Innominate Salter osteotomy using resorbable screws: a retrospective case series and presentation of a new concept for fixation.

PURPOSE: The Salter innominate osteotomy (SIO) in children is traditionally stabilized by Kirschner-wires, which have issues regarding stability, infection and the need to be extracted. To counter these disadvantages, we present a surgical method to stabilize SIO with modern resorbable poly lactic-co-glycolic acid screws. Using a case series of 21 patients treated with SIO for developmental dysplasia of the hip or Legg-Calvé-Perthes disease we evaluate the feasibility of the method. METHODS: The integrity of the osteotomy was interpreted by radiological measurements of acetabular index, centre-edge angle and Reimer's index. Perioperative and postoperative complications were evaluated. RESULTS: Radiographic evaluation revealed a stable osteotomy and favourable development in all measured parameters with the exception of one patient who fell out of bed the first day postoperatively. No other perioperative surgical complications were observed and there were no local reactions to the resorbable screws. CONCLUSION: Modern resorbable screws carry multiple benefits both for the patient and the surgeon. In our case series the implants provided sufficient stability and the implants caused no local reactions. The use of resorbable implants gave the surgeon a wider range of possible screw placements and avoided the need for implant removal. LEVEL OF EVIDENCE: Level IV - Case series.

Cardiovascular outcomes among sildenafil users: results of the International Men's Health Study.

AIM: To assess the incidence of serious cardiovascular disease (CVD) events [i.e. myocardial infarction (MI) and stroke] and all-cause mortality in men with erectile dysfunction (ED) who received prescriptions for sildenafil. METHODS: The International Men's Health Study (IMHS) was a prospective, observational cohort study of patients with ED and a new or existing prescription for sildenafil. Baseline and follow-up questionnaires provided information on demographics, CVD risk factors and ED. Postevent questionnaires were mailed to patients following possible nonfatal CVD events to collect information related to exposure to sildenafil/ED treatments before the event. RESULTS: Thirty-five CVD events were reported in 30 patients in the analysis set (n = 3813). The incidence of all-cause mortality, MI and stroke was 0.4, 0.6 and 0.1 per 100 patient-years of observation respectively. Among the six men who reported using sildenafil in the month before a nonfatal CVD event, two reported use in the 24 h before the event. CONCLUSION: The results of the IMHS support previous reports that ED and CVD are often comorbid and share risk factors.

Urine tissue-polypeptide-specific antigen (TPS) as a marker for bladder cancer.

OBJECTIVES: To determine the sensitivity and specificity of urine tissue-polypeptide-specific antigen (TPS) for bladder carcinomas and to evaluate whether urine TPS is influenced by tumour size, number, grade and stage. PATIENTS AND METHODS: A total of 260 patients entered the study, one group (n = 151) with known bladder cancer disease (79 with recurrent tumour and 72 with no tumour at cystoscopy). The other group (n = 109) consisted of patients without previously known bladder tumour disease, 55 with newly detected bladder tumour(s) and 54 investigated for microhematuria found to be idiopathic. TPS in urine was measured using an ELISA-kit, a solid phase two-site immunosorbent assay with polyclonal antibodies against cytokeratin 18. RESULTS: Urine TPS was significantly higher in patients with bladder tumours (p < 0.001). There was a significant correlation between TPS and tumour size (p = 0.004), grade (p = 0.001) and stage (p = 0.001). Tumour number was not significantly correlated to urine TPS (p = 0.75). With TPS 42 as a cut-off level, the sensitivity was 73% for newly detected tumours and 50% for recurrences; the specificity was 70% and 63% respectively. With a 95% specificity, the sensitivity for newly detected tumours was 33% and for recurrences 18%. The lower sensitivity and specificity for recurrences was mainly explained by differences in tumour size, grade and stage between the recurrences and the newly detected tumours. CONCLUSIONS: Urine TPS is a marker for bladder carcinoma correlated to size, grade and stage. The sensitivity and specificity for newly detected tumours are quite comparable with other markers. Its clinical usefulness is however not established and it appears less useful in the follow-up of patients with known bladder tumour disease.

[Both major breakthroughs and stagnation in urology. Industry, together with clinicians, are responsible for most innovations]. / Både stora genombrott och stagnation inom urologin. Industrin, tillsammans med kliniker, står för de flesta innovationerna.

Urology is a specialty with many branches, including urological oncology with 25% of all cancers. Development in certain areas been very rapid, for instance with the introduction of minimally and non-invasive methods such as ESWL and phosphodiesterase inhibitors, innovations which have brought obvious improvements and have been promptly adopted in clinical practice. In other areas such as chronic abacterial prostatitis and renal cancer, progress has been very limited. Still other areas have seen useful but less spectacular improvements for which it has taken time, clinical experience and a multitude of clinical studies before they have been embraced in daily clinical practice. Examples of these more gradual developments are hyperthermia for the treatment of benign prostatic hyperplasia and transrectal ultrasound in prostate cancer.

The importance of glucose for the Escherichia coli mediated citrate depletion in synthetic and human urine.

OBJECTIVE: Escherichia coli has previously been shown to reduce urine citrate and influence urine pH. In this study the influence of glucose on the E. coli mediated citrate decrease has been investigated. MATERIAL AND METHODS: In synthetic urine, a glucose concentration of > or = 1 mmol/l was a prerequisite for bacteria to grow and lower citrate. At glucose concentrations > or = 5 mmol/l an E. coli mediated pH decrease correlated to urine glucose was observed. RESULTS: In human urine, variations in urine glucose influenced the citrate decrease and addition of glucose accelerated the E. coli mediated citrate decrease, which in certain urines could be very pronounced. CONCLUSIONS: Citrate has a pronounced effect on the activity product of calcium oxalate and calcium phosphate and the E. coli mediated decrease in urine citrate may be involved in the formation of urinary tract stones and catheter encrustations.

Stage progression in Ta papillary urothelial tumors: relationship to grade, immunohistochemical expression of tumor markers, mitotic frequency and DNA ploidy.

PURPOSE: We studied 363 patients with stage Ta bladder tumors during long-term followup who were classified according to the 1998 WHO and International Society of Urological Pathology consensus classifications. We determine whether various immunohistochemical and molecular markers could predict tumor progression. MATERIALS AND METHODS: A total of 680 patients in western Sweden with a first diagnosis of bladder carcinoma in 1987 and 1988 were registered and followed for at least 5 years. There were 363 (53%) tumors that were papillary stage pTa. The tumors were classified as papillary urothelial neoplasm of low malignant potential in 95 patients, low grade papillary urothelial carcinoma in 160 and high grade carcinoma in 108. Of the patients in the latter group 95 were subdivided into WHO grade 2 and 13 into WHO grade 3. Tissue from the primary tumors that progressed in stage during followup was further analyzed with immunohistochemical methods (p21, p53, Ki67 and pRb), DNA ploidy and mitotic frequency. The results were compared with those in matched controls (nonprogressors). RESULTS: Recurrence developed in 35% of patients with papillary urothelial neoplasm of low malignant potential compared to 71% with low grade urothelial carcinoma and 73% with high grade carcinoma (p <0.0001). No papillary urothelial neoplasm of low malignant potential progressed in stage. Disease progressed in 4% of patients with low grade compared to 23% with high grade carcinoma (p <0.0001). Of the patients with WHO grade 3 disease progressed in 45% compared to grade 2 in 20% (p <0.0011). At first diagnosis p53 score was significantly higher (p <0.0022) among patients with WHO grade 2 carcinoma which later progressed compared to that in matched controls but there was no significant difference regarding the other markers. In contrast to grade 2 most grade 3 carcinoma was aneuploid, had high mitosis frequency, high p53 and Ki67 scores as well as loss of retinoblastoma gene expression. CONCLUSIONS: The 1988 WHO and International Society of Urological Pathology consensus classifications divide noninvasive papillary bladder tumors into 3 subgroups with different clinical behavior, which seems to be an advantage compared with the 1973 WHO classification. A disadvantage is that the high grade carcinoma group contains 2 subgroups with different progression rates and immunohistochemical marker profiles, corresponding to the 1999 WHO grades 2 and 3. Grade 2 tumors in patients that progressed in stage years later seem to have different immunohistochemical and molecular marker profiles compared to those in matched controls.

The results of routine evaluation of adult patients with haematuria analysed according to referral form information with 2-year follow-up.

OBJECTIVE: With the principal aim of determining how often investigation of haematuria results in a malignancy diagnosis, the referrals (n = 581) during one year to a department of urology (catchment area 250,000 inhabitants) where haematuria was mentioned in the referral form have been registered and analysed. The case records were evaluated after two years. RESULTS: The tumours detected were mainly bladder tumours (n = 43) and prostate cancers (n = 31). Only three upper urinary tract tumours were diagnosed. The incidence of malignancies was high in patients with macroscopic haematuria (24%), especially if it was asymptomatic (32%). The incidence was lower in microscopic haematuria (9%), especially if it was asymptomatic (5%). The incidence of malignancies was strongly age- and sex-related; in no female under 70 years and in no male under 45 years of age with microscopic haematuria was a malignant tumour detected. CONCLUSION: Macroscopic haematuria, especially in older patients, is often associated with a malignancy and the investigation must be given high priority. The incidence of malignant tumours in patients with symptomatic microscopic haematuria also warrants an investigation. In the case of asymptomatic microhaematuria. the risk is so low, especially in women that the need for a work-up must be strongly questioned.

[When is it meaningful to investigate hematuria? Macroscopic hematuria--investigate always. Microscopic hematuria--symptoms and age decide]. / När är det meningsfullt att utreda hematuri? Makroskopisk hematuri--utred alltid mikroskopisk-symtom, ålder avgör.

All patients (n = 578) referred during one year and for whom hematuria was mentioned in the referral form were monitored following urological evaluation including urography and cystoscopy. Evaluation of macroscopic hematuria was often associated with significant findings at both urography (stones) and cystoscopy (bladder tumors). The situation was the same even if not as pronounced for evaluation of microscopic hematuria with concomitant urinary tract symptoms. The evaluation of asymptomatic microscopic hematuria was, however, very rarely associated with significant findings, which were moreover totally lacking among women and younger males.

[Viagra is first choice preparation in the treatment of erectile dysfunction. Access to a variety of methods makes individual treatment possible]. / Viagra förstahandsmedel mot erektil dysfunktion. Tillgång till flera metoder möjliggör individuellt anpassad behandling.

Several pharmacological treatments for erectile dysfunction (ED) have recently been introduced. This study performed during 1999 shows that in Sweden mostly men in their 60's, often with circulatory disease and/or diabetes, where the ones who were treated for ED. The most frequently used drug (80%) is sildenafil (Viagra). The mean consumption is 4.8 tablets per month, the same consumption as for intracavernous prostaglandin injections. The pattern of prescription doesn't differ between general practitioners and urological surgeons. No evidence for "overconsumption" became evident in the study. Presently, the majority of men who seek help for ED are middle-aged, have circulatory disease and are prescribed sildenafil (Viagra).

Prospective registration of all patients in a geographical region with newly diagnosed bladder carcinomas during a two-year period.

OBJECTIVE: To report the age, stage and grade of all patients with newly diagnosed bladder carcinoma in a well-defined geographical region and to compare this cohort with previous reports which come mainly from large referral centres. MATERIAL AND METHODS: All newly diagnosed bladder carcinoma patients (n = 701) in Western Sweden were prospectively registered during a 2-year period (1987-88). The histopathological material was re-examined by a reference pathologist. All the original clinical records were reviewed by one urologist 5-7 years after diagnosis. Demographic data, tumor grade, stage, multiplicity, presence of carcinoma in situ and lymphatic invasion are presented. RESULTS: The mean age at diagnosis was 70.5 years. Grade and stage increase with age. The proportion of non-invasive tumors (55%) is higher than in any previous Scandinavian report. The age-standardized incidence in bladder carcinoma among men in the largest city (Göteborg) is 55% higher than in the rest of the region (p<0.0001). Deviations between the primary pathologist and the reviewer with regard to tumor grade were particularly seen in tumors of grades I and II. CONCLUSIONS: Differences in mean age, stage and grade distribution were found between the present report, which included all patients with newly diagnosed bladder carcinoma in a geographical area, and other reports, which mainly comprised patients from large treatment centres. These differences can probably and mainly be explained by selection factors such as various degrees of inclusion of low-grade papillary tumors.

Recurrence and progression in low grade papillary urothelial tumors.

PURPOSE: We report long-term followup data on patients with World Health Organization (WHO) grade I bladder tumors, and determine whether histopathological subgrouping as papillary neoplasm of low malignant potential and low grade papillary carcinoma is of clinical value. MATERIALS AND METHODS: All 680 patients in western Sweden with first diagnosis of bladder carcinoma in 1987 to 1988 were registered and followed for at least 5 years. Of the tumors 255 (37.5%) were stage Ta, WHO grade I. Tumors were further classified as papillary neoplasm of low malignant potential in 95 patients and low grade papillary carcinoma in 160 according to WHO and the International Society of Urological Pathology consensus classification of urothelial (transitional cell) neoplasms of the bladder. RESULTS: Mean age of patients at first diagnosis of low grade papillary carcinoma was 69.2 years, which was 4.6 years higher than those with papillary neoplasm of low malignant potential (p<0.005). During a mean observation time of 60 months our 255 patients underwent 577 operations for recurrences and had 1,858 negative cystoscopies. The risk of recurrence was significantly lower in patients with papillary neoplasm of low malignant potential compared to those with low grade papillary carcinoma (35 versus 71%, p<0.001). The risk of recurrence was higher in patients with multiple tumors at first diagnosis as well as those with recurrence at the first followup after 3 to 4 months. Stage progressed in 6 patients (2.4%), all with low grade papillary carcinoma at diagnosis. CONCLUSIONS: More than 90% of patients with stage Ta, WHO grade I have a benign form of bladder neoplasm, and few have truly malignant tumors. Future research should focus on reducing the number of recurrences and followup cystoscopies, and finding methods to identify malignant tumors so that pertinent treatment can be instituted. Subgrouping of WHO grade I bladder tumors as papillary neoplasm of low malignant potential and low grade papillary carcinoma seems to add valuable prognostic information.

Stone fragmentation pattern of piezoelectric shockwave lithotripsy in vitro.

Whole stones (N = 64; largest diameter 5-15 mm) were treated in vitro with piezoelectric shockwaves using the Edap LT-01 lithotripter with 2.5 Hz at either 100% or 54% power. The number of fragments larger than 2 mm was counted after every 30 seconds. The stones were defined as totally broken when all fragments were < 2 mm. Total fragmentation time was correlated with the energy level and the size of the stone. The number of large fragments did not correlate with the energy level but rather with the original size of the stone.

Long-term followup of a bladder carcinoma cohort: routine followup urography is not necessary.

PURPOSE: We evaluate whether routine excretory urography is needed in the long-term followup of patients with bladder carcinoma. MATERIALS AND METHODS: A total of 680 patients with an initial diagnosis of bladder carcinoma from 1987 to 1988 in western Sweden were prospectively registered and followed for at least 5 years. All carcinomas of the kidney, renal pelvis and ureter, and all surgically treated cases of ureteral stricture were registered. RESULTS: During followup renal pelvic or ureteral carcinoma developed in 16 patients, renal cell carcinoma was diagnosed in 2 and 6 underwent surgery for benign obstruction of the distal ureter. CONCLUSIONS: The low annual incidence of malignant upper urinary tract and renal tumors as well as ureteral strictures supports our opinion that routine imaging of the upper urinary tract is not indicated during followup of patients with bladder carcinoma. We recommend urography at initial diagnosis of bladder carcinoma, when tumor progression occurs and when symptoms or signs raise suspicion of upper urinary tract disease.

Combined treatment with temporary short-term high dose rate iridium-192 brachytherapy and external beam radiotherapy for irradiation of localized prostatic carcinoma.

PURPOSE: To evaluate the treatment outcome after radical radiotherapy of localized prostate cancer in 50 patients (38 patients with stage T1-2 and 12 patients with stage T3) after a median follow-up time of 45 months (range 18-92 months). METHODS: The treatment was given by combination of external beam radiotherapy (50 Gy) and brachytherapy (2 x 10 Gy). The brachytherapy was given using TRUS-guided percutaneously inserted temporary needles with a high dose rate remote afterloading technique with Ir-192 as the radionuclide source. Three target definitions and dose levels inside the prostate gland were used. Local control was evaluated by digital rectal examination, TRUS-guided biopsies and serum PSA evaluations. RESULTS: Clinical and biopsy verified local control was achieved in 48 of the 50 (96%) patients; for stage T1-2 in 37 of 38 (97%) patients and for stage T3 in 11 of 12 (92%) patients. A posttreatment serum PSA level < or =1.0 ng/ml was seen in 42 (84%) patients, values from >1.0 to < or =2.0 ng/ml were seen in four (8%) patients and values exceeding 2.0 were seen in four (8%) patients. The late toxicity was minimal. CONCLUSION: The local control results and the minimal toxicity after the combined radiotherapy treatment are promising. However, long term results are necessary before general use.

Irradiation of localized prostatic carcinoma with a combination of high dose rate iridium-192 brachytherapy and external beam radiotherapy with three target definitions and dose levels inside the prostate gland.

PURPOSE: Localized prostate cancer was treated with combined external beam radiotherapy and high dose rate Ir-192 brachytherapy with the purpose of a high dose. The technical aspects of a modified treatment are described. METHODS: The brachytherapy was given in two sessions preceded and succeeded by external beam radiation. The radioactive source was temporarily implanted by a remote afterloading device through six to 15 needles inserted transperineally guided by transrectal ultrasound. The entire prostate gland was included in the clinical target volume. The urethra and the tumour volume could be defined and irradiated to different dose levels in more than 90% of the patients. RESULTS: Fifty-four patients were treated. The total dose to the prostate was approximately 70 Gy and to the tumour volume 80 Gy. By calculating the corresponding dose given by 2.0 Gy fractions, considering the radiobiology by using the LQ formula and assuming an alpha/beta value for prostate tissue of 10, the dose to the prostate was approximately 84 Gy and to the tumour volume 112 Gy. For the late effects to the urethra an alpha/beta value of 3 was used, which corresponds to 85 Gy. The brachytherapy could be given with accuracy except when the dorsal border of the prostate was concave. The dose distribution then tended to be less satisfactory. Post-treatment calculations showed that the maximum dose to the rectum was 67 Gy (radiobiologically corrected to 88 Gy), given in a small volume. The early side effects from the brachytherapy were minimal. The treatment could not be performed as intended in four patients; three patients had a narrow pelvis and in one patient the prostate was unusually resilient, preventing the needles from being positioned properly. CONCLUSIONS: This modification of a previously reported brachytherapy technique for prostate carcinoma permits a high radiation dose to the tumour and to the prostate gland, which ultimately may improve local control.

Palliative effect of intravesical bacillus Calmette-Guerin in elderly patients with advanced bladder carcinoma.

PURPOSE: Intravesical bacillus Calmette-Guerin (BCG) was used to palliate severe local symptoms in patients with invasive carcinoma. MATERIALS AND METHODS: Four patients with unresectable bladder carcinoma who were unfit for radical cystectomy because of age and poor performance status were treated with a 6-week course of BCG followed by monthly instillations. RESULTS: Urgency and frequency were reduced in 3 patients and the improvement lasted for 9 to 19 months. All 4 patients ultimately died of bladder carcinoma. CONCLUSIONS: The results of palliative BCG treatment were encouraging, but further experience is necessary.

Long-term followup of all patients with muscle invasive (stages T2, T3 and T4) bladder carcinoma in a geographical region.

PURPOSE: We studied the relationship between long-term survival and treatment of stages T2, T3 and T4 bladder carcinoma in an unselected patient population. MATERIALS AND METHODS: A total of 680 patients with the initial diagnosis of bladder carcinoma in 1987 to 1988 in Western Sweden was prospectively registered and followed until 1994. Of these patients 107 had stage T2 to T3 and 41 had stage T4 disease. RESULTS: Of the patients with stage T2 to T3 disease 30 (mean age 66) underwent radical cystectomy, 33 (mean age 75) full dose radiotherapy and 44 (mean age 81) nonradical therapy (mainly transurethral resection of the bladder). The 5-year crude survival rates were 33, 15 and 14%, respectively. Of the patients with stage T4 disease 6 (mean age 61) underwent radical cystectomy, 9 (mean age 73) full dose radiotherapy and 26 (mean age 81) nonradical therapy (mainly transurethral resection of the bladder). All except 1 patient died of disease within 4 years. CONCLUSIONS: More than 60% of the patients in the cohort were considered unsuitable for radical cystectomy and their survival was poor, whether treated with full dose radiotherapy or transurethral resection of the bladder alone.

Analysis of the local control in lymph-node staged localized prostate cancer treated by external beam radiotherapy, assessed by digital rectal examination, serum prostate-specific antigen and biopsy.

OBJECTIVE: To describe local disease control after radical external beam radiotherapy of prostatic carcinoma, as judged by digital rectal examination (DRE), transrectal ultrasonography (TRUS)-guided biopsies and estimates of serum prostate-specific antigen (PSA). PATIENTS AND METHODS: The study comprised 175 patients (mean age 67.5 years, range 49-82; > 90% aged > or = 60 years) with localized prostatic carcinoma (T1-T3C, N0, M0) who underwent external beam radiation therapy (70 Gy), and were then regularly followed with a DRE, measurements of serum PSA and TRUS-guided biopsies to determine the outcome. RESULTS: The DRE revealed four patients with evidence of residual cancer in the prostate and biopsies showed no evidence of residual cancer in 131 (75%) of the patients. There was no correlation of residual cancer with tumour stage or grade but tumour size, as estimated by TRUS, correlated with the results of the biopsy. The nadir serum PSA level was < or = 1.0 ng/mL in 116 (66%) of the patients, of whom 76 (43%) had a nadir serum PSA level of < or = 0.5 ng/mL. The median time to the nadir level was 11 months. Serum PSA progression (> 4.0 ng/mL) at the latest PSA measurement after reaching the nadir occurred in 13% of the patients with a nadir PSA of < or = 0.5 ng/mL and in 25 of the 29 (86%) patients with a nadir serum PSA > 2.0 ng/mL. Cox regression analysis showed that tumour size and rectal irradiation dose were the most important factors for local control. CONCLUSIONS: Radiotherapy is effective in achieving local control in small prostate cancer tumours but less effective in large tumours. Tumour size and dorsal extension of the irradiated target, the rectal dose, were the two important factors for local control. A serum PSA level of < or = 1.0 ng/mL was associated with a higher chance of prolonged disease control.