Permanent prostate brachytherapy: a century of technical evolution.

PURPOSE: To summarise the practical aspects of the development of techniques of interstitial permanent prostate brachytherapy (PPB) implantation. Prostate brachytherapy dates back to Pasteau's publication in 1913 describing the insertion of a radium capsule into the prostatic urethra to treat carcinoma of the prostate. Various implantation methods were employed but with unsatisfactory results until the development of the transrectal ultrasound in the 1980s. The subsequent two-stage Seattle technique allowed for a planned homogenous distribution of radioactive sources throughout the gland resulting in biochemical control comparable to surgical and external beam radiotherapy series. With the advent of advanced computer software and improved imaging, the technique has developed accordingly to a single stage procedure with on-table dosimetric assessment. The principles of targeting dose to the prostate while avoiding surrounding organs at risk remain as relevant today as nearly a century ago. There is an array of techniques to consider for the novice PPB provider. Whether the evolution of PPB techniques will translate into improved biochemical control is yet to be seen.

Laparoscopic ureteroneocystostomy for benign lower ureteric stricture: case study and literature review.

The surgical treatment of distal ureteric strictures depends on their length and aetiology. Laparoscopic procedures in this setting are uncommon. We describe a laparoscopic non-refluxing ureteroneocystostomy for a symptomatic distal ureteric stricture performed on a 26-year-old man. The operation was carried out successfully without complication. Blood loss was 100 ml with an operating time of 250 min. He was discharged on the fourth day and returned to work after 11 days. Retrograde ureterography and cystography after 1 month showed no evidence of obstruction or reflux. At 3 months, an intravenous urogram showed excellent drainage and at 6 months the patient remained asymptomatic. We advocate the use of laparoscopic ureteroneocystostomy for benign distal ureteric stricture refractory to endoscopic procedures. In symptomatic patients, it is a feasible, safe, minimally invasive procedure with all the added benefits of laparoscopy compared with open repair. A non-refluxing anastomosis is preferable. Reconstructive and intracorporeal suturing skills are needed to carry out this procedure.

"Urological cold shower"--a novel treatment for intraoperative erection.

Intraoperative penile tumescence during endoscopic surgery is a troublesome complication and a challenge to the urologist. We describe a novel, convenient, safe, and readily available technique. We used an intracavernosal injection of epinephrine using a standard dental syringe and a cartridge of lidocaine 2% and epinephrine 1:80,000 to induce detumescence reliably.

Intravesical chemotherapy with epirubicin: a dose response study.

PURPOSE: We determined the difference in response to high and standard doses of intravesical epirubicin for treatment of superficial bladder cancer. MATERIALS AND METHODS: A total of 122 patients were entered into a randomized trial to compare the response of a marker tumor at 3 months, time to first recurrence and recurrence rates for 2 years after intravesical chemotherapy for superficial (pTa/pT1) bladder cancer. Patients were randomized to receive treatment for 1 hour with 1 (standard dose) or 2 mg./ml. (high dose) epirubicin (50 or 100 mg./50 ml. solution). RESULTS: There was no difference in the marker tumor response rate in 24 of 52 patients treated with the standard dose compared with 21 of 50 treated with the higher dose of epirubicin (p = 0.67). Similarly, the higher dose was not superior in regard to time to first recurrence, with a hazard ratio of 1.46 (p = 0.14, 95% confidence intervals 0.88 to 2.42). Considering the upper end of the confidence interval, we can reliably exclude an absolute difference of greater than 4% at 1 year for time to first recurrence in favor of higher dose chemotherapy. CONCLUSIONS: Epirubicin at double the standard dose for intravesical chemotherapy of superficial bladder cancer is not superior in regard to marker tumor response, time to first recurrence or recurrence rate.

Relative cytotoxicities of adriamycin and epirubicin in combination with lonidamine against human bladder cancer cell lines.

We have used a panel of bladder cancer cell lines to compare the toxicities of Adriamycin and epirubicin, two drugs used intravesically to treat superficial transitional cell cancer (TCC) of the bladder, alone and in combination with lonidamine, an agent known to be active against anthracycline-resistant disease. Comparing concentrations reducing colony-forming ability by 50%, epirubicin and Adriamycin were similar in their cytotoxicities, although epirubicin was more potent against every line except an Adriamycin-resistant subline. Combinations of the two drugs with a non-cytotoxic concentration (1 microgram/ml) of lonidamine were tested using the Adriamycin-resistant subline MGH-U1R and its sensitive parental line MGH-U1. The addition of lonidamine caused a two-fold increase in the sensitivity of the resistant subline to both drugs, while having no effect on the sensitivity of the parental line. The data indicate that this combination might be of value in anthracycline-resistant disease.

Superficial bladder cancer: the response of a marker tumour to a single intravesical instillation of epirubicin.

OBJECTIVE: To determine the response of a marker tumour to a single instillation of intravesical epirubicin. PATIENTS AND METHODS: Eighty-one patients (54 men, 27 women) with a mean age of 69.3 years (range 36-92) with superficial bladder cancer were randomized to receive a single instillation of intravesical epirubicin. At the initial cystoscopy all but one papillary marker tumour was resected. Subsequently the patients were randomized to receive either intravesical epirubicin at a concentration of 1 mg/ml (n = 40) or 2 mg/ml (n = 41) in 50 ml of saline for 1 h. The response of the marker tumour was determined at 3 months (first check cystoscopy). The toxicity associated with both treatments was also recorded. RESULTS: A complete response (no visible or microscopic bladder carcinoma) was observed in 46% (95% confidence interval (CI) 35-57%) of patients. No patient experienced systemic side-effects. Chemical cystitis and bladder irritability were the most frequent local side-effects, occurring in 15% (95% CI 8-24%) of the patients. CONCLUSIONS: A single instillation of intravesical epirubicin has a demonstrable effect in superficial bladder cancer. The results compare favourably with more onerous regimes. Side-effects were minimal at 1 mg/ml and acceptable at 2 mg/ml.

Ultrasound in renal carcinoma: an essential in follow-up.

A total of 115 patients underwent radical nephrectomy for renal carcinoma in this hospital between 1983 and 1990. Follow-up was available in 113 cases (mean 27 months, range 0-93). The overall actuarial survival was 66% at 2 years and 53% at 5 years. Fifty-three patients have been followed up with annual abdominal ultrasound over the last 2 years. Abnormal ultrasound scans were reported in 6 patients (11%) on follow-up. Two had para-aortic lymph node recurrence amenable to further surgery. One patient developed a metachronous tumour and a partial nephrectomy was carried out. Three patients had local recurrence not amenable to further surgery. Ultrasound and computed tomography have found an invaluable place in the pre-operative diagnosis and staging of renal carcinoma. Sixteen of 113 tumours were diagnosed by ultrasound or intravenous urography carried out for some other purpose; 8 were less than 5 cm in diameter and 12 were T category N0M0V0. The 2-year survival rate in this group was 85% (mean 30 months, range 19-67). We consider the routine follow-up of renal carcinoma with clinical examination and annual chest X-ray to be inadequate. The application of ultrasound in the follow-up of these patients has provided a valuable adjunct to our clinical practice. It has allowed the prompt diagnosis of lymph node recurrence or metachronous tumour amenable to secondary surgery with the potential for improved survival in this group of patients. We consider this to be the logical extension of the value of ultrasound in the pre-operative diagnosis of renal carcinoma.

A consumer's guide to laparoscopic equipment for urology.

The ever increasing amount of laparoscopic instrumentation and the lack of any objective comparison make choosing the most appropriate equipment a difficult task for the urological neo-laparoscopist. All major manufacturers of laparoscopic equipment were invited to submit as much of their equipment as possible for inspection. A selection of ports, hand instruments, haemostatic devices and imaging systems was then tested in a laboratory and clinical setting. Costings are provided for evaluated ports, hand instruments and imaging systems. Vessels with a diameter greater than 7 mm, such as renal artery and vein, should be secured with a linear stapler-cutter. The optics of the Olympus OTV-S4, CLV-10 light source, Olympus light cable and A5254A telescope are superior to the other imaging systems tested. Laparoscopic equipment is diverse in specification, performance and cost. Due consideration must be given to these factors when purchasing equipment to avoid disappointment and wastage of resources, particularly with regard to disposable instruments and imaging systems.

Bromodeoxyuridine labelling of transitional cell carcinoma of the bladder--an index of recurrence?

Nineteen patients with newly diagnosed transitional cell carcinoma of the bladder consented to receive an intravenous bolus of bromodeoxyuridine (BrdUrd) 3 to 6 h prior to transurethral resection of bladder tumour. Routine paraffin embedded sections were stained with anti-BrdUrd monoclonal antibody in order to determine the S phase fraction of the bladder tumours and to correlate this with tumour grade, category and the development of recurrence during follow-up. BrdUrd labelling of nuclei was reliably detected in 100% of the tumours. The mean labelling index of Ta tumours (n = 8) was 3.14%; in T1 tumours (n = 7) it was 8.6% and in T2-3 tumours (n = 4) it was 16.4%. A similar correlation was found in association with tumour grade. The patients were followed up for a mean of 23 months (range 18-30). Seven of the 15 superficial tumours recurred during the period of follow-up. These tumours had a mean labelling index (at diagnosis) of 8.4%, whereas the tumours that did not recur had a mean labelling index of 3.4%. The in vivo determination of BrdUrd uptake in transitional cell carcinoma of the bladder may be useful in predicting which superficial tumours are likely to recur following resection and so rationalise both the time to follow-up and intravesical chemoprophylaxis.