Serum amino-terminal propeptide of type 1 procollagen (P1NP) in prostate cancer: a potential predictor of bone metastases and prognosticator for disease progression and survival.

INTRODUCTION: To determine if amino-terminal propeptide of type 1 procollagen (P1NP) is reliable as a predictor of prostate cancer bone metastases and assess its value as a prognostic indicator of disease progression and survival. MATERIALS AND METHODS: A cohort of patients with prostate cancer between January 1999 and July 2001 were recruited. Prostate-specific antigen (PSA) and P1NP levels were measured. Two years following completion of recruitment, patient notes were reviewed for symptoms of bone metastases and survival. RESULTS: 24 negative and 12 equivocal or positive bone scans were reported for 36 recruited patients. Mean PSA values for patients with negative, equivocal and positive scans were 18.3, 24.9 and 122.5 ng/ml while mean P1NP for the same groups were 38.2, 73.4 and 119.9 ng/ml. For patients with equivocal and positive scan, mean P1NP with and without bone symptoms were 111.5 and 65.7 ng/ml while for surviving and dead patients the values were 63.9 and 120.8 ng/ml, respectively. CONCLUSIONS: Though this study involved a small number of patients, it demonstrates P1NP's potential as a predictor of bone metastases and a prognosticator for disease progression and survival.

Gyrus bipolar electrovaporization vs transurethral resection of the prostate: a randomized prospective single-blind trial with 1 y follow-up.

The Gyrus system uses bipolar electrocautery with saline irrigation to vaporize prostatic tissue and is compared to transurethral resection of the prostate (TURP) in a randomized prospective study with 1 y follow-up. Outcomes measured were fluid absorption, blood loss, period of catheterization, hospital stay, symptom scores, quality of life, flow rates, and post-void residual volumes at 3, 6, and 12 months. All measured parameters were similar, although re-catheterization rates were higher (30% vs 5%) in the Gyrus group. Clot evacuation rates were higher in the TURP group (19% vs 0%). The Gyrus device is safe and produces results that are similar to TURP at 1 y.

Outpatient ureteric procedures: a new method for retrograde ureteropyelography and ureteric stent placement.

OBJECTIVE: To evaluate a new method for retrograde ureteropyelography and retrograde ureteric stent placement. PATIENTS AND METHODS: Procedures were undertaken using a flexible cystoscope and digital C-arm fluoroscopy in outpatients under sedoanalgesia. The flexible cystoscope was used to identify the ureteric orifice and a straight 0.9 mm hydrophilic guidewire inserted and passed into the renal pelvis under fluoroscopic guidance. A 4 F general-purpose catheter was then passed over the wire and ureteropyelography performed. To place the stent the hydrophilic guidewire was exchanged for an ultra-stiff wire, over which the stent was passed directly. RESULTS: Over a 47-month period, 723 procedures were carried out in 472 patients. The clinical indications were ureteric obstruction in 229 (32%), stone disease in 165 (23%), unexplained hydronephrosis in 150 (21%), haematuria in 94 (13%) and others in 85 (12%). Of the 723 procedures, 643 (89%) were technically successful. Failure was most commonly caused by failure to cannulate the ureteric orifice (51, 7%). Just over half the procedures (366, 51%) involved stent placement or replacement. Immediate complications occurred in 17 patients (3%). Of those who were questioned, 94% (282 of 300) reported the procedure to be acceptable. CONCLUSION: Retrograde ureterography and ureteric stent placement may be satisfactorily undertaken with the patient under sedoanalgesia on an outpatient basis. This technique can reduce costs, hospital admissions, general anaesthetic use, demands on theatre time and complication rates.

Histological changes associated with long-term urethral stents.

OBJECTIVE: To assess the histological changes found in patients with long-term external sphincter, prostatic and urethral stents. PATIENTS AND METHODS: Eighteen patients with long-term stents (mean time since insertion 3.5 years) were investigated. Three had external sphincter stents for detrusor-sphincter dyssynergia secondary to spinal injury, eight had prostatic stents for obstruction secondary to benign prostatic hyperplasia and seven had urethral stents for recurrent strictures. Nine stents were occluded at investigation, of which seven were entirely removed. The mucosae overlying the remaining two were biopsied, as were mucosae over the nine patent stents, at urethroscopy. RESULTS: The changes observed included polypoid hyperplasia (11 of 18 patients) between and around the stent mesh wires, nonkeratinizing squamous metaplasia (two) or hyperkeratotic squamous metaplasia (seven), chronic inflammation (15) with prominent plasma cell infiltrates (11), variable foreign-body granuloma (two) and microabscess formation (five), usually associated with clefts formed around the stent wires (three of five). CONCLUSION: Stents become incorporated into the urethral wall by a process of polypoid hyperplasia through the stent mesh, with at least focal covering of the stent in most cases, and with variable inflammatory infiltrates, most of which are rich in plasma cells. The urothelial and connective tissue proliferation resulted in obstruction of the stent lumen in nine of the patients studied. Further long-term study is necessary to exclude the development of carcinoma in patients with keratinizing squamous metaplasia, although no malignancy was seen in this study.

Acute suppression of idiopathic detrusor instability with magnetic stimulation of the sacral nerve roots.

OBJECTIVE: To assess the effect of magnetic stimulation of the S3 nerve root on unstable contractions in patients with idiopathic detrusor instability. PATIENTS AND METHODS: Twelve patients with idiopathic instability were studied. The S3 nerve root was localized by mapping the response of the toe flexor muscles and anal sphincter to magnetic stimulation at different sites. Unstable contractions were provoked by rapidly infusing saline into the bladder and the effect of magnetic stimulation of S3 on contractions was assessed. RESULTS: Magnetic stimulation relieved the sensation of urinary urgency and reduced the duration and amplitude of provoked contractions in all patients. Stimulation reduced the area under the pressure/time curve by 80-98%. In some patients there was a shortlived residual suppressive effect lasting up to 90 s. CONCLUSIONS: Magnetic stimulation of S3 acutely abolishes unstable contractions in patients with idiopathic detrusor instability.

Vesico-ureteric reflux in adult patients with spinal injury.

OBJECTIVES: To review the incidence, aetiology, treatment and prognosis of vesico-ureteric reflux (VUR) in patients in a regional spinal injuries centre. PATIENTS AND METHODS: A retrospective review of radiological investigations revealed 34 of 447 (8%) patients with VUR on at least one study. The notes of these patients were examined to determine their management and outcome. RESULTS: Most patients developed VUR within 4 years of injury; the underlying intravesical pressure was high in half the patients studied. Patients were managed aggressively with a variety of medical and surgical techniques. The VUR of 15 patients resolved completely and in three patients there was some improvement. Renal function deteriorated in three patients as assessed by isotopic scanning. Two patients were transferred to our unit in end-stage renal failure associated with VUR and died within one year. CONCLUSIONS: VUR continues to be a problem in patients with spinal injury and remains potentially fatal through the effects of high transmitted pressure and infection. Renal failure does not always develop as a consequence of the combination of VUR and high intravesical pressure. No single aetiological factor for VUR was found. With active early treatment, the incidence of VUR can be minimized and long-term complications avoided.

Balloon dilatation of the external urethral sphincter in the treatment of detrusor-sphincter dyssynergia.

Balloon dilatation of the external urethral sphincter was introduced in our unit in 1990 as an alternative to sphincterotomy in the surgical management of detrusor-sphincter dyssynergia in spinally injured patients. The initial results with the technique looked promising. We performed 14 balloon dilatations in the period 1990-1993, and these patients have been followed up for 8-68 months (mean 55.5). The procedure was effective in relieving symptoms and had a low morbidity. Sphincter activity assessed at cystoscopy was initially abolished in all patients. Vesicoureteric reflux present in one patient pre-operatively resolved after the procedure. However the long-term results are disappointing, with an 85% failure rate (62% within 1 year). Balloon dilatation in our series has a lower success rate than both sphincterotomy and sphincter stenting and cannot be recommended for the treatment of detrusor-sphincter dyssynergia.

The management of superficial bladder cancer: an interactive seminar.

OBJECTIVES: To determine the current management of superficial bladder cancer in the United Kingdom. METHODS: An interactive seminar with a series of questions about management and hypothetical clinical scenarios was conducted at the 1995 conference of the British Association of Urological Surgeons. The responses of the audience were recorded electronically and analysed. RESULTS: The results showed that there is a wide variation in practice and some confusion over the place of intravesical treatment using cytotoxic drugs and bacille Calmette-Guérin. CONCLUSIONS: The management of superficial bladder cancer could be improved by a more widespread use of intravesical therapy, along with the introduction of local protocols and national guidelines.

Surgical shock presenting as lower limb ischaemic rest pain.

Ischaemic rest pain affecting the lower limb is characteristically constant, severe and distressing. Attention is thereby concentrated on the affected leg and its vascular supply which may distract the attending clinician from a precipitating cause. We present two patients with shock that led to acute onset of ischaemic leg pain.