Is there still a place for prolonged bladder distension?

Over a 2-year period, 31 patients underwent prolonged hydrostatic bladder distension for benign and malignant bladder disease in this unit. Of these, 29 patients had benign functional disorders or bladder contracture, and in 2 patients hydrodistension was performed for complications of treatment for bladder neoplasia. Of the 29 patients with benign disease, 6 observed marked improvement and 8 some improvement in their symptoms, and 12 received no benefit. Patients with detrusor hypersensitivity fared better than those with detrusor instability or interstitial cystitis. A patient with malignant bladder disease died soon after the procedure as a result of a myocardial infarction. Problems attributed to the hydrostatic balloon catheter were responsible for 2 failures. The regional anaesthetic technique failed to provide adequate anaesthesia for hydrodistension in 9 procedures and limited the duration to 2 h in 13 others. Following recall of the perished balloon catheters by the manufacturer, and the introduction of continuous spinal anaesthesia, the number of technical failures has been reduced. This technique still has an important role to play in the relief of severe symptoms unresponsive to medical treatment, but it is important that ideal conditions are provided for hydrodistension in order to ensure maximum success, particularly when the alternative is major surgery.

Is indoramin an effective alternative to prostatectomy?

Alpha-1-adrenergic antagonists are recommended for symptomatic treatment of patients awaiting prostatic surgery. Their efficacy has been confirmed in placebo controlled clinical trials, but to date no comparison of their effects with the results of subsequent prostatectomy has been made. Fifty-five patients awaiting prostatectomy were assessed (by symptom scores and peak urinary flow rates) prior to treatment, on indoramin 20 mg bd, and 2 months following prostatectomy. Side effects while taking indoramin were experienced by 36% of patients. Despite an overall improvement in mean symptom scores, 26% of patients with obstructive and 30% of those with irritative symptoms who were assessed while taking indoramin failed to experience any improvement. Of the 31 patients assessed while on indoramin and again following surgery, prostatectomy produced a greater symptomatic relief than indoramin. The increase in peak flow rate following prostatectomy was 11.7 ml/s compared with 3.2 ml/s on indoramin. However, 5 patients preferred to continue taking indoramin rather than proceeding to surgery. Indoramin is no substitute for prostatectomy. Although some patients might benefit from treatment while awaiting surgery, significant side effects may severely restrict its use for this purpose. The response to indoramin cannot be used as an accurate predictor of response to prostatectomy.

Effect of percutaneous nephrolithotomy on thermoregulation.

Hypothermia is a well recognised complication of open surgery. We had observed hypothermia, occasionally followed by rebound hyperthermia in the early post-operative period, in patients undergoing percutaneous nephrolithotomy, and therefore decided to monitor patients undergoing this procedure more closely. During a 12-month period, 32 patients were monitored during 38 percutaneous nephrolithotomies; 12 procedures were performed using irrigation fluid at room temperature (22 degrees C) and 26 with fluid warmed to 37 degrees C. Although no statistically significant differences between temperature changes were seen, the most profound temperature falls occurred in patients who received fluid at room temperature. The recovery ward staff observed improved post-operative recovery in patients who had received warmed fluid. Three of the 5 patients who underwent more than 1 percutaneous procedure received fluid at 22 degrees C and fluid at 37 degrees C on separate occasions. In each patient a more profound temperature fall occurred when the cold fluid was used. Only 1 patient, who received cold fluid, developed rebound hyperthermia in the early post-operative period. Warming of irrigation fluid and close monitoring of core temperature may prevent unnecessary morbidity in patients undergoing percutaneous nephrolithotomy.

Silent testicular metastasis from carcinoma of the prostate.

Secondary testicular tumours are rare, but metastasis of prostatic carcinoma to the testis is being reported more frequently. While this may not reflect a true increased incidence, more cases are detected by bilateral orchiectomy. Of 916 patients with carcinoma of the prostate diagnosed and treated over a period of 10 years, 124 underwent bilateral orchiectomy. Three patients were found to have testicular metastasis, 1 being bilateral. The route of spread seems to be through the lumen and/or lymphatics of the vas deferens. Although it is a sign of advanced disease, the prognostic significance is undetermined.

Urothelial tumours of the upper urinary tract.

We present a retrospective 10 year analysis of 76 patients with urothelial tumours of the upper urinary tract. Patients older than 65 years, and female patients, presented with more advanced stages and had a worse prognosis. The grade and stage of the tumour has the greatest impact on survival. No conclusions can be drawn on the efficacy of various types of surgery, but simple nephrectomy gave a 5-year survival of 68%, with a stump recurrence rate of 15%. We observed that patients with urothelial tumours had 4 fold increased chance of developing gastrointestinal cancer.

Blood groups and transitional cell carcinoma of the upper urinary tract.

A retrospective analysis of the blood groups of 74 patients with transitional cell carcinoma of the upper urinary tract is presented. The blood group distribution of the patients reflected that of the general population. No relationship was found between blood groups and stage and grade of the tumour or patient survival. Nor were blood groups predictive of bladder tumour recurrence and stump recurrence in patients who had undergone simple nephrectomy.

Urinary tract lymphoma.

Urinary tract involvement by non-Hodgkin's lymphoma is uncommon and whilst extranodal disease may be the first manifestation of NHL in 15% of patients, the primary site of origin of NHL in the urinary tract is very rare. At the time of diagnosis, apparently primary urogenital lymphoma is often widely disseminated, with a correspondingly poor prognosis.

Malignant phaeochromocytoma.

Malignant phaeochromocytoma is a rare tumour and experience in its management is therefore limited. Five patients are discussed in whom the development of metastases was associated with rapidly progressive disease.

Randomised trial of mesterolone versus vitamin C for male infertility. Scottish Infertility Group.

A prospective randomised trial was carried out to assess the effect of 9 months' treatment with either mesterolone or vitamin C in 368 men complaining of an infertile marriage. There was no significant difference in the wife's pregnancy rate between the two treatment groups. A separate analysis of the data was made to include only men with a low normal testosterone (less than 16 nmol/l) and low sperm density (less than 10 million/ml). This separate analysis was also restricted to men married to wives with normal test results for tubal patency and ovulation and again there was no difference in pregnancy rates between the two treatment groups. These results indicate that mesterolone therapy given in the absence of any defined endocrinopathy is of no benefit in promoting male fertility and furthermore we have been unable to find any subgroup who will respond. Improvements in the therapy of male infertility are only likely after a diagnosis has been defined.

Early detection of obstructed ureter by ultrasound following renal transplantation.

Serial ultrasound examinations were carried out following 144 renal transplants. Eleven patients (8%) required surgery for ureteric obstruction and in all cases the ultrasound correctly identified the obstruction at an early stage. One false positive result was obtained with the ultrasound and this compared favourably with both the intravenous urogram (IVU) and isotope renogram. There were false positive and false negative results with both the IVU and renogram in addition to which neither of these techniques, particularly the IVU, is as simple or atraumatic for the patient as the ultrasound. Serial ultrasound examinations have a useful role in the detection of ureteric obstruction as well as being of value in the detection of perinephric fluid collections and acute rejection.

Varicoceles--a ten year retrospective review.

A retrospective survey of men having ligation of varicoceles for infertility from 1969-79 was carried out. Out of 95 patients 71 were traced. The wives of 35 of the patients (48%) subsequently became pregnant while 36 (52%) did not. Almost 60 per cent of patients with a post-operative sperm count more than 40 million/ml achieved a pregnancy. Approximately half the successful pregnancies were achieved within 2 1/2 years but successful pregnancies continued until 5 1/2 years after operation.

Releasing factor tests in men with oligozoospermia.

FSH levels were assayed in 300 men attending with infertile marriages. From this number, releasing factor tests were carried out in 24 men with oligozoospermia and an initial FSH below our normal mean. In all of these cases there was a response to releasing factor. Isolated FSH deficiency is likely to be rare in adult men presenting with infertility and no previous endocrinological history.

Influence of HLA matching and blood transfusion on renal allograft survival.

One hundred and seven consecutive cadaver kidney transplants have been followed for up to 6 years. The beneficial effect of HLA matching, shown in previous studies, has been confirmed. The 2-year failure rate from rejection was 29% for grafts with less than two incompatibilities, in comparison with a figure of 52% where there were two or more incompatibilities. In contrast to some reports, the presence of HLA antibodies did not have an adverse effect on the survival of first grafts. Patients not transfused prior to transplantation had a much higher 1-year graft failure rate (72%) than those given either frozen-thawed red cells (29%) or whole blood (23%). This apparently beneficial effect of blood transfusion was no greater in patients transfused with more than five units compared with those given less than five units. We believe that blood transfusion has an important influence on the outcome of renal transplantation.

Prolactin gonadotrophins in 208 men presenting with infertility.

Prolactin, FSH and LH were measured in the plasma of 208 male partners of infertile marriages. We found 1 case of marked hyperprolactinaemia in 82 oligozoospermic men (1.2%). There was no difference in the mean prolactin levels of men with normal sperm counts and men with oligozoospermia or azoospermia. One-third of the men with azoospermia and with sperm density of less than 10 million had marked FSH elevation and our experience confirms the work of others that this indicates a poor prognosis.

Ultrasound in the staging of bladder tumours.

The ultrasonic features of 162 bladder tumours are described. Comparing clinical staging by the TNM system and the ultrasonic appearances, there is a high degree of accuracy in staging by ultrasound. The use of this painless non-invasive technique is assessed and should be used in staging bladder tumours only in conjunction with other established methods, and not in isolation.