Nephrobronchial fistula - a case report.

We report the case of a 58-year-old woman with a hydronephrotic left kidney who presented with a 4-month history of anorexia, weight loss and intermittent left loin pain associated with cloudy urine. Her urine grew lactose fermenting coliforms, and was treated with antibiotics. A computerized axial tomography scan (CT scan) was equivocal and she underwent retrograde ureteric stenting, which drained a pyonephrosis. She went on to develop a chest infection due to a lung abscess. A CT scan revealed a left perinephric collection extending across the diaphragm into the lower lobe of the left lung. She responded to antibiotics and awaits a nephrectomy.

Outcome and survival with nonsurgical management of renal cell carcinoma.

OBJECTIVE: To document long-term survival in patients with renal cell carcinoma (RCC) in whom the primary tumour was left in situ and treatment limited to palliative and symptomatic measures. PATIENTS AND METHODS: All patients with a diagnosis of RCC from January 1994 to January 1999 and in whom the primary tumour was left in situ were identified from hospital records (nine women and 16 men, mean age 69 years). The tumour stage was T1-T4. RESULTS: The mean survival overall was 19.3 months; patients with locally advanced disease, i.e. stage >or= T3a, had a mean survival of 16.9 months. CONCLUSIONS: There is renewed interest in the management of advanced RCC, with data supporting cytoreductive nephrectomy with systemic biological therapy. These results confirm that such patients with or without metastatic disease can survive for a considerable period with no aggressive surgical or systemic measures, and such intervention may offer no significant advantage in outcome and survival over supportive treatment alone.

Atrophy of kidney following extra corporeal shock wave lithotripsy of renal calculus in a paraplegic patient with marked spinal curvature.

OBJECTIVES: To discuss a rare complication of extra corporeal shock wave lithotripsy (ESWL) of renal calculus in a paraplegic patient, who had marked curvature of thoracic and lumbar spine. DESIGN: A case report of a paraplegic patient, who developed renal atrophy and hypertension after undergoing ESWL of staghorn calculus. SETTING: Regional Spinal Injuries Centre, Southport and Mersey Regional Lithotripsy Unit, Royal Liverpool University Hospital, Liverpool, UK. PARTICIPANT: A 28-year-old male with spina bifida, paraplegia at L-1 level and considerable curvature of spine and tilting of pelvis. METHOD: ESWL was carried out in three sessions by delivering 1934, 1876, and 2025 shock waves respectively. Localisation of the staghorn calculus was difficult because of spinal curvature and pelvic tilt. RESULTS: A follow-up IVU, performed 3 months after last ESWL treatment, revealed no residual stone in the left kidney, apart from a little low-density calcification in the renal parenchyma adjacent to the lower pole calyx. There were no calculi in the left ureter. The left kidney had become small, though still functioning. MAG-3 isotope renogram showed the left kidney to be markedly atrophic. Relative renal function: right kidney, 94%; and left kidney, 6%. He developed hypertension and a laparoscopic left nephrectomy was performed at another hospital. CONCLUSION: Difficulty in localisation of renal calculi for ESWL must be anticipated in spinal bifida and spinal cord injury patients, who have significant spinal curvature. Because of problems in the positioning of a patient with marked curvature of spine and pelvic tilt, and consequent difficulties in accurate localisation of renal calculi for lithotripsy, these patients may be at increased risk of developing renal parenchymal and vascular damage following ESWL.

Protocol of a prospective cohort study of the effect of different methods of drainage of neuropathic bladder on occurrence of symptomatic urinary infection, and adverse events related to the urinary drainage system in spinal cord injury patients.

BACKGROUND: To present a protocol of a prospective, cohort study in which four groups of spinal cord injury (SCI) patients will participate. (Patients with indwelling urethral catheter; patients who perform intermittent catheterisation without wearing a penile sheath; patients who perform intermittent catheterisation and wear penile sheath as well; and patients with penile sheath drainage). OBJECTIVES: (1) What is the incidence of symptomatic urinary infection in men with spinal cord injury who use different types of bladder drainage? (2) Which are predisposing factors for the occurrence of symptomatic urinary infection in men with spinal cord injury who practise different methods of bladder drainage? (3) What is the incidence of catheter and urinary drainage system-related adverse events in the four groups of SCI patients? PATIENTS: The criteria for inclusion are as follow: (1) Male patients with neuropathic bladder due to spinal cord injury, who are registered with the Regional Spinal Injuries Centre, Southport, England. (2) Age: 18 years or above. (3) Patients who are willing to give informed consent for participation in the study. (4) Patients willing to be contacted every two weeks by a staff of the spinal unit for 36 months. (5) Patients who are willing to maintain an accurate record of adverse events related to urinary catheter and urinary drainage system and predisposing factors for the occurrence of symptomatic urinary infection. (6) Patients, who are stabilised in a particular method of bladder drainage, and therefore, unlikely to make a permanent change in the method of bladder drainage (e.g. from penile sheath drainage to the use of long-term indwelling catheter) during a foreseeable future. METHODS: The participants will be observed for a period of 36 months. A staff of the spinal injuries unit will contact the participants by telephone every two weeks on a mutually agreed day and time. The information obtained during this standardised telephonic interview conducted once in two weeks will be entered in a database. When a participant develops symptom(s) suggestive of urinary infection, he will undergo urine and blood tests, and imaging studies of the urinary tract. CONCLUSION: This study will provide information regarding the occurrence of symptomatic urinary infection, predisposing factors for development of urinary infection, and adverse events related to urinary catheter and urinary drainage system in SCI patients using different methods of bladder drainage.

Blunt trauma to scrotum in men with spinal cord injury after they had completed rehabilitation in a spinal unit.

STUDY DESIGN: A report of three men with spinal cord injury (SCI) who sustained blunt trauma to scrotum after they had completed rehabilitation in the spinal unit. OBJECTIVES: To raise awareness amongst health professionals regarding: (1) mechanism of scrotal trauma in men with SCI (2) need for prompt assessment of scrotal injury (3) measures to be taken by men with SCI and their carers to prevent injury to the scrotum. SETTING: Regional Spinal Injuries Centre, Southport, England. CASE REPORTS: (1) A 31-year-old with C-6 tetraplegia sustained traumatic haematocele as he squashed his right testis while he jumped on to a toilet seat in a hurry for bowel movement. (2) A 28-year-old male with T-7 paraplegia sat on his left testis while transferring on to a car seat. (3) A boxer dog jumped on to the scrotum of a 40-year-old male with T-8 paraplegia, while he was lying on his bed. CONCLUSIONS: Men with SCI are at high risk of sustaining trauma to scrotum during transfers. The scrotum may be squashed by the weight of the body during transfers, or the scrotum may be trapped between the thighs or under the torso. Men with SCI or their carers should check after each transfer that the scrotum is not trapped between the thighs or under the torso. The health professionals should encourage men with SCI to update their transfer skills at regular intervals in order to prevent trauma to the scrotum during transfers. Blunt trauma to scrotum requires prompt evaluation by ultrasonography so that appropriate treatment can be instituted without delay.

Bilateral extracorporeal shock wave lithotripsy in a spinal cord injury patient with a cardiac pacemaker.

OBJECTIVES: To review the precautions to be observed before and during extracorporeal shock wave lithotripsy (ESWL) in spinal cord injury (SCI) patients with a cardiac pacemaker and the safety of bilateral ESWL performed on the same day. DESIGN: A case report of bilateral ESWL in a SCI patient with a permanent cardiac pacemaker. SETTING: The Regional Spinal Injuries Centre, Southport, the Lithotripsy Unit, the Royal Liverpool University Hospitals NHS Trust, Liverpool, and the Department of Cardiology, Manchester Royal Infirmary, Manchester, UK. SUBJECT: A 43-year-old male sustained a T-4 fracture and developed paraplegia with a sensory level at T-2. During the post-injury period, he developed episodes of asystole requiring implantation of a dual chamber (DDD) permanent pacemaker. Twenty-one months later, he developed a right ureteric calculus with hydronephrosis. A radio-opaque shadow was seen in the left kidney with no hydronephrosis. During right ureteric stenting, the ureteric stone was pushed into the renal pelvis. 1,500 shock waves were delivered to this stone on the right side, followed by ESWL to the left intra-renal stone with 1250 shock waves. RESULTS: The patient tolerated ESWL to both kidneys. The pacemaker was reprogrammed to a single chamber ventricular pacing mode at 30 beats per minute with a reduced sensitivity during lithotripsy. There were no untoward cardiac events during or after lithotripsy. The serum creatinine was 45 micromol/l before lithotripsy and 44 micromol/l two weeks after ESWL. CONCLUSION: SCI patients with a cardiac pacemaker may be able to undergo extracorporeal shock wave lithotripsy following temporary reprogramming of the pacemaker. Bilateral, simultaneous ESWL is safe in the vast majority of patients provided that there is no risk of simultaneous ureteric obstruction by stone fragments. However, it should be remembered that a decrease in renal function could occur following bilateral ESWL of renal calculi.

Occlusion of left common iliac vein by a distended urinary bladder in a male with paraplegia due to spinal cord injury.

STUDY DESIGN: A report of a male subject who sustained paraplegia at T-5 level due to spinal cord injury (SCI) 18 years ago, and in whom, occlusion of the left common iliac vein by a distended bladder was detected during a routine follow-up. OBJECTIVES: To illustrate a rare complication of chronic distension of the urinary bladder viz occlusion of the left common iliac vein, which persisted even after providing adequate bladder drainage by intermittent catheterisation. SETTING: Regional Spinal Injuries Centre, Southport, UK. METHODS: As part of a routine follow-up, we performed intravenous urography by injecting 50 ml of Ultravist 300 in a vein over the dorsum of the left foot. Opacification of collateral veins in the pelvis was seen in the 5- and 10-min films, which suggested iliac venous occlusion. In order to confirm the diagnosis, contrast was injected intravenously in the left foot and venography was performed. RESULTS: Venography revealed a distended left common iliac vein with contrast flowing into the right internal iliac vein through collateral veins in the pelvis; the right common iliac vein and inferior vena cava were patent. Duplex Doppler sonography showed compression of left common iliac vein by the posterior wall of a distended bladder with absence of blood flow through the compressed segment. Computerised tomography (CT) confirmed the diagnosis of extrinsic compression of the left common iliac vein against the promontory of sacrum by a distended bladder. CT excluded other causes for iliac vein occlusion. CONCLUSION: In a male subject with SCI, chronic bladder distension produced occlusion of the left common iliac vein. Health professionals caring for individuals with SCI should be aware that long-standing bladder distension could cause pressure effects upon adjacent structures in the pelvis.

Silent hydronephrosis/pyonephrosis due to upper urinary tract calculi in spinal cord injury patients.

STUDY DESIGN: A study of four patients with spinal cord injury (SCI) in whom a diagnosis of hydronephrosis or pyonephrosis was delayed since these patients did not manifest the traditional signs and symptoms. OBJECTIVES: To learn from these cases as to what steps should be taken to prevent any delay in the diagnosis and treatment of hydronephrosis/pyonephrosis in SCI patients. SETTING: Regional Spinal Injuries Centre, Southport, UK. METHODS: A retrospective review of cases of hydronephrosis or pyonephrosis due to renal/ ureteric calculus in SCI patients between 1994 and 1999, in whom there was a delay in diagnosis. RESULTS: A T-5 paraplegic patient had two episodes of urinary tract infection (UTI) which were successfully treated with antibiotics. When he developed UTI again, an intravenous urography (IVU) was performed. The IVU revealed a non-visualised kidney and a renal pelvic calculus. In a T-6 paraplegic patient, the classical symptom of flank pain was absent, and the symptoms of sweating and increased spasms were attributed to a syrinx. A routine IVU showed non-visualisation of the left kidney with a stone impacted in the pelviureteric junction. In two tetraplegic patients, an obstructed kidney became infected, and there was a delay in the diagnosis of pyonephrosis. The clinician's attention was focused on a co-existent, serious, infective pathology elsewhere. The primary focus of sepsis was chest infection in one patient and a deep pressure sore in the other. The former patient succumbed to chest infection and autopsy revealed pyonephrosis with an abscess between the left kidney and left hemidiaphragm and xanthogranulomatous inflammation of perinephric fatty tissue. In the latter patient, an abdominal X-ray did not reveal any calculus but computerised axial tomography showed the presence of renal and ureteric calculi. CONCLUSIONS: The symptoms of hydronephrosis may be bizarre and non-specific in SCI patients. The symptoms include feeling unwell, abdominal discomfort, increased spasms, and autonomic dysreflexia. Physicians should be aware of the serious import of these symptoms in SCI patients.

Milk of calcium in the inferior calyx of a hydronephrotic kidney in a tetraplegic patient - a diagnosis to be made before scheduling for extracorporeal shock wave lithotripsy.

STUDY DESIGN: A Case Report of renal milk of calcium in a tetraplegic subject. OBJECTIVES: To increase the awareness of renal milk of calcium in spinal cord injury (SCI) physicians. Renal milk of calcium contains a colloidal suspension of calcium crystals. Since upright views of the kidneys are not performed in tetraplegic subjects, the renal milk of calcium may be misinterpreted as renal lithiasis by routine radiography taken in supine position. SETTING: Regional Spinal Injuries Centre, Southport, England. METHOD: In a 41-year-old male with traumatic tetraplegia, X-ray of abdomen in supine position showed multiple opacities in the region of the left kidney. These radio opaque shadows were interpreted as renal calculi. Subsequently, computed tomography (CT) of the kidneys was performed. RESULTS: CT confirmed the presence of calculi in the mid-polar calyx. However, the density situated in the inferior calyx of the hydronephrotic left kidney exhibited a horizontal upper edge. This specific radiological finding as observed in the CT of kidneys, provided the clue to the presence of milk of calcium in the inferior calyx of the hydronephrotic left kidney. CONCLUSION: As plain film of the abdomen in standing position is not performed in SCI patients, physicians caring for SCI patients should have a high index of suspicion for renal milk of calcium. Prompt diagnosis of renal milk of calcium will help to avoid unnecessary surgery, or extracorporeal shock wave lithotripsy.

Heat shock protein expression independently predicts clinical outcome in prostate cancer.

Heat shock proteins (hsps) occupy a central role in the regulation of intracellular homeostasis, and differential expression of individual hsps occurs in a broad range of neoplastic processes. This study was performed to test the hypothesis that the particular patterns by which individual hsps become specifically modulated in human prostate cancers are correlated with behavioral phenotype and hence may be of value in determining the most appropriate clinical management of individual patients. Monoclonal antibodies specific for each hsp protein were used to assess expression of hsp27, hsp60, and hsp70 in formalin-fixed, paraffin wax-embedded, archival tissue specimens of early prostatic adenocarcinomas (pT1-2N0M0) removed at radical prostatectomy (n = 25) and in advanced cancers (n = 95) identified at transurethral resection of prostate (TURP). These findings were compared with similar data from control prostates (n = 10) removed at primary cystectomy for urinary bladder neoplasia not involving the prostate and also at TURP for benign prostatic hyperplasia (n = 50). Western blotting of whole cell lysates derived from established human prostatic epithelial cell lines PNT2, LNCaP, DU145, and PC3 was compared with expression of hsps by the primary human tissues. This study found that early in situ neoplastic transformation of normal prostatic epithelium was consistently associated with loss of hsp27 expression and that the level of hsp27 expression by individual prostate cancers was correlated with their Gleason grade. In advanced cancers, hsp27 expression was invariably associated with poor clinical outcome (P = 0.0001). Data from cell lines supported the primary tissue findings, with elevated hsp27 expression only in aggressive malignant cell lines and androgen-insensitive cell lines. Expression of hsp60 was significantly increased in both early and advanced prostate cancer when compared with nonneoplastic prostatic epithelium (P < 0.0001), as well as in malignant prostate cancer cell lines. Expression of hsp70 was unaltered in early prostate cancers when compared with nonneoplastic prostatic epithelium but showed a diminished expression in morphologically advanced cancers (P = 0.0029). No consistent correlation was found between levels of hsp60 or hsp70 expression and phenotypic behavior of individual primary prostatic cancers. Thus, patterns of hsp expression have been confirmed to be specifically and consistently modulated in both early and advanced human prostate cancers. Whereas absence of hsp27 is a reliable objective marker of early prostatic neoplasia, reexpression of this protein by an individual invasive prostatic carcinoma invariably heralds poor clinical prognosis. Because this protein has been shown to alter the balance between proliferation and apoptosis, understanding the mechanism(s) by which individual hsps regulate intracellular homeostasis may assist in explaining some key processes that occur during evolution of human prostate cancers. We suggest that hsp27 expression provides novel diagnostic and prognostic information on individual patient survival which, if obtained at the time of primary diagnosis, would assist in determining tumor-specific management strategies. Development of techniques to therapeutically modulate hsp27 expression raises the possibility of novel targeted approaches to regulate this homeostatic mechanism, thus allowing better control over tumor cell proliferation and hence patient survival.

Xanthogranulomatous funiculitis and epididymo-orchitis in a tetraplegic patient.

STUDY DESIGN: A case report of xanthogranulomatous funiculitis and epididymo-orchitis. Xanthogranulomatous inflammation is an uncommon, non-neoplastic process characterised by destruction of tissue, which is replaced by a striking cellular infiltrate of lipid-laden macrophages. CASE REPORT: A 21-year male sustained complete tetraplegia at C-6 level, after a fall in 1998. The neuropathic bladder was managed with an indwelling urethral catheter. He had many unsuccessful trials of micturition. Sixteen months after the cervical injury, he noticed swelling of the left side of the scrotum following removal of a blocked catheter. He was prescribed antibacterial therapy. Four weeks later, physical examination revealed a hard and irregular swelling encompassing the testis, epididymis and spermatic cord. The clinical diagnosis was epididymo-orchitis progressing to pyocele. Through a scrotal incision, the swollen testis, epididymis and diseased segment of the spermatic cord were removed en masse. Histopathology showed extensive areas of necrosis, with xanthogranulomatous inflammation in the spermatic cord and to a lesser extent in the testis/epididymis. CONCLUSION: Repeated episodes of high-pressure urinary reflux along the vas deferens during dyssynergic voiding, and subsequent interstitial extravasation of urine together with chronic, low-grade, suppurative infection possibly led to development of xanthogranulomatous inflammation in the testis and the epididymis. Since tissue destruction is a feature of xanthogranulomatous inflammation, the definite and curative treatment is either complete (or, where applicable, partial) excision of the affected organ in most of the cases.

Grading of benign prostatic obstruction can predict the outcome of transurethral prostatectomy.

PURPOSE: We investigate whether urodynamic grading of benign prostatic obstruction and detrusor contractility predicts the outcome of transurethral prostatectomy. MATERIALS AND METHODS: A total of 53 patients who were suitable candidates for transurethral prostatectomy completed an assessment protocol before and 3 months after surgery, which included International Prostate Symptom Score, uroflowmetry, ultrasonography (prostatic size and residual urine volume) and standard pressure flow study. The results of the pressure flow study were analyzed to grade obstruction (unequivocal, equivocal or no obstruction) and detrusor contractility (weak or normal) using our simplified pressure flow nomogram. RESULTS: Analysis of the pressure flow study data demonstrated that the efficiency of detrusor contraction was weak in 6 of 27 men with unequivocal, 11 of 23 with equivocal and 2 of 3 with no obstruction. Treatment outcome was significantly better in patients with unequivocal obstruction and normal detrusor contractility. Treatment failure occurred in 80% of patients with equivocal obstruction and impaired detrusor contractility, and 100% of the unobstructed group. Urodynamic grading of obstruction and detrusor contractility predicted treatment outcome with a sensitivity of 87%, specificity 93% and positive predictive value 95%. CONCLUSIONS: Urodynamic grading of benign prostatic obstruction and detrusor contractility can reliably predict treatment outcome and, therefore, enable the urologist to identify a subgroup of patients who would not benefit from surgery.

Hepatosplanchnic haemodynamics and renal blood flow and function in rats with liver failure.

BACKGROUND: Massive liver necrosis, characteristic of acute liver failure, may affect hepatosplanchnic haemodynamics, and contribute to the alterations in renal haemodynamics and function. AIMS: To investigate the relation between hepatosplanchnic haemodynamics, including portal systemic shunting, and renal blood flow and function in rats with acute liver failure. METHODS: Liver failure was induced in male Wistar rats by intraperitoneal injection of 1.1 g/kg of D(+)-galactosamine hydrochloride. The parameters assessed included; systemic, hepatosplanchnic, and renal blood flow (57Co microsphere method); portal-systemic shunting and intrarenal shunting (consecutive intrasplenic, intraportal, or renal arterial injections of 99mTc methylene diphosphonate and 99mTc albumin microspheres); arterial blood pressure and portal pressure; renal function; and liver function (liver function tests and 14C aminopyrine breath test). RESULTS: Progressive liver dysfunction was accompanied by the development of a hyperdynamic circulation, a highly significant decrease in renal blood flow and function, and an increase in intrarenal shunting 36, 42, and 48 hours after administration of D-galactosamine. The alterations in renal blood flow and function were accompanied by significant increases in portal pressure, portal venous inflow, and intrahepatic portal systemic shunting in galactosamine treated rats compared with controls. There was a significant correlation between changes in renal blood flow and changes in portal pressure, intrahepatic portal systemic shunting, and deterioration in liver function (r = 0.8, p < 0.0001). CONCLUSIONS: The results of this study suggest that both increased intrahepatic portal systemic shunting and hepatocyte impairment may contribute to alterations in renal haemodynamics and function.

Epidermal growth factor receptor in the vesical urothelium of paraplegic and tetraplegic patients: an immunohistochemical study.

Spinal cord injury (SCI) patients are at high risk of developing cystitis, and vesical neoplasia. As abnormal growth regulation of urothelium may be a predisposing factor for cystitis and vesical neoplasia, we studied alterations if any, in the expression and localization of epidermal growth factor receptor (EGRF) in the vesical urothelium by an immuno-histochemical technique, using monoclonal mouse anti-human epidermal growth factor receptor antibody (DAKO-EGFRI) in cold-cup biopsies taken from the trigone of the urinary bladder in 18 adult SCI patients who had a neuropathic bladder. Abnormal localisation of EGFR-p, i.e. cytoplasmic, was noted in 13 patients. A linear localization of EGFR-p along the cell membrane of the urothelium, considered as an essential requirement for effective function, was observed in only three cases. Combined cytoplasmic and cell membrane location of EGFR-p was seen in two patients. The three patients with cell membrane location of EGFR-p showed a strong expression of EGFR-p (2+, 2-3+, and 4+, respectively); the intensity of EGFR-p expression in cases of cytoplasmic immunostaining varied considerably. Histopathology revealed denuding cystitis in one; follicular cystitis in four; active inflammatory infiltrate in three; lymphocytic infiltrate in three; squamous metaplasia in six; and intestinal metaplasia in three biopsy specimens. The three specimens showing cell membrane location of EGFR-p were from patients who did not have an indwelling urethral catheter (a paraplegic man practising intermittent self-catheterisation, a tetraplegic patient on penile condom drainage, and a tetraplegic woman with reflex voiding), and histopathology revealed very little inflammatory infiltrate. In contrast, the biopsies from all the nine patients, who were on indwelling urethral catheter drainage and in whom the bladder biopsy revealed varying degree of cystitis, showed only cytoplasmic location of EGFR-p. Similarly, the biopsies from patients with bladder stone (n = 6) showed only cytoplasmic localisation of EGFR-p. In conclusion, abnormalities in vesical urothelial expression in EGFR in SCI patients may play a role in the pathogenesis of cystitis, vesical urothelial metaplasia, dysplasia and neoplasia.

The role of an advanced thermotherapy device in prostatic voiding dysfunction.

OBJECTIVES: To investigate the efficacy of an advanced transurethral thermotherapy (TUMT) device (T3, Urologix) using urodynamic analysis in addition to the standard evaluation protocol in patients with symptomatic benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: Fifty men with symptomatic BPH were assessed using the AUA symptom score, uroflowmetry and ultrasonography (to determine prostatic volume and residual urinary volume) before and 6 weeks, 3, 6 and 12 months after thermotherapy. TUMT was delivered using a focused microwave energy system for 1 h in each patient, treated on an out-patient basis. Video pressure flow studies with advanced urodynamic analysis were also performed before and 3 months after treatment. RESULTS: The mean AUA symptom score decreased by 63%, the mean peak flow rate increased by 64% and the post-void residual volume decreased by 30% 3 months after treatment; this improvement was maintained at one year after treatment. Advanced urodynamic analysis showed that 52% of the patients had a decreased severity of obstruction. Furthermore, the efficiency of detrusor contraction improved in 86% of the patients. The improvement in the symptom score, flow rate and residual urine was significantly better in patients with marginal obstruction than in patients with unequivocal obstruction. CONCLUSION: Urodynamic analysis can predict the treatment outcome of TUMT and the results of thermotherapy are significantly better in patients with marginal prostatic bladder outflow obstruction.

Quantification of voiding dysfunction in patients awaiting transurethral prostatectomy.

PURPOSE: We investigated the role of advanced urodynamic analysis in the diagnostic evaluation for transurethral resection of the prostate. MATERIALS AND METHODS: A total of 62 consecutive patients awaiting transurethral resection of the prostate with the American Urological Association symptom score of more than 12, peak flow rate less than 13 ml. per second and significant residual urine underwent routine video pressureflow studies with advanced urodynamic analysis to quantify outflow function. Postoperative outcome was assessed at 3 months by symptom scores, uroflowmetry and ultrasonography (residual urine). RESULTS: The parameters used in the diagnostic evaluation for transurethral resection of the prostate did not correlate with urodynamic diagnosis of unequivocal obstruction. Weak detrusor contractility (without significant obstruction) accounted for voiding dysfunction in 50% of the patients. The results of transurethral resection of the prostate were significantly better in patients with unequivocal compared to equivocal obstruction. Furthermore, patients with unequivocal obstruction but weak detrusor contractility had a significantly poorer treatment outcome. CONCLUSIONS: Advanced urodynamic analysis in the diagnostic evaluation of patients with symptomatic benign prostatic hyperplasia can predict treatment outcome and, therefore, allows the urologist to choose the most appropriate therapeutic option for individuals.

T-cell predominant balanitis in a traumatic tetraplegic patient: a case report.

T-cell predominant balanitis is described in a 38 year old uncircumcised tetraplegic man whose presenting feature was non-progressive red lesions over the inner prepuce and the glans penis without signs of infection, phimosis, or meatal stenosis. There was no regional lymphadenopathy. He was not exposed to any of the high risk factors for human immunodeficiency virus infection. As the lesion did not respond to topical antibacterial, antifungal, and corticosteroid medications applied in that order, circumcision was performed. Following circumcision, the remaining lesion over the glans penis regressed completely over a period of 1 month. Histopathology of the excised prepuce revealed that both areas of normal nonkeratinizing squamous epithelium as well as areas with hyperplasia. No atypia was noted and Bowenoid changes were not seen. Immunohistochemical studies on the inflammatory infiltrate in the excised prepucial lesion using tissue proliferation markers (PCNA and MIB-1) revealed active proliferation of the band-like infiltrate shown by immunophenotyping (anti-human T cell, CD45RO, clone UCHL1 and L26, pan-B marker) to consist predominantly of T-cells, further supporting the hypothesis of a local immune-mediated inflammatory process as the final pathogenic mechanism of the penile lesion.