Results of holmium laser resection of the prostate for benign prostatic hyperplasia.

PURPOSE: To assess the results of holmium laser resection of the prostate (HoLRP) in the treatment of benign prostatic hyperplasia. PATIENTS AND METHODS: Since October 1996, 259 patients have undergone elective HoLRP. Peak urinary flow rates (Qax), IPSS scores, and duration of catheterization and hospital stay from admission to discharge catheter free were used as outcome measures. RESULTS: There were no perioperative deaths nor cases of transurethral resection syndrome. Two patients required blood transfusion. The mean duration of catheterization was 1.6 days and the mean hospital stay 2.9 days. The mean IPSS decreased from 21.0 preoperatively to 7.0 at 1 year, whilst the Qmax increased from 10.5 mL/sec to 20.5 mL/sec. CONCLUSION: The HoLRP technique is a safe and effective treatment for benign prostatic hyperplasia, allowing resection of the prostate at the level of the capsule with minimal bleeding or fluid absorption and with results equivalent to those of standard transurethral resection.

High dose intravenous oestrogen (fosfestrol) in the treatment of symptomatic, metastatic, hormone-refractory carcinoma of the prostate.

OBJECTIVE: High dose intravenous stilboestrol has a direct cytotoxic effect on prostatic carcinoma cells. The purpose of this study was to assess subjective and objective responses in a select group of patients with metastatic, hormone-refractory carcinoma of the prostate with severe generalized bone pain in association with symptoms of advanced local disease. PATIENTS AND METHODS: Seventeen patients with metastatic carcinoma of the prostate, who had relapsed following a good initial response to androgen ablation, were treated as inpatients with once daily intravenous injection of 1104 mg diethylstilboestrol diphosphate (Honvan, Asta Medica, Cambridge, UK) for 7 days. The hormone-refractory status was confirmed by castrate serum testosterone levels. All the patients had failed to respond to second-line hormone manipulation and had progressive disease. All the patients had generalized bone pain, 11 also had symptoms of bladder outlet obstruction, 3 had recurrent haematuria and 3 had both. The mean age was 74 years (range 59-83), mean time to chemical relapse (rising PSA) was 29 months (range 1-70), and mean time to clinical relapse was 37 months (range 6-98). The WHO pain score, performance status score, and a patient-specific quality of life (daily living activity) were used as the subjective measures and the serum PSA as an objective marker. All the parameters were recorded before, during and up to three months after treatment. RESULTS: Two patients had a transient relief of bone pain with the pain score reducing by two points. Overall, the pain and performance scores and the local symptoms did not improve. The PSA level continued to rise in all patients. Despite parenteral pre-medication with pethidine and cyclizine, all the patients suffered nausea and pain following the injection. One patient died on the fifth day of treatment from a myocardial infarction and 4 developed deep vein thrombosis. All the patients required further symptom control measures. CONCLUSION: High dose intravenous stilboestrol causes considerable morbidity without any objective or subjective response in the treatment of patients with symptomatic, hormone-refractory metastatic carcinoma of the prostate.

The results of holmium laser resection of the prostate.

OBJECTIVE: To assess the results of holmium-laser resection of the prostate (HOLRP) in the treatment of benign prostatic hyperplasia. PATIENTS AND METHODS: Between 1994 and 1997, 967 patients underwent HOLRP in Tauranga, New Zealand, and in Derby, United Kingdom. The patients were followed at 1, 3 and 6 months after treatment using measurements of symptom score and urinary flow rate. RESULTS: There was a large and sustained improvement in symptom scores and urinary flow rates, with no mortality and low morbidity. CONCLUSION: We recommend this technique as an alternative to transurethral resection in the surgical treatment of bladder outlet obstruction due to benign prostatic hypertrophy.

The role of colour Doppler imaging in the management of Peyronie's disease.

OBJECTIVE: To determine the role of colour Doppler imaging (CDI) in the investigation of erectile dysfunction in patients with Peyronie's disease. PATIENTS AND METHODS: Fifty consecutive patients (age 35-75 years) with Peyronie's disease who were considered suitable for surgical treatment were investigated using CDI to determine the haemodynamic variables of penile vasculature after an intracorporeal injection of 20 microg of alprostadil (with manual self-stimulation). A clinician independently recorded the quality of erection and the deformity. RESULTS: Twenty of 50 patients (40%) considered they had normal erectile function despite their penile deformity and all had normal responses, although they tended to exaggerate the degree of penile deformity. Of the 30 remaining patients, 21 who considered themselves to have erectile dysfunction had normal clinical and CDI haemodynamic responses to alprostadil. The remaining nine patients had a variety of erectile problems and whilst CDI showed altered haemodynamic values, in no case did CDI alter the proposed treatment based on the clinically apparent features of those patients. CONCLUSION: Colour Doppler imaging of the penis after pharmacologically induced erection gives anatomical and functional information in patients with Peyronie's disease but does not provide useful additional information to aid the selection of surgical treatment for the disease.

Should Stamey colposuspension be our primary surgery for stress incontinence?

OBJECTIVE: To evaluate the outcome of the Stamey procedure for stress incontinence and to decide if it is an acceptable first-line option for the treatment of patients. PATIENTS AND METHODS: Between June 1987 and March 1993 67 women had Stamey bladder neck suspension carried out for the treatment of stress incontinence. In September 1993 all patients received a detailed questionnaire to ascertain their present status. RESULTS: Immediately after surgery 70% of patients were dry and 15% were much improved. At 6 months 56% of patients were dry and 21% were much improved. More than 1 year following surgery, of 58 patients responding only 31% were dry and 28% were much improved. More than 5 years after surgery only 18% of the 28 women responding were dry. The factors which were significantly associated with failure were obesity (P < 0.005) and the number of pads used per day (P < 0.05). Previous surgery may also be an important factor. CONCLUSION: The Stamey vesical neck suspension has a good early success rate but the results in the longer term are not acceptable. This operation should not be used as a first-line treatment for stress incontinence and should be reserved for specific patient subgroups.

New therapeutic options in prostatic enlargement.

Benign prostatic hyperplasia occurs in the majority of men past middle age. Transurethral prostatectomy has stood the test of time, but it may not be suitable for some men by virtue of concurrent medical problems or because patients prefer to avoid the risks and complications associated with surgery. This article outlines some of the alternative therapeutic options that are available.

Flexible cystoscopy.

Flexible cystoscopy allows examination of the bladder under local or general anaesthesia. This article describes the technique and the situations in which it is used, as well as its advantages and deficiencies. As the range of therapeutic applications of flexible cystoscopy increases, the need for rigid cystoscopy may disappear completely.

Terazosin in the treatment of benign prostatic hyperplasia: a multicentre, placebo-controlled trial.

The dynamic component of bladder outflow obstruction due to benign prostatic hyperplasia (BPH) has been shown to be modified by alpha 1 adrenergic receptors. Terazosin is an alpha 1 receptor-blocking agent with a long half-life permitting once-daily dosing. This drug was administered in a multicentre, randomised, placebo-controlled trial involving patients with symptomatic bladder outflow obstruction. Of 132 patients recruited for the study, 86 were randomised to receive placebo or terazosin, 81 completed the study, and 80 were considered eligible for efficacy analysis. All terazosin treatment groups showed dramatic improvement in obstructive symptoms when compared with the placebo group, but these differences were not statistically significant because of the small numbers of patients in each group. There were improvements in peak urinary flow rates, mean urinary flow rates, and residual urine volumes for the placebo and terazosin groups, but there were no statistically significant differences in the changes between the groups. Terazosin was well tolerated by patients in this study and may provide symptomatic relief in patients with BPH.

Single-blind, randomised, parallel group study of the Bard Biocath catheter and a silicone elastomer coated catheter.

A group of 69 community patients undergoing long-term urethral catheterisation for urinary incontinence took part in this study; 33 patients with a mean age of 70.03 years (+/- 16.6) received the Dow Corning Silastic catheter (16 F 10-ml balloon) and 36 patients with a mean age of 75.61 years (+/- 12.6) received the Bard Biocath catheter (16 F 10-ml balloon). Over a 16-week period catheters were monitored every 2 weeks and changed as necessary. The Bard Biocath catheter remained in situ for an average of 89.61 days (+/- 35.31) and the Silastic catheter remained in situ for an average of 56.7 days (+/- 38.8); this difference was statistically significant. Used catheters were analysed for encrustation using scanning electron microscopy (SEM). The average time in situ for non-encrusted Biocath catheters was 83.7 days and 25.28 days for non-encrusted Silastic catheters. It was found that 70% of patients who received Biocath catheters preferred them to their previous catheters whereas only 30% of patients in the Silastic group preferred the trial catheter. The incidence of bypassing was 28% in the Biocath group and 52.8% in the Silastic group.

Vasoactive intestinal polypeptide-, somatostatin- and substance P-immunoreactive nerves in the smooth and striated muscle of the intrinsic external urethral sphincter of patients with spinal cord injury.

Specimens obtained by transurethral sphincterectomy from patients with spinal cord injury and carcinoma of the bladder were studied immunohistochemically. In the smooth muscle region of the sphincter, vasoactive intestinal polypeptide-, substance P- and somatostatin-immunoreactive fluorescent, varicose nerve fibers were seen. In the striated muscle region, VIP-immunoreactive nerves were found around striated muscle fibers and bundles, while somatostatin- and substance P-immunoreactive nerves were confined to nerve bundles. In both the smooth and striated muscle regions of the intrinsic external urethral sphincter, VIP-immunoreactive nerves were seen around blood vessels. No differences were observed in the immunohistochemical localization of these peptide-containing nerves in the two groups of patients. No immunofluorescence for [Met]enkephalin, bombesin, neurotensin or serotonin was found in any nerves in the urethra.

Adrenergic and cholinergic innervation of the smooth and striated muscle components of the urethra from patients with spinal cord injury.

The adrenergic and cholinergic innervation of the smooth and striated muscle components of the urethra from spinal cord injury patients with detrusor sphincter dyssynergia were investigated neurochemically and histochemically. Catecholamine fluorescence histochemistry provided no evidence for the presence of adrenergic nerves associated with the skeletal muscle. The noradrenaline content of this region probably reflects the endogenous levels in adrenergic nerves associated with the blood vessels supplying the skeletal muscle. Choline acetyltransferase activity in the skeletal muscle was significantly lower in patients with cervical lesions than in those with thoracic lesions (p less than 0.01). The noradrenaline content of the smooth muscle was significantly lower in cervical lesions than in thoracic lesions in both the mid (p less than 0.02) and the distal (p less than 0.001) regions of the urethra. The proximal region revealed similar noradrenaline levels in both groups of spinal cord injury patients. The results are discussed in relation to the role of the autonomic nervous system in the control of voiding and to the presence of increased sympathetic outflow in patients with spinal cord lesions at higher levels.

Transuretero-ureterostomy--a review of its use in modern paediatric urology.

Transuretero-ureterostomy (TUU) was performed on 55 patients with a mean age of 10 years at operation and a mean follow-up of 4 years. The indications for this procedure are described and, if followed, it is safe and easily performed. The indications for its use may be as a primary procedure for unilateral ureteric pathology, as a salvage procedure, after failed ureteric reimplantation or as part of a urinary undiversion. There have been no deaths and only one patient later required a nephroureterectomy.

Urinary chemiluminescence--an evaluation of its use in clinical practice.

It has been proposed that a substance, as yet unidentified, is excreted in the urine and acts as a chemical carcinogen. This substance during oxidative reactions will exhibit urinary chemiluminescence (UCL) and it is this release of energy in the form of light which activates the intracellular changes responsible for carcinogenesis. One hundred and seventy-seven people, 110 patients being followed up endoscopically for transitional cell carcinoma of the bladder (TCCB) and 67 controls, had their UCL measured. The UCL estimations confirmed previously reported trends where those with active disease had the highest UCL (84) and the controls had the lowest (55). These results did not reach statistical significance and the wide variations of the results do not allow UCL, as yet, to be of practical clinical use.

The impact of optical urethrotomy on the management of urethral strictures.

The introduction of optical urethrotomy by Sachse has reduced the need for urethroplasty: 261 urethroplasties were performed between 1964 and 1983, of which 87 were performed in one stage on patients who would today have undergone urethrotomy as the procedure of first choice. The results in this group are compared with those in 151 patients treated between 1978 and 1983 by 265 internal optical urethrotomies. At 5 years 50% of those treated by urethrotomy needed no further treatment, compared with 83% of those treated by urethroplasty. Nevertheless, the ease and safety of urethrotomy makes it the procedure of first choice, and urethoroplasty should be reserved either for cases where urethrotomy is unsuitable or where it has been tried on several occasions without success.