Abstract: OBJECTIVE: To address the usability and safety aspects of current equipment for indwelling urinary catheter (IDC) manipulation, by assessing the attitudes of doctors and nurses to infection control, occupational health and environmental waste, and the perceived adequacy of available catheter packs, particularly drapes, when performing such manipulations. SUBJECTS AND METHODS: A self-administered survey instrument was created using an online database and completed by doctors and nurses. The survey covered basic demographics and experience with IDC, attitudes to infection control, occupational health and safety, and the environment, as well as adequacy of current equipment in containing spillage of urine and/or blood. RESULTS: In all, 87 doctors and 228 nurses completed 315 of 350 (90%) surveys. Doctors and nurses were concerned about infection control, occupational health and safety issues, and environmental waste. Incidents involving spillage of urine and/or blood often go unreported. There were no differences between nurses and doctors having specialist training in urology or experience (P > 0.05). The second major finding is that available catheter packs, particularly drapes, when manipulating IDCs, are inadequate and spillage is likely. These findings were more pronounced in doctors and those with urology training (P < 0.05). CONCLUSION: The attitudes of health professionals involved with IDC manipulations are consistent with other fields, as is the under-reporting of episodes of contamination by bodily fluids. The current equipment, particularly drapes, are inadequate for containing urine and blood, leading to infection control, occupational health, environmental and cost implications.
Abstract: This is the first report of a radical retropubic prostatectomy (RRP) in an achondroplastic dwarf. We highlight the pelvic anatomy, precluding laparoscopic or robotic prostatectomy, and making open surgery extremely difficult. We review relevant literature regarding general, urological, and orthopedic abnormalities of achondroplasia (ACH) and present a clinical case. No reports of RRP in achondroplastic dwarfs exist, with only one case of an abandoned RRP due to similar pelvic anatomy in a patient with osteogenesis imperfecta. Significant lumbar lordosis found in ACH results in a short anteroposterior dimension, severely limiting access to the prostate. We present a case of a 62-year-old achondroplastic dwarf who had Gleason 3+4 disease on transrectal ultrasound-guided biopsy in four from 12 cores. Surgery was difficult due to narrow anteroposterior pelvic dimension, but achievable. Histological analysis revealed multifocal prostate cancer, with negative surgical margins and no extraprostatic extension. RRP in ACH patients, although possible, should be approached with caution due to the abnormal pelvic dimensions, and discussions regarding potential abandonment of surgery should be included during informed consent. This case highlights the preoperative use of computed tomography to assist in the surgical planning for patients with difficult pelvic anatomy.
Abstract: In many disease states, the use of biomarkers is a standard method of determining both the presence and the risk of the future development of disease. For several years, total prostate-specific antigen (PSA) levels have been the standard measure for the diagnosis of prostate cancer (PCa) and other prostatic diseases. However, recent data have indicated that PSA can also be used to determine the risk of developing PCa in the future. This evolving use of PSA is supported by clinical trial data from the Baltimore Longitudinal Study of Aging, the European Randomized Study of Screening for Prostate Cancer, and the Malmö Preventive Medicine Study. Data from the European Randomized Study of Screening for Prostate Cancer have demonstrated that men with a PSA level of > or =1.5 ng/mL are at a significantly elevated risk of developing PCa compared with patients with a PSA level <1.5 ng/mL. The Malmö study showed that the PSA level could independently the predict cancer risk as far as 25-30 years into the future. Secondary nonserum risk factors (eg, age, family history, ethnicity) can also offer predictive value for determining the risk of developing future disease. Furthermore, recent investigations of novel biomarkers have yielded promising PCa prognostic candidates, including the PCa gene 3 and early PCa antigen 2. However, PSA remains the most reliable measure in assessing the risk of developing PCa.
Abstract: In the past 20 years, magnetic resonance imaging (MRI) has developed rapidly, along with the management of localized prostate cancer. We summarize current data on the efficacy of MRI for targeting cancer, compared with biopsies, in patients with previous negative prostate biopsies and persistently elevated prostate-specific antigen (PSA) levels. The key clinical question is how many men benefit by having had prostate cancer detected purely because of the MRI-targeted, as opposed to standard scheme, biopsies. We reviewed all available databases for prospective studies in patients having MRI and prostate biopsy with previous negative biopsies and persistently elevated PSA levels. Six studies fulfilled the selection criteria, with 215 patients in all; in these studies, the cancer-detection rate at repeat biopsy was 21-40%. For MRI or combined MRI/MR spectroscopy, the overall sensitivity for predicting positive biopsies was 57-100%, the specificity 44-96% and the accuracy 67-85%. In five studies, specific MRI-targeted biopsies and standard cores were taken, with a significant proportion (34/63, 54%) having cancer detected purely because of the MRI-targeted cores. The value of endorectal MRI and MR spectroscopy in patients with elevated PSA levels and previous negative biopsies to target peripheral zone tumours appears to be significant. Although more data obtained with current technologies are needed, published results to data are encouraging. A comparison study and cost-benefit analysis of MRI-targeted vs saturation biopsy in this group of patients would also be ideal, to delineate any advantages.
Abstract: Vulvar hematomas occur rarely outside the obstetric population but may present after other trauma to the pelvis or perineum. Spontaneous rupture of the internal iliac artery is described mostly in the presence of an aneurysm, with atherosclerosis, connective tissue disease, infection, and trauma as causative factors. It most often presents with abdominal pain and neurologic or urologic symptoms. We present an unusual case of a spontaneous rupture of the internal iliac artery that presented as a vulvar hematoma in a nulliparous woman that was successfully treated with selective arterial embolization and surgical evacuation. The literature is reviewed and management options discussed.
Abstract: PURPOSE: We investigated whether interoperator differences exist in the setting of prostate cancer detection by transrectal ultrasound guided prostate biopsy. Our secondary aim was to investigate whether a learning curve exists for prostate cancer detection. MATERIALS AND METHODS: A prospective database from 2000 to 2008 including 9,072 transrectal ultrasound guided prostate biopsies at our institution was limited to 4,724 done at initial presentation. Biopsies were performed by 4 uroradiologists. The OR for detecting cancer on transrectal ultrasound guided prostate biopsy was calculated for likely independent prognostic variables, including operator. We also examined the rate of biopsy positivity in increments, comparing the first and last cohorts. The senior radiologist (AT) with the most biopsies (75%) was considered the referent for prostate cancer detection. Univariate and multivariate logistic regression modeling was used to determine significant covariates with p <0.05 deemed relevant. RESULTS: Prostate cancer was detected in 2,331 men (49.3%). Operators performed a median of 514 transrectal ultrasound guided prostate biopsies (range 187 to 3,509) with a prostate cancer detection rate of 43.8% to 52.4% (p = 0.001). Other significant covariates were prostate specific antigen, suspicious lesions on ultrasound, nodule on digital rectal examination, smaller prostate volume and increasing patient age. Operator was a significant multivariate predictor of cancer detection (OR 0.67 to 0.89, p = 0.003). No learning curve was detected and biopsy rates were consistent throughout the series. CONCLUSIONS: Significant differences in prostate cancer detection exist among operators who perform transrectal ultrasound guided prostate biopsy even in the same setting. The volume of previously performed transrectal ultrasound guided prostate biopsies does not appear to influence the positive prostate cancer detection rate, nor could a learning curve be identified. Differences in prostate cancer detection among operators are likely related to unknown differences in expertise or technique. Further research is needed.
Abstract: PURPOSE: External sphincterotomy is an accepted option for treating patients with detrusor-sphincter dyssynergia. However, long-term outcome data are limited. We ascertained the outcome of treatment results for this procedure. MATERIALS AND METHODS: A database was reviewed for patients undergoing external sphincterotomy at a large tertiary referral spinal injuries center. RESULTS: For 84 primary sphincterotomies the mean duration of successful outcome was 81 months. A second procedure was required in 30 patients and mean duration of success thereafter was 80 months. Recurrent symptomatic episodes of urinary tract infection, recurrent detrusor-sphincter dyssynergia or upper tract dilatation eventually ensued in 57 of 84 patients (68%). Renal failure did not develop in any patients. CONCLUSIONS: External sphincterotomy protects the upper renal tracts and provides extended periods of satisfactory bladder emptying. However, it may require ongoing revision and should potentially be regarded as a staged intervention.
Abstract: Testosterone replacement has undergone somewhat of a revolution in the past decade with the introduction of topical administration techniques, including patches and gels, as well as an increasing interest in the treatment of older men with low testosterone levels for what is now termed andropause. Increasingly, testosterone replacement therapy is being individually tailored. Side effects to skin patches have been reported with irritant contact dermatitis being the most common. However, ulceration has previously not been reported. Herein, we present a case that highlights testosterone transdermal therapies, their potential side effects and management strategies, and broadens our knowledge as we approach an era where these types of treatments are likely to be more common.
Abstract: PURPOSE OF REVIEW: Phosphodiesterase 5 (PDE-5) inhibitors are established as first-line therapy in erectile dysfunction. There is emerging evidence that they may have a role in treating patients with lower urinary tract symptoms (LUTS) from benign prostatic hypertrophy. RECENT FINDINGS: All three commonly used PDE-5 inhibitors (sildenafil, vardenafil and tadalafil) appear to improve LUTS as measured by the International Prostate Symptom Score. However, to date, no change in urinary flow rates have been demonstrated. SUMMARY: Erectile dysfunction and LUTS frequently coexist in men of advancing age. There appears to be an emerging role for PDE-5 inhibitors as a treatment for both conditions. Further studies are required to elicit the exact mechanism of action in LUTS.
Abstract: OBJECTIVES: To compare the quality of uro-oncological Web sites, to assess for language or disease differences across Western languages, and to perform a longitudinal comparison between 2004 and 2009. Uro-oncological Internet information quality is considered variable but no comprehensive analysis exists. METHODS: Health on the Net (HON) principles may be applied to Web sites using an automated toolbar function. Using the Google search engine (http://www.Google.com), in 2004 and 2009, 2400 Web sites were assessed using the keywords prostate, bladder, kidney, and testicular cancer in English, French, German, and Spanish. The first 150 Web sites in each language had HON principles measured-a comparison between 2004 and 2009 was done. A further analysis of site sponsorship was undertaken. RESULTS: Regardless of language or cancer type, most sites are not HON accredited. English has consistently more than English, French, Spanish, or German. For the respective languages in 2009, prostate has the most (29, 14%, 16%, 12%), followed by bladder (29%, 22%, 14%, 13%), kidney (25%, 15%, 10%, 13%), and testis (26%, 19%, 7.11%). Significant differences were found comparing language and organ groups. The quality improved from 2004 to 2009. Nonprofit organizations (51%), government and/or educational (39%), commercial (20%), with urologists last (14%) were accredited. CONCLUSIONS: A lack of validation of most uro-oncological sites should be appreciated by urologists. Additionally, there is a discrepancy in quality and number of Web sites across uro-oncological diseases and major Western European languages, but with some improvement seen recently. We need to encourage informative, ethical, and reliable complimentary health Web sites on the Internet and direct patients to them.
Abstract: Stage I seminoma represents the paradigm of a curable malignancy, with survival of 100% an expected outcome no matter what treatment option is chosen. However, consensus has not been reached among urologists and oncologists regarding the optimal postoperative management in men with clinical stage I testicular seminoma. Currently, men are offered active surveillance, adjuvant radiation therapy, or single-agent chemotherapy. Active surveillance is associated with an 80% chance of no relapse, with all such events salvageable. Radiotherapy has an almost universal cure rate but has the potential for long-term toxicities and an overtreatment rate of about 80%. Chemotherapy efficacy and toxicity data are still immature. Recent guidelines recognize that the options of surveillance, chemotherapy, and radiotherapy are appropriate in the treatment of patients with clinical stage I seminoma. We believe active surveillance to be the best option, then radiotherapy (considering the efficacy and safety data), with single-agent chemotherapy emerging as a possible alternative.
Abstract: We believe that active surveillance is the optimal choice for compliant men who are able to handle the mental burden of not receiving adjuvant treatment. This takes into consideration the fact that a small number of men with clinical stage I (CSI) seminoma on surveillance will recur but are salvageable with equivalent outcome compared to those having adjuvant treatment which exposes eight in ten men to unnecessary short- and long-term risks with still the possibility of recurrence requiring salvation. This review will focus on CSI seminoma and the controversies surrounding its treatment and based upon current available evidence will outline the case for surveillance.
Abstract: OBJECTIVES: To reduce the complications associated with placenta percreta (PP) by adequate preoperative planning with a multidisciplinary team. PP is a rare and potentially morbid condition of pregnancy, particularly if the urinary tract is involved. Cesarean delivery and hysterectomy are typically required to reduce the pelvic hemorrhage, placing the urinary tract at risk. METHODS: We reviewed our urologic consultations and experience with PP in the past year. Maternal factors, surgical timing, blood loss, surgical complications, and outcomes were recorded. The timing of the urologic assessment was divided into preoperative and perioperative. RESULTS: Five cases of PP were available. Of the 5 cases, 4 had been successfully diagnosed by prenatal ultrasonography, with 2 also requiring magnetic resonance imaging. All patients underwent cesarean delivery and hysterectomy, with significant blood loss (median 12 U transfused). A preoperative urologic assessment was done in 2 of the 5 patients, with no urinary complications found in this group. Both patients had undergone cystoscopy with placement of temporary ureteral catheters, even though the cases were emergent. In contrast, 3 patients underwent urologic consultation during or immediately after surgery. All 3 had bladder injuries, with 1 ureteral injury and delayed convalescence in this group of patients. CONCLUSIONS: PP remains a technically challenging and high-risk obstetric condition. In the setting of urinary tract involvement, adequate imaging, surgical planning, and preoperative urologic assessment with placement of temporary ureteral catheters were associated with a lower incidence of urologic complications in our series. Adequate preoperative planning with a multidisciplinary team is recommended to reduce the complications associated with PP.
Abstract: OBJECTIVE To review our experience and delineate the role of magnetic resonance imaging (MRI) in identifying patients presenting with a raised prostate-specific antigen (PSA) level and clinical findings suggestive of anterior predominant tumours, which appear to be significant, particularly in those with a previous negative biopsy or low-volume disease undergoing active surveillance. PATIENTS AND METHODS We retrospectively reviewed our database to identify patients with anteriorly predominant tumours on MRI whom had undergone prostate biopsy. RESULTS In all, 31 patients with anterior predominant tumours on MRI also had a positive biopsy (14 on active surveillance and 17 with previous negative biopsies). MRI was usually invoked by the presenting PSA level or PSA velocity. MRI had a positive predictive value for anterior tumours of 87% (27/31). The Gleason score distribution for the 27 men with cancer was 6 in 15; 3 + 4 in three, 4 + 3 in six and 8/9 in three. For prostatic cores, 44/85 (52%) samples from the anterior prostate had cancer. Thirteen patients had a radical prostatectomy (pT2 in three, pT3 in seven and pT4 in three); seven of the 13 had positive surgical margins and a third of them had a biochemical recurrence at the 1-year follow-up. CONCLUSION There is a subset of patients either having a negative biopsy or low-volume disease and who are on active surveillance who should be considered for MRI and further biopsy, as their pathology might be aggressive. An entity might be emerging with anterior predominant tumours that are impalpable, and we believe the term 'prostate evasive anterior tumour syndrome' to be appropriate. This requires further analysis in a large prospective database with consideration for triggers for MRI and targeted biopsies.
Abstract: OBJECTIVE To test the hypothesis that urinary catheter balloons filled with sterile water, saline or glycine have equivalent rates of failure to deflate. MATERIALS AND METHODS This was an in vitro equivalence study designed to test whether saline or glycine are neither substantially worse nor substantially better than water in terms of balloon-deflation failure rates. Glycine was chosen as the third arm, as it is readily available during endoscopic procedures and would be useful to use in such situations. We hypothesised that balloon-deflation failure rates using saline or glycine were no worse than water by 10%. We calculated the sample size for equivalence testing; 600 catheters were randomized by computer-generated random numbers to receive 10 mL of water, saline or glycine, and then immersed in a heated artificial urine solution for 6 weeks. The catheter balloons were then deflated, noting any failures to deflate and recording the deflation volumes. RESULTS There was no failure to deflate in all 600 catheters. The median deflation volume for water, saline and glycine was 9.0, 9.2 and 9.1 mL, respectively (P < 0.001 Kruskal-Wallis test). Post-hoc pair-wise comparisons showed that the deflation volume difference between water and saline was significant (P < 0.001), as was that between water and glycine (P < 0.001). The practical implication of this difference is not apparent from this study. CONCLUSIONS The use of saline or glycine in catheter balloons has an equivalent deflation failure rate to using water, which in this study was zero.
Abstract: OBJECTIVES: In tumors, hypoxia stimulates angiogenesis and correlates with treatment resistance and poor prognosis. We have previously demonstrated hypoxia in human renal cell carcinoma (RCC) via direct oxygen probe measurements. Carbonic anhydrase IX (CA IX) is a protein stimulated by hypoxia and involved in angiogenesis, and is a potential tumor target for imaging and therapies using cG250, a monoclonal antibody that recognizes CAIX. Our objectives were to characterize intratumoral hypoxia in a human RCC xenograft model using oxygen probe measurements; investigate if (124)I-cG250 targets RCC correlating uptake on noninvasive positron emission tomography-computerized tomography (PET-CT) against traditional biodistribution studies, and investigate CAIX expression in this RCC model. METHODS: BALB/c nude mice had human RCC (SK-RC-52) subcutaneously xenografted with oxygen levels measured by probe. Positron emission tomography (PET/CT) and biodistribution studies ((124)I-cG250) were correlated with oxygen measurements. Immunohistochemistry and autoradiography were performed on selected tumors to confirm CAIX expression RESULTS: Oxygen tension in normal tissue (muscle) was 35.08 +/- 2.41 mmHg (mean +/- 95% CI), significantly greater compared to xenograft SK-RC-52 tumors at 5.02 +/- 1.12 mmHg. Biodistribution studies of (124)I-cG250 demonstrated isotope uptake in SK-RC-52 xenografts peaking at 23.45 +/- 5.07% ID/g (mean +/- SD) 48 hours after antibody injection, which was maintained for a further 2 days (19.43 +/- 4.31 and 10.64 +/- 5.64 % ID/g, respectively). PET studies demonstrated excellent localization of (124)I-cG250 in tumor, and a significant correlation between SUVmean, SUVmax, and %/ID (124)I-cG250. CAIX expression was present in all groups studied but there was no significant correlation between it and any oxygen parameter studied. CONCLUSION: Intratumoral hypoxia does exist within a human RCC xenograft model using invasive oxygen probe measurements. (124)I-cG250 targets RCC with correlation between uptake on noninvasive PET-CT studies and traditional biodistribution studies opening the possibility of using PET/CT in future studies. Finally, CAIX expression was not related to hypoxia in this model, supporting the hypothesis that cell lines may subvert known hypoxia mechanisms in hypoxic environments.
Abstract: ABSTRACT: Meta-analyses are an essential tool of clinical research. Meta-analyses of individual randomized controlled trials frequently constitute the highest possible level of scientific evidence for a given research question and allow surgeons to rapidly gain a comprehensive understanding of an important clinical issue. Moreover, meta-analyses often serve as cornerstones for evidence-based surgery, treatment guidelines, and knowledge transfer. Given the importance of meta-analyses to the medical (and surgical) knowledge base, it is of cardinal importance that surgeons have a basic grasp of the principles that guide a high-quality meta-analysis, and be able to weigh objectively the advantages and potential pitfalls of this clinical research tool. Unfortunately, surgeons are often ill-prepared to successfully conduct, critically appraise, and correctly interpret meta-analyses. The objective of this educational review is to provide surgeons with a brief introductory overview of the knowledge and skills required for understanding and critically appraising surgical meta-analyses as well as assessing their implications for their own surgical practice.
Abstract: Primary sclerosing lipogranuloma is an unusual benign condition of the genitalia typically presenting as a painless mass affecting the penis and scrotum. Its importance lies in differentiating it from malignancy to avoid extensive surgery. It is normally treated with total or partial excision. This is the first reported case where oral corticosteroids have been used to treat this condition whereby a six-week course resulted in the mass disappearing. In conclusion, if sclerosing lipogranuloma is suspected biopsy should be undertaken to exclude sarcoma. We believe surgery should be reserved for recurrent or refractory cases when steroids have failed as first-line treatment.
Abstract: PURPOSE: To demonstrate the construction of a simple training model from reconfigured chicken skin to simulate open and laparoscopic reconstructive pyeloplasty. MATERIALS AND METHODS: Reconfiguring and suturing chicken skin dissected off its muscle creates a model of the ureteropelvic junction. Dismembered pyeloplasty techniques may be practiced with open or laparoscopic equipment. Students with prior training in suturing and knot-tying only used the open pyeloplasty model on three occasions. Urology trainees experienced in surgery but not laparoscopic pyeloplasty used the model laparoscopically. RESULTS: Students demonstrated a significant improvement (P < 0.05) between their first (17.00 +/- 4.44 minutes; mean +/- 95% CI) and third (11.33 +/- 2.40 minutes) attempts using the open model. Urology trainees improved their mean times from the first (18.0 minutes) to third (11.8 minutes) attempts using the laparoscopic model. CONCLUSIONS: This cheap and readily available model is reproducible and applicable to training in both open and laparoscopic pyeloplasty.
Abstract: OBJECTIVE: To evaluate the accuracy of fine-needle aspiration (FNA) cytology of palpable inguinal lymphadenopathy before definitive management of the primary tumour, in predicting inguinal lymph node (LN) metastasis in men with primary squamous cell carcinoma (SCC) of the penis. PATIENTS AND METHODS: Sixteen men with primary SCC of the penis and palpable inguinal lymphadenopathy (unilateral or bilateral) were treated by primary resection and bilateral inguinal LN dissection. FNA cytology was analysed for 25 palpable inguinal LNs at the time of penile biopsy. The sensitivity, specificity and accuracy of FNA cytology was compared with the histological findings from surgical LN clearance. RESULTS: The 25 FNAs were without complication and without evidence of implantation of metastasis in the needle tracts; 14 FNA samples were positive for metastasis, 10 were negative, and one was inconclusive. From the histological assessment of the surgical inguinal LN specimens, FNA cytology had a sensitivity of 93%, and specificity of 91% in predicting metastatic disease. CONCLUSION: FNA cytology of palpable inguinal lymphadenopathy before surgery for the primary tumour has a high sensitivity and specificity for metastatic penile cancer. This procedure permits early inguinal lymphadenectomy where appropriate without need for prolonged initial antibiotic treatment.
Abstract: PET offers a noninvasive means to assess neoplasms, in view of its sensitivity and accuracy in staging tumors and potentially in monitoring treatment response. The aim of this study was to evaluate newly diagnosed primary brain tumors for the presence of hypoxia, as indicated by the uptake of 18F-fluoromisonidazole (18F-FMISO) and to examine the relationship of hypoxia to the uptake of 18F-FDG and molecular markers of hypoxia. METHODS: Seventeen patients with suspected primary glioma were enrolled prospectively in this study. Sixteen patients had histology, with 2 having metastatic disease. All patients had PET studies with 18F-FMISO and 18F-FDG and MRI studies. Immunohistochemistry was undertaken with tumor markers of angiogenesis and hypoxia. Patients were monitored for disease progression and statistical analysis of data was performed. RESULTS: Of the 14 patients with histology, 8 died with a median time of 16 mo (range, 2-30 mo) until death. Of those who died, 7 had positive and 1 had negative 18F-FMISO uptake. 18F-FMISO uptake was observed in all high-grade gliomas but not in low-grade gliomas. A significant relationship was found between 18F-FDG or 18F-FMISO uptake and expression of VEGF-R1 and Ki67 expression. Other immunohistochemical markers demonstrated a trend toward increased uptake but none was significant. CONCLUSION: 18F-FMISO PET provides a noninvasive assessment of hypoxia in glioma and was prognostic for treatment outcomes in the majority of patients. 18F-FMISO PET may have a role not only in directing patients toward targeted hypoxic therapies but also in monitoring response to such therapies.
Abstract: OBJECTIVES: To ascertain the frequency of in-hospital deaths after urological surgery in a compulsory reporting setting, and to identify the contributing and potentially reversible factors involved in patients who had had transurethral resection of the prostate (TURP). METHODS: We reviewed all hospital deaths reported to the State Coroner from Coronial Services Victoria (CSV), Australia, in 2000-2002 to identify those instances associated with urological surgery. These cases were then analysed using methods developed by CSV. Resources available included medical records, police reports, government data on operative procedures and autopsy results. RESULTS: There were 20 in-hospital deaths after urological surgery identified for the 3-year period; most related to pre-existing comorbidities, predominantly ischaemic heart disease. Two episodes of hospital-acquired infection, two instances of technical complication of surgery contributing to death, and one pulmonary embolus were identified. Numerically the largest group of deaths after surgery was patients having TURP, and these deaths represented 0.05% (nine of 17 044) of all TURPs in this period. Most in this group (eight) had an acute myocardial infarction. CONCLUSION: Death after urological surgery appears to be uncommon; assessing patients for coronary artery disease before urological surgery, particularly TURP, closer cardiovascular monitoring after surgery, and rapid transfer to a coronary care unit if required, may further reduce mortality.
Abstract: A simple technique using a fenestrated urethral catheter to assist in drainage of pericatheter urethral exudates from the anastomosis of the urethra to the bladder neck in radical prostatectomy is described. It is applicable to open and laparoscopic techniques of radical prostatectomy.
Abstract: Suspected spinal cord or cauda equina pathology is an emergency that must be dealt with swiftly, with appropriate referral and investigations. Constipation is a clinical diagnosis of exclusion, but should not be forgotten as a cause of major morbidity when severe in nature. It can mimic an acute abdomen, sepsis and even spinal cord pathology. We describe a case of cauda equina syndrome in a young man. The pathology responsible was found to be constipation with faecal impaction, once nerve and bony pathology were excluded. When treated, there was almost immediate resolution of the neurologic signs and urinary retention.
Abstract: BACKGROUND PURPOSE: Spleen-preserving distal pancreatectomy, although rarely performed, has become an option for treatment of distal pancreatic neoplasms. However, the spleen, once mobilised, is often free to tort. A reliable method of fixing the spleen would be a useful adjunct to this procedure. METHODS: We describe the use of a new technique to fix the spleen using a peritoneal "pillowcase" to envelop the spleen, thus preventing its torsion. RESULTS: This patient has done well, with no problems encountered intraoperatively or postoperatively, using this new technique of spleen fixation. CONCLUSIONS: The use of a peritoneal "pillowcase" to envelope the spleen following distal pancreatectomy has proven a useful adjunct to this somewhat difficult surgical procedure. It may be applied in other cases where spleen fixation is necessary.
Abstract: PURPOSE: To our knowledge this study represents the first analysis monitoring the efficacy of cyproterone acetate (CPA) monotherapy for achieving castrate testosterone levels prior to administering a luteinizing hormone-releasing analogue (LHRHA) for treating prostate cancer in the prostate specific antigen (PSA) era. MATERIALS AND METHODS: Patients with untreated locally advanced or metastatic prostate cancer were recruited prospectively. Treatment involved a 28-day course of oral cyproterone acetate and LHRHA depot injection on day 14. Patients had serum PSA, luteinizing hormone and testosterone monitored at intervals during a 56-day period. RESULTS: A total of 15 patients with a mean age of 74 years completed the study. Near castrate serum testosterone was achieved on day 7 (mean +/- 95% CI 83.38 +/- 17.87 ng/dl). There was a significant testosterone increase after LHRHA administration on day 14 compared with the level of 160.23 +/- 36.60 ng/dl on day 16 (p <0.01). Serum luteinizing hormone mirrored testosterone, increasing from a mean of 4.93 +/- 0.61 to 15.4 +/- 6.12 nmol/l after LHRHA administration (p <0.01). Mean serum PSA demonstrated a decrease from 199.25 +/- 6.12 microg/l at day 0 to 43.77 +/- 33.08 microg/l by day 56. There was no increase in serum PSA after LHRHA administration. CONCLUSIONS: Two weeks of priming with CPA does not eliminate the surge in serum testosterone (testosterone flare) upon LHRHA administration but the testosterone increase does not exceed pretreatment levels. Furthermore, 2 weeks of CPA may not offer a benefit over 1 week in lowering serum testosterone. Finally, there is no increase in serum PSA when LHRHA is administered after priming with CPA.
Abstract: OBJECTIVE: To assess renal tumours for hypoxic regions using 18F-fluoromisonidazole (18F-FMISO) positron emission tomography (PET), a recognized noninvasive method for detecting hypoxia in tumours, as renal cell carcinoma (RCC) can be potentially cured with nephrectomy but recurrence develops in most patients, who then respond poorly to treatments such as chemotherapy, and hypoxia is known to confer resistance to radiotherapy and chemotherapy in many solid tumours. PATIENTS AND METHODS: In all, 17 patients had 18F-FMISO PET scans before nephrectomy for presumed RCC. Specimens were examined histologically, and immunohistochemistry was used to compare the microvessel density (MVD) as an indicator of angiogenesis in the tumour and normal parenchyma, in 15 patients. Tumour oxygenation was measured invasively in three patients using a polarographic oxygen sensor probe. RESULTS: Of the 15 patients with histological results, 11 had RCC and four had other tumours. Although there was a trend there was no statistically significant (P = 0.14) difference in the maximum standardized uptake value (SUV(max)) when comparing the region of the kidney involved with RCC; the mean (95% confidence interval) SUV(max) in the tumours was 1.3 (0.15), whilst that in the normal contralateral kidney was 1.1 (0.22). The MVD was greater in RCC, at 13.7 (3.1) mean vessels per high-power field than in normal tissue, at 6.9 (1.9). Hypoxia as measured polarographically was detected in three RCCs (median pO2 9.6 mmHg) compared to normal parenchyma at 37.6 mmHg. CONCLUSIONS: Although 18F-FMISO scans showed significant uptake in other solid tumours, there was only mild 18F-FMISO uptake in the present RCCs. The invasive measurements indicated that there was hypoxia in RCC, but the median pO2 did not fall below 9.5 mmHg. Further direct studies of renal tumour oxygenation combined with therapies directed towards hypoxia may allow a better understanding of the relationship between 18F-FMISO results and the biological significance of hypoxia in RCC.
Abstract: Flexible cystourethroscopy is an accepted routine procedure in urology. The sterilization of instruments is time consuming and may damage flexible instruments. However, it must be performed to prevent contamination of the endoscopes. This study is the first to document experience using a flexible cystoscope with a disposable sheath in a urologic setting.
Abstract: OBJECTIVE: To compare the findings of multidetector computed tomography (CT) with surgical pathology and magnetic resonance imaging (MRI), to determine the accuracy of delineating the superior extent of inferior vena cava (IVC) thrombotic involvement in renal cell cancer (RCC). PATIENTS AND METHODS: A prospective database was examined of 11 patients (median age 65 years, range 45-77) being assessed for suspected IVC extension of RCC tumour thrombus with both multidetector CT and MRI. All had pathology confirming RCC, and eight of those undergoing surgery had pathological confirmation of tumour thrombus extent. All images were analysed originally, then re-analysed by two independent radiologists, an experienced urologist and a urological trainee unaware of the original reports and other imaging results, with a final determination on tumour thrombus level by consensus. RESULTS: The multidetector CT results were completely accurate when compared with surgical specimens and were in agreement with MRI on all but one occasion, where MRI determined the renal vein to be clear when it was involved on CT and at surgery, giving MRI an accuracy of seven of eight samples. CONCLUSIONS: Whilst there were few patients and further studies are needed, multidetector CT was comparable with MRI in determining tumour thrombus level. More importantly, in the eight patients with surgical pathological confirmation, multidetector CT was accurate in all. Ultimately, it may replace MRI as the 'gold standard' for imaging to delineate the upper limit of tumour thrombosis in RCC.
Abstract: OBJECTIVE: To present our experience of percutaneous nephrolithotomy (PCNL) for treating urolithiasis in patients with spinal cord injury (SCI) using a single-stage dilator for percutaneous access. PATIENTS AND METHODS: A prospective database of patients with SCI having PCNL using the single-stage dilator was assessed, analysing patient data, stone-free rates, morbidity and the follow-up outcome. RESULTS: In all, 26 patients had 54 PCNLs on 32 kidneys; 20 had unilateral and six bilateral stone disease; there were many staghorn calculi (24/54). Major complications occurred in three of 54 PCNLs (6%). The complete stone-clearance rate was 87% for PCNL alone, rising to 29 of 32 kidneys (91%) or 24 of 26 patients (92%) with adjuvant procedures. A further three kidneys required no further treatment and were monitored, having residual fragments of < or = 2 mm. CONCLUSIONS: PCNL has a high success rate and acceptable complication rate compared to extracorporeal shock-wave lithotripsy, and remains a valid first-line treatment option for kidney stones in patients with SCI.
Abstract: OBJECTIVE: To conduct a systematic review of studies on clinically relevant digital mobile phone electromagnetic interference with medical equipment. DATA SOURCES: MEDLINE and SUMSEARCH were searched for the period 1966-2004. The Cochrane Library and Database of Abstracts of Reviews of Effects were also searched for systematic reviews. STUDY SELECTION: Studies were eligible if published in a peer-reviewed journal in English, and if they included testing of digital mobile phones for clinically relevant interference with medical equipment used to monitor or treat patients, but not implantable medical devices. DATA SYNTHESIS: As there was considerable heterogeneity in medical equipment studied and the conduct of testing, results were summarised rather than subjected to meta-analysis. RESULTS: Clinically relevant electromagnetic interference (EMI) secondary to mobile phones potentially endangering patients occurred in 45 of 479 devices tested at 900 MHz and 14 of 457 devices tested at 1800 MHz. However, in the largest studies, the prevalence of clinically relevant EMI was low. Most clinically relevant EMI occurred when mobile phones were used within 1 m of medical equipment. CONCLUSIONS: Although testing was not standardised between studies and equipment tested was not identical, it is of concern that at least 4% of devices tested in any study were susceptible to clinically relevant EMI. All studies recommend some type of restriction of mobile phone use in hospitals, with use greater than 1 m from equipment and restrictions in clinical areas being the most common.
Abstract: OBJECTIVE: To assess the attitudes of final-year medical students to digital rectal examination (DRE) and their experience of performing DRE during clinical training. DESIGN: Questionnaire-based survey. SETTING AND PARTICIPANTS: All students in the final year of medical school at the University of Melbourne in 2003. OUTCOME MEASURES: Agreement with statements about attitude to DRE; number of DREs performed and abnormalities palpated; and ratings of frequency of supervision and perceived barriers to performing DRE. RESULTS: 222 of 256 students (87%) responded. Almost all (97%) believed that DRE is an essential requirement for a medical practitioner, and 94% that they should have the skill before graduating, while 92% said they had been taught how to perform it. The median number of DREs performed was two, with 17% of students performing none. Sixty-three per cent had palpated a prostate, 24% a prostate cancer, 19% a rectal tumour, and 11% faecal constipation. Half the students (52%) felt they could give a reasonable or confident opinion based on their DRE findings. The most often cited reason for not performing DREs was the lack of a doctor to act as a supervisor. CONCLUSIONS: A concerted effort is needed from academics, supervising doctors and students to improve medical students' proficiency in performing DRE and confidence about their findings.
Abstract: BACKGROUND: Ureteric stents have been used in urological practice for over 25 years and in many cases have become almost routine. The purpose of the present review is to highlight the uses, complications and risk management issues associated with their use. METHODS: An extensive literature review was conducted and knowledge from past experience was accessed to give a summary of past and current ureteric stent use in urology. RESULTS: Broadly, there are stone and non-stone indications for stenting. Complications may range from the commonly experienced 'stent syndrome' to the medico-legal dilemma of the forgotten stent. Risk management must be applied to all uses of stenting to minimize complications and achieve best practice. CONCLUSION: Although almost routine in many areas of urological practice, the complications and implications for risk management of ureteric stenting cannot be ignored.
Abstract: OBJECTIVES: To evaluate the role of 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) in the assessment of germ cell tumors after chemotherapy. METHODS: We reviewed patients' records for the histologic findings and clinical outcome. 18F-FDG PET results were correlated with tissue histologic features where available; and if not available, the correlation was with the clinical outcome. RESULTS: A total of 45 PET studies were performed on 38 patients (age range 19 to 64 years, median 31). All patients had received chemotherapy. In the nonseminomatous germ cell tumor (NSGCT) group, of the 31 patients with one scan, 18 PET scans were reported as positive, with only 2 not having active disease. Of the 12 negative scans, 6 showed teratoma, 1 tumor, and 5 did not show active disease. The equivocal scan revealed thyroid adenoma. In the seminoma group, the PET scans correlated well with the clinical and histologic outcomes. Four patients underwent salvage chemotherapy, and in this subgroup, the PET findings also correlated with the outcome. CONCLUSIONS: (18)F-FDG PET is a promising tool as an adjunct to current imaging techniques in detecting residual viable germ cell tumor after chemotherapy. In NSGCT, a positive PET scan was accurate in 16 of 18 patients, although negative PET studies did not exclude the presence of disease, mainly because of the presence of teratoma. In seminoma, a negative 18F-FDG PET study correlated with a favorable clinical outcome. PET was also predictive of the response to salvage chemotherapy and was highly specific for active tumor in both NSGCT and seminoma.
Abstract: PURPOSE: Tumor hypoxia plays a fundamental role in tumor progression and treatment resistance. Recent evidence that hypoxia also influences the regulation and transcription of various genes involved in malignant growth and metastases, and promotes a more aggressive tumor phenotype makes its diagnosis even more important. PROCEDURES: The evidence for the biology of hypoxia in tumors, and imaging of hypoxia with different technologies was reviewed through literature review and Medline searches, and clinical studies with 18F-fluoromisonidazole (FMISO) Positron Emission Tomography (PET). RESULTS: Until recently, determination of the level of tumor oxygenation was only possible using invasive methods that limited its clinical application. Imaging techniques that have shown promise in assessing hypoxia include magnetic resonance imaging and spectroscopy, single photon emission computed tomography (SPECT) and PET. Quantitative hypoxia measurement with 18F-FMISO PET in patients with malignant gliomas and lung cancer have demonstrated intratumoural hypoxia and dissociation of glucose metabolism from hypoxia in some cases, indicating the complex nature of cellular metabolic response to stress. CONCLUSION: The emerging role of therapies that have improved efficacy in hypoxic conditions, and recent advances in the ability to noninvasively measure in vivo intratumoral hypoxia with functional imaging has renewed interest in the clinical measurement of tumor hypoxia and its impact on cancer treatment.
Abstract: Polyorchidism is defined as the presence of two or more testes. It is a rare anomaly with approximately 77 cases reported in the literature. Polyorchidism is frequently associated with additional urological pathologies such as undescended testis, inguinal hernia, testicular torsion, hydrocoele, malignancy and infertility. Differential diagnosis includes spermatocoele, hydrocoele, epididymal cysts or aberrant epididymis. We report on an interesting case of polyorchidism in a 15-year-old man diagnosed on ultrasound and we review the literature and current management of polyorchidism.
Abstract: Foreign bodies placed into the ureter are uncommon. Unintentionally placed sutures may cause obstruction and stone formation. If not recognized, the patient may become symptomatic. A diagnosis of a suture in the ureter is best made and subsequently dealt with endoscopically. We report on laser ablation of the suture as a safe technique for its removal.
Abstract: Transrectal ultrasound-guided biopsy of the prostate is an integral step in the investigation of patients at risk of prostate adenocarcinoma. With an increasing number of biopsies being performed, uncommon forms of prostatic pathology will be identified more frequently. Amyloidosis of the prostate and/or the seminal vesicles may be noted on transrectal ultrasound-guided biopsy of the prostate and the implications of this histological diagnosis must be understood. We present our experience of two such cases of amyloidosis and review the literature regarding their management.
Abstract: Pyomyositis is relatively rare in temperate climates. This is the first report of a case of calf pyomyositis associated with septic arthritis of the knee. This case illustrates that pyomyositis should be included in the differential diagnosis of a swollen, tender calf in an emergency setting. The other notable feature of this case is that the infective organism was not the usual Staphylococcus aureus but rather the relatively rarely involved Streptococcus pyogenes.
Abstract: Testicular microlithiasis (TM) is a rare condition in which men have innumerable testicular calcifications. It is increasingly being reported on ultrasound. The published literature has reported an association between confirmed testicular malignancy and testicular microlithiasis. The relationship between TM and the risk of developing malignancy is unclear. The present paper reports a patient with a previously normal scrotal ultrasound except for bilateral sonographically detected TM who developed a testicular tumour. It also discusses the appropriate management of TM after reviewing the published literature.
Abstract: BACKGROUND: Pain is a personal, subjective experience. In the postoperative period, pain may be influenced by patient, pharmacological and environmental factors. In surgery the aim is to reduce pain in this period by educating patients and using adequate analgesia. The aim of the present study was to assess the effect of perceived wound size on pain, as indicated by wound dressing, in the immediate postoperative period. METHODS: Patients undergoing appendicectomy were randomized into a group having a dressing the same size (SSD) as the surgical wound or double the size (DSD) of the wound. Patients' pain perception and analgesic requirements were then recorded and analysed to compare the two groups. RESULTS: Both groups had similar results when comparing pain perception. The median total pain score for the SSD and DSD groups at 12 and 24 h postoperatively revealed no statistically significant difference (P > 0.05). CONCLUSION: The data do not support the hypothesis that postoperative pain may be altered by perceived wound dressing size. Dressing size does not appear to be a variable that could easily be altered to reduce postoperative pain in surgical patients.
Abstract: The primary objective of this study was to evaluate the incidence of warfarin use in 156 consecutive patients presenting to a single tertiary referral centre with spontaneous intracerebral haemorrhage. Our study found that 11% of patients (16/159) presenting with spontaneous intracerebral haemorrhage were on warfarin for prophylactic anticoagulation at time of presentation. Comparison was made to other published Australian data with regard to the incidence of warfarin use in patients presenting with spontaneous intracerebral haemorrhage. Patient outcomes were also examined.
Abstract: Suprapubic catheters have gained wide acceptance in urology. Although many regard their insertion a simple procedure, morbidity is significant and is probably underreported. We describe a percutaneous technique using intraoperative ultrasonography combined with flexible cystoscopy to ensure safe insertion, minimizing the risk to adjacent viscera.
Abstract: BACKGROUND: The aim of the present study was to assess the impact of surgical waiting times on patients scheduled for elective laparoscopic cholecystectomy (LC), with emphasis on morbidity and costs incurred. METHODS: A retrospective review of all patients who underwent cholecystectomy at the Launceston General Hospital between 1 January 1999 and 31 December 2001 was performed. RESULTS: A total of 322 LCs was performed during the study period. Median time on the waiting list was 130 (1-1481) days. While awaiting surgery, 44/322 patients (14%) re-presented to the emergency department with biliary symptoms (89 separate presentations); 21 patients (6%) were admitted (28 admissions), of whom 18 (86%) were on the waiting list for biliary colic symptoms only. Reasons for emergency admission included pancreatitis (1), cholangitis (3), choledocholithiasis (7), cholecystitis (7), and exacerbation of symptoms (10). Median hospital stay was 4 days (1-14 days) (total cost of 124 hospital days, excluding subsequent admission for cholecystectomy, $A128 712 according to average bed day costs), and 11 patients required endoscopic retrograde cholangiopancreatography (13 procedures). Mean (median) time on the surgical waiting list for patients who developed complications was 238 (203) days versus 185 (126) days for patients who had LC without interval complications. A total of 198 cancellations occurred in 124/322 patients (39%) before surgery. CONCLUSIONS: Prolonged waiting times for elective LC are associated with morbidity in 14% of patients at the Launceston General Hospital. This, combined with frequent cancellation of elective surgery, may result in significant costs to the health-care sector.
Abstract: INTRODUCTION: Wound blisters are formed in the epidermis adjacent to surgical incisions and are a significant cause of morbidity following hip surgery. This study was designed to compare two commonly used primary dressings, namely a nonadherent absorbable (NAA) dressing and paraffin tulle gras (PTG). Monitoring for the subsequent development of wound blisters in the epidermis adjacent to the surgical incision was then undertaken. METHODS: The present study was performed in the setting of a prospective, randomised trial of 50 consecutive patients undergoing hip surgery. It was assumed there would be no difference in the development of blisters between the dressing groups. The alternative hypothesis was that PTG would, because of its properties, provide less friction in the epidermis and contribute to fewer wound blisters. RESULTS: A statistically significant difference (P = 0.0028) between the two dressing groups was observed with the NAA group developing blisters in 17 (64%) patients and the PTG group in only two (8%) of the patients. CONCLUSION: The present study would suggest that PTG produces fewer wound blisters following hip surgery when compared to the NAA type as a primary dressing.
