The role of percutaneous nephrostomy in malignant ureteric obstruction.

OBJECTIVES: Uraemia as a result of malignant ureteric obstruction is a recognised event in those with advanced malignancy, usually of pelvic origin, which, if left untreated, is quickly a terminal event. Palliative decompression of the obstructed urinary system, either by percutaneous nephrostomy (PCN), ureteric stent or a combination of both is a recognised method of improving renal function, with presumed low morbidity. The aims of the study were to assess whether PCN placement in malignant ureteric obstruction provided any additional survival benefit or patient morbidity. PATIENTS AND METHODS: The case notes of 32 patients with a mean age of 68.1 years (16 male, 16 female) who underwent PCN drainage for malignant ureteric obstruction were retrospectively analysed. Data on the site of primary malignancy, mode of presentation, improvement in renal function, median survival, conversion to internal ureteric stents and intervention-related complications were collected for analysis. RESULTS: The median survival following PCN insertion was 87 days and was unrelated to the patient's age and renal function. Those patients with primary underlying gynaecological malignancies appeared to survive almost 4 times as long as those with underlying primary bladder cancer. Renal function took a mean of 16.8 days to reach a nadir. Almost 79% of patients were able to be discharged from hospital--each patient, however, being re-admitted back to hospital on average 1.6 times prior to their death through PCN or internal ureteric stent related events. Retrospective "useful quality of life" was seen in less than half of the patient cohort. CONCLUSIONS: In the presence of malignant ureteric obstruction, palliative percutaneous urinary diversion may be performed and is effective in improving renal function. However, long-term survival is limited and should, therefore, be performed only when the views and wishes of the patient and carers are taken into account and if there is a definitive treatment plan available for the patient as quality of life can be suboptimal.

The changing practice of transurethral prostatectomy: a comparison of cases performed in 1990 and 2000.

OBJECTIVES: Transurethral resection of the prostate (TURP) is considered by many to be the 'gold standard' treatment for benign prostatic enlargement. However, with the relatively recent introduction of pharmacological and other surgical treatment modalities, the performance of TURP appears to be in decline. METHODS: A retrospective casenote analysis of 200 patients who underwent TURP in 1990 and the year 2000 with the aim of identifying changes in the incidence and practice of TURP. RESULTS: There was a decline in the number of TURPs performed of 31.6% over the 10-year period, with more being carried out because of urinary retention. In 2000, the patient was older and the operative procedure took statistically longer than 10-years earlier, but the weight of prostate tissue resected, patient satisfaction and complication rates were similar. CONCLUSIONS: At present, TURP is in decline, with urinary retention being the commonest indication. The population at present is older but this does not carry additional co-morbidity. The weight of resection has not altered, although surgery currently takes longer to perform.

The catheterized patient undergoing transurethral resection of the prostate: a survey of the current practice of British urologists.

OBJECTIVE: To determine, using a postal questionnaire survey of practising British consultant urologists, the duration and type of antibiotic deemed most effective in patients with an existing indwelling catheter before transurethral resection of the prostate (TURP), as the value of prophylactic antibiotics before TURP is well recognized, but no data are available. METHODS: A questionnaire was posted to each of the 321 practising consultant urologists listed in the handbook of the British Association of Urological Surgeons (1998). A hypothetical situation in the opening statement proposed 'a patient with an indwelling catheter is to undergo TURP'. The type, timing and duration of prophylactic antibiotic usage were elicited by circling the appropriate response from a choice of several possibilities. RESULTS: In all, 250 questionnaires were returned; 98% of respondents recognized the importance of the prophylactic use of antibiotics in catheterized patients undergoing TURP, and routinely use them. Most urologists (53%) use more than one dose, with most of these preferring a second dose on catheter removal (60%). CONCLUSION: The magnitude and diversity of response suggests uncertainty about the appropriate prophylaxis in such patients, and the need for further studies to clarify this situation.

Limitations of ultrasound evaluation in acute closed renal trauma.

Imaging of the kidneys following acute closed renal trauma may be undertaken using one of several available modalities. Ultrasound evaluation is often the first choice of imaging modality, as it is quick, non-invasive and often readily available for urgent assessment. We report three cases in which significant under-evaluation of major renal parenchymal injury occurred using B-mode ultrasound; the injury was detected only by subsequent computerized tomography (CT) imaging.

Aminohexane diphosphonate in the treatment of Paget's disease of bone.

We studied the effects of the intravenous or oral administration of aminohexane diphosphonate (AHDP) in 42 patients with active Paget's disease of bone. Treatment of mouth (400 mg daily for 1 month) or intravenously (25 mg or 50 mg daily for 5 days) induced marked suppression of biochemical indices of disease activity. Urinary excretion of hydroxyproline fell to 39 and 42% of pretreatment values (oral and IV treatments respectively), and was followed by a similar decrease in the serum activity of alkaline phosphatase. In both groups of patients, disease activity remained suppressed for the 6 months of followup, and pain improved in 34 out of 37 patients who had bone pain attributed to Paget's disease. Both biopsies indicated that osteoblast and osteoclast numbers decreased with no adverse effects on mineralization. Neither regime was associated with significant side effects. We conclude that short courses of AHDP provide a promising treatment for the long-term control of Paget's disease.

Biochemical and histological evidence that carcinoma of the prostate is associated with increased bone resorption.

We have investigated the hypothesis that carcinoma of the prostate with skeletal metastases is associated with increased bone resorption. In 54 affected patients a close correlation was observed between serum activity of alkaline phosphatase and urinary excretion of hydroxyproline (r = +0.818; P less than 0.001), comparable to that seen in Paget's disease of bone. The administration of synthetic salmon calcitonin (100 U subcutaneously) induced a significant fall in serum calcium and urinary excretion of hydroxyproline, proportional to the prevailing rate of bone turnover, as assessed by serum alkaline phosphatase or hydroxyprolinuria. Administration of the diphosphonate, etidronate, also decreased hydroxyprolinuria, suggesting that urinary hydroxyproline reflected increased rates of bone resorption in this disorder. Histology of bone in sites adjacent to and distant from skeletal metastases showed increased histological indices of bone resorption. These results suggest that the skeletal disease associated with prostatic carcinoma is characterized by generalized increases in bone resorption as well as focal increases in bone formation.

Effects of intravenous etidronate disodium on skeletal and calcium metabolism.

The induction of hypercalcemia in malignant disease is almost invariably associated with increased bone resorption. However, tumor-induced changes in bone formation and renal tubular resorption of calcium are also important factors that induce hypercalcemia in some patients. In addition, alterations in calcium fluxes to and from the extracellular fluid secondary to hypercalcemia are important in maintaining or aggravating the hypercalcemic effects of increased bone resorption. These factors significantly affect the responses to treatment of hypercalcemia with inhibitors of bone resorption. This study examined the relative importance of these factors and the effects of intravenous etidronate disodium (etidronate) in neoplastic bone disease with and without hypercalcemia and in Paget's disease of bone. It is concluded that intravenous etidronate is an effective inhibitor of bone resorption, which accounts in large measure for its effects on serum calcium concentrations. These studies of etidronate in hypercalcemia suggest the response is sustained for several weeks.

Treatment of the hypercalcaemia of malignancy with intravenous clodronate.

We studied the effects of intravenous clodronate (100-300 mg daily for 3-10 days) in 27 episodes of hypercalcaemia due to malignancy. Comparisons were also made between responses in patients with haematological malignancies and those with solid tumours. Following extracellular volume expansion, clodronate induced a significant decrease in serum calcium within 2 days of the start of treatment which was maximal at 7 days. This was associated with a decrease in bone resorption as judged by decreases in urinary excretion of hydroxyproline and calcium. Hypercalcaemia recurred 5-7 days after stopping treatment. Patients with solid tumours had higher pretreatment serum calcium values than those with haematological malignancies despite comparable values for fasting urinary excretion of calcium suggesting that renal tubular reabsorption of calcium was more markedly increased in patients with solid tumours. No difference was observed in the final calcium values between patients with solid tumours and haematological malignancies except in those patients in whom renal tubular reabsorption of calcium was markedly increased before treatment. We conclude that intravenous clodronate provides a safe and effective treatment of hypercalcaemia due to a wide range of tumour types provided that increased bone resorption contributes significantly to the hypercalcaemia. When increased renal reabsorption of calcium is the predominant mechanism for the maintenance of hypercalcaemia, the response to clodronate is incomplete.

Biochemical markers and skeletal metabolism in carcinoma of the prostate. Use of decision matrix theory and ROC analysis.

The discriminative ability of several skeletal and tumour markers was assessed in 102 patients with prostatic disease. These comprised serum acid and alkaline phosphatase, serum albumin and osteocalcin, urinary excretion of calcium, hydroxyproline and 6-oxo prostaglandin F1 alpha. None of the tests was of value in distinguishing patients with benign prostatic disease from those with tumour not involving the skeleton. Values of serum osteocalcin, urinary excretion of calcium and urinary 6-oxo prostaglandin F1 alpha failed to discriminate significantly between patients with or without metastases. The remaining four markers were compared by decision matrix analysis and receiver operating characteristic (ROC) curves. Serum alkaline phosphatase provided the most sensitive marker of skeletal metastases (80.5%), followed by serum acid phosphatase (80%), hydroxyproline (68%) and albumin (30%). ROC analysis suggested that alkaline phosphatase conformed most closely to the "ideal marker" with highest specificity and sensitivity.

Generalised increase in bone resorption in carcinoma of the prostate.

Several indirect biochemical indices of bone resorption are increased in patients with carcinoma of the prostate and skeletal metastases. We have examined histological indices of bone resorption in biopsies from affected patients. Bone-forming surfaces and active osteoblast numbers were increased in skeletal sites adjacent to tumour tissue and indices of bone resorption were significantly increased at sites adjacent to tumour. Contrary to expectation, indices of bone resorption were also increased in bone distant from skeletal metastases. These findings suggest that prostatic cancer induces generalised loss of trabecular bone which may minimise disturbances in plasma calcium homeostasis but could contribute to morbidity.

Intravenous clodronate in the treatment and retreatment of Paget's disease of bone.

The effects of short courses (5 days) of intravenous clodronate 300 mg daily were studied in 31 patients with active Paget's disease of bone. The diphosphonate induced a striking reduction in biochemical indices of disease activity, which was sustained for at least 6 months after withdrawal of treatment. Apparent resistance to further treatment in patients previously treated for Paget's disease was an artefact due to incomplete relapse before retreatment. There was no significant difference in the degree of suppression of alkaline phosphatase activity between patients given intravenous clodronate and 45 patients given clodronate 1.6 g daily by mouth for 6 months. Short-term intravenous clodronate provides a useful alternative strategy for the treatment of patients with Paget's disease.

Thallium-technetium subtraction scintigraphy as an aid to parathyroid surgery.

We describe the application of thallium-technetium subtraction scintigraphy in nine patients with failed previous parathyroid surgery or with tertiary hyperparathyroidism due to chronic renal failure. The technique successfully located all adenomas, but only 45% of hyperplastic glands. The series included three abnormal glands located retrosternally. The technique appeared to be more useful in patients with primary hyperparathyroidism than in tertiary hyperparathyroidism, possibly related to differences in gland mass. We conclude that this method of scintigraphy is a valuable adjunct to the management of patients with parathyroid disorders, particularly those requiring revision surgery.