Early and late morbidity after vasectomy: a comparison of chronic scrotal pain at 1 and 10 years.

OBJECTIVE: To evaluate the incidence and timing of the onset of chronic scrotal pain after vasectomy in two populations at 1 and 10 years after surgery. PATIENTS AND METHODS: In a retrospective questionnaire-based study two groups of men were compared; 460 who had a vasectomy in 1991-92 (group A) and another 460 who had a vasectomy in 2000-1 (group B; 10 and 1 year after surgery, respectively). Data were collected on immediate complications, and the incidence and nature of chronic scrotal pain. Pain severity was graded using a visual analogue score (VAS). Patients were also asked if they regretted having a vasectomy because of pain. RESULTS: In all, 182 and 220 replies were received from patients in group A and B, respectively. Early complications included haematoma in five (2%) and two (0.9%) patients, respectively, and wound infection in 24 (13%) and 17 (7.7%). Eight patients who had scrotal pain even before vasectomy were excluded from the analysis (two in group A and six in group B). In group A, 25 of 180 (13.8%) had a new onset of scrotal pain of some nature, with eight (4.3%) having a VAS of > 5; one patient had an epididymectomy for this. Three of the 25 regretted having a vasectomy because of pain. In group B, 36 of 214 (16.8%) reported persistent scrotal pain, with 13 (5.9%) having a VAS of > 5. Six of the 36 regretted having a vasectomy because of the pain. The incidence of scrotal pain was not significantly different between the groups (P = 0.48, Fisher's exact test). CONCLUSION: Chronic scrotal pain after vasectomy is more common than previously described, affecting almost one in seven patients. All patients undergoing vasectomy must receive appropriate preoperative counselling about this. The incidence of this complication does not appear to increase with time.

Management of acute urinary retention secondary to benign prostatic hyperplasia in the UK: a national survey.

OBJECTIVE: To analyse current practice in the management of acute urinary retention (AUR) secondary to benign prostatic hyperplasia (BPH) in the UK, and to assess how much of this is evidence-based. METHODS: In all, 410 consultant urologists practising in UK hospitals were sent a questionnaire about the management of AUR secondary to BPH. Data were collected on practice relating to initial management, trial without catheter (TWOC), the use of alpha-blockers and the follow-up. The need for a uniform guideline in the management of AUR secondary to BPH was also assessed. RESULTS: We received 270 (66%) replies, of which six were excluded because they were from subspeciality interests (e.g. paediatric urology) or had ambiguous answers; 264 (64%) were therefore available for analysis. Urethral catheterization was the initial management of choice (98%), failing which a suprapubic catheter was inserted. Two-thirds (65.5%) admitted the patient after catheterization. Most consultants initiated alpha-blockers (70.5%), with 64% (118) of these using a TWOC 2 days after starting them. One failed TWOC was an indication for transurethral resection of the prostate for 192 (72.8%), with 136 (49.8%) re-admitting the patient for surgery later. Routine follow-up after a successful TWOC was advocated by 77.3%. Just over half the respondents (52.6%) felt that there was no need for uniform guidelines in the management of AUR secondary to BPH. CONCLUSION: This survey identified a reasonable national uniformity in managing AUR secondary to BPH in the UK, but significant aspects of current practice are not evidence-based.

Partner's influence on patient preference for treatment in early prostate cancer.

OBJECTIVE: To determine the partner's influence on the patient's choice of treatment for early prostate cancer, and whether partner characteristics and biases predict the preference. PATIENTS, SUBJECTS AND METHODS: Questionnaires for partners to complete retrospectively were sent to consecutive patients recruited in a study comparing treatment options for early prostate cancer. The partners' perceptions about prostate cancer were explored and the partners asked to comment on the suitability of each treatment option. Partners recorded their influence on the patient's choice using a 10-point visual linear analogue scale. RESULTS: Questionnaires were sent to 116 eligible patients and 82 were returned for analysis (mean partner age 63 years). When asked to recall the treatment options initially discussed, all partners recalled radiotherapy (EBRT), all but one radical prostatectomy (RP), 51% brachytherapy, but only 29% watchful waiting (WW); 41% of partners stated RP as their chosen option, 37% EBRT, 12% brachytherapy and 10% no clear favourite. None preferred WW. Employment and education status were not significant predictors of partners' preference but retired partners and those aged > 65 years were 3 times more likely to prefer EBRT than were their employed and younger counterparts, respectively. The partners' mean (median, SD) self-assessed influence factor was 4.8 (5, 3.4). Of the partners, 88% reported active involvement throughout the process, identifying information-gathering and emotional support as their primary roles. Most deliberately chose not to influence the patient's final decision. CONCLUSION: Partner preference is influenced by pre-existing conceptions about cancer and its treatment. While undoubtedly influential throughout the decision-making process, partners deliberately left the final decision to the patient.

Ureteric obstruction caused by aneurysm of the hypogastric artery.

We present the case of a 70-year-old man with haematuria who was found to have an internal iliac artery aneurysm causing ureteric obstruction. Urgent repair of the iliac artery aneurysm was performed but no urological intervention was necessary.

Periprostatic nerve block gives better analgesia for prostatic biopsy.

OBJECTIVE: To prospectively compare two local anaesthetic techniques for prostatic biopsies, which are usually taken with no anaesthesia; because multiple biopsy techniques are becoming more common and there is an increasing need for analgesia/anaesthesia during the procedure. PATIENTS AND METHODS: The study group comprised 86 consecutive men (median age 67.7 years) undergoing prostatic biopsy because of either an abnormality of prostate specific antigen level or digital rectal examination. They were randomized into four groups; men in group 1 received 10 mL of 1% lignocaine infiltrated into the periprostatic nerve plexus bilaterally; men in group 2 received 11 mL of 2% lignocaine gel rectally; men in groups 3 and 4 were recruited as controls, and given either plain gel rectally or an injection with saline into the periprostatic nerve plexus. Sextant prostate biopsies were taken in all cases using a standardized protocol. Immediately after the procedure patients were asked to indicate the degree of pain on a 10-cm visual analogue scale. RESULTS: Men in group 1 had significantly less pain than the others (P < 0.001). There was no statistically significant difference in pain between men who received plain gel rectally or saline injection (P = 0.35). The rectal instillation of 2% lignocaine gel did not reduce pain significantly (P = 0.186) compared with the controls. CONCLUSION: A periprostatic nerve block with 1% lignocaine was associated with significantly less pain during prostatic biopsy than was rectal lignocaine gel or placebo.

Extracorporeal shock wave therapy in the management of Peyronie's disease: initial experience.

OBJECTIVE: To evaluate prospectively the efficacy of extracorporeal shock wave therapy (ESWT) as a conservative treatment for Peyronie's disease. PATIENTS AND METHODS: After obtaining ethical committee approval, 37 patients with Peyronie's disease were treated using ESWT. Before treatment the degree of angulation was assessed by artificially inducing an erection with a vacuum device. The severity of pain on erection was assessed using a visual analogue scale (0-5). Each patient was treated with a minimum of three sessions of ESWT (3000 shock waves at an energy density of 0.11-0.17 mJ/mm2) at 3-week intervals. The results were analysed using the Wilcoxon signed-rank test. RESULTS: Of the 37 patients, 34 completed the protocol; the mean (range) duration of the disease was 19.43 (4-60) months and the mean follow-up 7.5 (5-11) months. Almost half (47%) of the patients reported an improvement in angulation, with a mean reduction of 29.3 degrees (10 degrees -60 degrees ) (P < 0.001); 12 of the 20 (60%) patients with pain on erection reported immediate relief, the mean reduction being 2.3 (1-4) on the visual analogue scale (P < 0.001). There was only minimal bruising at the site of treatment and no major side-effects were reported. CONCLUSION: ESWT is an effective and safe treatment for Peyronie's disease; the long-term follow-up and results are awaited.

Prostatic manipulation has a minimal effect on complexed prostate-specific antigen levels.

OBJECTIVE: To assess the effect of prostatic manipulation on complexed prostate-specific antigen (cPSA), as various forms of prostatic manipulation are known to increase the serum free and total PSA level. PATIENTS AND METHODS: A series of 92 men (58 after prostatic biopsy, 16 after digital rectal examination and 18 after flexible cystoscopy) were assessed. Blood samples were taken from each patient before and 30 min after manipulation. Total and cPSA levels were measured using appropriate assays, respectively. RESULTS: There was no significant increase in cPSA levels after flexible cystoscopy and digital rectal examination, but prostate biopsy caused a statistically significant although minimal rise in cPSA level. There was no statistically significant increase in cPSA level after prostate biopsy in patients with prostate cancer (P = 0. 35) although there was a statistically significant but minimal rise in cPSA level in patients with benign histology (P < 0.01, mean increase 2.13 ng/mL) compared with that of total PSA, which increased markedly (P < 0.01, mean increase 19.79 ng/mL). CONCLUSION: Prostatic manipulation has minimal effects on cPSA levels.

A prospective evaluation of scrotal ultrasonography in clinical practice.

OBJECTIVES: To prospectively evaluate scrotal ultrasonography (SUS) in patients presenting with scrotal symptoms and to make recommendations about use of SUS in clinical practice. PATIENTS AND METHODS: Forty-eight men with scrotal symptoms were examined by a urologist and independently underwent SUS by one radiologist with no knowledge of the clinical diagnosis. The clinical and SUS diagnoses were compared and the effect on subsequent management recorded. RESULTS: The clinical and SUS diagnoses agreed in 35 men (73%) although SUS provided an additional diagnosis in half of these men. The SUS diagnosis differed in 13 men (27%) although the management was altered in only four patients. CONCLUSION: The clinical diagnosis is correct in most men with scrotal symptoms; the routine use of SUS is inappropriate and should be reserved for specific indications.

The short-term prostate-specific antigen velocity before biopsy can be used to predict prostatic histology.

OBJECTIVES: To evaluate whether the short-term prostate-specific antigen (PSA) velocity before biopsy can be used to predict prostatic histology, and to assess the role of a second PSA measurement before prostate biopsy. PATIENTS AND METHODS: The study comprised 197 patients who were referred for transrectal ultrasonography (TRUS) and prostate biopsy. The PSA level was initially measured at the first outpatient assessment; patients with a serum PSA level of < 4 ng/mL and > 50 ng/mL were excluded. Blood samples were taken just before prostate biopsy for the second PSA measurement. The mean interval between the measurements was 2.2 months. The short-term PSA velocity was calculated and correlations between this variable and age, prostate volume and initial PSA levels determined. RESULTS: There was a statistically significant difference between the short-term PSA velocity of patients with benign prostate histology and those with prostate cancer (P < 0.05). The short-term PSA velocity alone had the same diagnostic accuracy as the serum PSA level (area under the receiver-operating characteristic curve 0.612). There was only a weak correlation between the short-term PSA velocity and prostate volume. However, there was no correlation with age and initial PSA level in patients with benign histology. The second PSA measurement had higher specificity without losing sensitivity. CONCLUSION: The short-term PSA velocity estimated before biopsy can be used to predict prostatic histology. By measuring serum PSA 2 months after the first in patients with serum PSA level of 4-10 ng/mL, the number of negative biopsies can be reduced by 17%.

Outpatient flexible cystoscope-assisted insertion of ureteric catheters and ureteric stents.

OBJECTIVE: To examine the feasibility of inserting ureteric catheters (before retrograde ureterography) and JJ ureteric stents (both traditionally performed under general anaesthesia on inpatients) using local anaesthesia in an outpatient setting and with no patient selection bias, thus providing procedures to ease the demand on inpatient lists. PATIENTS AND METHODS: All patients presenting with an appropriate clinical indication for either of the procedures underwent insertion during a scheduled flexible cystoscopy session in the outpatient department; information was collected on a standard proforma. Antibiotic prophylaxis and a nonsteroidal analgesic were administered 30 min before the procedure. RESULTS: To date, 20 patients (seven men, age range 32-74 years, and 13 women, age range 23-86 years) have undergone one of the two procedures. Fourteen patients had attempted retrograde catheter insertion, with success in 12, and six other patients underwent attempted JJ ureteric stent insertion, with success in five. The three failures were caused by an inability to see the relevant ureteric orifice. The mean duration of each procedure was 11 min; 14 of the 17 patients who had a successful procedure had no significant pain or discomfort, while the remaining three experienced significant pain and discomfort. There were no infective complications. CONCLUSION: These two procedures are suitable for the outpatient/day-case situation, and are well tolerated and accepted by most patients.

Free prostate-specific antigen 'in the field': a useful adjunct to standard clinical practice.

OBJECTIVES: To determine the clinical utility of the ratio of free to total prostate-specific antigen (f/tPSA), which may improve the discrimination of PSA testing in the assessment of patients with prostatic disease, in a busy clinical practice. PATIENTS AND METHODS: A series of 198 men undergoing transrectal ultrasonography (TRUS)-guided biopsy, because of a high total PSA level or an abnormal digital rectal examination or both, had blood samples taken for the assessment of both free and total PSA before any form of prostatic manipulation. The histological findings were compared with tPSA, fPSA and f/tPSA, evaluating three different thresholds of f/tPSA. RESULTS: PSA levels, PSA density and fPSA density differed significantly between those with benign histology and neoplasia. The f/tPSA only differed significantly in men with a PSA level of 10. 1-15 ng/mL. The f/tPSA threshold of 0.25 was the most useful clinically, with a negative predictive value for prostate cancer of 91%. Using this threshold would reduce the negative biopsy rate by 30%. CONCLUSION: The f/tPSA is of clinical value in reducing the negative biopsy rate and in the management of patients with a high PSA level and previous negative biopsies.

The effect of digital rectal examination, flexible cystoscopy and prostatic biopsy on free and total prostate specific antigen, and the free-to-total prostate specific antigen ratio in clinical practice.

PURPOSE: We evaluated the effects of common urological maneuvers on serum free prostate specific antigen (PSA) and established guidelines for clinical practice. MATERIALS AND METHODS: Total and free PSA, and free-to-total PSA ratio were determined in 82 men with lower urinary tract symptoms before and 30 minutes after 3 different prostatic manipulations: 1) digital rectal examination (36 cases), 2) flexible cystoscopy (26) and 3) transrectal ultrasound guided prostatic biopsy (20). PSA forms were measured with Hybritech Tandem-R assays. RESULTS: Cystoscopy had no effect on total PSA, while digital rectal examination had a slight, statistically significantly positive effect and biopsy uniformly increased total PSA (geometric mean ratio 2.43, t = 5.08, p <0.001). Free PSA was increased by digital rectal examination (geometric mean ratio 1.67, t = 4.25, p <0.001), prostatic biopsy (geometric mean ratio 4.80, t = 7.48, p <0.001) and cystoscopy (geometric mean ratio 1.21, t = 2.51, p = 0.019). There was a significant increase in free-to-total PSA ratio after each maneuver. The rate of change in free PSA and free-to-total PSA ratio after biopsy differed between patients with benign and malignant histological findings. CONCLUSIONS: Free PSA and free-to-total PSA ratios are altered by all forms of prostatic manipulation. The PSA response to manipulation may be different in patients with prostatic malignancy. Phlebotomy must precede digital rectal examination in the clinical and research setting to avoid misleading results.

Correlation between prostate size estimated by digital rectal examination and measured by transrectal ultrasound.

OBJECTIVES: To correlate prostate size estimates performed by single or multiple examiners through digital rectal examination (DRE) with volume measured by transrectal ultrasound (TRUS) and to propose measures for predicting prostate volume using DRE estimates in clinical settings. METHODS: Data from four sources were analyzed: (1) the Olmsted County community study of 397 patients examined by a single urology nurse, with TRUS measurements done by multiple examiners; (2) a community study in Stirling, Scotland, involving 480 patients with DRE and TRUS performed by one urologist; (3) baseline data from the Veterans Affairs Cooperative Study No. 359 in 1222 patients with DRE and TRUS measurements by multiple personnel at 31 centers; and (4) a clinical series of 100 men with DRE and TRUS by a single urologist. RESULTS: DRE estimates and TRUS volumes were significantly correlated (r = 0.4 to 0.9), but prostate size was underestimated by 25% to 55% for men with a prostate volume over 40 mL, depending on the study, with greater variability for studies involving multiple examiners. In one study that assessed prostate dimensions by DRE, posterior surface area (SA) correlated with overall TRUS volume (r = 0.4). According to receiver operating characteristic curves, SA showed a 70% and 76% chance of correctly identifying men with prostate volume greater than 30 or 40 mL, respectively; those with larger prostates were best distinguished by SA greater than 7 cm2 (sensitivity greater than 0.74, specificity greater than 0.50). CONCLUSIONS: DRE underestimates prostate size, particularly if TRUS volume is greater than 30 mL. However, DRE estimates may help identify prostates likely to be larger than certain cutpoints by TRUS. Posterior SA may be useful as a preliminary assessment when prostate size is an important predictor of therapeutic response.

Open versus closed epididymal sperm retrieval in men with secondarily obstructed vasal systems--a preliminary report.

OBJECTIVE: To evaluate and compare sperm quality and suitability for intracytoplasmic sperm injection (ICSI) from open and percutaneous epididymal aspiration in men with obstructive azoospermia, and to determine the relevance of epididymal morphology. PATIENTS AND METHODS: A series of 20 men undergoing vasectomy reversal were evaluated by percutaneous (PESA) and open epididymal sperm aspiration (MESA) before undergoing surgery for reversal. Two samples were taken with PESA, one with the needle in situ (PESA1) and the second while withdrawing the needle (PESA2). Epididymal morphology was graded as normal, distended and grossly distended. Five men undergoing vasectomy served as a control, nonobstructed group for percutaneous aspiration. Analysis of the aspirates was performed immediately after operation with no knowledge of the treatment, and aspiration was considered successful if sperm suitable for ICSI were retrieved. RESULTS: In the obstructed group, 15 of 20 men had successful PESA and 13 of these also had successful MESA. PESA was successful bilaterally eight times compared with MESA on five occasions; two men with successful PESA had no success with MESA. PESA2 was five times more successful than PESA1. Only one PESA in the non-obstructed group was suitable for ICSI. PESA was successful in 21 of 25 distended or grossly distended epididymi compared with only three of 21 non-distended systems. CONCLUSION: PESA is a viable alternative to MESA in patients with obstructive azoospermia, particularly when associated with clinically distended epididymi.

Reproducibility and observer variability of transrectal ultrasound measurements of prostatic volume.

Transrectal ultrasound (TRUS) is an established investigation in benign and malignant prostatic disease though the level of reproducibility of TRUS volume measurements is not known. A group of observers in the UK and the USA who were participating in linked prospective studies of benign prostatic hyperplasia each carried out measurements during real-time scanning and on a series of static TRUS images. Results demonstrated good reproducibility for measurements of antero-posterior, transverse, and longitudinal dimensions of the prostate by an experienced UK urologist; only a minor degree of interobserver variation occurred in measurements made between experienced UK and USA observers. Using static images, USA observers obtained results that were in good agreement, whereas the UK observers, only two of whom used TRUS regularly, were in poor agreement with each other. This study demonstrates a high level of reproducibility for TRUS volume measurements performed by experienced observers.