Ultramini-percutaneous nephrolithotomy versus retrograde intrarenal surgery in the treatment of 10-30 mm calculi: a randomized controlled trial

The surgical management of renal stones 10-30 mm is usually performed with percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS). Standard form of percutaneous nephrolithotomy has paved the way for miniaturized PCNL in many centres. We wanted to evaluate the efficacy, safety and the cost-effectiveness of ultramini-percutaneous nephrolithotomy (UMP) versus RIRS in the treatment of renal stones with stone burden 10-30 mm. Patients with renal stone burden 10-30 mm were prospectively randomized into either UMP or RIRS. The demographic data, stone characteristic, operative time and cost of the equipment were recorded. The stone free status, analgesic requirement, deterioration of the renal function and hemoglobin and the postoperative complications as per Clavein-Dindo grade were recorded. One hundred and fifty patients met inclusion criteria. Out of these 98 underwent UMP and 46 RIRS. Six withdrew the consent before the procedure. Mean stone size was comparable in either of the groups. Mean laser time and stone extraction time was significantly less for UMP compared to RIRS (41.17 min versus 73.58 min p < 0.0001). Mean consumable costs in the UMP group were considerably less at US$45.73 compared to the RIRS group at $423.11 (p < 0.0001). The stone free rates at 1 month of follow-up were 100% for UMP group and 73% for RIRS group. There were insignificant changes to mean hemoglobin and glomerular filtration rate (GFR) in all patients and the average length of the stay was similar in both the groups. The postoperative complications revealed Grade I and II rate of 10% in the UMP group and 35% in the RIRS group, respectively. We concluded that UMP to be safe, effective and more economical to the RIRS for renal stones up to 3 cm in size.Trial registered with ISRCTN registry ID ISRCTN20935105, Retrospective.

Trainee logbook analysis reveals regional operative experience

Objective:

Indicative operative numbers have become a new benchmark for higher surgical training. The aim of the deanery-led audit was to assess our regional operative experience using trainee logbooks against indicative number standards and to develop a tool to help guide regional training.

Subjects and methods:

Annual logbook data were collected using a questionnaire from urology trainees in a single region. Logbook data were excluded for an incomplete entry or work at multiple trusts in the same year. Logbooks were assumed to be current and validated. Analysis of variance (ANOVA) was used for statistical analysis.

Results:

Altogether 24 trainees across 19 different training sites responded to the questionnaire. A total of 9777 indicative procedures were included in the analysis. Median annual operative numbers were lower than required for 10/13 procedures, but mean annual operative numbers were higher than required for only 1/13 procedures (andrology). Significant variation in annual operative numbers across training sites was observed for 6/13 procedures. Annual logbook data was used to rank training sites by procedure-specific volumes and likelihood of trainees to achieve the annual operative target.

Conclusion:

Trainee logbook data is useful for objective ranking of training sites. In our region, difficulty in surpassing indicative numbers would arise due to significant case number variation between training sites and not due to regional insufficiency in case numbers. Regular analysis of trainee logbooks would allow better management of regional training with respect to indicative numbers.

Prospective Outcomes of Ultra Mini Percutaneous Nephrolithotomy: A Consecutive Cohort Study

PURPOSE

Ultra mini percutaneous nephrolithotomy is a less invasive technique of percutaneous nephrolithotomy to treat small to medium sized calculi.

MATERIALS AND METHODS

We prospectively evaluated the outcomes of ultra mini percutaneous nephrolithotomy in a single surgeon, consecutive cohort study. Data on 94 patients who underwent ultra mini percutaneous nephrolithotomy were collected.

RESULTS

Mean ± SD calculus size was 15.9 ± 4.5 mm and mean density was 1,106 ± 167 HU. Access was achieved via the upper pole in 8 cases, interpolar in 33 and lower pole in 54. Mean operative time was 54 minutes (range 28 to 120). Mean hemoglobin loss was 0.81 gm/dl and the mean creatinine increase was 0.05 mg/dl. There were no transfusions or kidney injuries. Grade I and IIIb complications were observed in 4 and 1 patients, respectively. The most serious complication was a perinephric collection. Postoperatively oral analgesia was sufficient in 86 patients (91%). Mean length of stay was 38.2 ± 15.9 hours. Nephrostomy drainage was used in 13 patients while 7 (7%) required a stent for 1 week. Intraoperatively 99% of renal units were stone free (absence of detectable calculi) on fluoroscopy, and 74% and 81% were stone free on day 1 postoperative ultrasound and 1-month computerized tomography, respectively. The 10 to 20 mm stones showed less bleeding, shorter operative time and a significantly lower requirement for nephrostomy or a Double-J(®) stent.

CONCLUSIONS

Ultra mini percutaneous nephrolithotomy appears to be effective and safe with a short length of stay. It may be a valuable addition to the armamentarium to treat 10 to 20 mm calculi in patients who wish to avoid routine nephrostomy or stents. Randomized, controlled trials are required.

A comparative study on intertidal faunal biodiversity of selected beaches of Mumbai coast

Comparative study has been done to examine the biodiversity and ecological status of the intertidal region of Tata Institute of Fundamental Research (TIFR), Bandstand and National Centre for Performing Arts (NCPA) rocky beaches in Mumbai, West coast of India. A total of 50 species of intertidal organisms were recorded from these shores. Shannon and Simpson's diversity index, Margalefs richness index and Pielou's evenness index indicated different level of ecological state of the shore in different months. Dendrograms and 2-D non metric MDS ordination from Bray-Curtis similarity matrix of occurrence of intertidal organisms from these sites showed highest similarity and combination pattern of occurrence between Nerita oryzarum and Planaxis sulcatus in TIFR and Bandstand shore. Nerita oryzarum and Tactarius malaccanus at NCPA shore. Abundance/biomass comparison (ABC) method of determining level of disturbance also pointed towards the polluted status of these shores. Study concludes that though these beaches are highly disturbed due to anthropogenic activities, they still support a rich intertidal biodiversity which need immediate attention for protection and conservation.

Immunohistochemical expression of muscarinic receptors in the urothelium and suburothelium of neurogenic and idiopathic overactive human bladders, and changes with botulinum neurotoxin administration

PURPOSE

To investigate the possible associations of urothelial and suburothelial muscarinic receptors with human bladder pathophysiology we examined the immunohistochemical expression of muscarinic receptors types 1, 2 and 3 in the bladder urothelium and suburothelium of patients with neurogenic or idiopathic detrusor overactivity compared with that in controls. We also examined associations with patient quantified symptoms and the effect of intradetrusor botulinum neurotoxin type A treatment.

MATERIALS AND METHODS

We obtained bladder biopsies from 36 patients with detrusor overactivity before, and 4 and 16 weeks after treatment with intradetrusor botulinum neurotoxin type A via flexible cystoscopy. Patients with neurogenic detrusor overactivity were injected with 300 U botulinum neurotoxin type A and those with idiopathic detrusor overactivity received 200 U. Control biopsies were taken from 7 patients during investigation for asymptomatic microscopic hematuria. We studied muscarinic receptor immunohistochemical expression using commercial antibodies to muscarinic receptors 1, 2 and 3 with results quantified by image analysis.

RESULTS

We noted decreased suburothelial muscarinic receptor immunoreactivity in detrusor overactivity biopsies vs controls, which were significant for muscarinic receptors 1 and 3. After successful botulinum neurotoxin treatment we noted only increased muscarinic receptor 1 and 2 immunoreactivity. Urothelial muscarinic receptor 1 and 3 immunoreactivity was increased after treatment. We identified no substantial urothelial muscarinic receptor 2 immunoreactivity. Receptor levels showed inverse correlations with patient urgency and frequency.

CONCLUSIONS

Decreased muscarinic receptor levels in the urothelium and suburothelium of patients with detrusor overactivity were largely restored to control levels after successful treatment with botulinum neurotoxin type A. Correlations of receptor levels with patient symptoms further support a role for urothelial and suburothelial muscarinic receptors in detrusor overactivity in humans.

Intertidal biodiversity and health status of Bandstand shore (Bandra), Mumbai, India

A study was carried out to assess the biodiversity status of the intertidal region of rocky shore of Bandstand (Bandra), Mumbai. Among 42 species recorded, Euchelus asper was maximum in density during December (123/m2). However, maximum biomass was recorded for Nerita oryzarum in November (146.94 g/m2). ANOVA revealed no variation in the occurrence of organisms according to transects, but the variation was recorded according to months and quadrates. Shannon and Simpson's diversity index, Margalef's richness index and Pielou's evenness index indicated different level of ecological state of the shore in different months. Dendrogram from Bray-Curtis similarity matrix and non metric Multi-Diamentional Scaling (MDS) revealed maximum closeness of occurrence between N. oryzarum and Planaxis sulcatus. Shepard diagram and abundance/biomass comparison (ABC) curve method revealed light to moderately polluted status of the shore. However, in spite of such condition, this shore is still rich in intertidal biodiversity that should be conserved.

Histological changes in the urothelium and suburothelium of human overactive bladder following intradetrusor injections of botulinum neurotoxin type A for the treatment of neurogenic or idiopathic detrusor overactivity

BACKGROUND

We examined, for the first time in a prospective study, the histological changes in the urothelium and suburothelium of patients with neurogenic (NDO) or idiopathic detrusor overactivity (IDO) after one or repeat treatments with intradetrusor BoNTA.

METHODS

Flexible cystoscopic bladder biopsies were obtained from patients with urodynamically proven intractable spinal NDO or IDO before and 4 and 16 wk after one or repeat treatments with intradetrusor injections of BOTOX1 (NDO 300 U, IDO 200 U). Specimens were stained for haematoxylin-eosin and analysed blindly for inflammatory changes, fibrosis, hyperplasia, and dysplasia in the urothelium and suburothelium. Statistical comparisons were significant at p values less than 0.05.

RESULTS

Signs of chronic inflammation were found in 59.1% of baseline biopsies (65.6% of NDO vs. 50% of IDO, p=0.049), 67.6% of post-first biopsies and 86.4% after repeat injections. The two groups were comparable for degree of baseline inflammation, which did not change significantly after first injection and up to 16 wk after a third injection. Mild fibrosis was found in 2.2% of biopsies examined, equally before and after treatment, but not after repeat injections. No dysplasia or hyperplasia was identified. Eosinophils were identified more frequently in biopsies taken after repeat injections compared with the post-first injection and baseline biopsies (chi2=8.23, p=0.018). No difference existed between NDO and IDO bladders.

CONCLUSIONS

BoNTA injections do not appear to be producing significant inflammatory changes, fibrosis, or dysplastic changes in human bladder urothelium/suburothelium after a single injection and in a limited number of repeat treatment biopsies. The presence of eosinophils might be treatment-related, because they were mostly found in post-treatment biopsies.

Sacral neurostimulation for urinary retention: 10-year experience from one UK centre

OBJECTIVES

To report our 10-year experience of sacral neurostimulation (SNS) for women in urinary retention, comparing the original one-stage with the newer two-stage technique, as SNS therapy is a well-established treatment for urinary retention secondary to urethral sphincter overactivity (Fowler's syndrome).

PATIENTS AND METHODS

Between 1996 and 2006, 60 patients with urinary retention had a SNS device inserted; their case records were reviewed and data on efficacy, follow-up, need for continued clean intermittent self-catheterization (CISC), complications and operative revision rate were assessed.

RESULTS

Overall, 43 of 60 (72%) women were voiding spontaneously, with a mean postvoid residual volume of 100 mL; 30 (50%) no longer needed to use CISC. During a total of 2878 months of SNS experience, adverse event episodes included lead migration in 20, 'box-site' pain in 19, leg pain/numbness in 18 and loss of response/failure in 18 patients; 53% of the women required a surgical revision related to their implanted stimulator. The efficacy of the two-stage was similar to that of the one-stage procedure (73% vs 70%). Women with a normal urethral sphincter electromyogram had worse outcomes than women with an abnormal test (43% vs 76%). Although the efficacy was no different in those taking analgesia/antidepressant medication, this group of women had a higher surgical revision rate. Failure and complications for the one-stage procedure were not restricted to the early follow-up period. The mean battery life of the implant was 7.31 years.

CONCLUSIONS

SNS has sustained long-term efficacy but the procedure has a significant complication rate. At present, the two-stage technique has comparable efficacy to the one-stage technique but a longer-term follow-up is required. The National Institute of Clinical Excellence recommended the use of SNS in women with urinary incontinence who fail to respond adequately to anticholinergic therapy, but patients choosing this treatment should be made aware of the high complication rate associated with the procedure.

A case of scrotal sarcoidosis that mimicked tuberculosis

BACKGROUND

A 38-year-old man presented with bilateral testicular swelling, night sweats and weight loss with little response to antibiotics. Examination revealed systemic lymphadenopathy and multiple small masses arising from both testes.

INVESTIGATIONS

Scrotal ultrasound revealed multiple intratesticular, hypoechoic lesions; chest radiograph and abdominal ultrasound were normal. A CT scan revealed multilevel lymphadenopathies. A Heaf (tuberculin) skin test was negative. Testicular biopsy revealed multiple granulomata, some of which showed patchy central necrosis.

DIAGNOSIS

A diagnosis of tuberculosis was initially made. After 3 months of clinical deterioration despite antitubercular drug therapy, however, the diagnosis was changed to sarcoidosis because blood results revealed hypercalcemia, elevated serum angiotensin-converting enzyme, and an elevated erythrocyte sedimentation rate.

MANAGEMENT

The patient improved dramatically on corticosteroid therapy, with complete regression of all testicular lesions on imaging after 2 months. Steroids were tapered, then discontinued after 6 months. The patient remained in complete remission, but became oligospermic by the 3 year follow-up.

Results of double-blind placebo-controlled crossover study of sildenafil citrate (Viagra) in women suffering from obstructed voiding or retention associated with the primary disorder of sphincter relaxation (Fowler's Syndrome)

OBJECTIVES

Women with the primary disorder of sphincter relaxation find voiding difficult. Studies have identified neuronal nitric oxide synthase in the female urethral sphincter, and nitric oxide donors have been shown to decrease sphincter pressures. The aim of our study was to determine if sildenafil could improve sphincter relaxation and thereby increase flow rates and improve bladder emptying.

METHODS

Twenty women with complete (5), partial retention or obstructed voiding (15) with a maximum flow rate (Qmax) of less than 15 ml/min with an elevated maximal urethral closure pressure (92--age cm H(2)O) and sphincter volume (>1.6 cm(3)) were included in the study. The study was a double-blind, randomised, placebo-control, crossover design, with patients taking sildenafil or placebo, and with measurement of flow rate and residual volume at baseline and after each treatment phase. Voiding diary, quality of life, and International Prostate Symptom Score (IPSS) data were also collected.

RESULTS

No statistical significant difference was seen in any voiding parameters and diaries when sildenafil citrate was compared with placebo. There was a significant mean decrease in IPSS of 3.64 between baseline and the sildenafil phase (p=0.0083), but not when compared with placebo. In the subgroup of women with partial retention and obstructed voiding (15/20), there was a statistically significant increase in Qmax of 4.7 ml/sec (p=0.025) between sildenafil and baseline; however this difference was not seen when compared with placebo.

CONCLUSIONS

This is the first study looking at sildenafil in voiding dysfunction in women. Clinical improvements with sildenafil were not significant when compared with placebo. Sildenafil was not effective as a therapeutic pharmacologic agent in this group of patients.

Urinary retention in women: its causes and management

OBJECTIVE

To report the experience of the last 4 years from a centre to which women with voiding difficulties and urinary retention were referred nationally, describing what investigations were helpful in making a diagnosis and the management strategies used.

PATIENTS AND METHODS

Women with voiding difficulties and urinary retention remain a diagnostic and management challenge, and those with no anatomical or neurological basis for their symptoms may be dismissed, assuming that their retention has a psychogenic basis. The finding of an electromyographic (EMG) abnormality of the striated urethral sphincter explaining their disorder (Fowler's syndrome) has led to the referral of women for consideration of that diagnosis. Thus we audited the referrals to the centre over a 4-year period of such women.

RESULTS

In all, 247 women (mean age 35 years) with complete (42%) or partial retention (58%) were referred; 175 (71%) had urethral pressure profilometry, 141 (57%) had a transvaginal ultrasonographic measurement of the sphincter volume, and 95 (39%) had sphincter EMG. The mean maximum urethral closure pressure difference between patients with an EMG abnormality (101.5 cmH(2)O) and the patients with known other causes of voiding dysfunction (66.2 cmH(2)O) was 35.3 cmH(2)O (P < 0.05). In patients with complete retention there was a significant difference in sphincter volume between those who were EMG-positive (2.14 mL) or EMG-negative (1.64 mL) (P < 0.05).

CONCLUSION

These investigations helped to classify the cause of retention in two-thirds of cases. The commonest diagnosis was Fowler's syndrome, in which sacral nerve stimulation is the only intervention that restores voiding.

Investigation of sequential mitomycin C and photodynamic therapy in a mitomycin-resistant bladder cancer cell-line model

OBJECTIVES

To investigate the hypothesis that sequential mitomycin C and 5-aminolaevulinic acid (ALA)-mediated photodynamic therapy (PDT) interact additively in both the J82 bladder cancer cell line and its mitomycin-C-resistant derivative, J82/MMC, and to assess the theoretical basis of this interaction by measuring the relative mitochondrial density of the respective cell lines, on the basis that the mitochondria are the intracellular site where ALA is metabolized to the active photosensitizer, protoporphyrin IX.

MATERIALS AND METHODS

Cell survival was assayed in J82 cell line and the J82/MMC derivative after treating them with sequential ALA-mediated PDT and mitomycin C, and with the sequence of treatments reversed. Cell survival was estimated using the tetrazolium assay. The relative mitochondrial density of the two cell lines was estimated using flow cytometry to measure 123rhodamine fluorescence.

RESULTS

The effect of sequential mitomycin C followed by ALA-mediated PDT enhanced the effect of PDT in both cell lines. In J82/MMC this effect was marginally supra-additive. When ALA-mediated PDT was administered before mitomycin C, the combined effect was 'sub-additive'. 123Rhodamine fluorescence was > 10 times greater in J82/MMC than J82, suggesting a significantly higher mitochondrial density in the former than the latter.

CONCLUSION

Mitomycin C appears to enhance ALA-mediated PDT when administered first. This appears to be particularly so in J82/MMC. This phenomenon may have clinical significance in recurrent superficial bladder cancer.

Urinary tract ultrasonography in the evaluation of haematuria--a report of over 1,000 cases

Over a 5-year period, 1007 patients with haematuria were investigated, using a protocol based on ultrasonography as the upper tract imaging modality of choice. Intravenous urography (IVU) was only used in selected individuals, including those patients with bladder cancer suspected on cystoscopy, suspicious or malignant cytology, previous investigation for haematuria, on-going haematuria at the time of their clinic visit, a history of flank pain or hydronephrosis on ultrasonography. Of this series, 840 (83%) had visible haematuria, 158 (15%) had microscopic or chemical haematuria and 9 (0.9%) had unspecified haematuria. A total of 133 bladder transitional cell tumours, 21 renal cell cancers and 2 upper tract transitional cell cancers (TCC) were diagnosed. The sensitivity of ultrasound with respect to bladder cancer was 63% and the specificity 99%. The odds ratio of diagnosing cancer in patients with visible haematuria compared to microscopic or unspecified haematuria was 3.3. No upper tract tumours were missed using this investigational protocol. An ultrasonography-based protocol could miss fewer upper tract TCCs than a standard IVU-based service would miss renal cell cancer. Provided there is no history of flank pain, no malignant cytology, no hydronephrosis and no previously investigated haematuria, IVU could be safely omitted.

Quantitative studies of the kinetics of 5-aminolaevulinic acid-induced fluorescence in bladder transitional cell carcinoma

Photodynamic therapy is a potential treatment for superficial bladder cancer that utilizes photosensitizer drugs, which are activated by light to cause tissue destruction. However, first-generation photosensitizers cause prolonged phototoxicity, have poor tumour specificity and can accumulate within detrusor muscle, resulting in permanent loss of bladder capacity following treatment. A newer drug, called 5-aminolaevulinic acid (ALA), generates a sensitizer called protoporphyrin IX (PpIX) in situ and has been shown, qualitatively, to be more tumour specific. The fluorescence kinetics of ALA-induced PpIX was investigated in patient biopsies of bladder tumour, normal urothelium and detrusor muscle, both in vitro after incubation of specimens in ALA-rich culture medium for various times and in vivo after instillation of intravesical ALA before endoscopic resection. The fluorescence in tumour tissue was twice that of normal urothelium in vitro and up to tenfold in vivo. There was little ALA-induced fluorescence in detrusor muscle, both in vitro and in vivo. Most importantly, no patients experienced phototoxicity or other adverse events following intravesical instillation of ALA.

Photodynamic therapy of bladder cancer cell lines

OBJECTIVE

To determine the effect of photodynamic therapy mediated by 5-aminolevulinic acid (ALA) on a range of bladder cancer cell lines, including a squamous cancer cell line and a multi-drug resistant cell line.

MATERIALS AND METHODS

Experiments were performed on cells growing in culture: the cell lines studied were the transitional cell cancer lines RT112, T24 and EJ138, the squamous cancer cell line, SCaBER, and the multi-drug resistant transitional cancer cell line, MGH-U1(R), together with its non-resistant parent line, MGH-U1. The kinetics of the ALA-mediated generation of fluorescent photosensitizer were determined using flow cytometry. Photodynamic therapy was performed by incubating cells in ALA followed by exposure to various doses of white light.

RESULTS

The response of the various transitional cancer cell lines to photodynamic therapy depended on dose. The squamous cell line was relatively resistant to photodynamic therapy. There was some cross-resistance of the MGH-U1(R) cell line to photodynamic therapy, although the mechanism of cross-resistance appeared not to be necessarily a property of the drug-resistant phenotype.

CONCLUSION

This study suggests that ALA-mediated photodynamic therapy may be effective in transitional cell carcinoma of the bladder. Based on these findings, this therapeutic method should be further evaluated clinically.

Is prednisolone as good as flutamide in hormone refractory metastatic carcinoma of the prostate?

PURPOSE

There are no generally accepted rules for the second line treatment of prostate cancer and few prospective studies have attempted to compare 2 therapeutic strategies with different modes of action.

MATERIALS AND METHODS

We describe a prospective, randomized study of 40 patients comparing the second line response of flutamide to prednisolone in patients with known hormone refractory stage M1 prostate cancer.

RESULTS

The median survival of patients receiving either treatment was 32.9 weeks, with no difference between the 2 groups. In terms of biological response 11 of 20 patients (55%) receiving prednisolone and 10 of 20 (50%) receiving flutamide exhibited prostate specific antigen (PSA) suppression. Average minimum PSA was 54 and 52% of the initial PSA in patients receiving prednisolone and flutamide, respectively. There was no difference between the 2 treatment groups in terms of long-term survival, although 35% of all patients survived beyond 1 year and 3 survived beyond 2 years.

CONCLUSIONS

More patients taking prednisolone described better pain relief, although both medications were well tolerated and there was no difference in terms of performance status or analgesic requirements.

Surgeons' follow-up practice after resection of colorectal cancer

Consultant surgeons in two United Kingdom Health Regions were invited to complete a questionnaire on details of their personal management of patients with colon and rectal cancer, with particular emphasis on follow-up. Replies from 140 (94%) were analysed by the surgeon's subspecialty of colorectal and gastrointestinal surgery (group 1) and all others (group 2). There was a wide variation in the duration of followup, but no difference between the two groups. More group 1 surgeons carried out investigations as a routine after colonic (P < 0.01) and rectal (P < 0.01) resection. Colonoscopy was used more frequently by group 1 (P < 0.0001) and barium enema by group 2 surgeons (P < 0.05). Investigations to detect asymptomatic metastases were used as a routine by 33.3% of surgeons, in whom there was no concordance over the choice or combination of tests and no difference between the two groups of surgeons. There is no consensus among surgeons as to the ideal duration, intensity and method of follow-up after resection for colorectal cancer and little difference between the practice of colorectal and gastrointestinal surgeons and that of other specialists, except in the use of colonoscopy and barium enema. These results reflect the continuing lack of evidence on which to base the follow-up of patients after surgery for colorectal cancer.

Effect of photodynamic therapy in combination with mitomycin C on a mitomycin-resistant bladder cancer cell line

Photodynamic therapy is a method for treating cancer using drugs activated by light. A new compound, 5-aminolaevulinic acid (ALA), is a precursor of the active photosensitizer protoporphyrin IX (PpIX) and has fewer side-effects and much more transient phototoxicity than previous photosensitizers. Cell survival of ALA-mediated photodynamic therapy was measured in the J82 bladder cancer cell line, along with its mitomycin C-resistant counterpart J82/MMC. This demonstrated that mitomycin resistance is not cross-resistant to photodynamic therapy. There was also a suggestion that the mitomycin-resistant cells were more susceptible to photodynamic therapy than the parent cell line. Photodynamic therapy appeared to enhance the effect of mitomycin C, when mitomycin C was given first. This phenomenon was apparent for both drug-resistant and drug-sensitive cell lines. This suggests a possible role for combined mitomycin C and photodynamic therapy in superficial bladder tumours that have recurred despite intravesical cytotoxic drug treatment.

Problematic renal calculi presenting during pregnancy

Urinary tract calculi presenting during pregnancy are rare, with less than 0.1% of pregnancies being associated with stones, the vast majority being asymptomatic and a chance finding. We outline six cases treated over an 8-year period. They presented with combinations of pain, sepsis and obstruction. Intervention was required in four cases: insertion of antegrade nephrostomy, double-J stent, Dormia basket stone extraction, open pyelolithotomy and induction of labour. In each case the pregnancy had a successful outcome. Renal colic can precipitate premature labour. Delayed diagnosis and intervention can result in permanent renal impairment. Ionising radiation and anaesthetic agents may be harmful during pregnancy. The problem is rarely encountered and we therefore present information on the relative risks in each trimester of exposure to the mother and fetus and present a clinical algorithm for the management of these patients.