The Distribution of PSA Age-Specific Profiles in Healthy Irish Men between 20 and 70.

Background. Ireland is estimated to have the highest European incidence rate of prostate cancer (Pca) in 2006 which will increase by 275% by 2025. This study aimed to determine PSA cutoff values in different age groups of healthy male patients without Pca. Methods. 660 men in a pilot men's health programme, aged 18-67, had PSA assayed. Men were grouped into 8 age groups at 5-year intervals: 30-34, 35-39, 40-44, 45-49, 50-54, 55-59, 60-64, and 64-70. Results. Linear regression demonstrates a PSA velocity of 0.024 ng/ml/year. The 95% confidence interval demonstrates a near flat line of PSA values from age 20 to 50 and rises after. When transformed logarithmically, PSA correlates highly with expected values from the normal distribution (0.98). A fractional polynomial quantile regression model was used to predict median and 95th percentile for PSA as follows: 30-34 (0.73, 1.57), 35-39 (0.71, 1.65), 40-44 (0.73, 1.85), 45-49 (0.78, 2.17), 50-54 (0.88, 2.63), 55-59 (1.01, 3.25), 60-64 (1.20, 4.02), and 64-70 (1.43, 4.96). Conclusions. PSA levels are similar to other racial groups but not as high as US Caucasians until 65 years. These data define the predicted PSA for the Irish population and provide a reference for future screening programmes.

An audit of 2273 ureteroscopies--a focus on intra-operative complications to justify proactive management of ureteric calculi.

BACKGROUND: At the national Stone Centre we have adopted a proactive management approach involving early ureteroscopy for ureteric calculi. As the efficacy of ureteroscopy is known this study focuses on the low intra-operative complication rate as justification for a proactive management protocol. PATIENTS AND METHODS: A retrospective study (1987-1997) identified 1936 patients undergoing 2273 ureteroscopies. A database was created from inpatient hospital records. The male to female ratio was 3 to 1, age range was 25 to 84 years. RESULTS: Twenty-three patients (1%) had an intra-operative complication during ureteroscopy. Immediate ureteric JJ stenting was performed in 16 cases with ureteric injury. Two cases underwent percutaneous drainage and delayed antegrade ureteric stenting, ureteroscopy was terminated because of poor visibility. Five patients (0.22%) underwent open surgery for: ureteric perforation (n = 2); Dormia basket ureteric avulsion (n = 1); impacted Dormia basket and stone (n = 1); and impacted balloon dilator and stone (n = l). Ureteroscopic complications were not related to the level of ureteric calculus. CONCLUSION: A protocol of proactive management of ureteric calculi facilitates rapid turnover of large patient numbers. This approach is supported by the low intra-operative complication rate, most of which can be managed by further endoscopic procedures. In the event of corrective open surgery a favourable outcome has resulted.

Rupture of the male membranous urethra.

BACKGROUND: Management of traumatic rupture of the male membranous urethra remains controversial. Long-term morbidity can include urinary incontinence, urethral stricture and erectile dysfunction. AIMS: To review management and outcome of urethral rupture to improve treatment protocols. METHODS: A retrospective study of 47 patients presenting with traumatic urethral rupture over 25 years was performed. RESULTS: All patients underwent emergency suprapubic catheterisation, 32 patients had open surgical realignment at 1-2 weeks; 78% of whom developed strictures. Ten patients unsuitable for early repair underwent delayed transabdominal transpubic urethroplasty at three months: 40% of whom developed strictures. Five patients with partial rupture were managed by cystoscopy and urethral catheter. Erectile dysfunction correlated to initial injury rather than treatment. CONCLUSIONS: If the patient is stable and requires emergency laparotomy for other abdominal injuries, he should have immediate realignment of the urethra. Early realignment of the urethra at laparotomy at 1-2 weeks can be combined with orthopaedic fixation of pelvic fractures. Patients who remain unstable due to associated injuries should have delayed urethroplasty at three months.

Epididymectomy in the management of intrascrotal disease: a critical reappraisal.

OBJECTIVE: To assess the outcome of epididymectomy as a method of treating epididymal pathology. PATIENTS AND METHODS: Forty-one patients who underwent epididymectomy between 1990 and 1995 were analysed retrospectively; their clinical records were reviewed and their satisfaction with the outcome and relief of symptoms assessed using a questionnaire and/or telephone interview. RESULTS: Twenty-nine patients with pain were subdivided into three categories depending on the indication for epididymectomy, i.e. post-vasectomy epididymal engorgement (eight patients), complex cystic disease (11) or 'chronic epididymitis' (10). The outcome was satisfactory in 27 of the 29 patients. The best results were obtained in the group who underwent epididymectomy after vasectomy, where seven of eight improved after the procedure. Those with chronic epididymitis had the least favourable outcome, with only seven reporting any improvement in symptoms. CONCLUSIONS: Epididymectomy has a valuable role in the management of epididymal pathology in appropriately selected patients.

The role of orchiectomy in the management of postpubertal cryptorchidism.

PURPOSE: Owing to the risk of future malignancy, many postpubertal male subjects presenting with unilateral cryptorchidism undergo orchiectomy rather than orchiopexy. We examined the incidence of spermatogenesis and carcinogenesis in whole orchiectomy specimens removed from postpubertal cryptorchid male subjects. We review the concept that orchiectomy is justifiable in these patients. MATERIALS AND METHODS: A total of 52 patients with postpubertal cryptorchidism (unilateral in 48, bilateral in 4) were retrospectively analyzed from 1984. Patient age ranged from 15 to 66 years (mean 26). Six patients presented with primary infertility (unilateral in 3, bilateral in 3). The undescended testicles were palpable in 32 cases (62%). All patients underwent unilateral orchiectomy and whole specimens were examined histologically. RESULTS: Histology showed normal spermatogenesis in only 1 orchiectomy specimen, while 15 had maturation arrest, 6 testicular agenesis and 30 seminiferous tubular atrophy and/or Sertoli-cell-only syndrome with no spermatogenesis. The location of the undescended testis was the superficial inguinal pouch in 32 cases, inguinal canal in 6 and inside the deep ring in 8. Absent spermatogenesis was significantly associated with a high level of maldescent and with increasing age. Two patients (4%) had carcinoma in situ of the testicle. Torsion of an undescended testicle occurred in 1 patient (2%). CONCLUSIONS: This analysis of cryptorchid testes in postpubertal male subjects confirms that the majority cannot contribute to fertility, have significant malignant potential and may undergo torsion. Therefore, orchiectomy remains the treatment of choice for the majority of postpubertal male subjects presenting with unilateral cryptorchidism.

Double pigtail ureteric stent versus percutaneous nephrostomy: effects on stone transit and ureteric motility.

OBJECTIVES AND METHODS: The effects of double pigtail ureteric catheters (JJS) and percutaneous nephrostomies (PN) on ureteric motility and artificial stone transit was assessed in 12 dogs. Each animal underwent bilateral nephrostomies and an artificial stone insertion into each upper ureter (n = 20). A 4-Fr JJS was inserted on one side (group 1) while a PN was left on the contralateral side (group 2). In 4 stone-only 'control' ureters (group 3), the PN was sealed after 72 h. Stone passage was assessed by plain x-rays. Pelvic and ureteric motility was assessed prior to stone insertion and again at 2 weeks. RESULTS: In group 1, only 1 of 8 stones (12.5%) passed completely. Four reached the midureter, 3 remained static. Six of 8 stones (75%) in group 2 passed completely. Two stones remained in the distal ureter. All 4 stones (100%) in group 3 passed by day 3 postoperatively. At laparotomy the J-stented ureters were dilated and both pelvic and ureteric contractions were diminished. Ureteric diameter was normal on the PN side. The ureters contracted with normal amplitude, but diminished rate of contraction above the stones in the ureters with residual calculi (n = 2), and in the 6 ureters from which spontaneous stone passage had occurred. A similar pattern was found in the 4 group 3 ureters. CONCLUSIONS: Double J stents are associated with ureteric dilatation, diminished peristalsis and impaired stone passage. APN preserves ureteric peristalsis and facilitates stone passage. In the initial phase, raised hydrostatic pressure appears to the most important factor determining stone passage.

Incidentally detected renal cell carcinoma: pathological features, survival trends and implications for treatment.

OBJECTIVES: To compare treatment outcomes in symptomatic and incidental renal cell carcinoma (RCC) with specific interest in the role of radical nephrectomy. PATIENTS AND METHODS: The records of 189 patients with a clinical diagnosis of RCC were reviewed. The mode of presentation, tumour size, grade and stage at presentation were correlated with final outcome, as measured by the disease-free and overall survival of the patients. RESULTS: The rate of incidental detection was 15%; incidental tumours were of a lower stage and patients with incidentally detected tumours had a significantly longer disease-free and overall survival than had those with symptomatic tumours (P < 0.05). CONCLUSIONS: The increased detection of incidental tumours should further improve survival in RCC. We continue to advocate radical nephrectomy for incidentally detected tumours, as it offers the best outcome and simplifies the follow-up.

The fate of the defunctioned bladder following supravesical urinary diversion.

OBJECTIVE: To determine the nature, incidence and severity of bladder complications after supravesical urinary diversion without cystectomy and to identify preventative risk factors. PATIENTS AND METHODS: A retrospective study of the last 25 years identified 35 patients who had supravesical urinary diversion without concomitant cystectomy (33 ileal loop diversions and two cutaneous ureterostomies). Urinary diversion was performed for a variety of lower urinary tract pathologies. Patients with urinary tract neoplasia were excluded. There were 15 males (mean age 41 years, range 13-72) and 20 females (mean age 49 years, range 15-81) with a mean follow-up of 5.2 years (range 1-25). RESULTS: There were bladder complications in 10 patients (28%) including pyocystis (one mild and two severe), haemorrhage (two mild and one severe) and pain/spasm (four mild and three severe). Patients with interstitial cystitis, bladder outflow obstruction and/or a vesical fistula appeared to have a higher risk of complications. Four patients required cystectomy to treat severe symptoms while the remaining six achieved control of symptoms with no surgery. No patient developed carcinoma during the follow-up. CONCLUSION: We recommend that cystectomy is considered at the time of supravesical urinary diversion, particularly in patients with interstitial cystitis, bladder outflow obstruction or a chronically infected bladder and especially in those with a vesical fistula.

Is there a role for in vivo methylene blue staining in the prediction of bladder tumour recurrence?

OBJECTIVE: To assess the role of in vivo staining with intravesical methylene blue in predicting tumour recurrence. PATIENTS AND METHODS: Thirty-nine patients (27 men and 12 women, age range 43-75 years) newly diagnosed with bladder tumours were prospectively studied and followed for a minimum of 2 years. Potential biopsy sites were identified by staining intravesically with a 1% methylene blue solution and compared with random biopsy sites. RESULTS: Biopsy directed by methylene blue staining detected carcinoma in situ more often than random biopsy. Rates of recurrence were similar in both stained and unstained groups. CONCLUSION: Methylene blue staining does not add significantly to the management of patients presenting with bladder tumours.

'Firm' versus 'soft' double pigtail ureteric stents: a randomised blind comparative trial.

It is generally considered that 'firm' double pigtail ureteric catheters, while easier to insert and less prone to migration, may cause more patient discomfort than the 'softer' variety of stent. Objective support for these perceptions is however lacking. The aim of this study was to compare firm and soft stents regarding their ease of insertion, positional stability, biocompatibility and patient tolerance. 155 patients were randomised to receive 'firm' (polyurethane, n = 78) or 'soft' (Sof-Flex, n = 77) stents. Ease and mode of insertion was recorded at time of initial placement. Positional stability, degree of bladder inflammation, stent encrustation and patient tolerance were recorded at the time of removal. Patient tolerance was assessed by symptom score in double-blind fashion. Results showed no significant difference in ease of insertion, positional stability, degree of bladder inflammation or stent encrustation between the two groups. There was a significantly higher incidence of dysuria, renal and suprapubic pain in the firm stent group. There was no significant difference in the incidence of urgency, frequency, nocturia or haematuria. Normal activity and return to work were reported in 67 and 45% of patients with soft and firm stents, respectively. The data indicates that patient tolerance appears to be related to the softness of the stent material.

Comparison of reagent strip (dipstick) and microscopic haematuria in urological out-patients.

Dipstick (reagent strip) and microscopic urine analysis for haematuria was performed prospectively on 1000 consecutive urine samples taken from urological out-patients. Haematuria was present in 185 samples (18.5%) and absent in 687 (68.7%) using both tests; 98 samples (9.8%) had dipstick haematuria that was not confirmed by microscopy and 30 samples (3%) had microscopic haematuria that was missed on dipstick urine analysis. Dipstick urine analysis had a sensitivity of 86.1% and a specificity of 85%. This study confirms that reagent strip testing for haematuria has both false positive and false negative results and indicates that cytoscopy should be considered in all patients with suspected haematuria.

Is retrograde ureterography indicated in pelviureteric junction obstruction?

The role of retrograde ureterography in the management of pelviureteric junction (PUJ) obstruction remains controversial and it has recently been reiterated that visualisation of the entire ureter on the affected side is mandatory owing to the high incidence of other ureteric abnormalities. In a review of 119 consecutive adult pyeloplasties carried out over a 9-year period, only 2 ureteric abnormalities were found in association with PUJ obstruction (duplex ureter/3-cm proximal stricture). Other anatomical abnormalities included aberrant vessels, fascial bands and renal anomalies. Most secondary abnormalities were undiagnosed prior to surgery and all were easily dealt with per-operatively.

Treatment strategy for piezoelectric shock wave lithotripsy of upper ureteral calculi.

In situ piezoelectric lithotripsy monotherapy for upper ureteral stones is an attractive option because it can be conducted on an outpatient basis. Difficulty in calculus localization with ultrasound is the limiting factor. We reviewed our experience with 99 patients treated for upper ureteral calculi with the EDAP LT.01 lithotriptor. For stones above the lower renal border we achieved a 53% stone-free rate compared to 25% for calculi below the lower renal border. In situ piezoelectric lithotripsy of upper ureteral calculi may be considered for stones above the lower renal border.

Effect of high-energy shock wave frequency on viability of malignant cell lines in vitro.

In this study, the effects of high-energy shock wave (HESW) frequency on the viability of three different malignant cell lines were evaluated using a piezo-electric generator. The cell lines studied were AR42-J, VX-2 and HeLa. These cells were targeted both in free suspension and immobilised in gelatine beads. All cell lines in free suspension were acutely sensitive to HESW over a range of frequencies. When cells were immobilised in gelatine, however, the effect on cell viability was not as pronounced. However, at frequencies of 80- and 160-Hz kill rates approaching 80 and 90%, respectively, were observed. Cell proliferation following HESW treatment was not adversely affected. This study demonstrates that single cell suspensions are not appropriate for assessing the in vitro cellular effects of HESW. However, even when cells were immobilised in gelatine, high-frequency HESW produced substantial kill rates. The effects of high-frequency HESW merit further evaluation particularly using in vivo tumour.

Acute and chronic bioeffects of single and multiple doses of piezoelectric shockwaves (EDAP LT.01).

Piezoelectric second generation lithotriptors are an established means of administering extracorporeal shockwave lithotripsy (ESWL) enabling treatment to be performed without anaesthesia or analgesia, but higher shockwave doses and multiple or staged treatment are frequently required. The bioeffects of this modality of ESWL, therefore, require further assessment. Seven experimental groups of adult male rabbits were treated using the EDAP LT.01 in order to determine the acute and chronic bioeffects of clinical dose, excess dose, divided excess dose, high frequency and multiple treatment (X10) piezoelectric shockwaves (PSW). Renal function was measured before and after treatment using mercaptoacetyltriglycine (MAG 3) scans. Gross and histological morphological changes were assessed at one and 30 days following application of PSW. Application of single clinical dose PSW was not associated with any significant functional or morphological renal injury. Excess dose PSW caused transient gross renal contusion, which resolved in the majority of animals with no persistent microscopic abnormality. Divided excess dose PSW resulted in no gross or microscopic damage. High frequency PSW was associated with mild histological abnormality. Multiple PSW treatments caused small discrete fibrotic lesions in all cases, without any change in renal function.

Use of the double pigtail stent in stone retrieval following unsuccessful ureteroscopy.

Insertion of a double pigtail stent is known to cause ureteric dilatation. We analysed the effect of an indwelling double pigtail stent on the success rate of calculus extraction by second ureteroscopy when the initial ureteroscopy fails. Over a 12-month period, a first ureteroscopy failed in 42 patients; 30 were then treated by ureteroscopy combined with a ureteric stent and 12 were treated without a ureteric stent. The group with an indwelling stent had a successful second ureteroscopy or spontaneously passed the calculus in 24 cases (84%) compared with 5 unstented cases (45%). Ureterolithotomy was necessary in 2 patients with a stent and 3 with no stent. It was concluded that following failed ureteroscopic manipulation of calculi, insertion of a double pigtail stent was associated with a higher subsequent success rate for removal of stone by ureteroscopy and a consequent lower rate of ureterolithotomy.

Ultrasonic imaging for extracorporeal shockwave lithotripsy: analysis of factors in successful treatment.

The emergence of real-time ultrasonic imaging for extracorporeal shockwave lithotripsy poses questions regarding the factors and techniques which facilitate stone imaging for clinicians with no previous practical experience in ultrasonography. The ability of these clinicians to assess when stone disintegration has been achieved also needs to be confirmed. A wide range of data was recorded from each of 2688 lithotripsy treatments performed over a 2-year period using the EDAP LT.01 ultrasound-imaged piezoelectric lithotriptor. An analysis of these data was performed using a comprehensive microcomputer-based statistics package. The mean time taken for stone imaging and positioning was reduced from 11.2 to 7.5 min over the 2-year period. Obese patients and those with renal pelvic stones were best imaged in a lateral position. Overall there was no difference in percentage stone disintegration or clearance between treatments in the supine or lateral positions, but a significant reduction in the clearance of small caliceal stones resulted when the lateral position was used. Factors associated with a significantly greater percentage of stone disintegration and clearance included pain experienced by the patient during fine adjustment of the processing head during treatment, acoustic focus attenuation and widening and acoustic shadow widening as detected by the urologist at the end of treatment. Among the factors not associated with significant alterations in the percentage of stone disintegration or clearance were the lithotriptor operator, the side or site of the calculus, obesity and shockwave frequency or power. This study confirmed the ability of urologists to develop expertise in ultrasonography for renal stone imaging and to interpret successfully the subtle signs of stone disintegration.