrasonography for post void residue.
The IVU revealed (in 83 patients) 22 abnormal findings in 19 patients. Relevant findings requiring surgical intervention was seen in only one patient (calculi). The lower urinary tract investigations revealed 46 findings in 35 patients. In all surgically correctable disorders were seen in 20 patients of whom 15 had previously unrecognized abnormalities.
All these patients had voiding difficulties or urinary retention and microscopic haematuria at follow-up or early recurrent UTI.
They conclude that routine upper urinary tract imaging seems dispensable in febrile UTI. The attention should be focused on lower urinary tract.
K. F. Quek, W. Y. Low, A. H. Razack and C. S. Loh (Health Research Development Unit, Faculty of Medicine, University of Malaya, and Department of Surgery, University Hospital, Kuala Lumpur, Malaysia)
Reliability and Validity of the International Prostate Symptom Score in a Malaysian Population
BJU Intl. July 2001 Vol. 88 (1) Pg. 21-25
This article assesses the value of the English version of the International Prostate Symptom Score (IPSS) in the Malaysian population.
Patients who were included in this study had to be literate and in a stable clinical condition. Patients < 40 years of age, illiterate and those who had previously been treated for lower urinary tract sepsis (LUTS) were excluded. The control group were patients who were free from major chronic or acute diseases.
The validity and reliability of IPSS was evaluated using the test-retest method and internal consistency using Cronbach’s a. Sensitivity to change was expressed as the effect size in the score before and after intervention in additional patients with LUTS who underwent transurethral resection of the prostate (TURP).
There was a high degree of internal consistency for each of the seven domains and for the total score (Cronbach’s a ³ 0.60 and ³ 0.79 respectively) in the populations studied. The test-retest correlation coefficient was highly significant.
The intra-class correlation coefficient was high. There was a high level of sensitivity and specificity for the effects of treatment with a very significant change between the seven scores domains in the treated group but not in the control group.
The IPSS is suitable, reliable, valid and sensitive to clinical change in the Malaysian population.
M. I. Patel, W. Watts and A. Grant (The Department of Urology, Royal Newcastle Hospital, Newcastle, NSW, Australia)
The Optimal Form of Urinary Drainage After Acute Retention of Urine
BJU Intl. July 2001 Vol. 88 (1) Pg. 26-29
The authors evaluate the efficacy of different forms of urinary drainage particularly for urinary tract infection (UTI), operative findings and patient preference in patients treated for acute retention of urine (AUR).
A feasibility trial was conducted of men presenting with AUR, after a short period of indwelling catheterization (IDC); patients were taught how to use intermittent clean self-catheterization (CISC).
Patients who failed this were re-catheterized and taught to manage a valve, or failing this a leg bag, and then discharged. They were followed up to assess the occurrence of spontaneous voiding, UTI, findings at prostatectomy and patient satisfaction.
CISC group (34 men) had a higher rate of spontaneous voiding than the IDC group (16 men). The incidence of UTI was 32% in the CISC group and 75% in the IDC group. At TURP, 20% of CISC group had UTI compared with 69% in the IDC group. Patients using CISC preferred it and had fewer complications than the IDC group.
They conclude that CISC is managed and accepted well by patients. It has fewer complications and should therefore be considered in patients who present with AUR.
T. Isotalo, M. Talja, P. Hellstrom, I. Perttila, T. Valimaa, P. Tormala and T. L. J. Tammela (Department of Surgery, Paijat-Hame Central Hospital, Division of Urology, Oulu University Hospital, Division of Urology, Helsinki University Hospital, Institute of Biomaterials, Tampere University of Technology, Department of Urology, University of Tampere and Tampere University Hospital)
A Double-Blind, Randomized, Placebo-Controlled Pilot Study to Investigate the Effects of Finasteride Combined with a Biodegradable Self-Reinforced Poly L-Lactic Acid Spiral Stent in Patients with Urinary Retention Caused by Bladder Outlet Obstruction from Benign Prostatic Hyperplasia
BJU Intl. July 2001 Vol. 88 (1) Pg. 30-34
This study evaluates the use of a combined therapy comprising finasteride and a biodegradable self-reinforced poly L-lactic acid (SR-PLLA) urethral stent, for acute urinary retention due to benign prostate hyperplasia.
55 such patients were treated as outpatients. They had a suprapubic catheter inserted and the SR-PLLA stent placed cystoscopically. After 2 weeks the patients were randomized to receive either finasteride 5 mg daily or placebo. They were assessed at baseline, and at 6, 12, and 18 months for maximum urinary flow rate, prostate volume and serum (PSA) prostatic specific antigen.
There was statistically significant increase in the mean maximum flow rate and a statistically significant decrease in prostatic volume and serum PSA in the finasteride group. The same number of patients discontinued in both groups due to poor therapeutic response.
The major problems were the discontinuation of treatment because of insufficient therapeutic response and breakdown of the spiral stent. New configuration of the bioabsorbable stent is needed.
A. Mehik, P. Hellstrom, A. Sarpola, O. Lukkarinen and M. -R. Jarvelin (Division of Urology, Department of Surgery, Oulu University Hospital, Department of Public Health Science and General Practice, Oulu University, Oulu, Finland, and Department of Epidemiology and Public Health, Imperial College School of Medicine, University of London, London, UK)
Fears, Sexual Disturbances and Personality Features in Men with Prostatitis: A Population-Based Cross-Sectional Study in Finland
BJU Intl. July 2001 Vol. 88 (1) Pg. 35-38
This study attempts to determine the occurrence of mental distress related to prostatitis in Finnish men.
A population-based cross-sectional survey was conducted of 2500 men (20-59) years in Finland. The final response rate was 75% (1832 men).
Fear of undetected cancer was reported by 17% (significantly higher than in normal men). Fear of having a sexually transmitted disease and suicidal thinking was also significantly higher. They preferred to be alone in a public toilet. Erectile dysfunction was reported by 43% with decreased libido by 24%.
They were often busy and nervous and had a meticulous attitude to life and its problems. Marital difficulties were reported by 17% and 4% felt that it was the cause for their divorce. Socioeconomic status and social well being had no influence on the occurrence of prostatitis. Psychological stress is common in men with prostatitis.
M. Bhandari, D. Dubey and B. S. Verma (Department of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India)
Dorsal or Ventral Placement of the Preputial/Penile Skin Onlay Flap for Anterior Urethral Structures: Does it make a Difference?
BJU Intl. July 2001 Vol. 88 (1) Pg. 39-43
Anterior urethral strictures, which cannot be excised and re-anastomosed, are best treated by substitution urethroplasty.
The authors report their experience in such cases with a dorsally/dorsolaterally placed penile/preputial vascularized flap, and compare their results with the traditional ventrally placed flap.
40 patients (mean age 40.5 years) with recurrent strictures of the penile/bulbar urethra were treated with longitudinal penile/circumpenile flap substitution urethroplasty. 19 patients underwent dorsal placement of the flap as an onlay (DO), whereas 21 patients had a ventral onlay flap (VO). 5 patients required inferior pubectomy to facilitate high proximal placement of the flap.
Both groups were well matched as far as age, previous interventions, stricture site and length and follow-up.
After a median follow-up of 27.5 months, the stricture recurred in 3 out of 21 VO flaps (24%) and 2 out of 19 DO flaps (11%). One patient with VO flap developed a fistula, which required surgery.
Flap pseudo-diverticulum and/or sacculation with postvoid dribble occurred in 6 VO flaps and none in the DO flaps.
Dorsal placement of the flap in anterior urethroplasty for strictures is anatomically and functionally more appropriate than the traditional VO flap.
M. Cornacchia, A. Zenorini, S. Perobelli, L. Zanolla, G. Mastella and C. Braggion (Cystic Fibrosis Centre and the Cardiology Department, Ospedale Civile Maggiore, Verona, Italy)
Prevalence of Urinary Incontinence in Women with Cystic Fibrosis
BJU Intl. July 2001 Vol. 88 (1) Pg. 44-48
This study evaluates the incidence of urinary incontinence (UI) in female patients (³ 15 years of age) attending a cystic fibrosis (CF) clinic in whom stress UI could be common, as chronic coughing and sputum production are frequent symptoms associated with progressive lung disease.
An anonymous questionnaire was completed by 176 women with CF (mean age 24.6 years) during routine assessment as outpatients.
72 patients (41%) had no incontinence. 61 women (35%) had occasional UI. 43 patients (24%) reported UI once or twice a month for 2 consecutive months.
Regular UI is associated with increasing age and lower mean forced expiratory volumes (FEV) than in women with no urinary symptoms.
All incontinent women recorded stress UI; coughing, laughing and physical activity were associated with UI in 92%, 33% and 21% of patients respectively.
Stress UI is a common symptom in women with CF. Patients should be specifically asked about this symptom (since they may be shy to admit it). Pelvic floor exercises are effective and should be considered in all cases.
A. D. Clark and M. S. Salloum (Department of Uro-Gynaecology, St. Mary’s Hospital, Portsmouth, Hampshire, UK)
Vaginal Retropubic Urethropexy with Intraoperative Cystometry for Treating Urinary Stress Incontinence
BJU Intl. July 2001 Vol. 88 (1) Pg. 49-52
This study evaluates the results of vaginal retropubic urethropexy with intraoperative cystometry in the treatment of urinary stress incontinence.
100 patients with genuine stress incontinence on urodynamic examination underwent this procedure and were followed up.
96 cases completed the follow-up but 4 were lost to follow-up. At the end of 1 year 91 patients (95%) were cured. But 5% had failed (recurrence of stress incontinence). The main complications were of suture erosion (6%).
This method of repair has given excellent results to date, with low complication and morbidity rates. Further studies may be necessary before it can be recommended generally.
I. Hara, H. Miyake, S. Hara, N. Yamanaka, Y. Ono, H. Eto, Y. Takechi, S. Arakawa and S. Kamidono (Department of Urology, Kobe University School of Medicine, Kobe, Department of Urology, Shinko Hospital, Kobe, Department of Urology, Hyogo Medical Center for Adults, Akashi and Department of Urology, Hyogo Prefectual Awaji Hospital, Sumoto, Japan)
Value of the Serum Prostate-Specific Antigen-a1-antichymotrypsin Complex and Its Density As A Predictor for the Extent of Prostate Cancer
BJU Intl. July 2001 Vol. 88 (1) Pg. 53-57
This study examines whether serum levels of prostate-specific antigen-a1-antichymotrypsin (PSA-ACT) and its density (ACTD) can predict organ-confined prostate cancer versus extracapsular disease.
Serum samples of 62 clinically localized prostate cancer patients were obtained before they underwent radical prostatectomy. PSA, PSA-ACT were measured using immunofluorometric techniques with different monoclonal antibodies against PSA and ACT respectively.
Furthermore, the PSA and PSA-ACT densities of the whole prostate (PSAD and ACTD) were calculated. The relationships of serum PSA, PSA-ACT, PSAD, ACTD and the pathological state of the prostatectomy specimen were analysed.
The disease was organ-confined in 30 and had extraprostatic spread in 32 patients.
In the organ-confined cancer the mean PSA, PSA-ACT levels were significantly lower than in those with extraprostatic disease.
The PSAD and ACTD levels were significantly higher in the cases of extraprostatic disease than in the organ-confined cases.
At each pathological stage there were significant differences in PSA, PSA-ACT, PSAD and ACTD, but there was no significant correlation between these variables and the Gleason score.
Receiver operating characteristic curve analysis for detecting organ-confined disease showed that PSA-ACT and ACTD had a larger area under the curve than PSA and PSAD respectively, but these differences were not significant.
PSA-ACT and ACTD showed better sensitivity for detecting organ-confined disease than PSA or PSAD respectively.
J. Baniel, S. Israilov, E. Segenreich and P. M. Livne (Institute of Urology, Rabin Medical Center, Beilinson Campus, Petah Tiqva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel)
Comparative Evaluation of Treatments for Erectile Dysfunction in Patients with Prostate Cancer After Radical Retropubic Prostatectomy
BJU Intl. July 2001 Vol. 88 (1) Pg. 58-62
This study evaluates the effectiveness of a progressive local treatment protocol for erectile dysfunction (ED) in patients after undergoing radical retropubic prostatectomy (RRP) for prostate cancer.
85 patients (mean age 59.5 years) with ED after RRP have been studied. Treatment was offered in 4 progressive phases, with the 2nd or next phase following only if the first one failed.
In phase I- patients used an erection device. In phase II sildenafil was used. In phase III intracorporal injection was used and in phase IV, phase I + phase III was combined. The follow-up was for one year.
Of 85 patients, 92% (78 patients) responded to phase I, but only 11 (14%) agreed to continue with it at home.
Of the remaining 74 patients, 69 (who had no contra-indications) were put onto phase II and 14 i.e. 20% had a positive response. 60 patients were then treated with phase III and 51 or 85% had a positive response (4 of the 9 failures in phase III responded to phase IV). 5 patients failed all 4 protocols.
After 1 year of follow-up, 76 of the 80 patients were successfully continuing treatment at home. 7 used phase I, 11 used phase II. 54 used phase III and 4 used phase IV. Overall the treatment gave a positive response in 94% cases.
G. Biagiotti and G. Cavallini (Andros-Italia, Perugia and Ferrara, Italy)
Acetyl-L-Carnitine Vs Tamoxifen in the Oral Therapy of Peyronie’s Disease: A Preliminary Report
BJU Intl. July 2001 Vol. 88 (1) Pg. 63-67
The study includes 48 patients with Peyronie’s disease (15 acute and 33 initial chronic), randomized equally into 2 groups. Group 1 used tamoxifen 20 mg twice daily for 3 months and Group 2 used acetyl-L-carnitine 1 gm twice daily for 3 months.
The disease and stages were diagnosed using history, objective examination, pharmacologically induced erection, autophotography during erection, and basic and dynamic colour Doppler ultrasonography.
Penile curvature, plaque size, pain and disease progression were assessed. The differences between the groups or between the variables before and after therapy were compared using analysis of variance and the chi-squared test.
Acetyl-L-carnitine was significantly more effective than tamoxifen in reducing pain and in inhibiting disease progression. It reduced penile curvature significantly while tamoxifen did not. Both drugs reduced plaque size. Tamoxifen had more side effects than acetyl-L-carnitine.
K. Sairam, E. Kulinskaya, G. B. Boustead, D. C. Hanbury and T. A. McNicholas (Lister Hospital, Stevenage, Health Research & Development Support Unit (HRDSU), Faculty of Health & Human Sciences, University of Hertfordshire, Hatfield, Herts, UK)
Prevalence of Undiagnosed Diabetes Mellitus in Male Erectile Dysfunction
BJU Intl. July 2001 Vol. 88 (1) Pg. 68-71
A prospective prevalence study was carried out in an andrology outpatient clinic. In all 129 consecutive men presenting with erectile dysfunction underwent FBG (fasting blood sugar) and urinary dipstick testing to detect diabetes mellitus (DM).
The prevalence of known DM was 17% and that of undiagnosed DM was 4.7%. Of the 107 remaining men an abnormal FBG level was found in another 12%. The sensitivity of the urine dipstick test was 20%.
DM is more prevalent in men with ED than the general population. ED is a marker symptom for DM. Glycosuria if used as a screening test will miss the diagnosis in 80% cases. FBG testing is more reliable.
Z. A. Memish and S. Venkatesh (Department of Infection Prevention & Control, King Fahad National Guard Hospital, Riyadh, Saudi Arabia)
Brucellar Epididymo-Orchitis in Saudi Arabia: A Retrospective Study of 26 Cases and Review of the Literature
BJU Intl. July 2001 Vol. 88 (1) Pg. 72-76
This retrospective study analyses 26 adult patients with acute brucellar epididymo-orchitis – their clinical features, diagnosis and their therapy.
The clinical picture was typical – gradual onset of scrotal pain with a palpably enlarged testis and/or epididymis. The diagnosis was confirmed on the basis of a positive blood culture or high agglutination titres of ³ 1:120.
Epididymo-orchitis occurred in 1.6% of all patients with brucellosis. 58% of these cases were 25-44 years of age. 77% presented with acute symptoms of < 2 weeks duration. All patients complained of swollen painful testes, undulant fever in 96%, chills in 54% and arthralgia in 23%. Four patients had dysuria and one had haematuria. Ten patients gave a history of ingestion of raw milk and milk products. One patient had laboratory acquired brucellosis.
Six patients had unilateral disease (two of them had florid presentations). The remaining had only orchitis (bilateral in two, right sided in 10 and left sided in 8). Leucocytosis was present in 6. 25 had initial agglutination titres of > 1:320 and one patient had a positive blood culture.
All cases were treated with antibiotics (1 M streptomycin for first 2 weeks or oral rifampicin for 6 weeks, followed by doxycycline or tetracycline for 6 weeks). All showed improvement – fever subsided in 2-5 days and the scrotal swelling and tenderness regressed. Only one patient had a relapse within one year.
N. Ade-Ajayi, D. T. Wilcox, P. G. Duffy and P. G. Ransley (Department of Urology, The Great Ormond Street Hospital for Children, London, UK)
Upper Pole Heminephrectomy: Is Complete Ureterectomy Necessary?
BJU Intl. July 2001 Vol. 88 (1) Pg. 77-79
This is a retrospective study of 60 upper pole heminephrectomies done in cases of duplex kidneys where the upper renal moiety was dysplastic. The heminephrectomy was done along with incomplete ureterectomy. The patients were 39 girls and 16 boys (mean age at primary surgery was 27 months).
58% i.e. 32 children had an antenatal diagnosis while 22% i.e. 12 children presented with urinary tract infection (UTI) and 11% i.e. 6 children with urinary incontinence.
29 out of the 60 renal units i.e. 48% had an associated ureterocele and in 9 i.e. 15% had an ectopic ureter. 10 infants (18%) underwent initial puncture of the ureterocele. 5 patients (8%) all females, required lower urinary tract re-operation either for recurrent UTI in all and a prolapsed ureterocele in one. All had ultrasonographic evidence of a dilated ureteric stump. One child had reflux into the retained ureter.
The authors conclude that the rate of re-operation for a redundant ureteric stump was only 8%.
M. P. J. Wright, R. A. Persad and D. W. Cranston (Departments of Urology, Bristol Royal Infirmary, and Churchill Hospital, Oxford, UK)
Renal Artery Occlusion
BJU Intl. January 2001 Vol. 87 (1) Pg. 9-12
Renal artery occlusion (RAO) is a rare but significant cause of kidney loss. Traube (1856) first described renal artery embolism, while von Recklinghausen (1861) first described traumatic occlusion of the renal artery.
The authors have reviewed the different mechanisms of presentation of RAO and have highlighted some of the controversies in the diagnosis and treatment.
The risk factors for RAO have been summarized as follows:
1) Congenital lesions of kidney e.g. horseshoe kidney, crossed renal ectopia polycystic disease.
2) Trauma- blunt abdominal trauma deceleration injuries, iatrogenic trauma
3) Cardiac arrhythmia, aortic valvular disease
5) Nephrotic Syndrome
6) Vasculitis (polyarteritis nodosa)
7) Procoagulant states
The presentation is with pain in lumbar region – atypical renal colic and haematuria and rarely anuria (if solitary kidney). Rarely they may present with hypertension and altered mental state.
The diagnosis is difficult and may often be missed. Serum LDH elevation is a good screening marker. IVU may show no renal shadow – rarely a cortical rim may be seen because of collateral circulation. Ultrasonography may confirm only the anatomical presence of the kidney but when combined with a color Doppler study may confirm renal artery occlusion.
CT scan may need to be done when in doubt and if combined with dye studies can be conclusive.
Surgery (renal artery embolectomy) is controversial. Thrombolytic therapy using a percutaneous transfemoral approach with or without balloon angioplasty have shown promising results.
T. T. Wu and J. -K. Huang (Division of Urology, Department of Surgery, Veterans General Hospital, et al)
Annual Changes in the Clinical Features of Prostatic Adenocarcinoma in Taiwan
BJU Intl. January 2001 Vol. 87 (1) Pg. 57-60
The authors use a clinical and pathological database to determine the annual changes in the characteristics of prostatic adenocarcinoma in Taiwan.
The study included 694 patients (1991-1999) newly diagnosed as prostate adenocarcinoma. Using logistic regression for dichotomous variables, the annual trends were assessed for changes in the percentage of T1c disease, incidental carcinoma, clinically localized disease and Gleason grade 4/5 scores. The annual trends for changes in the pathological features of disease in patients treated by radical prostatectomy were also analyzed.
The median age at diagnosis increased significantly and there was a significant increase in clinical T1c disease. There was a significant disease in incidental carcinoma, patients with a serum PSA level of > 20 ng/ml and with Gleason grade 4/5 tumours. There was no significant change in the percentage of clinically localized disease.
Radical prostatectomy was undertaken in 179 patients – the annual incidence of lymph node metastases decreased significantly and there was a significant increase in the relative risk of having organ-confined disease and in the Gleason grade 4/5 tumors.
E. Meuleman, B. Cuzin, et al (Department of Urology, Academisch Ziekenhuis, et al)
A Dose-Escalation Study to Assess the Efficacy and Safety of Sildenafil Citrate in Men with Erectile Dysfunction
BJU Intl. January 2001 Vol. 87 (1) Pg. 75-81
This study assesses the efficacy and safety of sildenafil citrate (Viagra) in a double blind placebo-controlled dose escalation study over a period of 26 weeks in men with erectile dysfunction of a broad spectrum of aetiology.
315 men from 50 countries were randomized into 2 groups (156 men with placebo) and (159 men with Viagra).
Hypertension (20%), a history of pelvic surgery (19%), diabetes mellitus (15%) and ischemic heart disease (10%) were the concomitant medical diseases.
Viagra was started as a dose of 25 mg (matching placebo) which could be increased to 50 mg and then to 100 mg based on efficacy and tolerability.
Assessment of efficacy comprised the 15 item International Index of Erectile Function (IIEF) including ability to achieve an erection and maintain it, a partner questionnaire an overall efficacy question and event-log data.
After 12 weeks of treatment 26%, 32% and 42% of patients were taking 25, 50 and 100 mg of Viagra respectively. A similar distribution of doses was reported after 26 weeks of treatment.
Viagra significantly improves the patients ability to achieve and maintain an erection as compared to placebo.
There was a significant improvement in the mean score for the erectile function domain regardless of the aetiology of dysfunction.
After 12 weeks and 26 weeks of therapy 89% and 72% showed improvement with Viagra as against 24% and 23% with placebo. Treatment related adverse effects were mild to moderate in 27% of patients in the Viagra group as against 8% in the placebo group.
Viagra is an effective and well tolerated treatment for men with erectile dysfunction.
J. H. Ku, M. E. Kim, et al (Department of Urology, Military Manpower Administration, Taejeon, et al)
The Excisional Plication and Internal Drainage Techniques: A Comparison of the Results for Idiopathic Hydrocele
BJU Intl. January 2001 Vol. 87 (1) Pg. 82-84
Between 1990 and 1998, 132 patients (mean age 54.36 years) underwent repair for idiopathic hydrocele using one of three techniques (excision, eversion/plication or internal drainage). The complications and recurrence rates for each technique were evaluated.
The excisional technique had the highest (81%) complication rate and the internal drainage technique the lowest (7%). Postoperative scrotal oedema occurred in 72% of patients after plication – the highest rate amongst the three techniques. There was very little difference in the rates of haematoma formation and wound sepsis in the three groups. The internal drainage technique had the highest recurrence rate (85%) and the excisional technique the lowest (1.3%).
These results suggest that plication is better than excision and better than internal drainage.
M. Fujisawa, K. Yamanaka, et al (Department of Urology, Kobe University School of Medicine, Kobe, Japan)
Expression of Endothelial Nitric Oxide Synthase in the Sertoli Cells of Men with Infertility of Various Causes
BJU Intl. January 2001 Vol. 87 (1) Pg. 85-88
This study investigates how endothelial nitric oxide synthase (eNOS) expression in the seminiferous tubules might be related to spermatogenesis, by examining eNOS expression in testicular tissue of patients with infertility from various causes.
The study included 5 fertile men with normal sperm concentration, 9 patients with obstructive azoospermia, 20 cases with varicocele and 8 with idiopathic azoospermia.
The testicular biopsy specimens were examined by immunohistochemistry for eNOS protein expression, in addition to routine pathological examination.
A Sertoli cell staining index (SSI) was defined as the ratio of stained Sertoli cells per total member of Sertoli cells, and was compared among the groups.
eNOS was localized to Sertoli cells in the seminiferous tubules and Leydig cells in the interstium; although some degenerating germ cells stained, normal germ cells did not. The SSI was significantly lower in patients with idiopathic azoospermia than in either fertile men or those with obstructive azoospermia or varicocele. However, the SSI did not correlate with the Johnsen score.
The expression of eNOS in Sertoli cells depends on the existence of germ cells and be associated with germ cell development.
I.S. Arda and I. Ozyaylali (Department of Pa
ediatric Surgery, Baskent University Faculty of Medicine, Ankara, Turkey)
Testicular Tissue Bleeding as an Indicator of Gonadal Salvageability in Testicular Torsion Surgery
BJU Intl. January 2001 Vol. 87 (1) Pg. 89-92
This study investigates the reliability of using bleeding from the cut surface of testicular tissue during surgery for torsion testis to assess testicular viability, compared with the duration of symptoms and preoperative findings on testicular Doppler ultrasonography (DUS).
The study includes 19 children with testicular torsion who underwent surgery. All underwent DUS before surgery. During surgery, the tunica vaginalis was incised and a deep incision was made through the medulla after obtaining a wedge biopsy for histological examination.
After waiting for 10 minutes to assess any fresh arterial bleeding from the cut surface the patients were categorized into three grades.
Grade I – Sufficient bleeding i.e. bleeding or oozing when the biopsy was obtained.
Grade II – Insufficient bleeding. No bleeding immediately after the incision but starting within 10 minutes.
Grade III – No bleeding within 10 minutes.
Grade I and II testes were saved and grade III testes were removed.
The biopsies were classified as haemorrhagic, necrotic or indeterminate. The patients were followed up at 15 days and at 1, 3, 6 and 12 months with, the affected testis examined using DUS.
At the end of the study, the sensitivity and specificity of the clinical features, DUS findings and biopsy findings and bleeding at surgery were calculated for predicting testicular viability.
The sensitivity, specificity, positive and negative predictive values were respectively 100%, 90%, 90% and 100% for a duration of symptoms of more than 10 hours. 78%, 80%, 78% and 80% for DUS findings, and 100%, 78%, 83% and 100% for testicular tissue bleeding in predicting gonad viability after torsion, respectively.
BMJ, Vol.323 (7311), 1 September 2001, Pg. 522
Summary : The challenge to clinicians caring for men with carcinoma of the prostate is to separate out those with low risk cancers who can simply be watched from those with high risk tumours who need early aggressive treatment. One useful measure (Mayo Clinic Proceedings 2001; 76:571-2; 576-81) is the doubling time for the concentration of prostate specific antigen.
It seems especially helpful in men whose disease has recurred: a long doubling time is associated with local recurrence whereas a short doubling time suggests systemic recurrence.
Ian M. Thompson
Pharmacologic Agents in Complementary Medicine in Prostatic Disease
Drugs of Today Vol.37 (6), June 2001, Pg. 427-433
Summary : Use of alternative medicine has increased considerably in the last 10 years. The very high frequency of urologic diseases such as benign prostatic hyperplasia and prostate cancer makes these diseases natural targets of alternative medicine.
As many as 80% of men at risk of prostate cancer are using alternative therapies. In the majority of cases, physicians were unaware of the fact that their patients were using these treatments.
Treatment of Prostate Cancer :
1) Vitamin E – Main function is its intracellular anti-oxidant activity. In preclinical models, vitamin E has been demonstrated to reduce growth rate of human LNCaP prostate cancer model.
Higher vitamin E levels have been suggested in epidemiologic studies to be associated with lower cancer risk. In a clinical trial it was found that prostate cancer rates were 1/3rd lower in men who had been randomized to receive vitamin E. Effect of vitamin E supplementation was seen almost at the inception of the study and persisted for its duration.
2) Selenium – It is a naturally occurring micronutrient. Humans receive it from ingestion of both plants and animals. A dramatic almost 2/3rds reduction in incidence of prostate cancer was observed among men receiving selenium. A large study is planned to determine relationship of this agent and prostate cancer risk.
3) Soy and Isoflavenoids – Soy is a major source of a group of weak estrogens known as isoflavenoids. One of these agents, genistein may be the most abundant and clinically significant. The exact mode of action of these isoflavenoids is not known.
Besides estrogenic effect, inhibition of epidermal growth factor receptor tyrosine kinase and inhibition of angiogenesis may be involved. Several prostate cancer cell lines have been found to have growth inhibition when exposed to genistein.
4) Dietary Fat – It has been associated with prostate cancer consistently. The precise cause is not understood but may be related to total caloric intake. HMG-CoA reductase inhibitors which block synthesis of cholesterol have a small effect. These agents have been reported to induce apoptosis in prostate cancer cells as well as in stromal cells.
5) PC-SPES – It has unquestionable activity against existing prostate cancer. It is a mixture of 8 herbs-chrysanthemum, isatis licorice, Ganoderma lucidum, Panax pseudo-ginseng, Rabdosia rubescens, saw palmetto and skullcap.
6) COX Inhibitors – Highest concentrations of COX-1 and COX-2 are found within the prostate. A significant reduction of prostate cancer risk among men taking NSAIDS or aspirin has been demonstrated.
Treatment of Benign Prostatic Hyperplasia –
(1) Saw palmetto (2) Pygeum africanum (3) Cernilton (4) b-Sitosterol have been discussed.
There is compelling evidence that a variety of the above therapies for both prostate cancer (prevention and treatment) and lower urinary tract symptoms (BPH) may be effective. Ongoing clinical trials will address to a greater degree of precision, the effect and optimal use of these agents.
M. R. Feneley and Alan W. Partin (Department of Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland)
Indicators of Pathologic Stage of Prostate Cancer and Their Use in Clinical Practice
The Urologic Clinics of North America August 2001 Vol. 28(3) Pg. 443-458
Pathologic stage has important prognostic and therapeutic implications for patients with prostate cancer particularly for those with clinically localized disease. In the absence of detectable metastases, the therapeutic outcome relates primarily to the pathologic stage of the primary tumour.
The clinical assessment is based on a digital rectal examination. DRE has a good positive predictive value but it has a poor negative predictive value for diagnosing organ confined disease. This inaccuracy of clinical staging by DRE can only be confirmed by a radical prostatectomy.
PSA is recognized as the most useful tumour marker in the diagnosis of prostate cancer. The levels of PSA correlate directly with the pathologic state. A level < 4.0 ng/mL suggests organ confined disease. In a prospective evaluation the percent free PSA (free PSA: total PSA) was predictive of pathologic stage with intermediate PSA levels (4-10 ng/mL) in those patients for whom total PSA is not predictive.
Imaging modalities have not contributed significantly towards identifying extracapsular spread of disease CT/MRI help in detection of lymph node involvement but still have limited value. Monoclonal antibody nuclear scan helps to detect soft tissue metastases. Bone radioscentigraphy helps in the detection of skeletal metastases.
Prostatic needle biopsy provides important prognostic data (Gleason grade microvessel density, DNA ploidy and altered chromosomes).
Radical prostatectomy is increasingly recognized as a definitive method for eliminating organ confined prostatic cancer. The risk of understaging by clinical examination is significant and associated with a greater likelihood of local recurrence.
The prognostic significance of pathologic staging would justify the use of accurate predictive models within decision algorithms. Hence careful clinical and pathological and radiological assessment relates to pathologic stage and may be used for its prediction.
J. W. Moul, C. J. Kane, et al (The Urology Service, Department of Surgery, Walter Reed Army Medical Center, Washington, DC et al)
The Role of Imaging Studies and Molecular Markers for Selecting Candidates for Radical Prostatectomy
The Urologic Clinics of North America August 2001 Vol. 28(3) Pg. 459-472
With the advent of PSA screening programs, and increased public awareness of the disease (carcinoma, prostate), its incidence has dramatically increased in the last decade.
There is now an awareness of the impact of early diagnosis on the ultimate outcome. Despite this 40-60 per cent of cases have extracapsular disease after radical prostatectomy and 40% have local recurrence at the end of 10 years.
There is now a search for methods to ensure an early diagnosis (organ-confined disease). Digital rectal examination, PSA value and biopsy tumour grade are the usual parameters used for determining the spread of the disease.
This article reviews the imaging modalities available to the urologist. Radionucleide bone scan has been done with strontium 85 (high gamma-photon energy and a long half life of 65 days) – but has been replaced by Technetium (Tc) 99 m – labeled polyphosphate (half life of 6 hours).
Currently the best agent available is Tc 99 m diphosphonate. However it is generally felt that PSA value if high is a good indicator of a positive bone scan and if < 10-20 ng/mL the per cent age of bone scans being positive is low.
CT scan for local staging of prostate cancer has reported a sensitivity of 55-75% and a specificity of 60-73%; and for seminal vesicle invasion, the sensitivity of 19-36%. For detection of lymph nodes CT scan has false negative findings from error in detecting small nodes.
It may show false positive results because CT scan cannot differentiate between inflammatory and metastatic nodes. Multiple investigators have demonstrated that for patients with newly diagnosed prostate cancer with a serum PSA under 20 ng/mL, an abdominal and pelvic CT scan rarely provides useful diagnostic findings.
One exception is the patient with a small cell or anaplastic variant of prostate cancer who often has extensive metastases – a CT scan may be positive.
MRI : Early studies have supported the use of MRI in detecting seminal vesicle invasion (91% accuracy) but has not been effective in detecting microscopic or extracapsular extension. Even with newer techniques a single study has showed only 28% demonstrated capsular irregularity on endorectal imaging.
Endorectal MR imaging provides the most comprehensive cross sectional imaging of the prostate. It is accurate in showing seminal vesicle involvement and gross capsular extension; however it is limited in its ability to demonstrate the subtleties of extracapsular extension and positive surgical margins which are of great surgical importance in the treatment of localized prostate cancer.
Indium III Capromab Pendetide (Prostascint) this is a new scintigraphic radiolabeled monoclonal antibody imaging of prostate – specific membrane antigen (PSMA). A SPECT scan done after injection of indium labeled monoclonal antibody can be informative. Expertise is required for proper interpretation of these scans.
Molecular Markers Detection of PSA expressing cells by the RT – PCR (Reverse Transcriptase – Polymerase Chain Reaction) in the peripheral blood and/or bone marrow indicated extraprostatic disease.
The following molecular markers have been studied in prostate needle biopsy specimens using immunohistochemistry: p53 tumour suppressor gene protein, bcl-1 oncogene tumour, the Ki-67 proliferation index using M1B-1 antibody, microvessel density assessment and E-cadherin.
None of these biomarkers have shown consistent results; of late, p-53 as a prognostic indicator has been found to be an independent predictor of recurrence after surgery.
In the long term, multiple gene expression profiling of biopsy material using gene chips may revolutionize the care of patients with prostate cancer and those who elect for radical prostatectomy.
R. E. Link and R. A. Morton (The Scott Department of Urology, Baylor College of Medicine, Houston, Texas)
Indications for Pelvic Lymphadenectomy in Prostate Cancer
The Urologic Clinics of North America August 2001 Vol. 28(3) Pg. 491-498
Pelvic lymphadenectomy (PL) provides extremely valuable staging information in patients being treated for adenocarcinoma of the prostate; however the cost and potential morbidity associated with this procedure suggests that it is not indicated in all patients.
This article reviews the indications for lymphadenectomy as well as factors that may influence how one chooses which patients will benefit from PL. It provides the initial steps for a decision analysis framework that will introduce health state utilities into the decision to perform PL on an individual patient basis.
N. Rosenblum, and Herbert Lepor (The Department of Urology, New York University School of Medicine, New York, New York)
Radical Retropubic Prostatectomy – Preoperative Management
The Urologic Clinics of North America August 2001 Vol. 28(3) Pg. 499-507
The preoperative management of surgical candidates undergoing radical retropubic prostatectomy is of paramount importance. This article describes the authors approach for optimizing the selection of surgical candidates and establishes guidelines for appropriate preoperative cardiovascular assessment.
Issues relevant to preoperative management include the management of anticoagulants, prevention of venous thromboembolism and pulmonary embolism, preoperative bowel preparation, use of prophylactic antibiotics, blood management prior to surgery and anesthetic selection are reviewed.
Herbert Lepor (The Department of Urology, New York University School of Medicine, New York, New York)
Radical Retropubic Prostatectomy
The Urologic Clinics of North America August 2001 Vol. 28(3) Pg. 509-519
Radical prostatectomy is a surgical technique associated with significant morbidity. The ability to minimize intra-operative bleeding and preserve continence and potency requires a comprehensive understanding of pelvic anatomy, meticulous surgical technique and appropriate surgical instruments.
The anatomic radical retropubic prostatectomy first described represents a technique in evolution. The detailed surgical technique described in this article represents the authors technique. The step by step illustrations and description of technique are designed to aid the urologic surgeon develop an efficient approach to this surgical procedure.
M. J. Scolieri, and M. I. Resnick (The Department of Urology Case Western Reserve University School of Medicine, University Hospitals of Cleveland, Cleveland, Ohio)
The Technique of Radical Perineal Prostatectomy
The Urologic Clinics of North America August 2001 Vol. 28(3) Pg. 521-533
Radical perineal prostatectomy has been used for the treatment of prostate cancer for nearly a century. Few contemporary urologists use this technique in the treatment of localized prostate cancer.
The attempt to reduce hospital costs and the use of laparoscopic lymphadenectomy in select patients has renewed interest in radical perineal prostatectomy. This article details the step-by-step technique and provides an overview of the current literature with regard to outcomes and morbidity for radical perineal prostatectomy.
M. H. Sokoloff, and C. B. Brendler (Urologic Oncology Research (MHS), Section of Urology, and Department of Surgery (MHS, CBB), The University of Chicago, Chicago, Illinois)
Indications and Contraindications for Nerve-Sparing Radical Prostatectomy
The Urologic Clinics of North America August 2001 Vol. 28(3) Pg. 535-543
With the success of prostate specific antigen screening programs, many prostate cancers are being diagnosed at an earlier stage when men are more concerned about maintaining sexual function.
Cavernous nerve preservation surgery employed to preserve erectile function can be performed safely in the majority of men undergoing radical prostatectomy.
Nonetheless, the primary goal of any extirpative cancer operation is to remove all of the tumor factors that are associated with an increased risk of leaving a positive surgical margin and they must be taken into consideration when evaluating a patient for nerve preservation surgery.
This article discusses contraindications to nerve sparing radical prostatectomy and describes the use of standardized frozen section analysis to help guide intraoperative decision making regarding neurovascular bundle preservation.
B Shekarriz, J Upadhyay, et al (University of California, San Francisco, California (BS); Hospital for Sick Children, Toronto University, Toronto, Ontario, Canada (JU); et al)
Salvage Radical Prostatectomy
The Urologic Clinics of North America August 2001 Vol. 28(3) Pg. 545-553
Salvage prostatectomy and cystoprostatectomy offer the best chance for cure in select patients with local recurrence after definitive radiation therapy for prostate cancer.
The best candidates are those with preradiation favorable prognostic factors. Early detection of local recurrence using serum prostatic specific antigen (PSA) has resulted in improved disease free survival compared with the pre PSA era over the last two decades.
The quality of life after salvage surgery is affected by urinary incontinence and impotence. The majority of patients are satisfied with their treatment results.
M. Han, A. W. Partin, et al (The James Buchanan Brady Urological Institute, Departments of Urology (MH, AWP, JIE, PCW) and Pathology (JIE), The Johns Hopkins Medical Institutions, Baltimore, Maryland; et al)
Long-Term Biochemical Disease-Free and Cancer-Specific Survival Following Anatomic Radical Retropubic Prostatectomy – The 15-Year Johns Hopkins Experience
The Urologic Clinics of North America August 2001 Vol. 28(3) Pg. 555-565
In a series of 2404 men who underwent anatomic radical prostatectomy with a mean follow-up of 6.3 years (range 1-17 years), the overall actuarial 5, 10, and 15 year recurrence free survival rates for these men were 84%, 74%, and 66% respectively.
The actuarial likelihood of a prospective recurrence increased with the advancing clinical stage, Gleason score, and preoperative PSA level and pathologic stage.
Subdivision of men with Gleason 7 tumors resulted in better stratification with similar actuarial likelihood of a postoperative recurrence for men with Gleason (4 + 3) and Gleason score 8 to 10 diseases; however the recurrence rate in men with Gleason (3 + 4) diseases was statistically different from that of men with Gleason score 6 or Gleason (4 + 3) diseases.
Excellent long-term results can be obtained with anatomic radical retropubic prostatectomy for men with clinically localized prostatic cancer. The proportion of men with early stage prostate cancer will continue to increase with wide use of screening using serum PSA testing and digital rectal examination.
J. I. Epstein (The Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland)
Pathologic Assessment of the Surgical Specimen
The Urologic Clinics of North America August 2001 Vol. 28(3) Pg. 567-594
There has been a dramatic increase in the number of radical prostatectomies performed per year. Concurrently there has been an explosion in articles dealing with the relation of both conventional histologic parameters and biomarkers to progression following radical prostatectomy.
This article reviews the handling of radical prostatectomy specimens and the relation of findings derived from the prostatectomy specimen to the prediction of postoperative prognosis.
K. V. Carlson, and V. W. Nitti (The Department of Urology, New York University School of Medicine New York, New York)
Prevention and Management of Incontinence Following Radical Prostatectomy
The Urologic Clinics of North America August 2001 Vol. 28(3) Pg. 595-612
Incontinence after radical prostatectomy can have a significant impact on the quality of life. Although several risk factors have been identified, surgical technique, experience of the surgeon, preoperative continence status, and age of the patient are important factors.
Despite advances in surgical technique incontinence still occurs in a relatively small group. Sphincteric dysfunction is the most common cause of postradical prostatectomy incontinence but bladder dysfunction cannot be discounted.
Treatments range from conservative to surgical and should be tailored to the individual based on the degree of bother and patient’s acceptance of the therapeutic options.
A. R. McCullough (The Department of Urology, New York University School of Medicine, New York, New York)
Prevention and Management of Erectile Dysfunction Following Radical Prostatectomy
The Urologic Clinics of North America August 2001 Vol. 28(3) Pg. 613-627
Erectile dysfunction (ED) remains the most common morbidity after radical retropubic prostatectomy (RRP) approaching 90% in some series. Etiologic factors are both non-surgical and surgical.
Age, time from surgery, preoperative sexual function, psychological issues and surgical technique all play a role in postoperative erectile dysfunction. The recovery of erectile function is a slow process requiring as many as two years.
The treatment of post RRP ED is highly successful and includes in increasing order of effectiveness, MUSE Sildenafil, intracorporeal injection therapy, vacuum erection devices and penile prosthesis.
The current areas of research include the early intervention clinical protocols as well as animal studies in the use of nerve and vascular growth factors to selectively encourage early nerve regeneration.