Upper and lower urinary tract obstruction secondary to inguinoscrotal hernia containing bladder and prostate gland.

Inguinal hernia is a common clinical presentation, with 1-3% containing some of the urinary bladder. Most cases are asymptomatic and diagnosed intraoperatively at hernia repair. We describe a case of an 84-year-old man presenting with acute urinary retention in a bladder had herniated entirely into his scrotum. He was managed conservatively with urinary catheterisation and discharged home. He re-presented with urosepsis secondary to bilateral ureteric obstruction. This was treated with antibiotics and nephrostomy and his hernia was ultimately repaired. Clinicians should consider both upper and lower urinary tract obstruction in patients with significant bladder herniation.

Multidrug-resistant NDM-1 Klebsiella outbreak and infection control in endoscopic urology.

UNLABELLED: What's known on the subject? and What does the study add? Since the first case of multidrug-resistant New Delhi metallo-ß-lactamase (NDM-1) Klebsiella and Escherichia coli UTI in January 2008, there have been more reports of cases worldwide. Urology is a specialty uniquely vulnerable to these organisms because the NDM-1 carriers tend to be the common UTI-causing organisms. Further, the nature of the procedures involved in endoscopy in the urinary tract confers the potential for direct exposure and transmission of the organisms that commonly cause UTI. Although decontamination by sterilization of urological endoscopes and surgical instruments is well established in the operating theatre suite, there were no national standardized guidelines for infection control measures with respect to the video camera head in endoscopic urology in the UK. This paper reports the first UK outbreak of NDM-1 Klebsiella UTI, for which the common source of infection was rapidly traced to the endoscopic camera head in the urology theatre, where single-use sterile disposable plastic camera sheaths were not routinely used and the camera head was regularly cleaned with detergent wipes. We found that infection control practices vary across UK urology units. In the context of infection control, we highlight a need for standardized practice in the use of camera sheaths and in the decontamination process for endoscopic video camera heads. Either sterilization or use of single-use sterile disposable plastic camera sheaths with regular cleaning of the camera head using approved disinfectant for all endoscopy work is recommended. OBJECTIVES: • To report the first UK outbreak of NDM-1 Klebsiella, for which the common source of infection was rapidly traced to the endoscopic camera head in the urology theatre, where camera sheathing was not routinely used and the camera head was regularly cleaned with detergent wipes. • To survey the use of camera sheath and infection control practices in endoscopy in urology in the UK. PATIENTS AND METHODS: • A structured questionnaire was conducted via telephone interview with urological theatre sisters/charge nurses from all urological units across the UK. • Data on the use of camera sheath, cleaning practices, type of disinfectant used and choice of prophylactic antibiotics were obtained. RESULTS: • Out of 206 NHS urology units, 158 (77%) units across the UK were surveyed. Forty-one (25.9%) do not use camera sheaths, 16 (10.1%) were used dependent on the consultant's preference, and the remaining 101 (63.9%) routinely used camera sheath. • Twenty-one (13.3%) units clean the camera head only at the end of the operating list and the remainder clean after every case. • The choice of cleaning agent/disinfectant used varied considerably. They are broadly categorised as alcoholic wipes 90 (57%), detergent wipes 46 (29.1%) and soapy water 21 (13.3%). • The choice of prophylactic antibiotic includes gentamicin alone (96.3%), augmentin alone (1.4%), gentamicin/amoxicillin (0.7%) and cefuroxime alone (0.7%). CONCLUSIONS: • In the context of infection control, we highlight the need for a standardized practice in the use of camera sheaths and the process of decontamination of the endoscopic camera head. • Either sterilization or use of single-use sterile disposable plastic camera sheath with regular cleaning of the camera head using approved disinfectant for all endoscopy work is recommended.

Cost-effectiveness and efficiency of shockwave lithotripsy vs flexible ureteroscopic holmium:yttrium-aluminium-garnet laser lithotripsy in the treatment of lower pole renal calculi.

UNLABELLED: What's known on the subject? and What does the study add? Stone management economics is a complex issue. FURS and SWL are recognised treatment option for lower pole kidney stones. There are paucity of data comparing cost implication and effectiveness of both treatment options. Both treatment modalities are equally efficacious. FURS incurred greater cost burden compared to SWL in the UK setting. In the present economic circumstance, clinicians should also consider cost-impact, patient's preference and specific clinical indication when counselling patients for treatment. OBJECTIVE: • To compare the cost-effectiveness and outcome efficiency of extracorporeal shockwave lithotripsy (SWL) vs intracorporeal flexible ureteroscopic laser lithotripsy (FURS) for lower pole renal calculi ≤20 mm. PATIENTS AND METHODS: • Patients who had treatment for their radio-opaque lower pole renal calculi were categorized into SWL and FURS group. • The primary outcomes compared were: clinical success, stone-free, retreatment and additional procedure rate, and perceived and actual costs. • Clinical success was defined as stone-free status or asymptomatic insignificant residual fragments <3 mm. • Perceived cost was defined as the cost of procedure alone, and the actual cost included the cost of additional procedures as well as the overhead costs to result in clinical success. RESULTS: • The FURS (n= 37) and SWL (n= 51) group were comparable with respect to sex, age, stone size and the presence of ureteric stent. • The final treatment success rate (100% vs 100%), stone-free rate (64.9% vs 58.8%), retreatment rate (16.2% vs 21.6%) and auxillary procedure rate (21.6% vs 7.8%) did not differ significantly. • The mean perceived cost of each FURS and SWL procedure was similar (£249 vs £292, respectively); however, when all other costs were considered, the FURS group was significantly more costly (£2602 vs £426, P= 0.000; Mann-Whitney U-test). CONCLUSION: • SWL was efficacious and cost-effective for the treatment of lower pole renal calculi ≤20 mm.

Local anesthetic and steroidal prostatic injection for chronic pelvic pain syndrome: an effective last resort?

OBJECTIVE: the chronic pelvic pain syndrome is a severely debilitating and protracted condition for patients and a challenging condition for clinicians to treat. We report our experience with an adjunctive treatment in four patients using peri- and intra-prostatic injection of Levobupivicaine and Methylprednisolone combination via a transperineal approach under general anaesthesia. METHODS: a retrospective observational report. RESULTS: all patients had found little or no relief of their perineal/pelvic pain with the use of antimicrobials, alpha blockers, anti-inflammatories, anticholinergics, Elmiron or with TURP. In all cases, the use of prostatic injection treatment has resulted in a complete eradication of perineal pain and significant improvement to quality of life for at least a period of time. DISCUSSION: we suggest prostatic injection treatment as a last resort therapy in relieving pain. Our report provides a basis for a larger randomised controlled study with longer term follow-up to evaluate its efficacy and durability.

Novel in vitro assays for the characterization of EMT in tumourigenesis.

BACKGROUND: Two novel assays quantifying Epithelial to Mesenchymal Transition (EMT) were compared to traditional motility and migration assays. TGF-beta1 treatment of AY-27 rat bladder cancer cells acted as a model of EMT in tumourigenesis. METHODS: AY-27 rat bladder cancer cells incubated with 3 ng/ml TGF-beta1 or control media for 24 or 48 h were assessed using novel and traditional assays. The Spindle Index, a novel measure of spindle phenotype, was derived from the ratio of maximum length to maximum width of cells. The area covered by cells which migrated from a fixed coverslip towards supplemented agarose was measured in a novel chemoattractant assay. Motility, migration and immunoreactivity for E-cadherin, Vimentin and cytokeratin were assessed. RESULTS: TGF-beta1 treated cells had increased "spindle" phenotype together with decreased E-cadherin, decreased Cytokeratin-18 and increased Vimentin immunoreactivity. After 48 h, the mean Spindle Index of TGF-beta1 treated cells was significantly higher than Mock (p=0.02, Bonferroni test) and there were significant differences in migration across treatment groups measured using the novel chemoattractant assay (p=0.02, Chi-square). TGF-beta1 significantly increased matrigel invasion. CONCLUSION: The Spindle Index and the novel chemoattractant assay are valuable adjunctive assays for objective characterization of EMT changes during tumourigenesis.

Radical exenteration surgery is curative in locally advance mucinous prostatic adenocarcinoma involving bladder and rectum.

The management of mucinous prostatic adenocarcinoma include hormonal treatment, radiotherapy and radical prostatectomy with variable long-term outcome. We report a 59 year old man with advanced mucinous prostatic adenocarcinoma involving almost the entire bladder and had failed treatment with hormonal and radiotherapy, but subsequently underwent radical pelvic exenteration surgery that resulted in long-term cure. He remains alive, his PSA remains undetectable and his surveillance CT scans did not show any evidence of recurrence after 11 years post-surgery. The favourable outcome of radical surgery suggests that radical surgery should be considered, especially in cases with failed initial treatments.

Improved cost-effectiveness and efficiency with a slower shockwave delivery rate.

OBJECTIVE: To determine the benefits of a slower shockwave (SW) delivery rate of 70 shocks/min on the treatment efficiency and cost-effectiveness of extracorporeal SW lithotripsy (ESWL). PATIENTS AND METHODS: Patients who had ESWL for their upper urinary tract radio-opaque calculi were categorized into two groups: slow (70 SW/min) and fast (100 SW/min) delivery rate. All treatment was carried out using a lithotripter (Model S, Dornier MedTech, Wessling, Germany) as an outpatient procedure with no anaesthesia or sedation. The groups were followed for > or =6 months. The primary outcomes compared were the stone-free rate, re-treatment rate, additional procedure rate, perceived cost and actual cost. Clinical success was defined as stone-free status or asymptomatic insignificant residual fragments of <3 mm. Perceived cost was defined as the cost of ESWL alone, and actual cost included the cost of additional procedures and overhead costs to result in clinical success. RESULTS: In all, the study included 102 patients, categorized into the fast (51) and slow (51) rate groups. The groups were comparable in terms of sex, age, body mass index, stone size and stone location. The slow group had a significantly better stone-free rate (67% vs 25.5%, P = 0.002, chi-square), fewer mean shocks to clinical success (3045 vs 4414, P < 0.001, U-test), lower re-treatment rate (22% vs 45%P = 0.013, chi -square), a lower additional procedure rate (12% vs 29%, P = 0.02, chi-square), greater efficiency quotient (0.51 vs 0.16) than the fast group. The mean perceived cost of ESWL (GB pound 297 vs 394 pounds, P = 0.013, U-test) and the mean actual cost of the slow group were significantly less (496 pounds vs 1002 pounds, P = 0.001, U-test). CONCLUSION: Slowing the SW delivery rate to 70/min significantly reduced the actual cost by half and improved treatment efficiency.

pcDNA3.1tdTomato is superior to pDsRed2-N1 for optical fluorescence imaging in the F344/AY-27 rat model of bladder cancer.

PURPOSE: Animal models are important for pre-clinical assessment of novel therapies in metastatic bladder cancer. The F344/AY-27 model involves orthotopic colonisation with AY-27 tumour cells which are syngeneic to F344 rats. One disadvantage of the model is the unknown status of colonisation between instillation and sacrifice. Non-invasive optical imaging using red fluorescence reporters could potentially detect tumours in situ and would also reduce the number of animals required for each experiment. MATERIALS AND METHODS: AY-27 cells were stably transfected with either pDsRed2-N1 or pcDNA3.1tdTomato. The intensity and stability of fluorescence in the resultant AY-27/DsRed2-N1 and AY-27/tdTomato stable cell lines were compared using Xenogen IVIS®200 and Olympus IX51 systems. RESULTS: AY-27/tdTomato fluorescence intensity was 60-fold brighter than AY-27/DsRed2-N1 and was sustained in AY-27/tdTomato cells following freezing and six subsequent sub-cultures. After sub-cutaneous injection, fluorescence intensity from AY-27/tdTomato cells was threefold stronger than that detected from AY-27/DsRed2-N1 cells. IVIS®200 detected fluorescence from AY-27/tdTomato and AY-27/DsRed2-N1 cells colonising resected and exteriorised bladders, respectively. However, the deep-seated position of the bladder precluded in vivo imaging. Characteristics of AY-27/tdTomato cells in vitro and in tumours colonising F344 rats resembled those of parental AY-27 cells. Tumour transformation was observed in the bladders colonised with AY-27/DsRed2-N1 cells. CONCLUSIONS: In vivo whole-body imaging of internal red fluorescent animal tumours should use pcDNA3.1tdTomato rather than pDsRed2-N1. Optical imaging of deep-seated organs in larger animals remains a challenge which may require proteins with brighter red or far-red fluorescence and/or alternative approaches.

Young patients with diverticular disease: a preliminary quality of life study.

BACKGROUND: Diverticular disease is more apparent in the younger population under 50 years however, its management remains controversial. We report a preliminary quality of life (QoL) assessment which may be useful when determining the optimal management strategy. METHODS: A retrospective review of clinical records was carried out from April 1999 to 2004, to identify all patients diagnosed with diverticular disease and its complications, confirmed either by radiology and/or histology evidence. The younger patients were classified according to their management: surgical or conservative. Information on demographic, investigations, treatment, follow-up and recurrent episodes was recorded, and the health-related SF-36 QoL questionnaire was administered. RESULTS: A total of 47 patients had confirmed diverticular disease. Forty-one patients were managed conservatively and six underwent surgery. Ten (24%) from the conservative group and one (17%) from the surgical group were re-admitted for recurrence of symptoms. About 80% (33 conservative and five surgical) responded to the QoL questionnaire. There was an overall negative impact on all QoL domains (conservative vs surgical): general health (54.1 vs 39.0), physical functioning (72.7 vs 56.0), social functioning (63.3 vs 67.0), physical role limitation (50.0 vs 45.0), emotional role limitation (58.6 vs 26.7), bodily pain (56.9 vs 48.5), vitality (45.0 vs 43.0), mental health (64.5 vs 57.6), PCS (44.5 vs 40.8), MCS (42.6 vs 38.8); and these domain scores did not differ significantly. CONCLUSION: Although there was a negative impact on the quality of life, the majority of patients can be treated adequately by conservative management. We highlighted the need to consider the QoL aspect when determining the optimal management of the disease in the younger population.

Pilot study of sexual dysfunction following abdominal aortic aneurysm surgery.

INTRODUCTION: The complication of sexual dysfunction as a quality of life (QoL) component after abdominal aortic aneurysm (AAA) surgery in men is poorly studied. AIMS: To investigate the prevalence of sexual dysfunction and to highlight the importance of discussing this issue with patients undergoing AAA repair. MAIN OUTCOME MEASURES: The self-reported sexual dysfunction prevalence pre- and postoperatively, the effects on sexual QoL, and the postoperative Sexual Health Inventory for Men (SHIM) scores. METHODS: Between April 1999 and July 2002, a questionnaire-based study, including the SHIM, was conducted on male patients 1-2 years after their elective open (EO) and rupture open (RO) or endovascular repair (EVAR) AAA repair. Demographics, risk factors for sexual dysfunction, sexual history, and postoperative sexual QoL data were obtained. RESULTS: Out of 142 alive male patients surveyed, 56 (40%) patients responded (26 EO, 21 EVAR, and 9 RO repair). The mean age was 69, 73, and 70 years, respectively, and 65%, 66%, and 66%, respectively, admitted to be sexually active postoperatively. The self-reported sexual dysfunction prevalence preoperatively was 27% (EO), 63% (EVAR), and 45% (RO); and postoperatively was 58%, 76%, and 67%, respectively. Detection using SHIM was higher at 70%, 95%, and 78%, respectively. There was a significantly greater increase in the postoperative prevalence of sexual dysfunction in the EO group than in the EVAR group (P < 0.05, chi(2)). The sexual QoL was worsened postoperatively in all groups: 53% (EO), 75% (EVAR), and 50% (RO); but only one-third of EO and EVAR patients, and none in RO patients, would seek treatment for their sexual dysfunction. CONCLUSION: There was a negative impact on the sexual QoL in all groups after surgery, and a significantly higher proportion of patients experienced deterioration in sexual QoL following EO surgical repair. Our results demonstrate the need for a prospective study.

Risk of postnatal depression after emergency delivery.

AIM: To identify whether women having emergency delivery are at increased risk of developing postnatal depression (PND). METHODS: This is a retrospective comparative cohort study design. Two hundred and fifty Malaysian women were part of a previous study examining the prevalence of PND in a multiracial country and the effects of postnatal rituals. All women were at least 6 weeks post-partum when asked to complete the Edinburgh Postnatal Depression Scale (EPDS). Sociodemographic and birth data were obtained. RESULTS: Data collected were divided into two groups: 55 emergency delivery and 191 non-emergency delivery. There were four missing data. There was no significant difference in the mean age, parity, gestational period, baby birthweight, 5 min baby Apgar score and EPDS scores of the two groups. However, the analysis of PND indicated that women with emergency delivery had a relative risk of 1.81 compared with women with non-emergency delivery. The comparison of the two groups using chi2 indicated a significant (chi2 = 3.94, d.f. = 1, P = 0.04) increase in the presence of PND in the emergency delivery. CONCLUSION: When compared with women having non-emergency delivery, women having emergency delivery had about twice the risk of developing PND. Special attention to this group appears warranted.