Misinterpretation of radioisotope imaging in pelvic kidneys.

We report the case of a gentleman referred with apparent worsening function in a hydronephrotic left-sided pelvic kidney. Imaging with Tc-99m-Mercaptoacetyltriglycine (MAG 3) in 1999, showed that the left kidney contributed 46% of renal function with no evidence of obstruction. Three years later, repeat scanning showed ectopic kidney function had decreased to 20% and with worsening pain, nephrectomy had been suggested. Review of the second MAG 3 scan revealed that only posterior images had been obtained. With pelvic kidneys, the pelvis forms a barrier between the radioactively labelled tracer and the gamma camera, thus, reducing the amount of radiation detected and underestimating function. A subsequent Dimercaptosuccinic acid scan (DMSA) was carried out with posterior and anterior images, the latter showing split renal function was identical to that seen on the initial scan. In patients with pelvic kidneys, anterior views must be obtained during radionuclide scanning if unnecessary nephrectomy is to be avoided.

Prolonging the life of the flexible ureterorenoscope.

The lifespan of medical equipment must be maximised to ensure cost-effectiveness. Flexible ureterorenoscopes have become widely used in the diagnosis and treatment of urolithiasis. They are relatively expensive and current literature shows that they require frequent repair and replacement. We have analysed our data for the number of procedures and repairs required for each new instrument we have used. So far we have used four new flexible ureteroscopes, which have been used for a total of 375 procedures, an average of 94 procedures each. On average each required repair twice. We believe that a few simple precautions taken during use and storage help to maximise the lifespan of the flexible ureterorenoscope and our results would appear to support this.

Flexible ureterorenoscopy: prospective analysis of the Guy's experience.

OBJECTIVE: To report our outcomes with small diameter, actively deflectable flexible ureterorenoscopy from a prospective database. PATIENTS AND METHODS: 114 flexible ureterorenoscopies were performed in 105 patients (mean age, 49.5 years; range, 19-85 years; 71 males, 34 females) over a 9-month period. Of these, 101 were for refractory stones following failed ESWL and 13 for diagnostic reasons. An Olympus URF P3 flexible ureteroscope with pressure irrigation was used. Electrohydraulic lithotripsy was used to fragment stones and the fragments were retrieved with Graspit, triradiate graspers or tipless baskets. RESULTS: Stents had previously been placed in 53% and dilatation of the ureteric orifice was necessary in 15%. In the stone group, the median operating time was 55 min (range, 15-210 min) and the median screening time 2.2 min (range, 0.3-9.1 min). Success was defined as complete stone clearance or good fragmentation to 2 mm or less. Overall success in this group was 72.3%. There was no statistically significant difference between lower and other calyces (P=0.83 Chi-square test). Successful outcome was achieved in 72% for stone size 10 mm or less, 80% for 11-20 mm and 50% for greater than 20 mm. Two or more procedures were needed in 8 patients. In the diagnostic group, the median operating time was 45 min (range, 20-60 min) and the median screening time 2 min (range, 0.3-8.3 min). The majority were for upper tract filling defects. Access and successful diagnosis was achieved in all cases. The major complication rate was 2.6%. The ureteroscope needed repair once during this series. CONCLUSIONS: Flexible ureterorenoscopy is an effective diagnostic and therapeutic tool in a select group of patients. It should be considered for ESWL-resistant upper tract stones but the results are poor in stones larger than 20 mm and percutaneous nephrolithotomy may be a better option in these patients.

Pseudoaneurysm formation after flexible ureterorenoscopy and electrohydraulic lithotripsy.

Although electrohydraulic lithotripsy (EHL) is regularly used to fragment urinary calculi, it has the potential to cause significant renal tract damage. We report a complication of EHL use during flexible ureterorenoscopy, where recovery was complicated by delayed, prolonged haematuria secondary to the formation of a pseudoaneurysm in an interlobar renal artery. Embolisation was achieved by the insertion of a coil.

16. Breast cancer in older women.

Elderly women are more likely to have less aggressive tumours, which are oestrogen receptor positive. They are less likely to be offered screening and often given inadequate treatment leading to a higher mortality rate. They should be assessed in the same way as their younger counterparts. Age should not be a consideration, rather life expectancy Patients' wishes are important but the mainstay of treatment is surgical, including axillary node clearance, with adjuvant tamoxifen as appropriate. Radiotherapy should not be withheld unless there are good reasons to contradict this. In unfit patients, tamoxifen alone is a suitable treatment but tumorectomy under local anaesthetic is preferable. If the tumour is oestrogen receptor negative, surgery and/or radiotherapy will be required.

Loin pain haematuria syndrome: distress resolved by pain relief.

Loin pain haematuria syndrome (LPHS) is a syndrome of severe chronic pain of unknown aetiology. This study assessed pain, mood variables and psychiatric status in patients (n=26) with LPHS. Patients were assessed before and after treatment with capsaicin. Assessment inventories used were the McGill Pain Questionnaire, the Pain Discomfort Scale, the General Health Questionnaire and the Hospital Anxiety and Depression Scale. Pain relief was achieved in 65% of patients. In this group pain (P < 0.001) and psychiatric (P < 0.01) scores were significantly reduced. By comparison, in those patients who did not gain pain relief, scores remained steady (P > 0.05). In addition, most pain-free patients completely stopped their opiate analgesia without addictive symptoms. These results suggest an organic pathology to LPHS and militate against suggestions of primary psychological cause or drug addiction. The results also show that the psychiatric disturbances associated with this chronic pain disappear if the pain disappears.

Amyloid tumour of the rectum.

Systemic amyloidosis results in diffuse deposition of amyloid proteins in various organs. Localized deposits in the form of nodules also occur but are rare in the gastrointestinal tract. A localized amyloid deposit in the rectum that was clinically indistinguishable from carcinoma of the rectum or prostate is described.

[Primary primitive neuroectodermal tumor of the kidney in an adult. Clinico-pathologic and immunohistochemical case report]. / Primärer primitiver neuroektodermaler Tumor der Niere bei einem Erwachsenen. Klinisch pathologischer und immunhistochemischer Fallbericht.

We report a case of a primary renal primitive neuroectodermal tumour in a 24-year-old man associated with multiple pulmonary metastases. Histologically, the bulk of the kidney was replaced by a small round-cell tumour with numerous true Homer-Wright rosettes and perivascular pseudorosettes; wide-spread vascular invasion was noted. There was no evidence at autopsy of a primary tumour elsewhere. Immunohistochemically, the tumour cells stained strongly positive for O-13, a monoclonal antibody, which recognizes a recently described cell membrane glycoprotein (p30/32MIC2), more weakly for NSE and at least focally for PGP 9.5; the tumour did not stain for other neural markers, cytokeratin, leucocyte common antigen, or desmin. The differential diagnosis of small round-cell tumours in this location and the relation of primitive neuroectodermal tumours and Ewing's sarcoma are discussed.

Extracorporeal shock wave lithotripsy with the Storz Modulith SL20: the first 500 patients.

Our initial experience of extracorporeal shock wave lithotripsy (ESWL) with the Storz Modulith SL20 is reported. A total of 500 patients with 551 renal and 120 ureteric stones, mean diameter 11.9 mm, underwent 746 treatments; 68.2% of patients required a single treatment. The mean treatment rate for renal calculi was 1.4 and for ureteric calculi it was 1.5, rising to 4.2 for staghorns; 62.2% of treatments were performed on an out-patient basis. Analgesia (intravenous fentanyl) was required in 60.9% of treatments for renal calculi but in only 38.2% of those for ureteric calculi. The overall stone-free rate at 3 months was 77.6%, with a further 14.7% of patients having fragments less than 3 mm in diameter that required no further treatment. The stone-free rate was dependent on the site of the stone, with the majority of residual fragments lying in a lower pole calix. There were few complications. The Modulith is an efficient and safe lithotripter capable of treating stones in the kidney and throughout the ureter.

Ectopic prostatic glands in bulbar urethra. Immunoperoxidase study.

Ectopic prostatic glands in the bulbar urethra of a sixty-year-old man were identified by an indirect immunoperoxidase stain for prostatic acid phosphatase. Cystoscopically the appearances were those of "urethritis" without the polypoid appearance previously reported in cases of ectopic prostatic tissue.

Report on the first 1000 patients treated at St Thomas' Hospital by extracorporeal shockwave lithotripsy.

Since March 1985, over 1000 patients have been treated on the lithotripter at St Thomas' Hospital. Since it is the only machine in the country offering treatment to National Health Service patients at no cost to the referring Health Authority, there has been a heavy demand for treatment and 97% of referrals have been accepted. Analysis of the first 1000 patients shows extracorporeal shockwave lithotripsy (ESWL) to be a safe procedure with a low morbidity rate and no mortality. The number of patients who were stone-free 3 months after treatment was low (44.1%) compared with the numbers reported in other series. The most likely reasons for this are the poor follow-up rate (48.9%), the stringent criteria for the diagnosis of "stone-free" and a possible skewed referral and follow-up pattern.

Subtrigonal phenol injection therapy for incontinence in female patients with multiple sclerosis.

24 female patients with multiple sclerosis presented with severe urge incontinence or leakage around an indwelling urethral catheter. All had failed to respond satisfactorily to drug therapy. After subtrigonal phenol injection 83% were dry.

Isolated ileal loop augmentation of existing ileal conduit.

A new method of stomal revision in an existing ileal conduit is described. Two cases are reported in which the procedure was a success. It is suggested that ileal loop augmentation of an existing ileal loop may serve, in selected cases, as a useful alternative to complete conduit reconstruction.

Subtrigonal phenol injection for urge incontinence secondary to detrusor instability in females.

Thirty female patients with urge incontinence or bypassing an indwelling urethral catheter have been treated by subtrigonal phenol injection. All were proven to have detrusor instability. The injection method is described. Seventy-six per cent of patients were rendered dry. The urodynamic changes are recorded.

Intra-prostatic urinary reflux: an aetiological factor in abacterial prostatitis.

That urine might reflux into the prostatic ducts during micturition has never before been proved. Using a suspension of carbon particles it has been demonstrated that this can occur. It is suggested that this may be important both as a route of infection in bacterial prostatitis and as a cause of the inflammatory process in abacterial prostatitis.

Clinical experience with intravesical prostaglandin E2. A prospective study of 36 patients.

In a prospective study, intravesical prostaglandins were given to 36 patients who had urinary symptoms associated with a poorly functioning detrusor; 67% of these patients were found to be in chronic retention. Using standard urodynamic techniques, 72% showed objective evidence of an immediate improvement in detrusor function and there was prolonged therapeutic benefit in 39%. A prolonged response occurred only in patients who had an intact sacral reflex arc and urodynamic evidence of a pathologically enlarged bladder, and who did not have radiologically demonstrable outflow obstruction. The use of intravesical prostaglandin to stimulate the detrusor was also found to be of value as a urodynamic technique for the investigation of the lower urinary tract.

Stimulation of dorsal column in multiple sclerosis.

The effect of stimulating the dorsal column in 19 selected patients with multiple sclerosis was studied in detail over two weeks. Before and during stimulation the patients were examined clinically; videotape recordings made of their movements; psychomotor performance tested; electrolaryngography performed; and urodynamic studies carried out. Improvement was seen in walking speed, power in certain muscle groups, chronic pain, and bladder function. The motor improvement was thought to be related to the effects of high motivation and practice, and therefore to be of doubtful importance. The changes in bladder function were more convincing and justify further study.

Co-trimoxazole in prevention of bacteriuria after prostatectomy.

In a prospective, double-blind trial prophylactic cotrimoxazole produced a highly significant reduction in the incidence of bacteriuria after prostatectomy. Only two out of 38 patients who received the drug developed bacteriuria compared with 19 out of 36 patients on placebo. Klebsiella-Enterobacter spp and coagulase-negative staphylococci were responsible for most infections. Although co-trimoxazole prophylaxis is obviously effective, widespread use might increase the incidence of bacterial resistance.