A survey of health care needs of physicians.

BACKGROUND: The healthcare needs of physician are not well studied. METHODS: We surveyed physicians attending a large primary care conference about their access and perceived barriers to receiving healthcare services. RESULTS: Response rate was 46 % (270/592). The majority were trained in family medicine. The age category of above 60 years was the most common (39 %) and 46 % were women. Important difficulty in accessing healthcare services was reported by 39 % of physicians and the majority (61 %) reported reverting to self-diagnosis and self-treatment. Female physicians reported more difficulties than male physicians (p < 0.001 for difficulty in securing access and p = 0.02 for self-diagnosis and treatment). The barriers cited were finding time for healthcare, concern about confidentiality, and lack of encouragement by employer. Respondents reported experiencing a career threatening illness themselves (20 %) or in a colleague (81 %). Forty-two percent experienced being concerned about a colleague being able to safely practice due to illness. Participants ranked substance abuse as the most common illnesses affecting a physician's ability to practice followed by psychiatric disorders, heart disease, neurological disorders and cancer. CONCLUSIONS: Physicians face important barriers to accessing healthcare services. Female physicians report worse access. The identified barriers are modifiable. This survey calls for efforts to improve physicians' health that require collaboration among physicians, employers and policymakers.

Percutaneous urinary drainage and ureteric stenting in malignant disease.

Patients with malignant ureteric obstruction often have a poor life expectancy, even if relief of urinary obstruction is achieved. Careful discussion between the patient, their family and all health care professionals involved in the case must be undertaken before any intervention. The goal of treatment in the palliative setting may be to offer symptom relief, avoid complications from renal insufficiency or allow further oncological systemic therapy. The obstruction can be relieved by placement of a percutaneous nephrostomy tube, a ureteric stent or, more rarely, due to the palliative nature of the patients, a more complex open surgical procedure. Nephrostomy tubes offer excellent drainage and can be placed under a local anaesthetic, although they do require and a bag, which can reduce a patient's quality of life. Bleeding, sepsis, bowel transgression and pleural complications can all be encountered when inserting a nephrostomy. JJ stents in comparison have a higher failure rate due to extrinsic compression and usually require a general anaesthetic for placement, although significant bleeding and other complications are reduced. Quality of life is still affected by irritative lower urinary tract symptoms. Metallic ureteric stents have recently been developed to try and offer better relief of obstruction than polymeric stents with fewer side-effects and increased intervals between changes. Initial data appear encouraging, although further trials are needed. No blueprint for treatment of malignant ureteric obstruction exists and each case must be decided on an individual basis with a fully informed patient.

Dystrophic ureteral calcification associated with Churg-Strauss vasculitis.

Churg-Strauss syndrome is an uncommon systemic vasculitis affecting small blood vessels. Renal involvement is typical; however, calcinosis of the urinary tract has not previously been described. Dystrophic calcification in the urinary tract is rare, although it is occasionally associated with schistosomiasis, tuberculosis, and polyarteritis nodosa. We report the case of a 19-year-old man with newly diagnosed Churg-Strauss syndrome who presented to us with dystrophic calcification in both ureters causing bilateral obstruction.

Long-term outcomes in patients with prostate cancer managed with intermittent androgen suppression.

OBJECTIVES: To assess the long-term outcomes of patients with prostate cancer managed with intermittent androgen suppression (IAS) following their enrollment in an open, non-randomised feasibility study initiated 10 years ago. PATIENTS AND METHODS: Patients with prostate cancer who developed marked side effects following androgen deprivation were considered for entry into the study. All patients were required to have been managed with androgen deprivation for a minimum of 9 months and to have achieved PSA remissions to levels <4 ng/ml or falls to greater than 90% of pre-treatment levels. Patients remained off treatment until PSA values rose to >20 ng/ml or individuals became symptomatic--at which stage a 9-month cycle of androgen suppression was repeated. Such on-off cycling continued until hormone-resistant disease developed and patients proceeded (off trial) to second-line therapies. RESULTS: 75 patients were recruited to the study following an initial referral with treatment-related side effects specifically associated with androgen deprivation. 86% of these remain alive at a median of 134 months (11 years) since initial histological diagnosis. Survival times and times to hormone resistance (from first cycle hormone deprivation) have also been calculated. Overall there is a median survival time of 95 months (8 years) from initial (first-cycle) androgen deprivation in those presenting with localised or locally advanced disease and a median survival time of 87 months (7 years) for those presenting with metastatic disease. There exists a median of 83 months to hormone resistance in the localised and locally advanced group and a median of 50 months in those presenting with metastatic disease. We have calculated a 100% 5-year actuarial survival rate for those presenting with localised or locally advanced disease (from time of first cycle hormone ablation) and a 70% 5-year actuarial survival rate for those presenting with metastatic. CONCLUSIONS: Long-term outcome figures and actuarial survival rates presented here provide further support for a pulsed or intermittent approach to androgen ablation in patients with prostate cancer. In addition, they serve as valuable extended outcome data for patients managed in this way. Likewise, data presented here suggests that apparent survival advantages appear related, at least in part, to a delay in the onset of androgen resistance and that such a management approach is both safe and effective in those presenting with both metastatic disease as well as those with more localised pathology.

Transurethral electrovaporization of the prostate (TUVP) is effective, safe and durable.

Transurethral electrovaporization of the prostate (TUVP) is one of the alternative, minimally invasive procedures to treat BPH with promising initial results. We reviewed the available English literature to evaluate the long-term safety, efficacy and durability of TUVP using various vaporizing electrodes. We performed a MEDLINE keyword search and assessed all prospective randomized studies, which compared TUVP to standard transurethral resection of the prostate (TURP) that reached 1 y follow-up. Data were analysed for improvement of IPSS and Q(max), operation time, hospital stay, perioperative bleeding, postoperative irritative symptoms, long-term side effects and reoperation rate. We reviewed a total of 244 TUVP compared to 259 TURP patients in six prospective randomized studies that reached 1 y follow-up. Less perioperative bleeding, shorter catheterization time (mean of TUVP: 30 h vs TURP: 61 h) and shorter hospital stay (mean of 1.4 days vs TURP: 3.4 days) were reported in the TUVP patients. The improvement in IPSS (71%) and mean Q(max) (20 ml/s) was similar in both groups. The reoperation rate was 2% per year in both vaporization and resection patients. In conclusion, analysis of the prospective randomized trials that reached 1 year follow-up revealed that TUVP is as effective as standard TURP in the treatment of BPH. Long-term side effects and reoperation rates are comparable and the initial improvement was maintained over 1 year for the majority of patients.

The self-expanding metallic ureteric stent in the long-term management of benign ureteric strictures.

OBJECTIVE: To evaluate and assess the long-term complications of using the thermo-expandable, nickel-titanium alloy stent (Memokath 051, Engineers & Doctors A/S, Hornbaek, Denmark) for managing benign ureteric strictures. PATIENTS AND METHODS: Over a 3-year period, 13 Memokath stents were inserted in 11 patients (mean age 58 years, range 35-85) with 12 lower ureteric strictures. The cause of the stricture was benign in all cases, i.e. radiation fibrosis in three, retroperitoneal fibrosis, ischaemic uretero-ileal anastomosis and scarring after ureteroscopy in two each, and diathermy damage, extraluminal endometriosis and stone passage in one each. Four stents were 9 F with proximal expansion to 17 F and the other nine used were 10.5 F with proximal expansion to 20 F. The patients were followed for a mean (range) of 18 (1.5-33) months. RESULTS: No complications or side-effects occurred with nine stents; four stents were removed at a mean (range) of 16.3 (4-33) months. Three of these had become encrusted, two of which had been placed in patients who had either a history of stone disease or recurrent urinary tract infection. The other stent had migrated. CONCLUSION: The Memokath stent appears to have a useful role in managing benign ureteric strictures, but it must be closely monitored in patients who are predisposed to encrustation.

A 3-year follow-up of a prospective randomized trial comparing transurethral electrovaporization of the prostate with standard transurethral prostatectomy.

OBJECTIVE: To compare the safety, efficacy and durability of transurethral electrovaporization of the prostate (TUVP) with standard transurethral resection of the prostate (TURP). PATIENTS AND METHODS: In all, 104 patients admitted from the waiting list for surgery for BPH were randomized to either TUVP (52 patients, mean age 67.5 years) or TURP (52 patients, mean age 70.2 years); 51, 47 and 40 patients in each arm completed 1, 2 and 3 years of follow-up, respectively. Patients were assessed at baseline and during the follow-up using the International Prostate Symptom Score (IPSS), the associated quality-of-life score (QoL), postvoid residual volume (PVR) and maximum urinary flow rate (Qmax). RESULTS: Both groups had comparable mean IPSS, QoL, Qmax and PVR at baseline. The mean (SD) values for TUVP and TURP, respectively, at 3 years showed a significant and maintained improvement in IPSS, at 4.1 (3.3) and 7.1 (6.2) (P = 0.01), in QoL, at 1.0 (0.9) and 1.6 (1.4) (P = 0.04), and in Qmax, at 22.2 (8.5) and 18 (7.1) mL/s (P = 0.02), with decreases in PVR of 30 (38) and 21.9 (26.2) mL (P = 0.27). The re-operation rate in each group was 4% during the first year, 4% during the second year and 5% during the third year. After surgery and at 1, 2 and 3 years of follow-up, impotence was reported in 17% of the TUVP group and 11% of the TURP group (P = 0.49), and retrograde ejaculation in 72% of the TUVP group and 89% of the TURP group (P = 0.47). CONCLUSION: The 3-year follow-up results confirm that TUVP is as effective as standard TURP in the treatment of moderate-sized BPH. The long-term side-effects and complications were comparable and the initial improvement was maintained over 3 years in most patients in both groups.

Stilboestrol plus adrenal suppression as salvage treatment for patients failing treatment with luteinizing hormone-releasing hormone analogues and orchidectomy.

OBJECTIVE: To investigate the efficacy of low-dose stilboestrol (SB) with hydrocortisone in patients with advanced prostate cancer refractory to androgen suppression. PATIENTS AND METHODS: Thirty-four consecutive patients (median age 70 years, range 51-83) with metastatic disease who progressed on hormone therapy, as shown by recurrent/worsening symptoms and an increase in prostate-specific antigen (PSA) level, were recruited and discontinued hormonal treatment before starting SB. Patients received SB (1 mg/day) combined with hydrocortisone (40 mg/day). In an attempt to reduce the incidence of thrombo-embolic events, aspirin (75 mg/day) was also added. RESULTS: Stilboestrol was the second-line treatment in 19 patients and the third or fourth in 15. The median (range) duration of treatment with SB was 5 (0.5-21) months and the median follow-up 7.5 months, with 18 patients still alive and 14 still on treatment. Of 29 symptomatic patients, 24 had symptomatic improvement and five had no clear benefit; the median duration of benefit was 6 (2-21) months. The PSA level decreased by 0-50% in six patients, by 50-90% in 13 and by > 90% in eight, while there was symptomatic improvement in these three categories in five, 11 and seven patients, respectively. The median times to PSA nadir and progression were 4 and 6 months, respectively. Some thrombo-embolic events and fluid retention occurred but overall the treatment was well tolerated. CONCLUSION: Low-dose SB with hydrocortisone is effective in refractory prostate cancer, although there is some toxicity. Randomized studies against hydrocortisone or SB alone are needed to establish the cost/benefit ratio of this combination.

Two-year follow-up of a prospective randomised trial of electrovaporization versus resection of prostate.

OBJECTIVES: Transurethral electrovaporization of the prostate (TUVP) has become a popular, minimally invasive procedure to treat BPH with promising initial results. This study was conducted to compare the efficacy, safety and durability of TUVP with standard TURP. We report the 2-year follow-up. METHODS: 104 consecutive men with BPH admitted for surgery were randomised to TUVP (52 patients, mean age: 67.5 years) or TURP (52 patients, mean age: 70.2 years). 47 patients in each arm completed 2-year follow-up. RESULTS: Follow-up data at 2 years show a comparable, significant and maintained improvement in mean IPSS (TUVP: 4.3 vs. TURP: 6.3), quality of life score (TUVP: 1. 1 vs. TURP: 1.7), and maximum flow rate (TUVP: 22.4 vs. TURP: 21.2 ml/s) with fall in mean post-void residual volume (TUVP: 18.8 vs. TURP: 22.8 ml). Postoperative impotence reported in TUVP: 17% vs. TURP: 11% (p = 0.49) and retrograde ejaculation TUVP: 72% vs. TURP: 89% (p = 0.47). Two patients in each arm (4%) had urethral stricture and 2 patients (4%) in the resected group had bladder neck stricture. Four patients in each group required re-operation for residual adenoma during the 2 years (4% in each arm each year). CONCLUSIONS: Our 2 years' follow-up results suggest that TUVP is as effective as standard TURP in the treatment of moderate-sized BPH with comparable durability.

Transurethral electrovaporization of the prostate--a possible alternative to transurethral resection: a one-year follow-up of a prospective randomized trial.

OBJECTIVE: To compare the efficacy, safety and durability of transurethral electrovaporization of the prostate (TUVP) with standard transurethral resection (TURP) in a prospective randomized trial. PATIENTS AND METHODS: The study included 104 consecutive men with symptomatic benign prostatic hyperplasia (BPH) admitted for surgery who were randomized to TUVP or TURP. The variables evaluated included the duration of surgery, catheterization and hospital stay, the International Prostate Symptom Score (IPSS), a quality-of-life assessment (QOL), the maximum urinary flow rate (Qmax) and the postvoid residual urine volume (PVR). RESULTS: Both groups showed a comparable significant and maintained decline in the mean IPSS, from 26.5 to 4.4 (TUVP) and from 26.6 to 5.9 (TURP), and increase in mean Qmax, from 8.6 to 20.8 mL/s [corrected] (TUVP) and 8.6 to 22.8 mL/s (TURP) after 1 year. However, there were significant differences in the mean duration of catheterization (TUVP 20.9 h, TURP 46.6 h, P<0.001), hospital stay (TUVP 2.2 day, TURP 3.1 days, P<0.001), and the duration and volume of post-operative irrigation (TUVP none, TURP 18.1 h with 17.5 L of saline). Two patients in each group developed urethral strictures (4%) and two patients in each group required re-operation for residual adenoma (4%); two patients undergoing TURP had a bladder neck stricture (4%). CONCLUSION: The results suggest that TUVP is as effective as standard TURP in the treatment of moderate-sized BPH. TUVP offers the advantage of using established instruments, has excellent peri-operative haemostasis and requires a shorter hospital stay.

Renal cell carcinoma containing fat mimicking angiomyolipoma: demonstration with CT scan and histopathology.

We report a case of a large renal tumour containing small amounts of fat and some calcification that proved to be a renal cell carcinoma. The CT appearance of the tumour was suggestive of an angiomyolipoma. Although the overwhelming majority of renal masses containing fat are angiomyolipomas, in the presence of calcification the diagnosis of renal cell carcinoma should be entertained.

Transurethral vaporization of the prostate: a promising new technique.

OBJECTIVE: To evaluate the efficacy and safety of transurethral electrovaporization of the prostate (TUVP), using a grooved roller electrode, for the surgical treatment of symptomatic benign prostatic hypertrophy (BPH). PATIENTS AND METHODS: TUVP was carried out using a grooved roller electrode, pure-cutting diathermy and a standard irrigating resectoscope to rapidly heat prostatic tissue to > 100 degrees C, resulting in vaporization and cavitation of the prostatic adenoma. Over a 10 month period, 116 patients (mean age 69.8 years, range 51-93) with symptomatic BPH (confirmed by a symptom score, urinary flow rate and an ultrasonographic estimate of residual volume) were treated by TUVP. Patients with carcinoma of the prostate, an elevated level of prostate-specific antigen or those in chronic urinary retention were excluded from the study. Each patient was followed up every 4 months during the first post-operative year, assessing their flow rate, residual volume and symptom score. RESULTS: Symptom scores improved by 67% and residual volumes by 72%; the mean maximal flow rate increased from 8.5 mL/s (range 3.5-14) before treatment to 20.5 mL/s (range 4.5-39.0) at the same 4 month review. The procedure was simple and safe, with a mean operative duration of 35 min (range 20-65), and no patients required a blood transfusion. Most patients had their catheters removed within 24 h and were discharged on the second day after treatment. CONCLUSION: The effectiveness of TUVP in improving symptoms and flow rates in patients with BPH was established. With minimal capital expenditure and a reduced in-patient stay. TUVP appears to have several advantages over other surgical treatments for BPH, although continued follow-up is needed to establish the long-term results.

Lack of inhibition of glyceryl trinitrate by diphenyleneiodonium in bovine coronary artery.

Recent studies indicate that diphenyleneiodonium is a potent inhibitor of glyceryl trinitrate-induced relaxation in rat aorta precontracted with phenylephrine. We have explored the generality of this action in bovine coronary artery precontracted with the thromboxane A2 mimetic, 9,11-dideoxy-11 alpha, 9 alpha-epoxy-methano-prostaglandin F2 alpha (U46619). Diphenyleneiodonium 0.3 microM was without effect (endothelium absent) or caused mild potentiation (0.3 microM or 10 microM; endothelium present) of the relaxant response to gylceryl trinitrate. Lack of inhibition was not due to U46619, since inhibition was still prominent in rat aorta precontracted with this agent. It is concluded that diphenyleneiodonium distinguishes between cellular mechanisms mediating vasodilator responses to glyceryl trinitrate in rat aorta and bovine coronary artery.

Urethral caruncle: an unusual presentation of ovarian tumour.

Secondary female urethral cancer presenting as urethral caruncle is extremely rare. We report a primary ovarian adenocarcinoma in a 78-year-old female patient presented initially as a urethral caruncle. This case represents the first reported case in the world literature. The clinical features, investigations and pertinent literature are reviewed.

The prostatron transurethral microwave device in the treatment of bladder outflow obstruction due to benign prostatic hyperplasia.

There is currently considerable interest in the development of non-surgical means of managing bladder outflow obstruction due to benign prostatic hyperplasia (BPH). We report the results of a 1-year follow-up of 140 men (mean age 67.2 years) presenting with symptoms of bladder outflow obstruction treated for 1 h in a single session by the Prostatron transurethral thermotherapy system. Symptom scores, using a system modified from Boyarsky, fell from baseline values of 23.7 to 11.6. Maximum urinary flow values increased from a mean of 10.1 to 12.4 ml/s. Although residual urine volumes decreased slightly, this was not statistically significant. A self-administered postal questionnaire returned by 114 patients 1 year after Prostatron treatment, and by 87 patients of similar age who had undergone transurethral resection of the prostate (TURP) in the same institution, revealed that patient satisfaction regarding the outcome of each procedure was higher for TURP than thermotherapy. However, more patients suffered sexual dysfunction after TURP than after microwave treatment. It was concluded that although treatment with the Prostatron device produces subjective and objective improvement in a proportion of patients with BPH, more work needs to be done to improve the overall results and to pre-identify patients who experience little or no benefit from this therapy.

Clinical experience using the Wolf Piezolith device at 2 British stone centers.

Machines using the principle of piezoelectric extracorporeal shock wave lithotripsy have been developed. This has allowed the prospect of painless treatment for renal and ureteral calculi. The experience with use of 2 Wolf Piezolith machines for 1 year is presented. Different second generation lithotriptors have varying techniques of production of shock waves and different imaging methods. The Wolf Piezolith device uses ultrasound imaging and piezoelectric crystals for shock wave generation. Between June 1987 and May 1988, 545 patients 5 to 84 years old were treated with the Wolf Piezolith device. Of these patients 2-month followup data are available for 367 (398 renal units). Outpatient treatment was used routinely. For renal calculi complete fragmentation (into particles less than 2 mm. in size) was achieved in 94 per cent of the patients, with 53 per cent being completely free of stone at 2 months. For ureteral stones treated in situ the best results were obtained in the upper and lower ureter. Over-all, 62 per cent of the patients required more than 1 treatment, with the number of treatment sessions required increasing with the size of the stone treated. Morbidity was low. Ultrasound imaging has proved to be as effective as x-ray imaging. Compared to Dornier HM-3 lithotripsy, installation and running costs were low. The machine offers a favorable alternative to first generation lithotriptors.