Symptomatic bladder endocervicosis: does it need surgery? A case report and review of the literature.

Endocervicosis of the urinary bladder is a rare benign condition exclusively seen in women, usually of reproductive age. To the best of our knowledge there are only about twenty cases reported so far. It causes non-specific symptoms and is seen as a submucosal lesion on cystoscopy. On histological examination one finds endocervical glands embedded deep within the muscle layers. It can be confused with an adenocarcinoma of the bladder. Unless the correct diagnosis is made these patients can undergo potentially debilitating surgery. As demonstrated in our patient even symptomatic endocervicosis can be managed conservatively.

Why oral calcium supplements may reduce renal stone disease: report of a clinical pilot study.

AIMS: To investigate whether increasing the daily baseline of gut calcium can cause a gradual downregulation of the active intestinal transport of calcium via reduced parathyroid hormone (PTH) mediated activation of vitamin D, and to discuss why such a mechanism might prevent calcium oxalate rich stones. To demonstrate the importance of seasonal effects upon the evaluation of such data. METHODS: Within an intensive 24 hour urine collection regimen, daily calcium supplementation (500 mg) was given to five stone formers for a 10 week period during a six month crossover study. In a further population of patients on follow up for previous renal stone disease, observations were made on 1066 24 hour urine samples collected over five years in respect of seasonal effects relevant to the interpretation of the study. RESULTS: In the group of patients on calcium supplements the following results were found. During calcium supplementation, the proportion of urine calcium to oxalate was higher (increased calcium to oxalate molar ratio), the 24 hour urine product of calcium and oxalate did not rise, and urine oxalate was lower during the first six weeks of supplementation. Twenty four hour urine calcium was 10.2% higher than baseline in the final four weeks of the 10 weeks of supplementation. Twenty four hour urine phosphate was 11.4% lower during the first six weeks of supplementation, but then rose while the patients were still on supplementation; renal tubular reabsorption of phosphate (TmP/GFR) mirrored the urine phosphate changes inversely. PTH was higher after stopping supplementation, but 1,25-(OH)2-cholecalciferol changes were not detected. In the 1066 urine samples collected over five years the following results were found. Calcium and oxalate excretion correlated positively and not inversely. Urine calcium and phosphate excretion were 5.5% and 2.5% higher, respectively, in "light" months of the year compared with "dark" months. A post summer decline in both urine calcium and urine phosphate was relevant to the interpretation of the study. CONCLUSIONS: Regular calcium supplementation does not raise the product of calcium and oxalate in urine and the proportion of oxalate to calcium is reduced. The underlying mechanisms of the changes seen in phosphate, calcium, and PTH and the observations on 1,25-(OH)2-cholecalciferol are not clear. Observed changes in phosphate could possibly be part of a calcium regulating feedback loop operating over a period of weeks. In evaluating these mechanisms background seasonal effects are important. It is possible that "programming" of the gut mucosa in terms of calcium transport is a major determinant of the relation between calcium and oxalate concentrations in urine and their relative abundance. Increased oral calcium, in association with a reduction of the relative proportion absorbed, may be pertinent to the prevention of calcium oxalate rich stones.

Inappropriate phosphate excretion in idiopathic hypercalciuria: the key to a common cause and future treatment?

AIMS: To present experimental evidence in support of a proposed common cause for absorptive hypercalciuria, renal hypercalciuria, renal phosphate leak and enhancement of 1,25-(OH)2-vitamin D concentrations in patients presenting with renal stone disease; and to suggest further investigation with a view to new management. METHODS: An oral calcium loading test was administered to 15 patients with renal stones and 10 normal controls in the fasting state: urine and blood were collected hourly. After the second urine sample, 400 mg calcium dissolved in water was administered orally. Serum calcium, albumin, parathyroid hormone (PTH), and phosphate were measured together with urine calcium clearance and urinary phosphate from which the TmPO4/glomerular filtration rate (GFR) ratio was calculated. Serum 1,25-(OH)2-vitamin D was measured in the first serum sample. In addition, 24 hour urine calcium results were collected retrospectively from the patients' case notes over the previous 18 months. RESULTS: In the basal state, renal stone patients had an overall greater phosphaturia (lower TmPO4/GFR: median 1.72 compared with 2.10 in controls) and increased calcium clearance. Serum corrected calcium and PTH concentrations did not differ between the groups. After calcium loading, serum calcium and urine calcium clearance rose in both groups, with patients with renal stones experiencing a greater percentage fall in phosphaturia. In both groups TmPO4/GFR fell (greater phosphaturia) with increased serum corrected calcium, with the patients showing notably greater phosphaturia for any given calcium concentration. Patients also had notably greater phosphaturia compared with the serum calcium concentration for any given PTH value. Serum 1,25-(OH)2-vitamin D was higher in patients than controls and for any 1,25-(OH)2-vitamin D concentration phosphaturia measured against serum calcium was greater in patients than controls. 1,25-(OH)2-vitamin D did not correlate with phosphaturia relative to serum calcium concentrations within the patient and control groups. CONCLUSIONS: It is proposed that patients with idiopathic hypercalciuria have an "inappropriately' high phosphate excretion for any given serum calcium concentration. Loss of phosphate may induce increased activation of 1,25-(OH)2-vitamin D. Some of the commonly described causes of stone formation may be manifestations of a single mechanism.

The influence of retinoic acid receptor (RAR) status of bladder tumours on the course of the disease.

Retinoids influence bladder tumour development in animals and tumour recurrence in man. Some human tumours contain intracellular receptor proteins for retinoids. The effect of the presence of such retinoic acid receptors (RAR) on tumour response to conventional therapy has been studied in 59 patients. Thirty-two of 36 RAR+ve and 11 of 23 RAR-ve tumour patients were alive after a mean follow-up period of 2.6 years. Higher stage and grade were more commonly associated with RAR-ve tumours. Independent of stage, recurrence was more common in RAR-ve tumours. These studies suggest that RAR-ve tumours are more likely to recur and more likely to become invasive. However, further studies are required to determine the clinical value of RAR receptor status as a prognostic indicator.

Mortality in acute pancreatitis.

The mortality from acute pancreatitis at a single centre between 1967 and 1980 is described. The overall mortality was 11% and remained at a similar level throughout the review period during which annual admission rates doubled. Two main groups of mortality were identified. In those with primary pancreatico-biliary or gastric pathology, there were less associated medical conditions and death was commonly due to abscess formation. In those without such primary pathology pre-existing poor medical condition was common and contributed to death from milder forms of pancreatitis. Our findings suggest that a decrease in the mortality of acute pancreatitis is more likely to be achieved through improved medical management than by operative intervention.

Leiomyosarcoma of the spermatic cord.

Leiomyosarcoma of the spermatic cord is extremely rare. We report a case associated with recurrent papillary bladder tumours and benign hyperplasia of the prostate. The use of adjuvant chemotherapy is described for the first time in the management of this condition.

Urodynamic investigation in a district general hospital.

In patients with disorders of micturition there is a poor correlation between clinical diagnosis and urodynamic findings. Thirty-three out of 82 patients studied in a Urodynamic Unit had their treatment plan altered as a result of the investigation.