Long-term surveillance of bladder tumours: current practice in the United Kingdom and Ireland.

INTRODUCTION: Surveillance of transitional cell carcinoma of the bladder forms a major part of the workload of many urology units. Unfortunately, the policy for long-term surveillance of these cancers is neither clear nor agreed upon in the absence of evidence base. Our study was performed to provide current national practice data, and begin the debate on consensus guidelines. MATERIALS AND METHODS: A questionnaire was sent to Consultant Urologists (CUs) in the UK and Ireland (n=501) asking about their policy on the long-term surveillance of different bladder tumours once patients are free of recurrence. RESULTS: A 73% response rate was observed (365/501). Views varied considerably. They ranged from life long cystoscopic surveillance for low-stage low-grade tumours (pTaG1) to discharge after 5 years (or less) of a recurrence-free period for pT1G3 tumour. Once long-term surveillance with cystoscopy had been discontinued, 55% of CUs felt no role was indicated for urine cytology in further follow up, whereas 17% would use it for all tumour types and 28% are selective. CONCLUSION: Our study has shown the complete lack of consensus regarding the long-term surveillance of bladder cancer in the UK and Ireland. This has major implications for policy making, resources allocation and cancer survival. We highlight the need for national guidelines in this area for optimal surveillance of bladder cancer, as a good prospective evidence-based data will not be available for many years. We believe our study might form the basis for discussion on such guidelines.

Outpatient clinic: where is the delay?

In outpatient clinics, consultation times are often eroded by extraneous activities. We measured the components of each outpatient episode in 167 patients attending a general urology follow-up clinic. 41% of time in the clinic was spent away from the patient-administration 17%, disturbances 15%, finding results 9%. The inefficiencies had changed little since a study in the same setting thirteen years earlier. Since then, parallel nurse-practitioner-run clinics have been introduced in the hope of giving consultants longer with the patient; however, time with each patient is now 4.8 min compared with a previous 7.6 min. The most easily addressed inefficiencies are those relating to missing information, such as radiology reports.

Oral agents for the treatment of type 2 diabetes mellitus: pharmacology, toxicity, and treatment.

Currently available oral agents for the treatment of type 2 diabetes mellitus include a variety of compounds from 5 different pharmacologic classes with differing mechanisms of action, adverse effect profiles, and toxicities. The oral antidiabetic drugs can be classified as either hypoglycemic agents (sulfonylureas and benzoic acid derivatives) or antihyperglycemic agents (biguanides, alpha-glucosidase inhibitors, and thiazolidinediones). In this review, a brief discussion of the pharmacology of these agents is followed by an examination of the adverse effects, drug-drug interactions, and toxicities. Finally, treatment of sulfonylurea-induced hypoglycemia is described, including general supportive care and the management of pediatric sulfonylurea ingestions. The adjunctive roles of glucagon, diazoxide, and octreotide for refractory hypoglycemia are also discussed.

A prospective, randomized, double-blind study comparing lignocaine gel and plain lubricating gel in relieving pain during flexible cystoscopy.

OBJECTIVE: To determine the optimum duration for the retention of 2% lignocaine gel intraurethrally as an anaesthetic for flexible cystoscopy in men. PATIENTS AND METHODS: A prospective, randomized, double-blind, placebo-controlled trial was conducted in two parts. Initially, the importance of duration was determined, i.e. whether pain relief was significantly improved when lignocaine gel was instilled for longer than is currently practised. As pain relief was improved by retaining the lignocaine gel for longer, the optimum time was determined in a second trial. Initially, 90 patients were divided into four groups receiving 20 mL of 2% lignocaine gel or plain lubricating gel for 5 or 25 min. Subsequently, 60 men were divided into two groups receiving 20 ml of 2% lignocaine gel for 15 or 25 min. The patients' discomfort was recorded using a 4-point descriptive pain scale and a 100 mm non-graphical visual analogue scale. RESULTS: In the first study, those patients receiving lignocaine gel for 25 min experienced significantly less pain than the other three groups. In the second, lignocaine gel in the urethra for 15 min provided the same level of pain relief as lignocaine for 25 min. CONCLUSION: Pain during flexible cystoscopy can be significantly reduced when 20 mL of 2% lignocaine gel is left in the urethra for 15 min; lignocaine gel would be more effective when left for longer than is currently practised.

The Probot--an active robot for prostate resection.

As men age, their prostates can enlarge, causing urinary difficulty. Surgery to correct this [transurethral resection of the prostate (TURP)] is a skilled and time-consuming operation requiring many repetitive motions of a cutter. A robot has been developed to perform these motions, relieving the surgeon of much of the burden of surgery. This robot has been tried both in the laboratory and later on human subjects and has proved itself capable of performing prostate resection. The Probot system consists of on-line imaging and three-dimensional prostate model construction, an appropriate surgeon-computer interface, a counterbalanced mounting frame and a computer controlled robot.

Comparison of prostatic volume and dimensions by transrectal and transurethral ultrasonography.

OBJECTIVE: To compare the volumes and dimensions of the prostate gland as measured by transrectal and transurethral ultrasonography (TRUS and TUUS) and to study the prostatic changes that occur in the presence of an urethral instrument. PATIENTS AND METHODS: Twenty men (mean age 71 years, range 43-85) with symptoms of prostatic enlargement underwent TRUS and the dimensions and volumes of their prostates were obtained by the dimensional method and by step planimetry. Within 24 h, all the men were examined cystoscopically under sedoanalgesia and underwent TUUS. Their prostatic volumes and dimensions were again measured by the dimensional method and by step planimetry. Step planimetry was carried out using a specially designed indexer firmly attached to the examination couch or operating table. All the static images and planimetry slices were video recorded for later computer enhancement and to study the three-dimensional changes occurring in the prostate. The volumes and dimensions obtained by TRUS and TUUS were compared. RESULTS: Volumes obtained by transurethral step planimetry were 22% greater than those from transrectal planimetry. Although there was a good correlation (r = 0.984) between transurethral planimetry and the volumes derived using the transurethral dimensions with the prolate ellipsoid formula, the latter produced values 17% and 25% lower by the transurethral and transrectal routes, respectively. These volume estimates varied widely, indicating that the simple addition of a constant to the prolate ellipsoid formula would not correct the volume. Three-dimensional changes of the prostate occurred with TRUS and TUUS: with TUUS, the craniocaudal and anteroposterior diameters were significantly larger (by 7% and 18%, respectively) while the transverse diameter was smaller by 20%. CONCLUSION: The estimated volumes and dimensions of the prostate differed when measured by TRUS and TUUS and three-dimensional changes in the prostate occurred in the presence of an urethral instrument.

Transrectal ultrasonography: why are estimates of prostate volume and dimension so inaccurate?

OBJECTIVES: To determine why there are variations in the volumes of the prostate obtained by step planimetry and those calculated from the prolate ellipsoid formula using the measured maximum gland dimensions, to assess the reproducibility of estimates of prostate volume from transrectal ultrasonography (TRUS) and to determine the effect of the angle of the transrectal probe, the human error in the clinical setting and the benefit of computer enhancement of the ultrasonograms. PATIENTS AND METHODS: Forty-five men (mean age 72 years, range 43-89) with symptoms of prostatic enlargement were divided randomly into three groups; those in group 1 had their prostate volume estimated three times by measuring the maximal gland dimensions and calculating the volume using the prolate ellipsoid formula (dimensional method) and by step planimetry, to assess the reproducibility of TRUS; men in group 2 had their prostate volume estimated using the dimensional method and by step planimetry with the probe in the optimal axis, and then from scans repeated after deflecting the transrectal probe 5 degrees anteriorly and posteriorly; men in group 3 had their prostate volume estimated once by the dimensional method and by step planimetry. Step planimetry was carried out using a specially designed indexer firmly attached to the examination couch. All 'frozen' images and planimetry slices were videotaped for later computer enhancement. The volumes and dimensions obtained by each method were compared. RESULTS: The volumes obtained by step planimetry were 17% greater than those obtained by the dimensional method because the craniocaudal, anteroposterior and transverse diameters were underestimated significantly by the latter (by 13%, 2% and 7%, respectively). The largest anteroposterior and transverse diameters were included in the same axial scan in only 44%, while the largest craniocaudal diameter was in the midline in only 38%, of the patients. The human error in the clinic was negligible (2%) with a good correlation between the dimensions and volumes obtained in the clinic and those from computer-enhanced images (r = 0.94). There were no advantages in computer enhancing the TRUS images. Volumes calculated from the dimensional method using the maximum dimensions obtained from planimetric contours correlated well with planimetric volumes (r = 0.93). The reproducibility of TRUS showed a mean error of 8% by the dimensional method and 1% by step planimetry. Anterior deflection of the transrectal probe reduced the estimated volume by 2% and posterior deflection increased the volume by 4%, using the dimensional method, while there were no significant volume changes when estimated by step planimetry. CONCLUSION: This study confirms that to estimate accurately the volume of the prostate using the prolate ellipsoid formula, the current methodology needs to be changed. The largest anteroposterior and transverse diameters may need to be measured in different transverse scan slices and the largest craniocaudal diameter in a sagittal scan away from the midline. If volume estimation is to be repeated then step planimetry is reliable and TRUS using the prolate ellipsoid formula is not.