Health-related quality of life in Australian men remaining disease-free after radical prostatectomy.

OBJECTIVE: To determine the health-related quality of life (HRQOL) of Australian men after radical prostatectomy. DESIGN: Cross-sectional study. SETTING: Private and public practices of three urologists in south-east Queensland, July 1989 to June 1995. PARTICIPANTS: 140 men with no evidence of disease recurrence 1 to 6 years after radical prostatectomy. MAIN OUTCOME MEASURES: Voiding and erectile potency and HRQOL. Recall of preoperative status and status at survey were established by an independently administered multi-item questionnaire. RESULTS: 112 men (80%) completed the study questionnaire. Difficulty with bladder control before the operation was reported by 25 (22%; 95% confidence interval [CI], 15%-31.2%), and the incontinence rate after treatment was 22/112 (20%; 95% CI, 12.7%-28.2%). Men with incontinence after operation were more likely to recall preoperative urinary symptoms. Eighty-four (75%) men were happy or coping with their sexual function after radical prostatectomy despite an erectile potency rate of only 12% (95% CI, 7%-20%). Twenty-eight (25%) had tried penile injections and three have had penile prostheses since their operation. Impotence was reported more frequently (40%) as the treatment-related problem most affecting life, followed by "concern about cancer" (12%) and incontinence (8%). Impotence was also the most common cause given for diminished HRQOL. CONCLUSIONS: Loss of sexual function after radical prostatectomy is more commonly perceived as a major problem and is more likely than urinary incontinence to adversely affect HRQOL. Loss of sexual function and its effect on HRQOL needs to be given greater emphasis in counselling before radical prostatectomy.

Bowel motility after enterocystoplasty.

OBJECTIVE: To determine whether the distension of bowel-augmented bladders during filling and urine storage stimulates gastrointestinal peristalsis, resulting in diarrhoea and increased bowel frequency. PATIENTS AND METHODS: Five patients with symptomatic diarrhoea occurring after enterocystoplasty were studied; all had undergone bladder augmentation using ileum or colon at least 6 months previously. Using bowel frequency charts and colonic transit-time studies, their bowel function was assessed over 6 days while patients self-catheterized 4-hourly. This was repeated when the patient's bladders were decompressed with an indwelling catheter, and the results before and after bladder decompression compared. RESULTS: One patient showed a significant increase in colonic transit time, from 44.4 to 57.6 h, a decrease in the percentage of liquid motions from 50% to 42.8% and a corresponding small decrease in bowel frequency with bladder decompression. One patient reported an increase in liquid stools, but there was a minor decrease in colonic transit time. The remaining three patients showed no improvement with bladder decompression. When data were combined and analysed using Student's paired t-test, there were no significant changes in colonic transit time, bowel frequency and diarrhoea stools with bladder decompression. CONCLUSIONS: Eliminating bladder distension and hence distension of the incorporated bowel segment in reconstructed bladders has no impact on bowel motility.

Advanced prostate cancer. The role of high priced hormone therapy.

OBJECTIVE: To compare the costs of the various options presently available in Australia for treatment of advanced prostatic carcinoma by androgen deprivation. DESIGN: Forty patients underwent a bilateral orchidectomy for prostatic carcinoma during the 1990/91 financial year at the Princess Alexandra Hospital, Brisbane. The Yale Cost Model, as adapted for use in Australian case-mix projects, was used to derive a diagnosis related group (DRG) cost for this procedure. This was compared with the projected cost that would be incurred in treating patients with the various medical alternatives. To enable comparison, expenses were calculated assuming a mean duration of survival of two years. RESULTS: The average cost of a bilateral orchidectomy was $2869. This compared to $11,253 for goserelin and $12,329 for cyproterone acetate when used alone in treating a single patient. Flutamide is presently only approved for combination therapy with a luteinising hormone-releasing hormone agonist, and when used with goserelin an average cost of $16,148 per patient was projected. CONCLUSIONS: Bilateral orchidectomy is clearly the cheapest means of hormone manipulation for prostatic carcinoma. Unless the costs of alternative therapies are drastically reduced in Australia, their use is difficult to justify in other than exceptional circumstances. We believe their use should be restricted presently to patients who would otherwise require a bilateral orchidectomy and have an anticipated survival of less than six months.

An assessment of the complications of the Brantley Scott artificial sphincter.

A Brantley Scott artificial sphincter has been inserted into 95 patients since 1981; more than half of the patients had lower urinary tract neuropathy and most of the others post-TUR incontinence. The main problem with the device has been cuff failure (12), which should be resolved by the new "dipped" cuffs. The major surgical complication has been erosion (10), usually associated with infection. Twenty-four patients had variable degrees of incontinence but the artificial sphincter remains the cornerstone of continence control when other methods have failed or are inappropriate.

The longer-term results of undiversion.

Thirty patients have been undiverted over the past 7 years. All but six were originally diverted for neuropathic problems of incontinence and/or upper tract compromise. Eighteen were undiverted because of deteriorating renal function. Only two were reconstructed for purely social reasons. Twenty-eight patients have stable renal function, though three are enuretic and two have persistent Pseudomonas infection. Ureteric "failure" remains the most difficult problem.

The effect of warm irrigation on blood loss during transurethral prostatectomy under spinal anaesthesia.

In this prospective trial a study was made of the effect of warm irrigation on blood loss during transurethral prostatectomy (TURP). A control group of 21 patients in whom irrigating fluid at operating room temperature (mean 21.5 degrees C) had been used was compared with a statistically comparable group of 19 patients in whom warm irrigating fluid (mean 33.1 degrees C) had been used. Blood loss in ml, in ml/g of tissue resected and in ml/min of resection time was not increased by the use of warm rather than room temperature irrigation. It was found that warm irrigation decreased heat loss and shivering in the patient during TURP and led to improved comfort both for patient and operator. The method of heating the irrigation bags was safe and economical.

Reduction of heat loss during transurethral resection of the prostate.

A prospective trial was performed on 100 patients to determine whether using a reflective blanket (Space Blanket) and heated glycine 1.5% bladder irrigation solution would decrease the fall in body temperature associated with transurethral resection of the prostate under spinal anaesthesia. Patients who received a combination of reflective blanket and heated glycine 1.5% solution had their fall in body temperature significantly reduced when compared with those patients managed without a reflective blanket and/or heated 1.5% glycine. There was a marked decrease in the number of patients shivering and no increase in blood loss was seen when heated bladder irrigation solution was used.