Comparative outcomes following endoscopic ureteral detachment and formal bladder cuff excision in open nephroureterectomy for upper urinary tract transitional cell carcinoma.

PURPOSE: The introduction of laparoscopic nephroureterectomy highlights the need for the critical appraisal of approaches to the distal ureter at surgery for upper tract transitional cell carcinoma. We compared differences after endoscopic ureteral detachment and open bladder cuff excision in nephroureterectomy. MATERIALS AND METHODS: A total of 138 patients underwent open nephroureterectomy for upper urinary tract transitional cell carcinoma from 1982 to 2005 with a median followup of 43 months. Of these patients 90 underwent endoscopic ureteral detachment and 48 underwent bladder cuff excision. Demographic, perioperative and oncological outcome data were collected in all cases. Statistical analyses were performed using the Student t test, chi-square and log rank tests, and logistic and Cox regression. RESULTS: Mean operative duration was significantly lower in the endoscopic detachment group than in the bladder cuff group (p <0.01). There were 49 (54.4%) bladder recurrences in the endoscopic detachment group, of which 8 (16.3%) were muscle invasive and 3 (3.3%) developed at the resection site. There were 23 (47.9%) bladder recurrences in the bladder cuff group, of which 3 (13.0%) were muscle invasive and 2 (4.2%) developed at the resection site. All 5 resection site tumors occurred after excision of muscle invasive distal ureteral tumors and 4 of these had positive margins. There were no differences in recurrence-free survival or disease specific survival between the groups. Operation subtype did not predict oncological outcome on univariate or multivariate analysis. CONCLUSIONS: Endoscopic ureteral detachment reduces operative duration and is associated with equivalent oncological outcomes compared with open bladder cuff excision in nephroureterectomy. Caution should be exercised in patients with low ureteral tumors.

Epithelioid perineurioma: an unusual variant.

An unusual epithelioid variant of perineurioma of the groin occurring in a 53-year-old man is described. The lesion appeared to be associated with a femoral nerve branch. The tumour was characterised by the presence of a syncytial proliferation of epithelioid cells, mimicking a meningioma of syncytial type. In addition there was a minor component of a conventional perineurioma. The tumour cells were EMA+, claudin-1+ and collagen type IV+. Bcl 2 was focally expressed. This case highlights the possibility of a common histogenetic pathway for meningiomas and perineuriomas. Although ultrastructural evidence of possible meningiomatous differentiation within an otherwise histologically typical perineurioma has been described, this is the first reported case of an unconventional epithelioid variant of perineurioma, histologically resembling meningioma.

Holmium: YAG lasertripsy for ureteric calculi: an experience of 300 procedures.

OBJECTIVE: To assess the success of holmium:YAG lasertripsy in the management of ureteric calculi and to audit the complications of the procedure, with special reference to strictures in the ureter. PATIENTS AND METHODS: A total of 300 ureteroscopic laser procedures were carried out on 265 patients (204 male and 61 female, median age 51 years, range 2-95) with ureteric calculi. At ureteroscopy, the calculi were present in the upper ureter in 44%, mid-ureter in 37% and lower ureter in 19% of patients; most calculi were > 5 mm. A 7.5 F Wolf semi-rigid ureteroscope was used and the holmium:YAG laser energy delivered using the Sharplan ML210 device at 0.8-1.0 J/pulse. The patients were followed up at approximately 6 weeks with limited intravenous urography or ultrasonography to assess clearance and the incidence of strictures. RESULTS: Stones were completely cleared in 90% of the patients, with the best results in the lower and mid-ureter (97% and 96%, respectively) followed by the upper ureter (89%). Alternative procedures were required in only 17 (7%) patients; extracorporeal shock-wave lithotripsy in 13, percutaneous nephrolithotomy in two and open pyelolithotomy in two patients. Complications with ureteric perforation in 11 patients, including laparotomy for peritonitis in one, serious sepsis in two and strictures in 10 patients. Strictures were more common in association with impacted calculi in the upper ureter early in the series. CONCLUSIONS: Holmium:YAG lasertripsy is a highly effective treatment for ureteric calculi, with strictures related to the treatment of difficult upper ureteric calculi.

Peri-urethral silicone microimplants (Macroplastique) for the treatment of genuine stress incontinence.

OBJECTIVE: To establish the safety and efficacy of the periurethral injection of silicone microimplants (Macroplastique) for the treatment of genuine stress incontinence in women. PATIENTS AND METHODS: Forty women (median age 50 years, range 27-74) with genuine stress incontinence confirmed on medium-fill video-cystometry were recruited to the study. Macroplastique (3-7 mL) was injected periurethrally 1 cm distal to the bladder neck at three or four points 'around the clock' under cystoscopic control. Where possible, the urodynamic study was repeated after 3 months. Results were graded as excellent (dry, no protection), good (better, but not totally dry) or poor (no improvement). RESULTS: Three months after a single injection, 16 (40%) were completely dry, 13 (33%) were improved and 11 (27%) were no better. Four patients who were improved were rendered dry by a second injection. After 3 years, 16 (40%) remained completely dry, seven (18%) were improved and 17 (42%) required alternative treatment with a Stamey bladder neck suspension. Dysuria for 48 h occurred in almost all patients; two were catheterized overnight and one required a catheter for 6 weeks. A comparison of maximum voiding pressures and flow rates before and 3 months after a single injection of Macroplastique revealed no urodynamic evidence of obstructed voiding (n = 25). CONCLUSION: Injectable silicone microimplants produced a good to excellent result in 73% of patients in the short-term and 58% of women maintained this response after 3 years. The injection is a day-case procedure which provides a satisfactory medium-term outcome in over half of patients with genuine stress incontinence. There are few side-effects and those patients with no improvement may go on to be treated by open surgery without complication.

Urinary bladder dysfunction following anterior lumbosacral spine fusion: case report and review of the literature.

A 34-year-old woman suffering from chronic degenerative low back pain involving L5-S1 disc space, refractory to conservative treatment, underwent spinal fusion. A combined instrumented posterolateral, followed by anterior, interbody allograft fusion through a left retroperitoneal approach was performed. Postoperatively, the patient was unable to evacuate her bladder and control her micturition. Anal tone and sensation were intact. A self-catheterisation regime was instituted with a diagnosis of parasympathetic nerve injury during the anterior spinal fusion. After a period of 3 months, the patient regained control of urination. We report this case to highlight the importance of protecting the parasympathetic presacral nerve during L5-S1 anterior interbody fusion, as injury to this nerve affects urinary evacuation.

Long-term results of intermittent low-friction self-catheterization in patients with recurrent urethral strictures.

OBJECTIVE: To ascertain the duration of intermittent low-friction self-catheterization (ILSC) required to cause stricture stabilization. PATIENTS AND METHODS: Over a 4 year period, 101 patients with a median age of 62 years (range 16-85) with recurrent urethral strictures were recruited to the trial. All the strictures were treated by internal urethrotomy and the patients were then randomized to perform ILSC twice weekly for either 6 months (group 1) or 36 months (group 2). Out-patient follow-up with urinary flow rate was initially at 1 month and then at 3 monthly intervals. Stricture recurrence rates were compared between the two groups. RESULTS: Of 101 patients, seven failed to attend after the first out-patient appointment. A further 21 died of unrelated disease whilst on ILSC (although 13 had been followed up for at least 24 months and so were included in the analysis). The median follow-up was 67 months (range 24-78). Ten patients in group 2, who had suffered from recurrent strictures, refused to stop catheterizing at the appointed time and all remain stricture-free on permanent ILSC. Of the remaining 76 patients, 48 catheterized for 6 months and 28 patients performed ILSC for 12 to 36 months (nine stopped earlier than intended). Forty per cent of patients who stopped at 6 months developed a recurrence compared with 14% who catheterized for more than 12 months (P < 0.05) (chi-square test with Yates' correction). CONCLUSIONS: Our results indicate that ILSC is safe and effective in preventing stricture recurrence in the long term. The recurrence rate of urethral strictures was significantly lower when ILSC was continued for more than 12 months compared with ILSC that was stopped at 6 months. We conclude that catheterization for at least 1 year is required to achieve adequate urethral stabilization.

Ureteric stricture formation following ureteric instrumentation in patients with a nephrostomy drain in place.

OBJECTIVE: To determine what effect the presence of a nephrostomy, left on free drainage, might have on the rate of occurrence of ureteric strictures after ureteric instrumentation. PATIENTS AND METHODS: Eighteen patients were identified in this unit who had had ureteric instrumentation while a nephrostomy was in place. RESULTS: Eight of 11 patients in whom the nephrostomy was left open developed ureteric strictures. None of seven patients in whom the lumen was maintained by stenting and/or clamping of the nephrostomy developed strictures. The strictures needed dilatation and stenting in seven patients and the ureter had to be reimplanted in the other. CONCLUSION: In patients in whom a nephrostomy is in place, the opening should be occluded after ureteric instrumentation or a stent should be inserted if it is to be left on free drainage.

Clam enterocystoplasty in general urological practice.

A series of 45 patients (31 female) underwent clam enterocystoplasty for urgency and incontinence. The majority had detrusor instability. Prolonged conservative treatment had failed in all cases. Improvement occurred in 71% and those younger than 30 years had better overall results; 29% remained incontinent, with 9% requiring a urinary diversion. Many patients did not achieve maximum benefit until 9 months post-operatively. Surgery had no statistically significant effect on any urodynamic parameter and post-operative complications were common. The operation was performed in either the coronal (19) or the sagittal plane (26); this did not influence results. In general, surgery was found to be technically simpler in the sagittal group and it is recommended that this becomes the standard procedure. We feel that this operation involves major surgery and should only be offered with reluctance.

Oestrogen dosage in prostatic cancer: the threshold effect?

We present the results of a prospective randomised trial of Estradurin, a long-acting oestrogen preparation (polyoestradiol phosphate), 160 mg per month, compared with bilateral orchiectomy in patients with advanced prostatic carcinoma (T3M1; T4MO/M1). The dose was lower than that usually recommended to induce a consistent fall in serial plasma testosterone levels to within the castrate range. Most patients treated with oestrogen showed an initial clinical and biochemical response equal to that obtained for patients undergoing orchiectomy. The inevitable relapse in hormone sensitivity sometimes occurred very soon after the start of oestrogen treatment. Many patients had poorly suppressed plasma testosterone expressed as a mean of monthly serial measurements, but then responded to secondary orchiectomy. These data only suggest that, in the treatment of hormone-sensitive prostatic carcinoma, it may be necessary to reduce plasma testosterone to midway between castrate and normal ranges. The data support the theory that response to androgen withdrawal is qualitative rather than quantative. The effective dose of oestrogen may therefore be reduced and the risk of thrombo-embolic complications minimised.

Ureteric stone surgery in practice.

From 1983 to 1986 140 patients underwent surgery for ureteric calculus. In approximately 30% "blind" basket extraction was considered appropriate and continued to be effective. Increasing expertise with the rigid ureterorenoscope led to a considerable reduction in open ureterolithotomy (15% in 1985-86), the majority following failed ureteroscopic extraction. In the same year both "blind" basket extraction and ureteroscopy were successful in 82 and 86% of attempts respectively. Electrohydraulic and ultrasonic lithotripsy were used in 12 patients to reduce large impacted calculi. The commonest complication of ureteroscopic stone surgery was perforation; this occurred in 14% of cases, though it was usually trivial and near the vesicoureteric junction. Perforations higher in the ureter tended to follow endoscopic lithotripsy and were often associated with urinary extravasation. Extra-ureteric stone fragments were also occasionally observed in such cases. There were no serious sequelae, although the in-patient stay was prolonged beyond the 48 h customary for uncomplicated extraction. The results suggest that ureteroscopic stone extraction, which can be conveniently introduced into urological practice, should become a standard endoscopic procedure.

Bone imaging and serum phosphatases in prostatic carcinoma.

One hundred and twenty-seven patients with locally advanced prostatic cancer were evaluated for the presence and progress of bone metastases before and during hormonal therapy, by serial radionuclide imaging and frequent measurement of plasma acid (tartrate-labile) and alkaline phosphatase. For comparison, serial changes in imaging and phosphatases were classified in each patient into one of six groups. Of 71 patients with negative imaging before treatment, 82% had normal alkaline phosphatase levels and 83% had normal acid phosphatase levels. Of 56 patients with bone metastases at presentation, false negative alkaline and acid phosphatase levels were noted in 18% and 36% respectively, though a few patients eventually developed abnormal levels. Serial plasma biochemistry and particularly alkaline phosphatase showed a response to treatment which was not always obvious on imaging. An assessment of the hepatic component of alkaline phosphatase by reference to plasma gamma glutamyl transpeptidase and isoenzyme electrophoresis was helpful in the evaluation of a false positive result but unnecessary where imaging was positive and phosphatase elevated. It is concluded that serial alkaline phosphatase estimation is essential in the follow-up of patients with prostatic cancer and bone metastases, and probably renders serial imaging studies superfluous once the presence of skeletal metastases has been proven. By comparison, acid phosphatase is a much less effective marker.

Carcinoma of the prostate of ductal origin.

Thirty-nine patients with ductal prostatic carcinoma have been reviewed. Their mode of presentation, initial stage, plasma phosphatase levels and response to hormone therapy were found to be similar to those in a group of 124 patients with the common acinar prostatic cancer. Histochemical examination demonstrated prostate-specific antigen in all ductal carcinomas.

Nesbit's operation for Peyronie's disease.

Nineteen patients with Peyronie's disease were treated by a modification of Nesbit's operation. The deformity was completely corrected in 18 patients. Potency was restored to 4 of the 6 impotent patients and satisfactory coitus became possible for 15 patients, whereas it had been possible for only 3 before operation.

Popliteal artery aneurysm.

Fourteen patients with atherosclerotic aneurysms of the popliteal artery, which were bilateral in 13, have been managed in a vascular unit where ultrasound, xerography, and isotope angiography are available for investigation. Although these methods are useful in confirming a suspected diagnosis, they cannot replace an awareness of the condition and clinical methods of examining the ischaemic lower limb. Reconstructive vascular surgery was effective in preserving the presenting leg in 5 cases and amputation was needed in 6, while no operation was needed in 3. Elective arterial surgery was carried out on the asymptomatic contralateral leg in 7 cases with good results and this active approach to treatment is recommended.

Radionuclide angiography of the popliteal arteries in occlusive vascular disease.

Before undertaking a femoro-popliteal bypass graft it is important to know whether the popliteal artery is patent to receive the distal end of the graft. Patency was assessed in 48 studies of 46 patients with peripheral vascular disease by radio-nuclide angiography. The procedure consists of imaging the popliteal arteries using a gamma camera after a bolus injection of 99mTc-sodium pertechnetate. The radio-nuclide angiograms were compared with the operative X-ray popliteal angiograms. Reliable information was obtained from the radio-nuclide images regarding the patency of the popliteal artery provided a femoral pulse was present. Quantitative data generated from the activity time curves were of no value in assessment of the patency of the popliteal arteries.