Male lower urinary tract symptoms: is surgery always necessary?

A transurethral resection of the prostate is a good operation to relieve bladder outflow obstruction and has a low incidence of complications. However, recent work suggests that many men with symptoms may not require an operation, and it can probably be delayed in a majority for many years. This may be particularly important in old and frail patients. Many men with outflow obstruction have irritative symptoms such as urgency, frequency and nocturia; these could be treated with anticholinergics, provided they have normal flow rates and small or absent residual urine volumes. Pharmacological treatment to relieve outflow obstruction is disappointing. There may be some benefit from alpha-adrenoreceptor antagonists, but the place for 5 alpha-reductase inhibitors is still unsure. All drugs have side effects which are unacceptable in patients who are not bothered by their urinary symptoms and can wait for active treatment.

Retroperitoneal malignancy masquerading as ureteric colic.

This study reviews 6 patients who were referred with severe loin pain radiating to the groin and in whom a presumptive diagnosis of ureteric colic was made. Of these, 3 patients were found to have carcinoma of the pancreas and the remaining 3 had retroperitoneal lymph node metastases. Retroperitoneal malignancies rarely present with loin pain, but this diagnosis should be considered in patients with long-standing loin pain in whom an obvious diagnosis is not apparent.

Tubulovillous adenoma arising 30 years after ileocystoplasty.

The possibility of recurrent colonic metaplasia occurring as a complication of pelvic ileal pouches after ileo-rectal anastomosis has been raised. Several reports have documented malignant bladder tumours developing in patients many years after an ileocystoplasty. The case of a 50 year old man, who developed a tubulovillous adenoma in the ileal patch 30 years after an ileocystoplasty had been performed to enlarge a tuberculous shrunken bladder, is reported. The adjacent small intestinal mucosa showed features suggestive of colonic metaplasia.

The management of impotence in diabetic men by vacuum tumescence therapy.

The treatment of impotence in diabetic men with vacuum tumescence therapy was studied in a specialist clinic. Of 54 diabetic men referred with impotence, seven declined treatment, three chose self-injection with papaverine, and 44 chose vacuum therapy. Patients underwent autonomic function testing (heart rate response to respiration), measurement of penile blood flow (duplex Doppler scanning), and estimation of serum prolactin and testosterone levels. After 2 months, 33 men (75%) were able to have satisfactory intercourse using vacuum therapy. Three others could produce a satisfactory erection with vacuum therapy but their partners found it unacceptable. Eight men (18%) were unable to have satisfactory intercourse; six of these were later treated by self-injection. The median frequency of use of vacuum therapy was 5.5 (1-26) times a month. Outcome was independent of penile blood flow, autonomic function or endocrine status. Impotent diabetic men should be given counselling and offered a choice of the available treatments. Vacuum tumescence therapy is an effective and simple treatment which requires little investigation.

Surgical technique for inguinal surgery and its effect on fertility in the Wistar rat model.

This study has explored the relatively neglected effects of operative manipulation of the vas deferens on fertility. Following unilateral vasectomy the contralateral vasa of 52 4-week-old Wistar rats were subjected to 7 different manipulations. After 7 weeks a fertility trial was conducted. All sham operated rats (n = 18) were fertile. Of the remaining 34 rats, 22 (65%) were sterile. All of those with tight ring reconstruction (n = 6) were sterile, due initially to venous obstruction. Nine of 14 rats with acute clip trauma (65%) remained fertile but 11 of 14 (78%) with full mobilisation were sterile owing to extensive avascular fibrosis of the vas deferens. These results suggest that overzealous cord handling and operative technique in the immature animal is counterproductive and leads to vasal occlusion. This may have important repercussions in paediatric inguinal surgery, with a subsequent higher incidence of azoospermia and male subfertility.

A prospective study of the value of conventional CT, dynamic CT, ultrasonography and arteriography for staging renal carcinoma.

The value of dynamic CT scanning for staging renal carcinoma was studied prospectively in 28 patients and the results compared with those of ultrasonography, arteriography and conventional CT. Arteriography correctly staged 48% of tumours; ultrasonography and conventional CT correctly staged 50% and dynamic CT correctly staged 72%. Dynamic CT staged renal carcinoma more accurately than ultrasonography, conventional CT or arteriography and it is suggested that arteriography should be restricted to specific indications such as the mapping of arterial anatomy and therapeutic renal artery embolisation.

Obstructive uropathy from endometriosis after hysterectomy and oophorectomy; two case reports.

Two patients with obstructive uropathy as a result of post menopausal endometriosis are reported. They both illustrate the potential problems of hormone replacement therapy after bilateral salpingo-oophorectomy and hysterectomy in patients who have had extensive endometriosis. It is suggested that in such patients the potential of reactivation of the disease with hormone-replacement therapy should be recognised and ureteric involvement be excluded by intravenous urography or renograms.

Ureteroscopy and ureteric calculi: how useful?

The results of management in 134 patients admitted to hospital during 1985 with ureteric colic are presented in relation to the size and position of a ureteric stone. Spontaneous passage of a stone occurred in 100 patients and 34 required surgical intervention. Stones measuring 5 mm or less in maximum dimension passed spontaneously in 92% of cases; stones measuring 6 mm or more had only a 28% chance of passing. Of 34 surgical procedures 19 were endoscopic. In three cases a stone was removed under vision with ureteroscope and Dormia basket. In five patients ureteric dilatation before attempted ureteroscopy permitted later passage of the stone. In 1986 similar results were obtained with ureteroscopic stone removal performed in three cases. Fewer open operations and more Dormia basket extractions were performed in 1986. In this series the size of the stone was closely related to outcome. The high chance of spontaneous passage (75% in 1985 and 84% in 1986) puts the need for surgical intervention, and in particular ureteroscopy, into perspective in the management of patients with ureteric colic.