Robotic-assisted partial nephrectomy (RAPN) and standardization of outcome reporting: a prospective, observational study on reaching the "Trifecta and Pentafecta"

Partial nephrectomy (PN) for small renal masses is common, but outcomes are not reported in a standard manner. Traditionally, parameters such as 90-day mortality, blood loss, transfusion rates, length of stay, nephrometry scoring and complications are published but their collective impact on warm ischemia time (WIT) and post-surgery GFR is rarely determined. Thus, our aim was to assess if “Trifecta” and “Pentafecta” outcomes could be used as useful surgical outcome markers. A prospective database of 252 Robotic-Assisted PN (RAPN) cases (2008–2019) was analysed. “Pentafecta” was defined as achievement of “Trifecta” (negative surgical margin, no postoperative complications and WIT of < 25 min) plus over 90% estimated GFR preservation and no CKD stage upgrading at 1 year. Binary logistic regression analysis was conducted to predict factors which may prevent achieving a Trifecta/Pentafecta. Median tumour size was 3 cm and mean WIT was 15 min. Positive surgical margins (PSM) occurred in 2 cases. Overall, the intra-operative complication rate was 7%. One recurrence conferred 5-year cancer-free survival of 97%. Trifecta outcome was achieved in 169 (67%) and Pentafecta in 141 (56%) of cases. At logistic regression analysis, intraoperative blood loss was the only factor to affect Trifecta achievement (p = 0.018). Advanced patient age negatively impacted Pentafecta achievement (p = 0.010). The Trifecta and Pentafecta outcomes are easily applicable to PN data, and offer an internationally comparable PN outcome, quality measure. We recommend applying this standardization to national data collection to improve the quality of reporting and ease of interpretation of surgeon/centres’ outcomes.

Chronic tyrosine kinase inhibitor (TKI) use in metastatic renal cell carcinoma (mRCC): can this lead to the adverse effect of hypogonadism?

Background: Patients with metastatic renal cell carcinoma (mRCC) are commonly treated with tyrosine kinase inhibitors (TKIs). An adverse effect frequently suffered by patients is lethargy, which often leads to dose reduction or drug cessation. We aimed to assess whether hypogonadism is related to treatment with TKIs. Methods: We prospectively assessed gonadal function in 41 consecutive males with mRCC treated with TKIs. Demographic, clinical, and biochemical variables were collected, and statistical analyses performed to assess correlation and survival. Data Capture for each patient was perfomred at the time of entry in the study. Results: There was a 77% incidence of hypogonadism in this cohort. Assessment of testosterone level and time on TKI treatment revealed a correlation with linear regression R² of 0.24 and regression coefficient of -0.003 (p = 0.019). Odds ratio for hypogonadism at >30 months on TKIs was 12.1 (p = 0.011). Odds ratios above and below this value showed a confirmatory trend, suggesting that this may be a chronic adverse effect. Conclusions: Our findings provide an important and robust hypothesis for a prospective clinical trial to be performed. Expert Opinion: Given the present data, patients who have symptoms suggestive of hypogonadism must have an assessment of gonadal function and be treated.

Outpatient Clinic: Where is the Delay?

In outpatient clinics, consultation times are often eroded by extraneous activities. We measured the components of each outpatient episode in 167 patients attending a general urology follow-up clinic. 41% of time in the clinic was spent away from the patient—administration 17%, disturbances 15%, finding results 9%. The inefficiencies had changed little since a study in the same setting thirteen years earlier. Since then, parallel nurse-practitioner-run clinics have been introduced in the hope of giving consultants longer with the patient; however, time with each patient is now 4.8 min compared with a previous 7.6 min. The most easily addressed inefficiencies are those relating to missing information, such as radiology reports.

Stromal expression of VEGF-A and VEGFR-2 in prostate tissue is associated with biochemical and clinical recurrence after radical prostatectomy

BACKGROUND

There is probably significant overtreatment of patients with prostate cancer due to a lack of sufficient diagnostic tools to predict aggressive disease. Vascular endothelial growth factors (VEGFs) and their receptors (VEGFRs) are potent mediators of angiogenesis and tumor proliferation, but have been examined to a limited extent in large prostate cancer studies. Meanwhile, recent promising results on VEGFR-2 inhibition have highlighted their importance, leading to the need for further investigations regarding their expression and prognostic impact.

DESIGN

Using tissue microarray and immunohistochemistry, the expression of VEGFs (VEGF-A and VEGF-C) and their receptors (VEGFR-2 and VEGFR-3) were measured in neoplastic tissue and corresponding stroma from radical prostatectomy specimens in 535 Norwegian patients. Their expression was evaluated semiquantatively and associations with event-free survival were calculated.

RESULTS

High expression of VEGFR-2 in either stroma or epithelium was independently associated with a higher incidence of prostate cancer relapse (HR = 4.56, P = 0.038). A high combined expression of either VEGF-A, VEGFR-2 or both in stroma was independently associated with a higher incidence of biochemical failure (HR = 1.77, P = 0.011).

CONCLUSIONS

This large study highlights the prognostic importance of VEGF-A and VEGFR-2 stromal expression. Analyses of these biomarkers may help distinguish which patients will benefit from radical treatment. Together with previous studies showing efficiency of targeting VEGFR-2 in prostate cancer, this study highlights its potential as a target for therapy, and may aid in future selection of prostate cancer patients for novel anti-angiogenic treatment.

Prostate cancer. Foreword

Professor Hiten Patel is an expert in Laparoscopic and Robotic Surgery for treating prostate disease. He is also a leading researcher in basic science and `clinical research. His basic science research is focused on studying the pathways for improving prostate cancer diagnosis and prognosis through biomarker application, and his clinical research includes new technology applications for training surgeons and improving patient care outcome. Prof Patel is also Chairman of the Urology group for the Enhanced Recovery after Surgery Society.

Robotic and minimal access surgery: technology and surgical outcomes of radical prostatectomy for prostate cancer

Since the 1990s, minimal access surgery has been utilized in urology. In the past 15 years, robotic surgery has evolved and become a natural part of minimal access surgery. The dissemination has been fast and the opportunity of prospective trials has been missed. Nevertheless, robotic surgery has obvious benefits for the surgeon and patient. Even though the scientific evidence is not strong, robotic surgery is here to stay. However, there are lessons to learn from the implementation of the da Vinci system with regards to patient safety and prospective evaluation of the new technology. The future of surgery will include technologies derived from robotic surgery.

Biomarkers and personalized risk stratification for patients with clinically localized prostate cancer

Prostate cancer (PCa) is the most common neoplasia among men in developed countries and a leading cause of cancer-related morbidity and mortality. PCa is a very heterogeneous disease, both clinically and biologically. Currently, it is difficult to stratify patients into risk groups that entail different disease management. Therefore, a personalized view of this disease is mandatory, through the development of new and more accurate biomarkers that may help clinicians to stratify patients according to threat that PCa poses for each patient. Hence, this review focuses on recent developments of molecular and immunohistochemical biomarkers for PCa risk stratification that might enable a personalized approach to PCa patients. However, despite the increasing amount of available data, there is also an urgent need to translate the most promising biomarkers for clinical use through large multicenter validation trials. Ultimately, these will contribute for an improved clinical management of PCa patients.

Strategies to improve quality of life in bladder cancer patients

Bladder cancer is a heterogeneous disease that includes both tumors with low risk of dissemination as well as highly malignant tumors with a considerable potential to metastasize. The patient's quality of life is closely related to the management of the disease. The challenge for the urologist is to acknowledge the malignant potential of the cancer and to adjust the approach to the patient accordingly. Patients with low-risk bladder cancer should avoid an exaggerated follow-up, but on the other hand high-risk patients must be sufficiently surveyed to secure that definitive surgical treatment is performed before it's too late. When the decision to perform a cystectomy has been made, it is crucial that the patient understands the consequences of the surgery as well as the possible options for urinary reconstruction. This review focuses on aspects of bladder cancer management that we believe are vital for the quality of life of these patients.

Robotic laparoscopic surgery: cost and training

The advantages of minimally invasive surgery are well accepted. Shorter hospital stays, decreased postoperative pain, rapid return to preoperative activity, decreased postoperative ileus, and preserved immune function are among the benefits of the laparoscopic approach. However, the instruments of laparoscopy afford surgeons limited precision and poor ergonomics, and their use is associated with a significant learning curve and the amount of time and energy necessary to develop and maintain such advanced laparoscopic skills is not insignificant. The robotic surgery allows all laparoscopists to perform advanced laparoscopic procedures with greater ease. The potential advantages of surgical robotic systems include making advanced laparoscopic surgical procedures accessible to surgeons who do not have advanced video endoscopic training and broadening the scope of surgical procedures that can be performed using the laparoscopic method. The wristed instruments, x10 magnifications, tremor filtering, scaling of movements and three-dimensional view allow the urologist to perform the intricate dissection and anastomosis with high precision. The robot is not, however, without significant disadvantages as compared with traditional laparoscopy. These include greater expense and consumption of operating room resources such as space and the availability of skilled technical staff, complete elimination of tactile feedback, and more limited options for trocar placement. The current cost of the da Vinci system is $ 1.2 million and annual maintenance is $ 138000. Many studies suggest that depreciation and maintenance costs can be minimised if the number of robotic cases is increased. The high cost of purchasing and maintaining the instruments of the robotic system is one of its many disadvantages. The availability of the robotic systems to only a limited number of centres reduces surgical training opportunities. Hospital administrators and surgeons must define the reasons for developing a robotic surgical program: it is very important to show that robotics will add a dimension that will benefit the hospital, the patient care and institutional recognition. Another essential task to overcome is the important education of the operating room nursing staff, a significant difference between this modality and traditional surgery. Without operating room environment support, most surgeons will revert to traditional methods even after a few successful robotics cases. As the field of robotic surgery continues to grow, graduate medical education and continuing medical education programs that address the surgical robotic learning needs of residents and practicing surgeons need to be developed.

Trans-obturator tape: a single centre experience

AIM

To assess the clinical outcome of TOT tape for stress and mixed urinary incontinence in a single centre.

METHODS

From March 2002 to October 2006, 82 patients completed the study, all were evaluated at 3 and 12 months by physical examination and validated questionnaires. Seventy nine patients had the procedure under epidural anaesthesia and all women received antibiotics starting before surgery.

RESULTS

TOT was mostly performed as a day case surgery with short operative time of 22 minute (range 15-38 minute). A total of 62 (70.4%) patients were discharged from the hospital within a few hours (4.3 +/- 1.7 hours).

CONCLUSION

The TOT tape can safely be performed as a day-case procedure, which has a continence cure rate of approximately 80%. This figure is comparable with the more established TVT, however the TOT tape has a significantly lower morbidity in our experience.

Robotic Oncological Surgery: Technology That's Here to Stay?

A robot functioning in an environment may exhibit various forms of behavior emerge from the interaction with its environment through sense, control and plan activities. Hence, this paper introduces a behaviour selection based navigation and obstacle avoidance algorithm with effective method for adapting robotic behavior according to the environment conditions and the navigated terrain. The developed algorithm enable the robot to select the suitable behavior in real-time to avoid obstacles based on sensory information through visual and ultrasonic sensors utilizing the robot's ability to step over obstacles, and move between surfaces of different heights. In addition, it allows the robot to react in appropriate manner to the changing conditions either by fine-tuning of behaviors or by selecting different set of behaviors to increase the efficiency of the robot over time. The presented approach has been demonstrated on quadruped robot in several different experimental environments and the paper provides an analysis of its performance.

Significance of alterations in plasma lipid profile levels in breast cancer

HYPOTHESES

The relationship between lipids and breast cancer is obscure. Until now, conflicting results have been reported on the association between lipids and risk of breast cancer in women. Therefore, the major aim of this study is to examine the role of alterations in lipid profile in breast cancer.

STUDY DESIGN

Plasma lipids (ie, total cholesterol [TC], high-density lipoprotein [HDL], low-density lipoprotein [LDL], very-low-density lipoprotein [VLDL], and triglycerides [TG]) were analyzed from 70 controls, 30 patients with benign breast disease (BBD), 125 untreated breast cancer patients, and 93 posttreatment follow-up samples.

METHODS

Samples were analyzed using highly sensitive and specific spectrophotometric methods.

RESULTS

Plasma TC, LDL, VLDL, and TG were significantly lower (p = .042, p = .003, p = .024, p = .014, respectively) in patients with BBD compared with controls. Plasma TC and HDL were significantly lower (p = .026, p = .0001, respectively), and VLDL and TG were significantly higher (p = .009, p = .05) in breast cancer patients as compared with controls. Plasma VLDL and TG were significantly higher in breast cancer patients as compared with patients with BBD. The receiver-operating characteristic curve showed that plasma TC, LDL, VLDL, and TG levels could significantly discriminate (p = .001, p = .005, p = .005, p = .005, respectively) between controls and patients with BBD. Plasma levels of TC, HDL, VLDL, and TG could significantly distinguish (p = .01, p = .002, p = .001, p = .002, respectively) between controls and breast cancer patients. Plasma levels of VLDL and TG could significantly discriminate (p = .000, p = .000, respectively) between patients with BBD and breast cancer patients. Odds ratio analysis revealed that higher levels of TC and HDL were significantly associated with a reduction in breast cancer risk (p = .01 and p = .0001, respectively), whereas higher levels of VLDL and TG were significantly associated with increased breast cancer risk (p = .001 and p = .002, respectively). Plasma VLDL and TG levels were significantly lower in complete responders as compared with pretreatment levels (p = .000, p = .000, respectively), and plasma TC and LDL levels were significantly lower in nonresponders as compared with pretreatment levels (p = .015, p = .009, respectively).

CONCLUSION

The alterations in lipid profile levels showed a significant correlation with breast cancer risk, disease status, and treatment outcome.

Clinical importance and therapeutic implications of the pivotal CXCL12-CXCR4 (chemokine ligand-receptor) interaction in cancer cell migration

Chemokines are small, secreted proteins and are now the largest known cytokine family. They mediate their effects through a family of G-protein-coupled receptors and were initially recognized for their ability to act as chemo-attractants and activators of specific types of leucocytes in a variety of immune and inflammatory responses. However, during the past 5 years there has been a chemokine revolution in cancer and all scientists and clinicians in oncology-related fields are now aware of their crucial role at all stages of neoplastic transformation and progression. The most important chemokine ligand-receptor interaction is that of the CXCL12 (stromal cell-derived factor-1, SDF-1) ligand with its exclusive receptor CXCR4; this interaction has a pivotal role in the directional migration of cancer cells during the metastatic process. This has been demonstrated by in vitro and in vivo experiments in addition to retrospective clinical studies. These findings have exciting implications in the field of cancer therapeutics, with several small molecule CXCR4 antagonists having been developed, which may provide clinical benefit in the therapy of cancer metastasis. Interestingly, it is likely that the effect of the anti-HER2 antibody [trastuzumab (Herceptin] in breast cancer involves downregulation of the CXCR4 receptor. Unfortunately, a major problem is that chemokine receptors are expressed in other cells within the body, particularly those of the immune system and it is not clear what effects long-term CXCR4 antagonism could have on innate and adaptive immunity. However, there is little doubt that the great strides made in elucidating the complex relationship between chemokines and their role in cancer will soon translate into significant survival benefits for patients.

Trans-Obturator Tape for Incontinence: A 3-Year Follow-Up

AIM

To assess operative and functional outcomes, including morbidity, after using the trans-obturator tape for stress incontinence.

PATIENTS AND METHODS

The first 24 consecutive patients undergoing trans-obturator tape insertion in a single centre were included in this retrospective study. All patients were female with a mean age of 63 (range 40-83) years. Fifteen patients (62.5%) suffered from pure stress incontinence, and 9 patients (37.5%) had mixed incontinence. Of the latter, 2 patients also had nocturnal enuresis. Each patient was followed up for between 3 and 12 months postoperatively and again at 36 months. The patients were assessed by clinical examination, ultrasound for residual urinary volume, and subjective satisfaction which was assessed at 3 and 12 months. At 36 months, all patients completed a validated incontinence questionnaire (International Consultation on Incontinence Questionnaire: ICIQ) which assessed female lower urinary tract symptoms and their impact on the quality of life.

RESULTS

All operations were performed under epidural anaesthesia in day surgery, and the mean operative time was 20 (range 15-38) min. Nineteen patients (79.2%) showed significant improvement postoperatively, with 16 of those (66.6%) being completely cured of their incontinence. The remaining 5 patients (20.8%) were considered to have had failed procedures. There were no vascular, bladder, or urethral injuries. One patient had perforation of the vaginal fornix, and 3 patients developed vaginal erosion.

CONCLUSIONS

The trans-obturator tape is a safe and effective treatment for stress incontinence and has a low morbidity after a 3-year follow-up period; however, it should only be performed by clinicians with the relevant surgical expertise and experience in treating female incontinence.

Robotic extraperitoneal radical prostatectomy: an alternative approach

PURPOSE

Laparoscopic radical prostatectomy with or without a robot has been increasingly performed worldwide, primarily using a transperitoneal approach. We report our experience with daVinci(R) robot assisted extraperitoneal laparoscopic radical prostatectomy.

MATERIALS AND METHODS

A total of 325 patients underwent robot assisted extraperitoneal laparoscopic radical prostatectomy for clinically localized prostate cancer at our center during a 2-year period. Perioperative data, and oncological and functional results were prospectively recorded.

RESULTS

Perioperative demographics included mean age, PSA and Gleason score, which were 60 years (range 42 to 76), 6.6 ng/ml (range 0.6 to 26) and 6 (range 5 to 9), respectively. Preoperative clinical stage was 81%, 16% and 3% for T1c, T2a and T2b, respectively. Average total operative time was 130 minutes (range 80 to 480). Intraoperative data included a mean blood loss of 196 cc with no open conversions. Bilateral, unilateral and nonnerve sparing prostatectomy was performed in 70%, 24% and 6% of patients, respectively. Of the patients 96% were discharged home within 8 to 23 hours of surgery. Pathological stage was pT2a, pT2b, pT3a and pT3b in 18%, 63%, 14% and 5% of all radical prostatectomy specimens, respectively, with an overall positive surgical margin rate of 13%. Two of 92 patients had positive nodal disease after lymph node dissection. Continence and erectile function were measured.

CONCLUSIONS

The extraperitoneal approach offers the advantages of improved dexterity and visualization of the robot, while avoiding the abdominal cavity and potential associated morbidity. As surgeons gain more experience with this new technology, the extraperitoneal approach simulating the standard open retropubic technique is likely to gain popularity.

Penile Sensitivity and Sexual Satisfaction after Circumcision: Are We Informing Men Correctly?

OBJECTIVES

Currently no consensus exists about the role of the foreskin or the effect circumcision has on penile sensitivity and overall sexual satisfaction. Our study assesses the effect of circumcision on sexually active men and the relative impact this may have on informed consent prior to surgery.

MATERIALS AND METHODS

One hundred and fifty men between the ages of 18 and 60 years were identified as being circumcised for benign disease between 1999 and 2002. Patients with erectile dysfunction were excluded from the study. The data was assessed using the abridged, 5-item version of the International Index of Erectile Function (IIEF-5). Questions were also asked about libido, penile sensitivity, premature ejaculation, pain during intercourse and appearance before and after circumcision. IIEF-5 data was analysed using two-tailed paired t test to compare pre-operative and post-operative score changes across the study group. For the rest of the questions, data was analysed using 'Sign Test', calculating two-sided p values and 95% confidence intervals.

RESULTS

Fifty-nine percent of patients (88/150) responded. The total mean IIEF-5 score was 22.41 +/- 0.94 and 21.13 +/- 3.17 before and after circumcision, respectively (p = 0.4). Seventy-four percent of patients had no change in their libido levels, 69% noticed less pain during intercourse (p < 0.05), and 44% of the patients (p = 0.04) and 38% of the partners (p = 0.02) thought the penis appearance improved after circumcision. Penile sensation improved after circumcision in 38% (p = 0.01) but got worse in 18%, with the remainder having no change. Overall satisfaction was 61%.

CONCLUSIONS

Penile sensitivity had variable outcomes after circumcision. The poor outcome of circumcision considered by overall satisfaction rates suggests that when we circumcise men, these outcome data should be discussed during the informed consent process.

Tension-free vaginal tape: avoiding failure

A prospective, single-centre study to assess the outcome of incontinence surgery in the first 120 consecutive patients who had tension-free vaginal tape (TVT) by a single surgeon. All patients were initially seen at 3 months postsurgery, with a cough provocation test, measurement of residual urine volume and a satisfaction survey. At a mean of 26 months (6-42 months) after surgery, a validated telephone interview was performed. The operation was performed in accordance with the original technique described by Ulmsten et al. [Int Urogynecol J Pelvic Floor Dysfunct 1996; 7: 81-5]. A total of 87 of 120 patients completed the study with the others either not complying or having died. Sixty-three (72.4%) patients were completely dry on cough provocation test. Of these, four (4.5%) had a slow stream and 10 (11.4%) suffered persistent urgency. The remaining 24 patients had varying degrees of leakage (operative failure). Sixteen (18.3%) patients subjectively considered the procedure to have failed at 3 months follow-up, either because leakage occurred once or more a day, and/or the persistence of the preoperative frequency/urgency syndrome. Of these 16 TVT failures, two had previous pelvic radiotherapy, two had double incontinence and eight had TVT for recurrent incontinence. Among the failures, 81.3% had mixed incontinence with predominant urge and nocturia three times per twenty four hours. Our study highlights the need for selection when performing TVT. We recommend that TVT be performed for those who have simple stress incontinence failing conservative measures (pelvic floor exercises and physiotherapy), with no history of incontinence surgery, pelvic radiotherapy, faecal or mixed incontinence.

Antibiotics on urethral catheter withdrawal: a hit and miss affair

Globally, millions of patients undergo urethral catheterization every year. Our objective was to study the current use of prophylactic antibiotics on urinary catheter withdrawal. A questionnaire (N = 300) was sent to healthcare professionals involved in the management of patients with urinary catheters (consultant microbiologists, infection control nurses, consultant urologists, specialist nurses in urology, continence advisers and consultants in the care of older people). The questionnaire asked about their use of prophylactic antibiotics on the withdrawal of a urethral catheter. Sixty percent of healthcare professionals advocated the use of antibiotics for either all or selected groups of patients. The remainder did not. The use of prophylactic antibiotics varied among different groups. Of the healthcare professionals who used antibiotics, the majority cited more than one reason for their use (prevent bacteraemia, avoid an infection in a prosthesis or urinary tract infection). The course and type of antibiotic used varied. Our study has shown diversity in practice that is of concern. At present, just over one-half of patients with urinary catheters are being given antibiotics, although there is no evidence to suggest that such an intervention confers any benefit. If benefits do not exist, these patients are being exposed to the harm of antibiotics and providers are incurring costs unnecessarily. A formal trial to address this issue is urgently needed.

Bladder Neck Stenosis after Transurethral Resection of Prostate: Does Size Matter?

AIM

To understand the risk factors associated with the incidence of bladder neck stenosis (BNS) after transurethral prostate surgery.

PATIENTS AND METHODS

We retrospectively reviewed 900 patients who underwent transurethral prostate surgery over a 4-year period. The mean age of the men was 72.3 (47-94) years. The specific outcome data assessed related to BNS, including type of operation performed, resected tissue weight and history of previous surgery in the lower urinary tract.

RESULTS

29 (3.4%) patients developed BNS at a mean of 10.3 (3-33) months, with a mean resected prostatic tissue weight of 11+/-3.7 g. Four of the 29 patients with BNS were treated with bladder neck resection and re-stenosed. Fifty-four men underwent bladder neck incision for small prostates with a high bladder neck, measured by digital rectal examination and assessed cystoscopically, with no BNS. All the remaining patients from our series did not have a BNS, with a mean resected weight of 28+/-8.9 g, which is statistically greater than in the BNS group (p<0.05, unpaired t test).

CONCLUSIONS

BNS after transurethral prostate surgery is a significant problem. It is clear from our study that resection in small prostates with no sign of a high bladder neck will increase the development of BNS. Thus, small prostates should be managed by an initial bladder neck incision, even if the bladder neck is not high.

CURRENT TRENDS IN BLADDER CANCER IN ENGLAND AND WALES

PURPOSE

We examined trends in bladder cancer (BC) incidence, mortality and survival in England and Wales during a 30-year period.

MATERIALS AND METHODS

Age standardized incidence and mortality rates for BC, cohort incidence ratios, and 1 and 5-year relative survival from BC were calculated, and current trends were assessed.

RESULTS

Between 1971 and 1998 the total number of cases of BC increased by 57% from around 7,200 to almost 11,400. Between 1971 and 1998 directly age standardized incidence increased by 16% in males and 37% in females. Directly age standardized mortality decreased by 26% in males and showed little change in females during the same period. Five-year relative survival improved by around 15% points in the 1970s and early 1980s. However, there was less improvement in survival thereafter in that 5-year relative survival for patients diagnosed in 1993 to 1995 was 67% in men and 58% in women.

CONCLUSIONS

With an almost 60% increased incidence during the last 3 decades, BC incidence remains much higher in men but has increased more rapidly in women. There have been steady decreases in mortality rates, more marked in men than in women. Unusually, women have a significantly lower survival rate than men. Reasons for these patterns and trends are unclear. The trends in bladder cancer incidence by birth cohort suggest that the relationship with smoking may not be that strong and that other factors may be involved. Further research should focus on reasons for the recent increase in bladder cancer incidence in younger female birth cohorts.

Modified ureterosigmoidostomy (Mainz II): a long-term follow-up

OBJECTIVE

To assess the long-term results in patients treated using a modified ureterosigmoidostomy (Mainz II).

PATIENTS AND METHODS

Between 1994 and 1999, 17 patients had their lower urinary tract reconstructed by a ureterosigmoidostomy, modified by reconfiguring the rectum to make a low-pressure reservoir (Mainz II). All patients were followed on a standard protocol. Data were extracted from the database and from a review of the case-notes. In 12 patients the procedure was with a radical cystectomy for carcinoma. Five had a failed conventional ureterosigmoidostomy for bladder exstrophy and therefore proceeded to a Mainz II. The data on continence and complications were retrieved for a retrospective analysis; the mean (range) follow-up was 6.4 (4-8.6) years.

RESULTS

Ten of those with bladder cancer and one in the revision group were continent. Two patients in the revision group had sufficiently severe nocturnal incontinence to require conversion to a colonic conduit. Seven of the 17 patients had hyperchloraemic acidosis, one had pyelonephritis and one had renal stones. There were no anastomotic neoplasms.

CONCLUSION

The Mainz II has a good outcome if used as the primary procedure. In patients with an existing ureterosigmoidostomy who are incontinent, detubularization of the rectosigmoid alone is unlikely to restore continence.

Tissue microarrays: a current medical research tool

Recent research in molecular biology has identified a significant number of novel markers, which may have diagnostic, prognostic and therapeutic significance. This is particularly pertinent in the field of cancer. Validation of these markers in multiple clinical specimens is currently performed by traditional histopathological techniques, which are disappointingly time consuming, labour intensive and, therefore, economically costly. These limitations have hampered the introduction of many novel markers into everyday clinical practice. The tissue microarray (TMA) is a high throughput technique, which allows the rapid and cost effective validation of novel markers in multiple pathological tissue specimens. Tissue from up to a 1000 histology blocks can be arrayed accurately onto a newly created paraffin block, at designated locations. Subsequently, morphological and molecular investigations can be performed to determine the clinical significance of the novel markers tested. It is now firmly established that the TMA can significantly accelerate the processing of a very large number of tissue specimens with excellent quality, good reliability and preservation of original tissue, with ultimate clinical benefit.

DICLOFENAC SUPPOSITORY ANALGESIA FOR TRANSRECTAL ULTRASOUND GUIDED BIOPSIES OF THE PROSTATE: A DOUBLE-BLIND, RANDOMIZED CONTROLLED TRIAL

PURPOSE

A significant proportion of men undergoing transrectal ultrasound (TRUS) and prostate biopsy report pain during the procedure. A number of different methods of pain relief have been suggested in the literature. We prospectively evaluated the effect of diclofenac suppositories on pain experienced by men undergoing TRUS and prostate biopsy.

MATERIALS AND METHODS

A prospective, randomized, double-blind, placebo controlled study was performed in 72 patients requiring prostate biopsy. Patients were randomly assigned to receive 100 mg diclofenac or placebo 1 hour prior to the procedure. They were asked to indicate on a 10 cm visual analogue scale the degree of discomfort during the procedure. The patients were then seen 2 weeks later and any morbidity, including infection and bleeding, was assessed.

RESULTS

Patients given diclofenac had significantly lower pain scores than those given placebo (2.8 vs 4.9, p <0.001). The 2 groups were similar in regard to age, prostate volume, biopsy number, prostate specific antigen, histological diagnosis and complication rate.

CONCLUSIONS

Rectal administration of diclofenac 1 hour prior to TRUS and prostate biopsy is a simple procedure that significantly relieves the pain experienced with no increase in morbidity. With the trend toward more core samples, screening for prostate cancer and the younger age of patients undergoing biopsy we urge urologists to provide analgesia for this painful procedure.

Intratesticular cysts and malignant potential: conservative management is an option

Benign intratesticular cysts are rare, but recognition is essential to prevent unnecessary surgical intervention. The diagnostic dilemma is to differentiate these cysts from testicular malignancy. As they are extremely uncommon, experience of their management is limited and controversial. We present a case of a simple intratesticular cyst and discuss the diagnostic and management principles.

A national survey of transrectal ultrasound-guided prostatic biopsies: time for a national guideline

The aim of this study was to elicit similarities and differences in transrectal ultrasound guided prostatic biopsy regimens in the UK and the Republic of Ireland. A telephone survey of 60 centres was conducted and information collected on the operator, the anaesthesia used, antibiotic prophylaxis and number of biopsies taken. Most prostatic biopsies were performed by urologists and most procedures involved six cores. There was a marked variation in the use of antibiotic prophylaxis, and anaesthesia was used sparingly. Our survey has shown a diversity in protocols used in transrectal ultrasound guided biopsies in the UK and Ireland. It seems sensible to standardise the technique for optimal patient satisfaction, as well as clinical efficiency. A national co-ordinated, prospective trial is needed.

Rare Case of Primary Lymphoma of the Prostate: Giving the Patient the Benefit of the Doubt

One third of non-Hodgkin lymphomas are extranodal, however it is uncommon for the lower urinary tract to be involved. We present an unusual case of a low-grade primary lymphoma affecting the prostate, which responded well to radical radiotherapy.

Epididymo-orchitis risk factors in traumatic spinal cord injured patients

STUDY DESIGN

Retrospective audit and interview-based study of a traumatic spinal cord injured cohort, assessing the incidence and risk of epididymo-orchitis (E-O).

OBJECTIVES

Assess the potential risk factors for E-O in this cohort (spinal cord injured patients).

SETTING

Janbazan Clinic for Spinal Cord Injuries, Mashad, Iran.

METHODS

A retrospective notes audit of 169 male traumatic spinal cord injured (SCI) patients was performed. In addition, interviews were performed to confirm any equivocal data. The following risk factors were assessed: history of recurrent urinary tract infections (UTIs), urethral stricture, urethral diverticuli, urinary fistula, urinary calculi, spinal injury type, neurogenic bladder type, autonomic dysreflexia, vesico-ureteral reflux, sphincterotomy, vasectomy, marriage status, bladder residual and emptying method, ejaculation, spinal injury level, micturation control, and muscular spasm, which included detrusor, external sphincter or lower limb spasm.

RESULTS

A total of 65 patients from our group (38.5%) had suffered E-O at least once. E-O presented on average, 3.9 years after the SCI. Patients with a history of muscular spasm appeared less likely to develop E-O (P<0.05). None of the vasectomised patients developed E-O. The relation between all the other factors and E-O were not significant.

CONCLUSIONS

Our study has shown that the presence of muscular spasm decreases the risk of E-O, although the mechanism remains unclear. Surprisingly, the other historical risk factors showed no clear relation with E-O occurrence.

Diagnostic accuracy of flow rate testing in urology

OBJECTIVE

To highlight the importance of methodological standards in diagnostic testing in urology, by reviewing the extent of compliance with these standards in reports of published evaluations.

METHODS

Sixteen papers evaluating the diagnostic accuracy of urinary flow-rate testing were independently assessed by two reviewers for compliance with the following methodological standards: specification of study population, analysis of pertinent subgroups, avoidance of evaluation (verification) bias, avoidance of review bias, reporting of precision of estimates of test accuracy, indeterminate test results, and test reproducibility. Compliance with each standard was expressed as a percentage with a 95% confidence interval.

RESULTS

Compliance ranged from just 12.5 (1.5-38)% for reporting of test reproducibility to 87.5 (62-98)% for specification of the study population. Only nine of the 16 evaluations complied with four or more of the methodological standards; one paper did not comply with any.

CONCLUSIONS

This evaluation of urological flow-rate testing show poor compliance with accepted methodological standards. The study design, reporting and evaluation of new diagnostic tests can be improved by adhering to these standards. Policy-makers, purchasers and providers would be less likely to adopt new diagnostic tests inappropriately if they were to appraise published evaluations against the standards. A reduction in the inappropriate use of tests would in turn lead to more cost-effective use of healthcare resources.

Catheter-associated urinary tract infections: prevalence of uropathogens and pattern of antimicrobial resistance in a UK hospital (1996-2001)

OBJECTIVE

To assess the change in the bacterial profile and pattern of antibiotic resistance of catheter-associated urinary tract infections (CAUTIs, the most prevalent form of nosocomial infections) between 1996 and 2001.

MATERIALS AND METHODS

Catheter samples of urine (CSUs) submitted in 1996, 1998 and 2001 (2451, 2460 and 3349 specimens, respectively) were analysed. The distribution of different uropathogens in bacterial CAUTIs and their in vitro antimicrobial resistance was evaluated over the study interval. The likelihood ratio test was used to assess whether there was a linear trend according to calendar year.

RESULTS

Escherichia coli was the most frequently isolated pathogen in all years, but its frequency declined over time (35.6%, 32.5% and 26.6%, respectively). Enterococcus was the second most frequent overall, with a significant increase in frequency with time (11.8%, 15.3% and 22.0%, respectively). There was also a considerable change in resistance patterns to antibiotics. As a result, in 1996, CAUTIs were least often resistant to ciprofloxacin (8.0%) followed by co-amoxiclav (18.5%) and cephalexin (25.4%). In 2001, CAUTIs were least often resistant to co-amoxiclav (22.5%), followed by ciprofloxacin (27.2%) and nitrofurantoin (28.8%).

CONCLUSION

The types of organisms associated with CAUTI have changed over the last 5 years in a UK institution, as have the patterns of antibiotic resistance. Currently, the most appropriate agents for the empirical management of CAUTIs seem to be co-amoxiclav, ciprofloxacin and nitrofurantoin.

The use of the Memokath stent in the treatment of detrusor sphincter dyssynergia in spinal cord injury patients: a single-centre seven-year experience

AIMS

A retrospective analysis of our seven-year experience with the Memokath urethral stent for the treatment of detrusor sphincter dyssynergia (DSD) in spinal cord injured (SCI) patients.

PATIENTS AND METHODS

Twenty five patients with SCI underwent rhabdosphincter Memokath stent insertion. The mean age was 45.5 years (range 32-65 years). The level of injury was cervical in 14 and thoracic in 11 patients. All patients were shown to have neurogenic detrusor overactivity with DSD associated with high detrusor pressures and incomplete emptying on pre-operative video-cystometrograms (VCMG). The Memokath stent was inserted using a standardized protocol. Follow-up assessment included blood chemistry, ultrasound scan (upper tracts and residual urine) at one and three months after insertion, and a follow-up VCMG at six months. The pre-operative and six-month post-operative VCMG results were analysed by the paired t-test and p value <0.05 was taken as significant.

RESULTS

There was a significant reduction in maximum detrusor pressure, duration of contraction and residual urine volume (p<0.05) on the VCMG six months after insertion of the stent. At present six patients have a Memokath stent in situ at a mean of 34.7 months (range 6-86 months). Nineteen stents were removed for several reasons at a mean of 20.3 months (range 0.25-41 months). These include, exacerbation of autonomic dysreflexic symptoms (n=3); stent migration (n=7); encrustation and stone formation (n=5); incomplete bladder emptying without obstruction (n=3); entrance into fertility program (n=1).

CONCLUSION

The Memokath stent is safe, easy and quick to insert with minimal trauma to the urethra. It is effective in the management of DSD and decreasing the detrusor pressure and residual urine volume in SCI patients. Moreover the ease of its removal in a non-traumatic fashion makes this stent an attractive option when patients are still contemplating the method of bladder management, in those wishing to be involved in fertility program and in recently SCI patients who may recover some manual dexterity to perform clean intermittent self-catheterisation. It must be remembered that this is a temporary stent, as our study clearly shows that the majority are removed within two years of insertion.

The treatment of male stress urinary incontinence with polydimethylsiloxane in compliant bladders following spinal cord injury

STUDY DESIGN

Retrospective analysis.

OBJECTIVES

To evaluate the safety and efficacy of polydimethylsiloxane (PDS, Macroplastique) submucosal injections, in the treatment of male genuine stress urinary incontinence secondary to spinal cord injury (SCI).

SETTING

London Spinal Injuries Unit, Stanmore, UK and Institute of Urology and Nephrology, London, UK.

PATIENTS AND METHODS

A retrospective analysis identified 14 patients treated with PDS for stress urinary incontinence secondary to SCI between 1997 and 2001. A single surgeon at a specialist spinal injuries unit managed all patients. A total of 13 patients had suffered a traumatic SCI (T11:n=2; T12:n=5; L1:n=5; L2:n=1), while one developed stress incontinence after spinal surgery. The mean age was 41 years (range 26-69 years) and the mean duration of injury was 9.6 years (range 1.5-48 years). The preoperative investigations included video cystometrogram (VCMG) confirming the presence of urodynamically proven stress incontinence without evidence of urge incontinence. Complete cure was defined as a cessation of pad usage with no evidence of leakage on VCMG. Incomplete cure with improvement was defined as a >50% reduction in the number of pads used, with incontinence present on VCMG.

RESULTS

The follow-up ranged from 12 to 58 months (mean 34.7 months). Five patients (36%) reported complete success, confirmed by VCMG. Three patients (21%) reported improvement with >50% reduction in the use of pads. The procedure failed completely in six patients (43%). No immediate or late complications were noted with the procedure.

CONCLUSIONS

The use of PDS is a safe and minimally invasive treatment for genuine stress urinary incontinence in males following SCI with a stable compliant bladder. We achieved complete cure in 36% of our patients with confirmation on VCMG. A further 21% reported greater than 50% reduction in usage of pads; however, on VCMG stress incontinence was demonstrated in these patients. We suggest that PDS can be used as the first line of treatment in this difficult group of patients with complex problems.

Long-term surveillance of bladder tumours: current practice in the United Kingdom and Ireland

INTRODUCTION

Surveillance of transitional cell carcinoma of the bladder forms a major part of the workload of many urology units. Unfortunately, the policy for long-term surveillance of these cancers is neither clear nor agreed upon in the absence of evidence base. Our study was performed to provide current national practice data, and begin the debate on consensus guidelines.

MATERIALS AND METHODS

A questionnaire was sent to Consultant Urologists (CUs) in the UK and Ireland (n=501) asking about their policy on the long-term surveillance of different bladder tumours once patients are free of recurrence.

RESULTS

A 73% response rate was observed (365/501). Views varied considerably. They ranged from life long cystoscopic surveillance for low-stage low-grade tumours (pTaG1) to discharge after 5 years (or less) of a recurrence-free period for pT1G3 tumour. Once long-term surveillance with cystoscopy had been discontinued, 55% of CUs felt no role was indicated for urine cytology in further follow up, whereas 17% would use it for all tumour types and 28% are selective.

CONCLUSION

Our study has shown the complete lack of consensus regarding the long-term surveillance of bladder cancer in the UK and Ireland. This has major implications for policy making, resources allocation and cancer survival. We highlight the need for national guidelines in this area for optimal surveillance of bladder cancer, as a good prospective evidence-based data will not be available for many years. We believe our study might form the basis for discussion on such guidelines.

Experience of tension-free vaginal tape for the treatment of stress incontinence in females with neuropathic bladders

STUDY DESIGN

Retrospective.

OBJECTIVE

To evaluate the safety and efficacy of the tension-free vaginal tape (TVT) for the treatment of stress incontinence in females with neuropathic bladders.

SETTING

London Spinal Injuries Unit, Stanmore & Institute of Urology, London, UK.

METHODS

Twelve women (mean age 53.3 years; range 41-80 years) with neuropathic bladder dysfunction and stress urinary incontinence were treated with tension-free vaginal tape (TVT) between November 1997 and December 2000. The group consisted of women with: (i) traumatic spinal cord injuries (n=3); (ii) post lumbar spinal surgery (n=6); (iii) spinal stenosis (n=3). Four of the 12 patients had previously failed surgery for stress incontinence. All patients underwent pre- and post-TVT evaluation with video-urodynamic studies.

RESULTS

Mean follow-up was 27.1 months (range 17-54 months). Three patients were voiding spontaneously (stress voiding) before surgery and continued to do so post-operatively. The remaining 9 were performing clean intermittent self-catheterisation before the insertion of TVT and continued to do so after the surgery. At follow up 10 patients (83.3%) were dry. The procedure failed in one patient and the other complained of mild leakage, but she reported a decrease in the number of pads used. One patient developed detrusor hyperreflexia on post-operative video-urodynamics but there was no evidence of stress incontinence. One patient had a bladder perforation on insertion of TVT, managed successfully with extended use of a urethral catheter post-operatively. Three patients developed post-operative urinary tract infection successfully treated with oral antibiotics.

CONCLUSIONS

Tension-free vaginal tape insertion is minimally invasive, safe and effective for the treatment of stress incontinence in females with bladder neuropathy with intrinsic sphincter deficiency. Previous surgery for incontinence did not affect post-operative complications or outcome.

Chemokines: key players in cancer

Chemokines are a family of low molecular weight (8-10 kDa) pro-inflammatory cytokines, which bind to G-protein coupled receptors. Their primary function is chemoattraction and activation of specific leucocytes in various immuno-inflammatory responses. However, new research suggests that they are key players in cancer being involved in the neoplastic transformation of cells, promotion of aberrant angiogenesis, tumour clonal expansion and growth, passage through the extracellular matrix (ECM), intravasation into blood vessels or lymphatics and the non-random homing of tumour metastasis to specific sites. In view of the increasing significance of chemokines and their receptors in cancers of a variety of types, manipulation of this signalling pathway may be important in the development of new anticancer agents. This review provides an overview of recent research advances in this field and examines the potential therapeutic benefits future developments may bring.

The mesh wallstent in the treatment of detrusor external sphincter dyssynergia in men with spinal cord injury: a 12-year follow-up

OBJECTIVE

To assess the long-term effectiveness of the UroLume trade mark wallstent (Pfizer Inc., UK) in the treatment of detrusor external sphincter dyssynergia (DESD) in quadriplegic patients.

PATIENTS AND METHODS

Twelve patients with quadriplegia secondary to spinal trauma underwent external striated sphincter stenting with the UroLume wallstent instead of an external sphincterotomy for DESD (mean age 41.8 years, range 26-65). The level of injury was C4 in two, C5 in four, C6 in four, C7 in one and T6 in one. All patients were shown by preoperative video-cystometrography (VCMG) to have DESD and high-pressure, hyper-reflexic bladders with incomplete emptying.

RESULTS

Seven of the 12 patients had a mean (range) follow-up of 12.7 (12.17-13.6) years; two others were lost to follow-up at 1 and 3 years and both remained free of complications during that time. Two patients developed encrustation causing obstruction, requiring stent removal within a year of insertion. Another patient with an adequately functioning stent died 7 years after surgery (chest infection). Urodynamic follow-up of the seven patients showed a significantly sustained reduction in maximum detrusor pressure and duration of detrusor contraction at> 10 years of follow-up. Five of the seven patients developed bladder neck dyssynergia of varying degrees, as shown on VCMG; all were successfully treated with bladder neck incision. There were no problems with stent migration, urethral erosion, erectile dysfunction or autonomic dysreflexia.

CONCLUSION

Permanent urethral stenting using the UroLume wallstent is effective in managing DESD and provides an acceptable long-term alternative to sphincterotomy. Subsequent bladder neck dyssynergia is the main complication but this can be managed successfully with bladder neck incision. Importantly, unlike sphincterotomy, there is no significant interference with erectile function. Also, the procedure is reversible, minimally invasive and requires a shorter hospital stay.

Outpatient clinic: where is the delay?

In outpatient clinics, consultation times are often eroded by extraneous activities. We measured the components of each outpatient episode in 167 patients attending a general urology follow-up clinic. 41% of time in the clinic was spent away from the patient-administration 17%, disturbances 15%, finding results 9%. The inefficiencies had changed little since a study in the same setting thirteen years earlier. Since then, parallel nurse-practitioner-run clinics have been introduced in the hope of giving consultants longer with the patient; however, time with each patient is now 4.8 min compared with a previous 7.6 min. The most easily addressed inefficiencies are those relating to missing information, such as radiology reports.

Penile cancer: an overview

Carcinoma of the penis affects 1 in 100,000 men per year in most developed countries. It accounts for less than 1% of adult malignancies in Europe and the USA. Survival is excellent if diagnosed early, but most men present up to 1 year after the initial lesion is noted. Unfortunately the treatment of metastatic disease is still disappointing.

The 'top 10' urological procedures: a study of hospital episodes statistics 1998-99

OBJECTIVE

To summarize the urological procedures recorded in Hospital Episodes Statistics (HES, 1998-99) and to examine the accuracy of coding and HES.

MATERIALS AND METHODS

Data on the 10 commonest urological procedures from the Department of Health website (www.doh.gov.uk/hes) were extracted, summarized and presented.

RESULTS

Urethral catheterization, endoscopic procedures on the bladder, prostate, urethra and ureter (excluding ureteric stone extraction), minor open procedures on the foreskin and the vas, bladder instillation, extracorporeal shockwave lithotripsy and prostatic biopsy are the 10 commonest procedures, according to finished consultant episodes. There is published evidence that the data from coding and HES are not completely accurate.

CONCLUSION

This study highlights shortfalls in the HES data (1998-99) which may directly affect the funding of urological services.