The Charlson comorbidity score: a superior comorbidity assessment tool for the prostate cancer multidisciplinary meeting.

INTRODUCTION: Multidisciplinary team (MDT) meetings use precise prognostic factors to select treatment options for patients with prostate cancer. Comorbidity is judged subjectively. Recent publications favour the Charlson comorbidity score (CS) for the use in the management of prostate cancer. We assess the feasibility of using the CS by our MDT in planning the treatment of patients with prostate cancer. PATIENTS AND METHODS: Patients from the histopathology database aged less than 75 years and with a diagnosis of localized prostate cancer between 1993 and 1995 were included in a notes audit. A second group consisted of patients recommended for curative treatment for localized prostate cancer by the local MDT in 2004. Data on comorbidity, prostatic malignancy and survival up to 10 years was collected. The prognostic accuracy of the CS was assessed for those patients offered radical treatment between 1993 and 1995. RESULTS: Of 1043 patients initially assessed, 37 patients with localized prostate cancer were identified. Using Cox regression, we found the CS to be a statistically significant predictor of survival, following radical treatment for localized prostate cancer (P=0.005). Current practice in 2004 (56 patients) shows a mean (range) Charlson probability of 10-year survival for radical prostatectomy of 0.823 (0.592-0.923) and for radical radiotherapy of 0.653 (0.07-0.936). CONCLUSIONS: Our results support the findings of recent research. We also found the CS easy to calculate and therefore feasible to use in our MDT setting. We propose the introduction of the Charlson score by prostate cancer MDTs to assess age and comorbidity.

Case report: endurance cycle ride associated with a significant rise in PSA.

A number of disease processes are associated with an elevation in serum PSA. However, several studies have concluded that cycling is not an activity associated with an elevation in PSA. Herein, we summarise the literature and describe the case of a 54-year-old man who had presented to his General Practitioner (GP) with lower urinary tract symptoms 3 days after the completion of a 39-h endurance cycle ride. The PSA level was initially found to be elevated at 28 ng/ml, but decreased to 4 ng/ml and then 2 ng/ml within two and six months of the date of the cycle ride, respectively. It is probable that the elevation in PSA was caused by prolonged mechanical stimulation of the prostate during the cycle ride.

Is preputioplasty effective and acceptable?

Foreskin complaints in childhood, if not manageable conservatively, are usually treated by circumcision. A less radical surgical option, when balanitis xerotica obliterans is absent, is preputioplasty. We sent questionnaires to the parents of 23 boys who had had this procedure and 22 replied. Mean interval since operation was 20 months (range 3-36). The main indications for surgery had been irretractable foreskin in 9, recurrent balanoposthitis in 10 and ballooning on voiding in 3 and the operation had dealt successfully with these in 7, 7, and 3, respectively. In all but one case the parents were satisfied with the cosmetic result. However, in 8 cases (36%) the parents said they would have preferred circumcision and 3 of the boys had been listed for further surgery. Preputioplasty is a satisfactory alternative to circumcision in selected cases.

A right-sided renal carcinoma uniquely presenting as a mass in the spermatic cord.

Renal cell carcinoma presenting as a mass in the left testis or spermatic cord has previously been described with retrograde venous spread along the gonadal artery as the suggested mechanism. However a right-sided presenting lesion has not been described and suggests an alternative method of spread.

Gastrostomy tubes in patients with recurrent gynaecological cancer and intestinal obstruction.

OBJECTIVE: Women with recurrent gynaecological cancers who are not suitable for exenterative surgery commonly present with gastrointestinal dysfunction. This paper is a retrospective review of the use of gastrostomy tubes in such women. METHODS: We performed a chart review of women with recurrent gynaecological cancer who had a gastrostomy tube placed between January 1991 and April 1998. RESULTS: Thirty-nine women (mean age 53.2 years, range 17-82) had a gastrostomy tube placed. Twenty-eight (72%) had ovarian cancer, eight (21%) had cervical cancer, two had endometrial cancer and one had vaginal cancer. In 14 women a gastrostomy tube was placed as the sole procedure for palliation (11 elective, 3 emergency). In the remaining 25 women, who underwent major surgery, a gastrostomy tube was placed in anticipation of, or in the presence of, significant intestinal distension and expected prolonged post-operative ileus. Eleven women (28%) died without leaving hospital after their operation (median 11 days, range 2-36). All but one of the 28 women who left hospital had satisfactory oral intake. Twenty-one women (54%) died with the gastrostomy tube in place (median 28 days, range 2-157) and 18 (46%) had the gastrostomy tube removed (median 14.5 days, range 9-180), 13 of whom (33%) have since died (median 167 days, range 77 days-7 years). Five women (13%) are alive (median 2.2 years, range 10 months-4.5 years). There were no problems which required the gastrostomy tube to be removed. CONCLUSION: Gastrostomy tubes have an important role in the treatment of women with recurrent gynaecological cancer, allowing gastric drainage and decompression without the disadvantages of nasogastric tubes.

Role of atrial natriuretic peptide in nocturnal polyuria in elderly males.

OBJECTIVES: To demonstrate nocturnal polyuria objectively and to assess the role of atrial natriuretic peptide (ANP) in healthy elderly males with and without nocturnal polyuria (NP). PATIENTS AND METHODS: 31 healthy elderly men known to have NP (passing more than 33% of their 24-hour urine output during an 8-hour period overnight) and 12 controls without NP were invited to take part in the study. Blood and urine samples were collected at 4-hourly intervals in order to measure urine output, serum and urine electrolytes and osmolality as well as serum cortisol, renin, aldosterone, arginine vasopressin (AVP) and ANP. RESULTS: 26 men with NP and 8 controls agreed to take part in the study. Subjects with NP were found to have a diuresis and natriuresis as well as a significant increase in ANP overnight compared to the control group. There was no difference in the other parameters between the 3 groups, with the exception of aldosterone and AVP. CONCLUSIONS: This study has shown a group of subjects with increased natriuresis and diuresis overnight, associated with an increase in ANP. It is possible that subclinical cardiac failure causes an increase in ANP therefore causing nocturnal urinary symptoms and this theory needs further exploration.

Desmopressin in the treatment of nocturnal polyuria in the male.

OBJECTIVES: To assess whether desmopressin (1-desamino 8-d-arginine vasopressin) is safe and effective in the treatment of nocturnal polyuria in elderly men. PATIENTS AND METHODS: Twenty men (age 52-80 years) complaining of nocturia were found to have nocturnal polyuria, determined from frequency-volume charts and defined as the production of >33% of the 24 h urine volume overnight, averaged over a 1-week period. In a double-blind study of cross-over design, a 1-week placebo run-in period was followed by two 2-week periods of placebo or 20 microg intranasal desmopressin, and ended with an open 2-week treatment period with 40 microg desmopressin. RESULTS: Desmopressin caused a significant reduction in nocturnal urine volume and the percentage of urine passed at night, but the reduction in nocturnal frequency was only significant during treatment with 40 microg desmopressin. Four patients on desmopressin experienced side-effects, three of which were thought to be due to fluid retention. CONCLUSION: Desmopressin is an effective treatment for nocturnal polyuria in some elderly men. However, it can cause fluid retention and should not be given to patients with cardiac failure. Those undergoing treatment must be closely monitored.

Emergency obstetric hysterectomy - an increasing incidence.

Ten women underwent obstetric hysterectomy at St George's Hospital, London between 1992 and 1998, with an apparent seven-fold increase in incidence in recent years. All hysterectomies were performed as emergency procedures, with massive postpartum haemorrhage being the major indication for operation in nine cases. Abnormal placentation was the single commonest cause, seven cases being associated with previous caesarean section. There were no maternal or fetal mortalities, but major surgical complications, including urinary tract and vascular injury occurred in one case. In view of the increasing risk of obstetric hysterectomy following previous caesarean section, high risk cases associated with abnormal placentation may be identified using ultrasound, allowing appropriate pre-operative counselling regarding the risk of peripartum hysterectomy.

The prognostic significance of beta human chorionic gonadotrophin and its metabolites in women with cervical carcinoma.

AIMS: To examine long term survival of women with primary and recurrent cervical carcinoma in relation to (1) excretion of beta-core (a urinary metabolite of beta human chorionic gonadotrophin (beta hCG)) and (2) beta hCG immunostaining of the tumours, to determine the suitability of these markers for assessing prognosis. METHODS: This was a prospective observational study undertaken in a gynaecological oncology centre: 57 women with primary cervical cancer and 42 with recurrent disease were recruited between January 1990 and September 1992. Kaplan-Meier survival analysis with the log rank test was used to assess survival differences with survival rate given per year of follow up. RESULTS: In primary disease, the four year survival for the beta-core negative group was 79%, compared with 14% for the beta-core positive group (p = 0.001). This was still significant for early stage disease or squamous lesions alone. In recurrent disease, beta-core positivity was not prognostically significant. Immunohistochemistry was of no prognostic significance in either group. CONCLUSIONS: beta-core excretion appears to be useful in assessing prognosis of primary cervical cancer but not of recurrent disease. A large prospective study of urinary beta-core in early stage cervical cancer is needed to determine whether it can be used as an index for modifying treatment.

An open, in-patient incremental safety and efficacy study of desmopressin in women with multiple sclerosis and nocturia.

OBJECTIVES: To examine the safety and efficacy of desmopressin in three doses given to women with multiple sclerosis to treat nocturia with or without enuresis. PATIENTS AND METHODS: Eight women with clinically confirmed multiple sclerosis and nocturia with or without enuresis were entered as in-patients into an open, nonrandomized, placebo-controlled study of incremental doses of 20, 40 and 60 micrograms desmopressin. Urinary and serum sodium, plasma arginine vasopressin and urine osmolality were monitored every 4 h for 24 h. A single dose of placebo or desmopressin was given during each of four 24-h periods. RESULTS: There was a significant decrease in nocturnal urinary volumes and a significant increase in nocturnal urinary osmolalities in patients taking desmopressin when compared with those taking a placebo, but there was no difference among the desmopressin doses. There was no significant difference in serum sodium level between the desmopressin doses. However, at the end of the 24-h period with the 60 micrograms dose, serum sodium was decreased significantly. CONCLUSIONS: Neither a significant decrease in nocturnal urinary volumes nor an increase in urinary osmolality was achieved by doses of desmopressin > 20 micrograms. A dose of 60 g was associated with a decreased serum sodium level at the end of the 24-h period but there was no biochemical hyponatraemia. Because there were no benefits and a possibility of clinical hyponatraemia with higher doses, doses of > 20 micrograms desmopressin cannot be recommended.

Measurement of urinary beta core fragment of human chorionic gonadotrophin in women with vulvovaginal malignancy and its prognostic significance.

Tumours of the vulva and vagina are rare and there are relatively few studies of circulating markers in these conditions. The urinary measurement of the core fragment of the beta-subunit of hCG has been proposed as a useful tumour marker in non-trophoblastic gynaecological malignancies. This study describe the measurement of urinary beta-core in 50 patients with vulvovaginal malignancy. In contrast to other studies corrections were made for both the effect of urine concentration and the age of the patient. Each patient was followed up for at least 24 months, and at this time their status was correlated with their initial level of urinary beta-core. The sensitivity of beta-core was only 38%, but of those patients with elevated levels 90% had died within 24 months, while only 32% of those with normal levels had died. For both patients at initial presentation and those with recurrent disease, there was a highly significant difference in the survival curve between those with elevated beta-core levels and those with normal levels. This is similar to findings in cervical carcinoma, and suggests that for lower genital tract cancer the measurement of urinary beta-core may be valuable as a prognostic indicator, allowing a more informed approach to treatment and follow-up.

Laparoscopic nephrectomy results in better postoperative pulmonary function.

The pulmonary response to nephrectomy was studied in 16 patients undergoing laparoscopic (n = 8) or open (n = 8) nephrectomy using a standardized anesthetic technique. Although there was no significant difference between the two groups at 24 hours, postoperative pulmonary function measures (P = 0.02-0.03) and oxygenation (P = 0.03) were significantly better in the laparoscopic surgery group at 48 hours. The median opiate analgesic requirement (P = 0.02) and the number of nights spent in the hospital (P = 0.003) also were significantly lower in this group. The results of this study suggest that laparoscopic nephrectomy offers a real biological advantage in terms of postoperative preservation of lung function and that this might therefore be the safest technique for nephrectomy in patients with limited respiratory reserves.

Serum placental-type alkaline phosphatase activity in women with squamous and glandular malignancies of the reproductive tract.

AIM: To investigate serum placental-type alkaline phosphatase (PLAP-type) activities in women with squamous and glandular malignancies of the reproductive tract using an immunoradiometric assay. METHODS: PLAP-type immunoreactivity was measured in 180 women with non-ovarian malignancies of the reproductive tract and the values were compared with those from 334 controls. The cases comprised 18 vulval, nine vaginal, 103 cervical, 46 endometrial, and five fallopian tube cancers. RESULTS: Serum PLAP-type activities were no different from controls in patients with squamous cell tumours. Women with adenocarcinoma of the cervix, endometrium, and fallopian tube had increased values: women with endometrial cancer had a median value nearly four times greater than that of controls. There was no direct correlation between PLAP-type activities and stage of disease in patients with endometrial cancer, but values reverted to normal after treatment. CONCLUSIONS: Serum PLAP-type measurements are of no value in the management of patients with squamous cell tumours of the female reproductive tract. Raised activities can, however, be found in glandular tumours, in particular endometrial cancer where serum PLAP-type measurements may be of value in predicting remission.

The prognostic significance of urinary beta core fragment in premenopausal women with carcinoma of the cervix.

The mortality of premenopausal women with cervical carcinoma has increased in recent decades despite attempts to provide screening. The urinary concentration of the beta core fragment of hCG has been proposed as a sensitive marker in gynecological malignancies, although most studies have not corrected for urine concentration. We measured the urinary concentration of beta core and creatinine in 61 women who developed cervical cancer premenopausally and expressed the concentration of beta core per millimole of creatinine using the 90th percentile of a control group as a cutoff level. While correcting for urinary concentration results in a reduction in sensitivity of the test (67 to 51%), there is improved correlation with prognosis in that after 18 months 81% of women positive for beta core had died, while 80% of women negative for beta core were still alive. Of those initially presenting and dying there was an increase with increasing stage of disease. For patients with initial presentation disease, 11 (79%) of the 14 patients with elevated levels had died compared with 1 of 21 (5%) who were negative for beta core. Urinary beta core fragment may have a major role as a prognostic indicator in cervical carcinoma rather than as a screening or diagnostic marker and enables identification of patients at higher risk of an aggressive disease.

The measurement of urinary beta core fragment in conjunction with serum CA125 does not aid the differentiation of malignant from benign pelvic masses.

The urinary concentration of the renal metabolite of the beta subunit of human chorionic gonadotropin (beta core) has been proposed as a tumor marker in certain nontrophoblastic malignancies including those of the female genital tract. A previous study investigated the use of urinary beta core in conjunction with serum CA125 in distinguishing malignant from benign pelvic masses and showed that the combined test improved the overall sensitivity to 88%; this was greater than that for either test alone. However, the cutoff levels used to distinguish normal from abnormal were approximately six times greater than those generally used for CA125 and four to five times lower than those used for beta core in our laboratory. Furthermore there was no recognition of the possible difference in normal levels of beta core between pre- and postmenopausal women. We have examined a similar group of cases using our cutoff levels for urinary beta core of 0.36 ng/ml in premenopausal women and 0.48 ng/ml in postmenopausal women and 35 u/ml for CA125. We show that measurement of CA125 is substantially more sensitive that that of beta core and that the combination of beta core with CA125 does not improve the overall sensitivity of the test. However, there was a small improvement in positive predictive value if both tests were positive (97.5%) and of specificity when one or the other test was negative (98.5%).