Prediction of complications after partial nephrectomy by RENAL nephrometry score.

INTRODUCTION: Discussing and planning the appropriate management for suspicious renal masses can be challenging. With the development of nephrometry scoring methods, we aimed to evaluate the ability of the RENAL nephrometry score to predict both the incidence of postoperative complications and the change in renal function after a partial nephrectomy. METHODS: This was a retrospective study including 128 consecutive patients who underwent a partial nephrectomy (open and laparoscopic) for renal lesions in a tertiary UK referral centre. Univariate and multivariate ordinal regression models were used to identify associations between Clavien-Dindo classification and explanatory variables. The Kendall rank correlation coefficient was used to examine an association between RENAL nephrometry score and a drop in estimated glomerular filtration rate (eGFR) following surgery. RESULTS: An increase in the RENAL nephrometry score of one point resulted in greater odds of being in a higher Clavien-Dindo classification after controlling for RENAL suffix and type of surgical procedure (odds ratio [OR]: 1.29, 95% confidence interval [CI]: 1.04-1.64, p=0.043). Furthermore, a patient with the RENAL suffix 'p' (ie posterior location of tumour) had increased odds of developing more serious complications (OR: 2.60, 95% CI: 1.07-6.30, p=0.042). A correlation was shown between RENAL nephrometry score and postoperative drop in eGFR (Kendall's tau coefficient -0.24, p=0.004). CONCLUSIONS: To our knowledge, this is the first study that has shown the predictive ability of the RENAL nephrometry scoring system in a UK cohort both in terms of postoperative complications and change in renal function.

Pelvic lymph node metastases from bladder cancer: outcome in 83 patients after radical cystectomy and pelvic lymphadenectomy.

PURPOSE: We evaluate the outcome in patients with node positive bladder cancer with particular reference to the effect of individual characteristics of positive nodes on survival after meticulous pelvic lymphadenectomy at cystectomy. MATERIALS AND METHODS: This prospective analysis contains 452 cases of bladder cancer staged preoperatively as N0M0, managed with pelvic lymphadenectomy and cystectomy between 1984 and 1997. A total of 83 (18%) patients with histologically confirmed node positive disease are included in our study. RESULTS: The median overall survival of patients with positive nodes was 20 months. Median 5-year survival was 29%. Patients who survived were found with positive nodes at each site in the pelvis. The median survival of 57 patients with less than 5 positive nodes was 27 months, compared with 15 months for 26 with 5 nodes or more (log-rank test p = 0.0027). Median survival of 26 patients with no lymph node capsule perforation was 93 months, compared with 16 months for 57 with capsule perforation (p = 0.0004). The median survival of 18 patients with a maximum diameter of lymph node metastasis up to 0.5 cm. was 64 months, compared with 16 months for 65 with nodal metastasis greater than 0.5 cm. (p = 0.024). Contralateral positive nodes were found in 16 of 39 (41%) patients with unilateral bladder cancer. CONCLUSIONS: Long-term survival is possible with node positive bladder cancer. Those patients with few as well as smaller and, therefore, unsuspected nodal metastases, and those without lymph node capsule perforation have the best results after removal of pelvic metastatic nodal disease. Because patients who survive may be found regardless of the site of pelvic nodal metastases, meticulous bilateral pelvic lymphadenectomy is warranted in all patients at the time of attempted curative cystectomy for bladder cancer, particularly if there is no clinical evidence of nodal involvement.

Bladder substitution in women.

Although numbers are still small and follow-up is often limited, female orthotopic bladder reconstruction has been shown to provide excellent, near-normal voiding and storage function in selected patients, and its popularity has been growing over the last decade. The true role of this form of surgery, however, is not yet fully established. This paper discusses the indications for patient selection, operative technique and outcome of female bladder substitution. Outcome is equivalent to that seen in male patients, although in some series there is a higher rate of voiding dysfunction requiring intermittent self-catheterization. Although further data regarding urethral recurrence rates are awaited, it would seem that with careful patient selection and operative technique, cancer surgery may not be compromised. Functional results have been excellent and patient satisfaction is very high. Provided there is a functional external sphincter and tumor margins can be safely cleared, this form of surgery offers patients the best opportunity to preserve quality of life following cystectomy.

Five meters of H(2)O: the pressure at the urinary bladder neck during human ejaculation.

BACKGROUND: There are no data in the literature on pressure changes in the prostatic urethra during ejaculation. In healthy men, it has always been postulated that there must be a pressure gradient in order to prevent retrograde ejaculation, but scientific proof for that is pending. METHODS: In five healthy male volunteers, the pressure profile in the prostatic urethra was registered during ejaculation, using a 10 French balloon catheter with 16 pressure channels. The channels were arranged in pairs at 5-mm intervals, beginning just below the balloon at the bladder neck and extending down to the external urethral sphincter. RESULTS: In the proximal part of the prostatic urethra, a pressure of up to 500 cm of H(2)O was measured in all subjects. Contrary to that, pressures did not exceed 400 cm of H(2)O distally to the verumontanum. CONCLUSIONS: A novel method to register the pressure profile in the lower urinary tract during ejaculation (ejaculomanometry) is presented. This study adds to the knowledge of the normal physiology of reproductive function and may be useful in the evaluation of male sexual and reproductive disorders.

Absence of urethral post-void milking: an additional cause for incontinence after radical prostatectomy?

OBJECTIVE: Urinary incontinence following radical prostatectomy is thought to be mainly due to stress leak as a result of sphincter insufficiency or detrusor dysfunction. However, a number of patients complain of stress-independent urinary leakage following voiding, i. e. a post-micturition dribble, of uncertain origin. In order to establish wether post-micturition dribble is related to altered post-void milking in the urethra, voiding cystourethrograms (VCUGs) were performed before and after radical prostatectomy and correlated with the presence of post-micturition dribble. METHODS: 23 VCUGs were recorded before and 19 VCUGs at 10-15 days following radical prostatectomy. A standard questionnaire regarding urinary symptoms was given to all patients pre- and postoperatively at defined intervals. RESULTS: 12 of 19 patients (63%) had post-void urethral milking prior to surgery, none of these reported post-micturition dribble. 6 of the 7 patients (86%) without post-void urethral milking reported post-micturition dribble. Postoperatively only 1 of 16 patients (6%) had post-void urethral milking. Of the 15 patients without postoperative urethral milking, 13 (87%) reported post-micturition dribble. The decrease in rate of milking and increase in rate of post-micturition dribble from before to after surgery was statistically significant (chi(2) test, p = 0.0001 and p<0.0001, respectively. CONCLUSIONS: These data suggest that post-void milk-out of the urethra is often absent in the early postoperative period after radical prostatectomy and that this is associated with post-micturition dribble. Aside from detrusor and sphincter dysfunction, urethral dysfunction, i.e. the absence of urethral post-void milking, seems to be an additional cause of incontinence following radical prostatectomy.

Female orthotopic bladder substitution: a good operation in the right circumstances.

PURPOSE: We present the long-term results of orthotopic bladder substitution in women. MATERIALS AND METHODS: We prospectively assessed 15 female patients undergoing orthotopic bladder substitution between October 1984 and April 1998. The indication for diversion was bladder carcinoma in 8 cases, gynecologic malignancy in 2 and benign disease in 5. RESULTS: At a median followup of 19 months daytime and nighttime continence was 100% and 80%, respectively. All but 1 patient voided spontaneously. Two patients who were initially able to void successfully had voiding difficulties in the initial 10 months due to prominent mucosal tissue at the bladder neck. In each case this condition was successfully managed by endoscopic resection. There has been no local recurrence of bladder carcinoma. CONCLUSIONS: With strict selection criteria and vigilant followup female orthotopic bladder substitution produces excellent long-term functional results comparable to those in men. However, the limits in women who require radical cystectomy for invasive bladder cancer cannot be determined from our results. Further long-term data on the local recurrence rate of invasive urothelial malignancy are needed before the true risk may be quantified accurately.

Metabolic consequences of continent urinary diversion.

PURPOSE: Continent diversion, in particular orthotopic bladder substitution, is a well accepted form of urinary diversion. However, potential metabolic consequences in the early postoperative period as well as long term remain a serious problem. MATERIALS AND METHODS: We review the possible complications associated with removing bowel and incorporating it in the urinary tract. RESULTS: Metabolic complications following continent urinary diversion are common. In the majority of cases, and with correct patient selection and education, problems may be minimized with use of an appropriate bowel segment and early intervention. CONCLUSIONS: Careful patient selection and vigilant followup are essential for good long-term results in patients undergoing continent urinary diversion.

Maximisation of the erectile response in the investigation of impotence.

UNLABELLED: The aim of this study was to assess whether redosing with a combination of intracavernosal (IC) vasoactive agents could produce a complete erectile response, thereby providing a reliable and reproducible method of dynamic investigation of erectile dysfunction. Forty-one impotent men were redosed with a combination intracavernosal agents until a constant penile rigidity was achieved. They were then shown audiovisual sexual stimulation (VES) by means of a videotape. The erectile responses were monitored continuously by RigiScan (Dacomed). RESULTS: Despite a constant rigidity with intracavernous injection (ICI), 16 men (39%) still had an improved response with VES that was clinically detectable. CONCLUSION: Dynamic investigation of erectile dysfunction with a combination and redosing of IC agents may still lead to an incomplete erectile response. This may potentially lead to patients being incorrectly labelled and confirms the limitations of follow-up studies using dynamic tests of erectile function.

Arguments against the long-term use of combined androgen blockade.

Androgen deprivation therapy is the most effective systemic treatment for advanced prostate cancer. However, as most patients who die from prostate cancer have hormone refractory disease, fine tuning of antiandrogen treatment by combined androgen blockade (CAB) can not be expected to improve survival significantly. Only the South West Oncology Intergroup (SWOG) study 0036 has shown a significant advantage for CAB compared with luteinizing hormone-releasing hormone (LH-RH) agonist alone. However, the results of this study should be interpreted with caution as the patients had to self-administer their treatment by daily injection so compliance may not have been optimal. Also, those receiving LH-RH agonist alone were not covered against disease flare. Indeed, no trial using depot LH-RH agonist with or without flutamide has been able to show a survival benefit. When treatment with LH-RH agonist plus antiandrogen was compared with orchiectomy alone, only the European Organization for Research and Treatment of Cancer (EORTC) study 30,853 showed a significant difference in favour of CAB. However, in this study an increased proportion of patients receiving CAB may have had a more favourable prognosis. Only one study comparing orchiectomy plus antiandrogen with orchiectomy alone has shown an advantage for CAB therapy, and this was only slight. Therefore, as yet there is no justification for long-term use of CAB. However, short-term antiandrogen treatment must be used to prevent disease flare during initiation of LH-RH agonist treatment.

Reproducibility of penile arterial colour duplex ultrasonography.

OBJECTIVE: To assess the reproducibility of penile arterial colour duplex ultrasonography (CDU) in patients with impotence. PATIENTS AND METHODS: Fifty-eight patients underwent CDU of their penile arteries on two occasions 2 weeks apart. Group A (n = 34) received 60 mg of papaverine intracavernosally before CDU and group B (n = 24) received a combination of papaverine, prostaglandin E1 and phentolamine. The variables measured during CDU were peak systolic velocity (PSV) and the end diastolic velocity (EDV), with the systolic rise-time (SRT) also recorded in group B. RESULTS: In both groups of patients the reproducibility between the first and second recordings was poor for all variables. The mean variation in PSV was 31.5% and 40.2%, and in EDV was 44.9% and 50.1%, for groups A and B, respectively. For the SRT, measured only in group B, the mean variation was 25.7%. CONCLUSIONS: These results show that CDU is a poorly reproducible technique for assessing vascular status in patients with impotence. Therefore, it is not reliable in the long-term follow-up of patients and single measurements should be interpreted with caution.

Chlamydiazyme plus blocking assay to detect Chlamydia trachomatis in endocervical specimens.

Three methods to detect Chlamydia trachomatis in endocervical swab specimens collected from 502 women with genitourinary or abdominopelvic symptoms were evaluated: (1) a direct immunofluorescence assay, (2) an enzyme-linked immunoabsorbent assay, confirming positive samples with a blocking assay, and (3) conventional tissue cell culture. C. trachomatis was detected by at least one method in 72 specimens, of which 56 (11%) were determined to be true-positive results by repeated testing and by performing a confirmatory assay. The sensitivity, specificity, and positive and negative predictive values were 91%, 100%, 100%, and 99%, respectively, for culture and the enzyme-linked immunoabsorbent assay plus blocking assay and 74%, 98%, 83%, and 96%, respectively, for the direct immunofluorescence assay. In this population of women, using the enzyme-linked immunoabsorbent assay with the confirmatory assay is a rapid, reliable, and cost-effective alternative to culture for diagnosing infection with C. trachomatis.

Detection of influenza virus by centrifugal inoculation of MDCK cells and staining with monoclonal antibodies.

Two methods for detection of influenza virus in 451 clinical respiratory specimens were compared: (i) 24-well-plate centrifugation with Madin-Darby canine kidney (MDCK) cells and staining with monoclonal antibody pools to influenza viruses A and B (Centers for Disease Control, Atlanta, Ga.) in an indirect immunofluorescence assay after incubation for 40 h, and (ii) conventional tissue cell culture with primary monkey cells and hemadsorption. For 100 of these specimens, direct examination of smears by the direct fluorescence assay with monoclonal antibodies (Boots Cell Tech/API Analytab Products, Plainview, N.Y.) was also performed. Influenza A virus was recovered from 28 specimens by tissue cell culture after incubation for an average of 4.75 days (range, 2 to 14 days). Influenza B virus was recovered from 35 specimens by tissue culture after incubation for an average of 5.4 days (range, 3 to 14 days). By the centrifugation assay, 23 specimens were positive for influenza A virus and 30 were positive for influenza B virus. All specimens positive by the centrifugation assay were also positive by conventional tissue cell culture. The sensitivities of the centrifugation assay were 82% for detection of influenza A virus and 86% for influenza B virus (84% overall); the specificity of the assay was 100%. Of the 100 specimens studied by direct examination, 15 were positive for influenza virus by both conventional culture and centrifugation assay; however, the direct-smear results for these 15 specimens were negative in 13 cases and inconclusive in 2. The centrifugation assay is a rapid and specific method for detection of influenza A and B viruses in clinical specimens, and it can serve as a valuable and cost-efficient adjunct to conventional culture methods.

Effect of dexamethasone on detection of herpes simplex virus in clinical specimens by conventional cell culture and rapid 24-well plate centrifugation.

During a 4-month period, two methods for rapid detection of herpes simplex virus (HSV) were examined: (i) pretreatment of A549 cells with dexamethasone for conventional tissue culture (277 specimens) and (ii) 24-well plate centrifugation using A549 cells with and without dexamethasone pretreatment and staining with serotype-specific monoclonal antibodies (Syva Co., Palo Alto, Calif.) after incubation for 16 to 18 h (153 specimens). By conventional tube cell culture, both with and without dexamethasone, HSV was identified in 88 of 277 (32%) specimens. Significantly more specimens were positive for HSV at 24 h (46 versus 27 specimens) and at 48 h (a total of 72 versus 59 specimens) (P less than 0.0001) in dexamethasone-treated A549 cells. Of the 153 specimens tested by conventional culture and 24-well plate centrifugation, HSV was detected in 44 (29%) by conventional culture, and by 24-well plate centrifugation with and without dexamethasone, HSV was detected in 32 (21%) and 30 (20%) specimens, respectively. The sensitivity, specificity, and positive and negative predictive values of 24-well plate centrifugation with A549 cells for detection of HSV were 73 (71% without dexamethasone), 100, 100, and 90%, respectively. In conventional tube cell culture, pretreatment of A549 cells with dexamethasone results in more rapid detection of HSV. Centrifugal inoculation of dexamethasone-treated and untreated A549 cells in 24-well plates and staining with monoclonal antibodies after incubation for 16 to 18 h is an insensitive means to detect HSV in clinical specimens and should not replace conventional tube cell culture.

Conventional tube cell culture compared with centrifugal inoculation of MRC-5 cells and staining with monoclonal antibodies for detection of herpes simplex virus in clinical specimens.

During a 15-month period, two methods for detection of herpes simplex virus (HSV) in 699 clinical specimens were compared: (i) 24-well-plate centrifugation (24WPC) with MRC-5 cells and staining with type-specific monoclonal antibodies (Syva Co., Palo Alto, Calif.) after incubation for 16 to 18 h and (ii) conventional tube cell culture with primary rabbit kidney and A549 cells. HSV was identified by conventional tube cell culture in 165 (24%) of 699 specimens and by the 24WPC method in 116 (17%) of 699 specimens. One specimen was positive for HSV by the 24WPC method alone, compared with 50 specimens positive only by conventional cell culture (P less than 0.0001). The sensitivity, specificity, and positive and negative predictive values of the 24WPC technique with MRC-5 cells for detection of HSV in clinical specimens were 70, 99.8, 99, and 91%, respectively. Centrifugal inoculation of MRC-5 cells in 24-well plates and staining with monoclonal antibodies after incubation for 16 to 18 h is an insensitive means of detecting HSV in clinical specimens and should not replace conventional tube cell culture with primary rabbit kidney cells.