Haematuria: a long-term problem after prostatectomy.

OBJECTIVE: The causes of 'late' haematuria (2 years or more) following endoscopic and open prostatectomy were studied. METHODS: Between 1994 and 1996, more than 400 patients were evaluated for haematuria. Ninety patients with post-prostatectomy haematuria were investigated with upper tract imaging and cystoscopic examination. Amongst these 90 patients, 30 presented with haematuria within 2 years of surgery. These patients were excluded from the study as they had normal investigations. RESULTS: Of these 60 patients, 24 (43%) had demonstrable causes of haematuria in their urinary tract. Six of them had urinary tract malignancy. CONCLUSIONS: There is a substantial likelihood of finding a cause for haematuria in patients who had prostatectomy even though they had full-scale urological investigations before. There is a need, therefore, to carry out necessary screening investigations in such patients.

A 23-year review of the management of acute retention of urine: progressing or regressing?

A retrospective review of all patients in Oxford under the care of one consultant urologist (GJF) who presented on alternate years over a 23-year period with acute retention of urine was undertaken. Data were collected on the: (i) number of patients discharged from hospital with an in-dwelling catheter; (ii) duration of catheter drainage prior to surgery; and (iii) duration of postoperative stay. In all, 244 patients underwent prostatectomy. Over the 23-year period, there was a significant increase in the proportion of patients discharged prior to surgery (P < 0.001) as well as their median duration of catheterisation (P < 0.001): more than 50% were catheterised for more than 3 months in 1997. Conversely, post-operative hospital stay has decreased. Prolonged catheter drainage carries considerable morbidity, with 72% experiencing some complication. Most patients feel they lose dignity, 69% consider it uncomfortable and more than 50% complain of burning sensations, bladder spasms and a persistent desire to micturate. We recommend that patients should not be placed on routine waiting lists where they are liable to remain for an unacceptably long time. Targets should be set to admit them within a set period and theatre lists made available. We feel that six weeks is a realistic target.

Bilateral ureteric obstruction secondary to the prolonged use of tiaprofenic acid.

There is increasing awareness that the long-term use of the non-steroidal anti-inflammatory agent tiaprofenic acid (Surgam) is associated with a severe form of cystitis. The condition is usually reversible with complete resolution of symptoms on stopping the drug. We present a case of tiaprofenic acid-induced cystitis resulting in bilateral hydronephrosis suggesting ureteric obstruction. The previous reported cases are reviewed and the risks of delay in withdrawal of the drug and of permanent ureteric damage are discussed.

Symptomatic urethral hair ball and diverticulum complicating island flap urethroplasty.

A 29-year-old man underwent a one-stage island flap urethroplasty, using perineal skin, to treat a urethral stricture. Four years following surgery he represented with symptoms from a urethral diverticulum containing a hair ball. This was at the site of the previous urethroplasty and was treated by excision.

The Oxford Laser Prostate Trial: a double-blind randomized controlled trial of contact vaporization of the prostate against transurethral resection; preliminary results.

OBJECTIVE: To compare the results of contact laser vaporization and transurethral resection of the prostate (TURP) in a double-blind randomized controlled clinical trial. PATIENTS AND METHODS: The study comprised 148 patients with clinical benign prostatic hypertrophy (BPH) who were recruited and allocated randomly to undergo either TURP (72 patients) or laser ablation of the prostate (76 patients). The outcome was assessed using the American Urological Association (AUA -7) symptom score after 1 and 3 months as the primary measure and by urinary flow rates, haematological factors and the duration of hospital stay and length of catheterization. RESULTS: With 90% statistical power, the results at 3 months showed no clinical or statistical difference between the treatments in change in AUA symptom score. A lower blood loss, hospital stay and duration of catheterization significantly favoured the laser treatment, although the failure rate of trial without catheter and the rate of re-operation were higher after laser treatment. CONCLUSIONS: These early data are encouraging for this technique, although the outcome after one year requires evaluation before advocating the widespread uptake of this method.

A prospective, randomised study to compare goserelin acetate (Zoladex) versus cyproterone acetate (Cyprostat) versus a combination of the two in the treatment of metastatic prostatic carcinoma.

A prospective randomised study was performed to test the hypothesis that total androgen ablation, achieved by combining an LHRH analogue, goserelin acetate (Zoladex), with an antiandrogen, cyproterone acetate (Cyprostat), is more effective than conventional monotherapy in delaying the time to progression of metastatic prostatic cancer. 525 patients were recruited at 18 UK centres between May 1986 and January 1989, 175 patients being allocated to each arm. Patients were clinically and biochemically assessed at 1, 2, 3, 6, 9 and 12 months after initiation of therapy and then every 6 months until a maximum duration of 48 months. There was no statistically significant difference in terms of median time to progression between the combination treatment arm and either monotherapy arm, although there was a statistically significant difference between goserelin acetate alone and cyproterone acetate alone, in favour of goserelin acetate (p = 0.016). All treatment regimens were well tolerated and cyproterone acetate reduced both tumour flare reactions and hot flushes in patients receiving goserelin acetate. It is concluded that total androgen ablation using cyproterone acetate (300 mg/day) and goserelin acetate (3.6 mg every 28 days) confers no advantage in terms of time to progression, to conventional monotherapy, but can reduce certain side effects caused by LHRH analogue treatment alone.

Marker tumour response to Evans and Pasteur bacille Calmette-Guérin in multiple recurrent pTa/pT1 bladder tumours: report from the Medical Research Council Subgroup on Superficial Bladder Cancer (Urological Cancer Working Party).

OBJECTIVE: To compare the efficacy of Evans bacille Calmette-Guérin (BCG) and Pasteur BCG in eradicating marker bladder tumours and to compare the toxicity of the two strains. PATIENTS AND METHODS: Ninety-nine patients with multiple recurrent pTa or pT1 bladder tumours were allocated at random to six instillations at weekly intervals of either Evans BCG or Pasteur BCG. All tumours were resected except one marker tumour. At cystoscopy 3 months after randomization all tumours including the marker tumour, if still present, were resected. RESULTS: The incidence of adverse events was similar in the two groups but numbers were small and only large differences would have been detected. No statistically significant difference in efficacy regarding the response of the marker tumour or the appearance of other tumours at 3 months was noted in the two groups. There was no evidence of stage progression of the marker tumours. CONCLUSIONS: In multiple recurrent pTa or pT1 bladder tumours clearing the bladder of all except one marker tumour provides a safe and convenient way of measuring the response to intravesical therapy. No significant difference in efficacy or toxicity was detected between Evans BCG and Pasteur BCG.

The mobile lithotriptor: an answer for the smaller centre.

The mobile lithotriptor is a new method of providing extracorporeal shock wave lithotripsy (ESWL) directly to the smaller urological centres. The unit, containing a Dornier HM4 lithotriptor, has treated 135 patients with a total of 168 treatments in 2 centres in the Oxford region. The overall success rate was 87% with no serious morbidity or mortality. The results compare well with the results from larger centres and the system is cost-effective. We suggest that it is one of the best methods of providing ESWL to the smaller urological centres.

Prevalence and outcome of renal impairment at prostatectomy.

Of 382 patients undergoing prostatectomy in Oxford in 1985 the prevalence of renal impairment (defined as plasma urea > 14 mmol/l or plasma creatinine > 200 mumol/l) was 8%; prostatectomy patients had significantly higher plasma ureas than age-matched patients undergoing herniorrhaphy and cholecystectomy in the same hospitals in the same year. A review of the case records of men with renal impairment showed that case history could not predict renal impairment. Although few case notes gave follow-up information, it was evident from the information available that recovery of renal function after prostatectomy did not occur invariably. Renal impairment in men undergoing prostatectomy represents substantial and unrecognised morbidity.

Treatment of advanced localised prostatic cancer by orchiectomy, radiotherapy, or combined treatment. A Medical Research Council Study. Urological Cancer Working Party--Subgroup on Prostatic Cancer.

A total of 277 patients with apparently localised prostatic cancer (T2-T4 NXMO) were allocated at random to receive radiotherapy alone (88), orchiectomy alone (90) and combined therapy (99) between 1980 and 1985. The main outcome measures were survival, time to appearance of metastases and treatment of local disease progression by further transurethral resection. Orchiectomy, whether alone or with radiotherapy, produced a significant delay in detection of metastases when compared with radiotherapy alone. There were no statistically significant differences between the 3 treatment groups in local disease control or in overall survival.

Flexible cystoscopy compared with ultrasound in the detection of recurrent bladder tumours.

A combination of transrectal and transabdominal ultrasound was compared with flexible cystoscopy as a means of detecting recurrent bladder tumours. The study group comprised 50 patients who had previously had rigid cystoscopy. They underwent combination ultrasound in the out-patient department 1 week before flexible cystoscopy. Combination ultrasound identified 25 patients with recurrent tumours and flexible cystoscopy identified 26. Thirty-four patients (68%) preferred ultrasound, 10 (20%) preferred flexible cystoscopy, 3 (6%) preferred general anaesthesia and rigid cystoscopy and 3 (6%) had no preference. The main objection to ultrasound was the use of the transrectal probe.