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.

Standardization of the renogram technique for investigating the dilated upper urinary tract and assessing the results of surgery.

OBJECTIVE: To recommend a standard technique for the renographic evaluation of the dilated upper urinary tract, and for evaluating the results of surgery. METHODS: This review is an update of the previously recommended consensus report of the 9th International Symposium of Radionuclides in Nephrourology. RESULTS: State-of-the-art recommendations are detailed for standardizing common radionuclide investigations. CONCLUSIONS: Where open, laparoscopic or endourological techniques for treating pelvi-ureteric junction obstruction are under study, results can only be compared by standardizing the investigational techniques. The guidelines produced here are recommended for this purpose.

Priapism in sickle-cell disease; incidence, risk factors and complications - an international multicentre study.

OBJECTIVE: To define the incidence, risk factors and complications of priapism in a large population of patients with sickle-cell anaemia in five centres in the UK and Nigeria, as priapism is common among these patients, but the precise characteristics of the condition in this population are poorly documented. PATIENTS AND METHODS: A questionnaire was developed and administered to patients with sickle-cell disease. Questions were designed to define the incidence, nature, precipitants, duration, treatment and complications of priapism. A distinction was made between acute (severe) priapism and the recurrent, 'stuttering' type. RESULTS: The questionnaire was completed by 130 patients (mean age 25 years, sd 11, range 4-66) from the five centres; 102 (78%) were homozygous Hb SS genotype, 19 (15%) were Hb SC genotype and two (1.5%) were Hb Salpha-thalassaemia. Of the patients, 46 (35%) reported a history of priapism, and of these, 33 (72%) had a history of stuttering priapism, while 24 (52%) had had an acute episode of priapism. The mean age of onset of priapism was 15 years, with 75% of patients having the first episode before their 20th birthday. Sexual activity was the most frequent precipitating factor, with fever and/or dehydration being the next most common. Of the 46 patients, 10 (21%) with a history of priapism reported having erectile dysfunction. A similar proportion reported dissatisfaction with sexual intercourse, including a fear of engaging in sexual activity. CONCLUSION: The incidence of priapism among patients with sickle-cell anaemia is high (35%). The implications of priapism for erectile and sexual function are significant and documented in this large series. The treatment of this condition in these patients remains unstandardised. This study highlights the need for an increased awareness of the problems associated with priapism among patients, families and medical professionals.

Obstructive uropathy.

Obstructive uropathy refers to the condition of obstruction to urine flow from the kidney to the bladder. Such obstruction may be acute or chronic, complete or incomplete, and unilateral or bilateral. It has many diverse causes each with their own specific features and yet each producing similar disturbances to renal function and urine flow. This paper discusses the unique role of nuclear medicine techniques in the diagnosis and management of urinary tract obstruction in current urological practice.

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.

The community-based morbidity of flexible cystoscopy.

OBJECTIVE: To evaluate patients' experience after flexible cystoscopy (FC), particularly concentrating on the prevalence and degree of symptoms, the frequency of visits to their General Practitioner (GP), subsequent antibiotic rates and the actual incidence of urinary tract infection (UTI). PATIENTS AND METHODS: Consecutive patients (420) presenting for FC were audited prospectively. A pain score for the procedure was recorded immediately afterward (linear scale 0-10) and a self-administered questionnaire completed at 7 days, to assess the objective and subjective symptoms and their duration, and the incidence of GP visits and subsequent antibiotic provision noted. An interim analysis was conducted on the initial 274 datasets received. To estimate the incidence of FC-induced UTI, the final 110 patients were asked not to consult their GP but to present to the urology department at 3 days after FC (or the emergency department if clinically necessary). These patients had initially provided a mid-stream urine (MSU) sample before FC and were assessed symptomatically with a subsequent sample obtained if a urinary dipstick test 3-days after FC was abnormal. RESULTS: In all, 384 (91%) evaluable forms were returned. The median (range) pain score for FC was 1.1 (0-8.5), with seven patients (1.8%) recording a pain score of > 5 (all men); 382 patients (99.5%) declared they would be happy to undergo an identical procedure in the future if medically indicated. Pain on voiding was reported in 190 patients (50%), urinary frequency in 142 (37%) and gross haematuria in 73 (19%). Eighteen of the initial 274 patients (6.6%) visited their GP, with 15 (5.5%) of these receiving antibiotics. The MSU data from the final 110 patients showed a FC-mediated infection in three (2.7%). CONCLUSION: Although FC is well tolerated, gross haematuria, urinary frequency and dysuria occur afterward much more frequently than expected. Patients should be thoroughly counselled before FC about these potential symptoms, to reduce their concern, any unnecessary GP visits and the use of antibiotics.

The choice of timing for diuresis renography: the F + 0 method.

OBJECTIVE: To investigate a method of diuresis renography where the radiopharmaceutical and frusemide (diuretic) are given simultaneously, in contrast to conventional renography which involves an intravenous injection with frusemide 20 min after administering the radiopharmaceutical (F + 20) or 15 min before (F - 15), with particular interest in the effect of this change on assessing split renal function and interpreting upper tract drainage dynamics. PATIENTS AND METHODS: In a prospective study, 29 patients (18 women and 11 men, mean age 47 years, range 21--86) were assessed. Each patient had two renograms taken over a 48-h period, either by the F + 20 or F - 15, and the F + 0 method: Data for split renal function and drainage curves were obtained in the usual way. Two independent assessments of the drainage curves were obtained and the results compared. RESULTS: The split function assessments were identical (< 5% variation) in all but two patients; 26 of 29 (90%) gave identical conclusions about the drainage curves. The three patients with discrepancies between the studies had either hugely dilated upper tracts or otherwise had multiple complicating factors, e.g. impaired renal function, neuropathic bladder. CONCLUSIONS: F + 0 renography has been used in paediatric urological practice before, but there are no comparative studies and no data on its use in adults. This prospective study confirmed that in investigating dilated upper tracts, the F + 0 technique gives similar results to the conventional techniques. The F + 0 method has the potential to reduce the time required to undertake standard F + 20 renography but it may not be useful in evaluating the grossly dilated upper tract, where the F-15 technique has the best record in terms of reducing equivocal results.

The long-term results of Anderson-Hynes pyeloplasty.

OBJECTIVES: To examine the durability of open pyeloplasty for pelvi-ureteric junction obstruction. PATIENTS AND METHODS: The records of 56 Anderson-Hynes pyeloplasties undertaken by two surgeons between 1981 and 1994 were examined. Attempts were made to trace all patients and for them to undergo diuretic renography to examine the current status of the operated renal unit. RESULTS: In all, 41 evaluable patients were identified; 24 agreed to return for reassessment. The mean (range) time from surgery was 10.6 (6-19) years. The results showed an improvement over the preoperative split renal function in 19 patients (79%) and an improvement in drainage in 23 (96%). CONCLUSIONS: The Anderson-Hynes pyeloplasty is an excellent procedure for treating pelvi-ureteric junction obstruction, and produces a lasting improvement in function and drainage in most patients. It is the 'gold standard' against which newer techniques should be compared.

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.