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.

Testicular microlithiasis needs long-term surveillance.

We present a case of testicular microlithiasis in which testicular biopsy failed to predict the development of a testicular tumour.

Bladder dysfunction after simple hysterectomy: urodynamic and neurological evaluation.

Many women presenting with symptoms of bladder dysfunction relate their onset to the operation of simple hysterectomy. This study reviews the urodynamic findings in 126 women who had a simple hysterectomy, of whom 25 also had sacral reflex latencies measured. The results show that 47.0% had detrusor instability, 36.7% had urethral obstruction, and 24.8% stress incontinence. These findings are statistically significant when compared to controls. 80% of the women who underwent measurement of sacral reflex latencies had evidence of nerve conduction abnormality.

Chronic urinary retention--a sensory problem?

Factors which predispose some men with benign prostatic hyperplasia to chronic urinary retention whilst others develop acute retention are not understood. In order to assess whether there is an occult neuropathy associated with chronic retention, neurophysiological measurements were used to test the integrity of the lower urinary tract nerve supply. A series of 22 male patients with chronic urinary retention secondary to prostatic hyperplasia underwent sacral reflex latency measurement; 73% demonstrated a sensory suprasacral abnormality with intact spinal reflex arcs. These results suggest that although the sacral reflex pathways are intact, there is a sensory/proprioceptive abnormality in the higher neurological centres which may be an adaptive mechanism to the presence of bladder outflow obstruction.

The use of sacral reflex latencies in detrusor bladder neck dyssynergia.

Detrusor bladder neck dyssynergia (DBND) is a well recognised cause of bladder outflow obstruction, especially in the younger man. The cause is unknown, and the aim of this study was to determine if any neurological dysfunction is associated with this condition. Twenty-five males with proven DBND had sacral reflex latency studies performed. The conduction latencies indicate that the underlying cause is unrelated to any demonstrable neuropathy. Sacral reflex latencies are not helpful in the investigation of DBND.

A physiological approach to the investigation of chronic urinary retention.

Twenty-six male patients with chronic urinary retention were investigated by self filling cystometry, followed by fast filling cystometry. Fast filling cystometry tended to increase the end filling pressure and to indicate a smaller bladder capacity than did self filling cystometry. Inadequate filling of the bladder may lead to an unrepresentative detrusor voiding contraction and an incorrect diagnosis of detrusor failure. Fast filling cystometry masks detrusor instability, which may be a factor producing upper tract dilatation and renal impairment. It is suggested that chronic retention of urine should be investigated by self filling cystometry.

Endoscopic bladder transection.

Endoscopic bladder transection has been performed in 30 patients with symptoms as a result of unstable bladder activity. The symptomatic improvement produced justifies the use of this new operation which should replace the open procedure.

The importance of urodynamic investigation following spontaneous rupture of the bladder.

We report a case of spontaneous intraperitoneal rupture of the bladder. Followup urodynamic studies revealed unsuspected detrusor bladder neck dyssynergia that was treated by unilateral endoscopic bladder neck incision. The pathogenesis of spontaneous bladder rupture is discussed and we recommend urodynamic evaluation in all cases of spontaneous rupture.

The vesico-psoas hitch as an adjunct to megaureter repair in childhood.

The vesico-psoas hitch usually has been advocated for the management of lower ureteral injuries or failed ureteroneocystostomies when there is inadequate ureteral length. Since 1966 we have used this technique in 36 children with obstructed megaureters. There has been no postoperative obstruction and reflux has been prevented in all but 1 case. The vesico-psoas hitch has proved to be an important adjunct in the repair of the obstructed megaureter, since it allows the construction of a long intravesical ureter, thus avoiding reflux, and locates the new ureteral hiatus in the bladder at a fixed point so that ureteral kinking and obstruction are prevented.

Critical evaluation of direct vision urethrotomy by urine flow measurement.

Fifty-two male patients were studied prospectively to assess the results of direct vision urethrotomy in the treatment of urethral strictures. The prognosis was found to be significantly worse in those patients who had received extensive previous treatment. A catheter is recommended for at least 3 days and for 4 weeks in patients who have had minimal previous treatment or who have impaired detrusor function. The use of a urine flowmeter is essential for determining the success of treatment and stricture recurrence. Measurement of the recurrence-free period is important for assessing progressive improvement following repeat urethrotomy and for determining which patients cannot be cured by direct vision urethrotomy.

The neuropathic urethra.

The hypothesis is advanced that the functional urethral obstruction found in neuropathic states is due, in part at least, to urethral supersensitivity following sympathetic decentralisation. A simple postural test for this condition is described. By its use it has been shown that urethral denervation occurs not only in disorders of the central nervous system but with peripheral damage such as may result from rectal excision and hysterectomy. In some cases with functional urethral obstruction, attributable to suersensitivity of the urethra, no neurological abnormality has been found. These may be examples of localised visceral neuropathy.