A prospective randomized trial evaluating endoscopic Nd:YAG laser prostate ablation with or without potassium titanyl phosphate (KTP) laser bladder neck incision.

OBJECTIVE: To investigate whether performing a potassium titanyl phosphate (KTP) laser bladder neck incision (BNI) in conjunction with a Nd:YAG endoscopic ablation of the prostate (ELAP) compared with an ELAP alone, improves early post-operative voiding rates and clinical outcome. PATIENTS AND METHODS: A prospective randomized trial that was both double-blind and power-determined (80%) compared 88 patients with benign prostatic enlargement undergoing ELAP and those undergoing KTP BNI and ELAP. A dual-wavelength KTP/532TM (Laserscope) laser was used with Add/Stat side-firing fibres. A urethral catheter was inserted post-operatively and was removed after 18 h. Patients unable to void at this stage were then re-catheterized, discharged and readmitted 2 weeks later for catheter removal. Patients were followed up at 3 month intervals. RESULTS: Post-operatively, 80% of the patients undergoing KTP BNI and ELAP were able to void on catheter removal at 18 h, compared with only 57% of the patients undergoing ELAP alone (P < 0.05, chi-square). After 1 month, two patients from the former and four from the latter group failed to void and required further surgery. At 3 months, there was a significant improvement in the post-void residual volume, maximum flow rate, symptom and quality-of-life scores compared to the pre-operative values for both groups (P < 0.005). However, there was a greater improvement in the flow rate and symptom score in patients undergoing KTP BNI and ELAP (P < 0.05). CONCLUSION: This study shows the benefit of performing a KTP BNI with ELAP in terms of early voiding rates and initial clinical outcome, and this treatment is recommended.

Is the conservative management of the acute scrotum justified on clinical grounds?

OBJECTIVE: To determine whether there is justification for a policy of conservative management of acute scrotal emergencies, based on the ability to exclude a twisted testicle or the assumption that there is a "missed torsion' when the duration of symptoms is prolonged. PATIENTS AND METHODS: The case notes of 209 consecutive emergency scrotal explorations, carried out in one district general hospital over a 7-year period, were reviewed. The decision to operate was based solely on a clinical diagnosis, with no information from additional radiological investigations. RESULTS: The commonest finding was testicular torsion (39.5%) with an orchidectomy rate of 22%. Only 5% of scrotal torsions occurred in patients < 12 years of age, whereas 26% occurred in those > 20 years of age. In five of 82 cases (6%) of confirmed testicular torsion, the surgeon did not consider this the most likely diagnosis. With a pain duration of < 16 h, 89% of testes were salvaged, but with pain for > 16 h this decreased to 25%. In three cases the testis was viable after pain had been present for > 24 h. CONCLUSION: In the absence of supportive radiological investigations, a small but significant number of twisted testes will be missed if conservative management is adopted.

Urethral catheterisation--is anybody listening?

All house officers perform male urethral catheterisation and although complications may occur awareness of the potential problems varies considerably. 43 house officers from 12 different medical schools were interviewed to determine the amount of training that they received regarding this procedure as students and during their first pre-registration post. The results suggest that there is no planned approach to teaching urethral catheterisation which would be in the interests of both junior doctors and patients alike.

Do not catheterise your nephrectomies.

A retrospective study of 100 consecutive nephrectomy patients showed a 20% catheterisation rate. Of the 11 carried out post-operatively only 4 were for urinary retention. The post-operative catheterisation rate for males was 7.1% and for females 2%. The rate of post-operative retention was 4.4%, which is much lower than that reported from other units. This rate of post-operative catheterisation for retention is so low that in spite of the very mild increase in complications compared with intra-operative catheterisation, the practice of routine prophylactic catheterisation of nephrectomy patients is unnecessary and cannot be recommended.

Acute retention of urine: is trial without catheter justified?

Following an episode of acute retention of urine in men it is commonplace for urinary catheters to be removed to see if micturition is re-established. Many patients will require definitive treatment, however and, to assess which patients do benefit from a trial without catheter, the outcome of this practice was analysed against the relevant features of the history in 100 men. The majority of patients both with and without previous symptoms suggestive of outflow obstruction had further retentions. Trial without catheter was of value in three groups of patients: those with urinary tract infection without previous obstructive symptoms, those with gross constipation and those recently commenced on drugs with anticholinergic properties. With these exceptions, definitive treatment was necessary in 93% of the remainder. Most of those in whom micturition was re-established are still under active review and may yet come to surgery, in view of poor flow rates. With the exceptions detailed above it is concluded that trial without catheter is not justified in acute retention of urine and definitive treatment should be instituted at an early stage.

Fractionated urinary cytology in the follow-up of bladder cancer.

Cytological examination of voided urine is an established investigation in urological practice. In a pilot study of 50 patients with histologically proven transitional cell carcinoma of the bladder, urine cytology was undertaken on samples from the initial, mid-stream and terminal parts of the void. Analysis showed that although the cell density varied between the samples in some cases, no part of the void was consistently richer in benign or malignant cells and similar cell types were seen in every sample from any given patient. It was concluded that fractionated cytology did not improve the diagnostic accuracy of urinary cytology and that any sample of urine was suitable for cytological purposes.

Long-term follow-up of the MAGPI operation for distal hypospadias.

Following the introduction of the MAGPI procedure, this operation has become established in the management of distal hypospadias. In our unit 45 boys have been treated in this way and the long-term results have been assessed in 28. The cosmetic result of surgery and the direction of the urinary stream were satisfactory in 27 patients. In all but 2 cases there was partial ventral regression of the urinary meatus when compared with the immediate post-operative appearances. In the long term, it is our experience that the MAGPI operation does not maintain a terminal position for the external urinary meatus, but the functional and cosmetic results are satisfactory.

Are urodynamics necessary in female patients presenting with stress incontinence?

A urological and urodynamic database was used in a prospective study of female patients whose initial symptom was stress incontinence alone. The urodynamic diagnoses in 89 such patients were analysed against any additional symptoms. Fifty-four patients complained of stress incontinence without other symptoms and none of these had detrusor instability. One patient from a group of 25 who had frequency with stress incontinence had low bladder compliance but the others had normal urodynamic studies. Of the 10 patients with urgency in addition to stress incontinence, 5 had unstable bladders. A detailed urological history must be taken in all patients who are assessed for stress incontinence. Urodynamics are unnecessary in patients with stress incontinence alone but should be considered in those with additional urgency.

Bone mineral content in patients with carcinoma of the prostate.

This study investigated the effect of metastatic prostatic carcinoma on bone density. Thirty patients underwent a lumbar spine scan with a dual photon absorptiometer. Of these patients, 9 had proven skeletal metastatic deposits in the area being investigated. Comparison of results with a non-matched control population with proven benign prostatic histology showed a significantly elevated linear bone mineral content (BMC) in the disease group. Patients scanned after a 3- or 6-month period of hormonal therapy demonstrated a rise in BMC values, although the trend was not statistically significant. Indices of calcium metabolism have also been investigated.

Long-term follow-up of unilateral bladder neck incision.

Sixty-four patients who underwent unilateral bladder neck incision (BNI) between 1980 and 1983 were reviewed. In 53 cases the flow rates showed no significant change from immediate post-operative values. All patients were interviewed or completed a questionnaire which demonstrated that 87% were satisfied with the long-term outcome of surgery. The incidence of repeat bladder neck incision or transurethral resection of prostate (TURP) compared well with the incidence reported in other studies, as did the recorded incidence of retrograde ejaculation at 16%, although 52.5% of patients noted a reduction in the volume of ejaculate.