Urethral stricture following high dose rate brachytherapy for prostate cancer.

PURPOSE: To evaluate the incidence, timing, nature and outcome of urethral strictures following high dose rate brachytherapy (HDRB) for prostate carcinoma. METHODS AND MATERIALS: Data from 474 patients with clinically localised prostate cancer treated with HDRB were analysed. Ninety percent received HDRB as a boost to external beam radiotherapy (HDRBB) and the remainder as monotherapy (HDRBM). Urethral strictures were graded according to the Common Terminology Criteria for Adverse Events v3.0. RESULTS: At a median follow-up of 41 months, 38 patients (8%) were diagnosed with a urethral stricture (6-year actuarial risk 12%). Stricture location was bulbo-membranous (BM) urethra in 92.1%. The overall actuarial rate of grade 2 or more BM urethral stricture was estimated at 10.8% (95% CI 7.0-14.9%), with a median time to diagnosis of 22 months (range 10-68 months). All strictures were initially managed with either dilatation (n=15) or optical urethrotomy (n=20). Second line therapy was required in 17 cases (49%), third line in three cases (9%) and 1 patient open urethroplasty (grade 3 toxicity). Predictive factors on multivariate analysis were prior trans-urethral resection of prostate (hazard ratio (HR) 2.81, 95% CI 1.15-6.85, p=0.023); hypertension (HR 2.83, 95% CI 1.37-5.85, p=0.005); and dose per fraction used in HDR (HR for 1 Gy increase per fraction 1.33, 95% CI 1.08-1.64, p=0.008). CONCLUSIONS: BM urethral strictures are the most common late grade 2 or more urinary toxicity following HDR brachytherapy for prostate cancer. Most are manageable with minimally invasive procedures. Both clinical and dosimetric factors appear to influence the risk of stricture formation.

Extraperitoneal laparoscopic caliceal diverticulectomy.

Three women with symptomatic stone-containing caliceal diverticula in the right kidney were treated by extraperitoneal laparoscopic diverticulectomy. The diverticula measured 31 x 21 mm, 15 x 12 mm, and 12 x 9 mm, with the calculi measuring 10 x 8 mm, 5 x 4 mm, and 6 x 6 mm, respectively. The site of the diverticulum was identified by the presence of a depression on the surface of the kidney. The diverticulum was marsupialized, the lining fulgurated, and in the second and third patients, a flap of Gerota's fascia and perirenal fat inserted. The mean operating time was 127 minutes. The mean postoperative analgesic requirement was six doses of pethidine (meperidine). The median time to drainage tube removal was 3 days, and the median time to discharge after surgery was 4 days. Complications were minimal. On follow-up, all patients were stone free and asymptomatic. The first patient had a slight recurrence of the diverticulum, measuring 15 x 7 mm. Laparoscopic caliceal diverticulectomy has been successful in three patients.

Transurethral Needle Ablation of the prostate (TUNA): clinical results and ultrasound, endoscopic, and histologic findings in pilot study of patients in urinary retention.

Transurethral Needle Ablation of the prostate (TUNA) is a new thermal ablation treatment for benign prostatic hyperplasia (BPH) utilizing radiofrequency electric current delivered by needles into the depth of the prostate to produce an area of coagulative necrosis. A pilot study of 10 patients in urinary retention was undertaken to assess the procedure. After treatment, nine patients voided at a median time of 3 days, although a further two required transurethral resection because of chronic infection in one and chronic urinary retention in the other. At 3 months' follow-up, the mean Qmax was 13.0 mL/sec, the mean AUA Symptom Score was 9.1, and the mean quality of life score was 1.6. The mean Pdet fell from 73.3 to 39.0 cm H2O. On transrectal ultrasound at 3 months, cystic lesions were seen in two patients, with a third having large cavities. A 10.2% reduction in mean prostatic volume, from 48.8 cc to 43.8 cc, was noted but considered to be not significant. On endoscopy at 3 months, mucosal retraction was seen in seven patients, with cavities in two patients. Histologic study in patients undergoing transurethral resection 4 to 6 months after TUNA showed necrosis and fibrosis. It is considered that an area of coagulative necrosis is produced by TUNA that resolves either by scar formation with retraction or by liquefaction with cyst formation. If the lesion communicates with the urethra, a cavity may form, which is undesirable. Our early experience is encouraging. The TUNA treatment is effective, can be given without anesthesia, and should be either a day case or an office procedure. It should prove to have a significant place in the treatment of BPH.

The visual endourological removal of ureteric calculi.

A prospective study was carried out of new techniques that allow the endoscopic removal of all ureteric calculi. Over 19 months, 50 consecutive patients with ureteric calculi that required surgical intervention were treated initially by 53 visual endourological procedures. This was successful for 45 (90%) patients, which included all patients with calculi in the upper and lower thirds of the ureter. Five patients with mid-ureteric calculi required open ureterolithotomy. The mean stone size was 8.8 mm (range, 5-22 mm). For patients with calculi in the upper third of the ureter, the most effective procedures were retrograde manipulation of calculi which was followed by percutaneous nephrolithotomy and antegrade ureteroscopy, with extraction or ultrasonic lithotripsy. For patients with calculi in the lower third of the ureter, retrograde ureteroscopy with extraction or lithotripsy was successful in all cases. Midureteric calculi presented the greatest problem and may require open ureterolithotomy. Means of improving the success of endoscopic procedures for these stones are discussed. Complications occurred in eight (16%) patients, but were resolved with conservative measures. The mean postoperative length of stay in hospital after a successful endourological procedure was 4.5 days (range, 1-21 days). We conclude that visual endourological techniques are safe and effective, and offer the advantages of the avoidance of open surgery, a reduced hospital stay and a shortened convalescence time.

Percutaneous ultrasonic disintegration and removal of renal calculi.

We report the first use in Australia of the technique of percutaneous ultrasonic disintegration and removal of renal calculi. The first three patients who underwent the procedure had a successful outcome. These three patients are described, the method is detailed and the problems which were encountered are discussed.

Disseminated cryptococcosis after transurethral resection of the prostate.

A 63-year-old man presenting with acute retention and dysuria underwent transurethral resection of the prostate for suspected benign prostatic hypertrophy. Ten days postoperatively he developed disseminated cryptococcosis. Re-examination of the prostatic chips revealed cryptococcal prostatitis. Treatment consisted of amphotericin, flucytosine and transfer factor along with wedge resection of a pulmonary toruloma. He remains well 12 months after cessation of treatment. This appears to be the first case report in Australia of cryptococcal prostatitis with dissemination after transurethral resection of the prostate.

Staging pelvic lymphadenectomy for carcinoma of the prostate risk versus benefit.

A total of 125 patients underwent limited staging lymphadenectomy for adenocarcinoma of the prostate. Of these patients 19 per cent with clinical stage B1 disease, 52 per cent with clinical stage B2 disease and 59 per cent with clinical stages C disease had positive nodes. There was 1 death secondary to myocardial infarction and postoperative complications occurred in 7.2 per cent of the 125 patients. Limited staging pelvic node dissection provides information regarding nodal dissection similar to that identified after more extensive dissection and it can be accomplished with little morbidity.

Accuracy of radionuclide imaging in distinguishing renal masses from normal variants.

To determine the accuracy of scintigraphy in distinguishing true renal masses from normal variants, 40 patients with excretory urographic findings indicating a possible, but not definite, mass lesion were studied. Scintigraphy correctly identified 17 true masses and 17 normal variants. Four false positive and two false negative results were obtained.

Traumatic rupture of the female urethra.

The clinical course of 4 female patients with complete traumatic rupture of the urethra was evaluated in an effort to propose guide lines for the investigation and initial management of this unusual injury. Treatment modalities are determined by the level of urethral injury and the subsequent effect on continence. We recommend a retropubic approach for bladder neck injuries, a transvaginal approach for proximal urethral ruptures with reanastomosis over a stenting catheter and acceptance of a hypospadiac neomeatus for distal urethral ruptures.

Retrocaval ureter in Turner syndrome.

Turner syndrome is commonly associated with urinary tract anomalies. A second case is reported of its unusual association with retrocaval ureter and massive hydronephrosis.