Magnetic Resonance Imaging and the Use in Small Renal Masses.

The incidence of small renal masses (SRM) has been increasing, and this is mainly attributed to the incidental finding of such masses on imaging performed in asymptomatic patients. Consequently, this calls for careful evaluation and management of these masses to determine their nature and need for treatment. This article reviews current literature regarding the evaluation and management of SRM. It focuses on the specific use of MRI in the diagnosis and management of SRM. A Medline review of the literature was performed from 1996 to the present time. Computed tomography (CT) imaging has been the investigation of choice for evaluating SRM. However, some remain difficult to determine their malignant or benign nature and remain indeterminate. In such cases, further imaging with magnetic resonance imaging (MRI) can be performed to evaluate the mass in more detail. It can also be used where CT is contraindicated and where active surveillance is the treatment of choice and radiation exposure is a concern. MRI is a useful tool in evaluating an indeterminate small renal mass. Accurate diagnosis and management of SRM require close collaboration between a urologist and radiologist to identify potentially malignant tumours to subsequently reduce mortality from renal cell cancer.

Non-Surgical Ablative Therapy for Management of Small Renal Masses-Current Status and Future Trends.

A large number of small renal masses (SRMs) with size less than 4 cm are being identified due to advances in diagnostic imaging. As the natural history of these tumours remains unknown, there is no reliable way to predict their behaviour or future growth. Although, partial nephrectomy is the gold standard for treatment of these tumours, ablative non-surgical therapies such as cryoablation and radiofrequency ablation provide a less invasive option of treatment with comparable oncological outcomes. In this systematic review, the principle, indications, methods of treatment, oncological control, complication and renal function of ablative therapies are critically reviewed. Cryotherapy utilizes the principle of inducing tissue destruction by freezing and thawing using argon and helium gasses, respectively. Radiofrequency ablation (RFA) works on the principle of tissue heating. Ablative treatments are particularly useful in the elderly patients, those with comorbidities or in patients with SRMs in solitary kidneys or renal impairment. Ablative therapies have less procedure-related complications and have promising medium-term oncological outcome. Longer-term results are accumulating. Cryotherapy may be a better modality for oncological control than RFA. Ablative therapy has emerged as a viable treatment options for SRMs with recurrence free survival rates approaching that of extirpative surgery. However, there is no consensus in the literature on the best selection criteria and this needs further refinement. Prospective long-term data with regards to oncological control is still needed.

Evaluation of the pressure leak test in increasing the lifespan of flexible ureteroscopes.

INTRODUCTION: Flexible ureteroscopes are expensive and delicate instruments that are integral in the offering of a minimally invasive technique of diagnosis and treatment of urolithiasis. Published literature has identified the importance of early damage recognition in preventing frequent use of the scope that would lead to further damage and high repair and replacement costs. Our study was designed to examine the outcome of the pressure leak test on the condition of flexible ureteroscopes after every use and analysing the damage and costs of maintenance. PATIENTS AND METHODS: A prospective study was designed with two treatment groups. Group 1, 95 consecutive procedures (n = 95) of flexible ureterorenoscopy and laser fragmentation of renal calculi were performed with ACMI DUR 8, (a scope with no in-built leak test facility). This was compared against group 2, where 98 procedures of laser fragmentation of renal calculi (n = 98) were performed using Storz Flex X(2) Ureteroscopes (with a in-built leak test facility). All scopes in Group 2 were tested for pressure leak after every procedure and the outcome of the tests recorded. RESULTS: Both groups were comparable for grade of surgeon; stone location, size & number; access sheath usage and duration of lasering. In Group 1, there were seven scope damages resulting in repairs/replacement amounting to costs $46264.40 (7.1% damage). In Group 2, three scopes revealed a positive pressure leak test, implying damage with repair costs of $9952.80 (3.1% damage) (p < 0.05). Significant cost savings and reduction in downtime were made in Group 2. CONCLUSIONS: Pressure leak testing following flexible ureterorenoscopy helped to significantly control costs of maintenance and repair. Newer scopes should have a leak testing mechanism as it prevents further detrimental damage to the scope, build-up of repair costs are avoided and there is an increase in the longevity of these delicate instruments.

The assessment of surgical competency in the UK.

INTRODUCTION: The assessment of surgical competence is a vital component of the surgical training process, the accreditation of specialists, and the maintenance of public confidence in the surgical profession [Grantcharov TP, Bardram L, Funch-Jensen P, Rosenberg J. Assessment of technical surgical skills. Eur J Surg 2002;168:139-44.]. The introduction of the Calman system, the European Working Time Directive, the Hospital at Night project, and financial pressures to increase productivity has nearly halved the surgical case load that trainees are exposed to. With less time to acquire surgical proficiency, surgeons may be insufficiently skilled at completion of training [Moorthy K, Munz Y, Sarker SK, Darzi A. Objective assessment of technical skills in surgery. BMJ 2003;327:1032-7.]. We look at the current methods of assessing surgical competency and what new innovative methods are on the horizon. METHODS: A Medline search was performed in April 2005 using the keywords 'surgical training', 'surgical competence', 'surgical simulation' and 'virtual reality'. Only papers published in English have been cited in this review. Articles were reviewed for relevance, impact within the field, and applicability to the UK training system. RESULTS: A large number of articles explore the potential of training techniques - including wet and dry laboratories, computer simulators and virtual reality trainers - to complement traditional 'apprenticeship' surgical training. All of the methods demonstrate the ability to distinguish surgeons of varying competence. DISCUSSION: The advantages of the training methods discussed are many and there is great enthusiasm for introducing skills assessment within a nationally standardised and validated surgical curriculum [Aggarwal R, Moorthy K, Darzi A. Laparoscopic skills training and assessment. Br J Surg 2004;91:1549-58.], as well as using it as an adjunct to traditional methods of training.

Tubular ectasia of the rete testis: a diagnostic dilemma.

Tubular ectasia of the rete testis is a pathologically benign process with complex and varied aetiology. It must be differentiated from neoplastic disease of the testis clinically with patient age, mode of presentation, tumour marker status and the characteristic ultrasound and Doppler study findings. Awareness and diagnosis of this clinical entity can prevent unnecessary surgical intervention in these patients.

Phentolamine re-dosing during penile dynamic colour Doppler ultrasound: a practical method to abolish a false diagnosis of venous leakage in patients with erectile dysfunction.

Increased sympathetic tone may cause an equivocal response to a prostaglandin E1 (PGE1) penile Doppler ultrasound (US) examination interpreted as a venous leak. We evaluated the US parameters and erectile response to the addition of phentolamine to a PGE1 penile Doppler US examination to ascertain whether addition of phentolamine would abolish a suboptimal response. 32 patients (median age 29 years, range 17-70 years) with either a previous Doppler US pattern of venous leakage or a clinical suspicion of venogenic impotence, underwent Doppler US after a total dose of 20 microg of PGE1. Peak systolic velocity (PSV), end diastolic velocity (EDV) and grade of erection were documented. If erectile response was suboptimal irrespective of the EDV measurement, 2 mg-intracavernosal phentolamine was administered and measurements repeated. Six patients had a normal erectile response, the remaining 26 received phentolamine. A significant increase in PSV between baseline and 20 microg PGE1 (p<0.001) was observed in all cases. Following phentolamine there was a significant increase in grade of erection (p=0.0001) and a significant reduction in the EDV (p=0.0001). A reduction of the EDV to below 0.0 cm s(-1) was observed in 16 patients. Four patients with EDV <5.0 cm s(-1) but >0.0 cm s(-1) had improved erectile response following phentolamine while six showed persistent EDV elevation >5 cm s(-1). No priapism was documented. It is essential to ensure cavernosal relaxation using phentolamine before a Doppler US diagnosis of venous leak is made. This two-stage assessment will allow this to be done efficiently and with a low risk of priapism.

T1G3 bladder cancer--indications for early cystectomy.

OBJECTIVES: To review our experience with early radical cystectomy in patients with T1G3 Transitional Cell Carcinoma of bladder (TCC). PATIENTS AND METHODS: Thirty patients, who underwent early radical cystectomy over a 10-year period for clinical stage T1G3 TCC bladder, were studied. Of these 21 (70%) had radical cystectomy without treatment with intravesical chemo/immunotherapy. The number of tumours, presence or absence of Carcinoma In-Situ (CIS) and the pathological stage of the cystectomy specimen were recorded in each patient. Disease specific survival was determined in the subgroups using Kaplan-Meier estimates. RESULTS: Seventeen patients underwent radical surgery for a single tumour without concomitant CIS (Group A). The other 13 had multiple tumours with or without concomitant CIS or a single tumour with CIS (Group B). The disease was upstaged after cystectomy in 1 (6%) patient in Group A compared to 7 (55%) in Group B, (p = 0.009). Nine (53%) had pT0 disease in Group A compared to 0% in Group B, (p = 0.0017). The 5-year cancer specific survival rates were 92% in Group A and 82% in Group B. CONCLUSIONS: In patients with multiple T1G3 tumours with or without associated CIS, or in those with single T1G3 tumour with associated CIS the incidence of the disease being already muscle invasive at the time of clinical diagnosis is 55%. Early radical cystectomy should be advocated in this group. Conversely, for a single T1G3 tumour without associated CIS, conservative bladder preserving strategy with immuno-chemotherapy and close surveillance is justified.

Colour Doppler ultrasound of the penis.

Because it is a superficial structure, the penis is ideally suited to ultrasound imaging. A number of disease processes, including Peyronie's disease, penile fractures and penile tumours, are clearly visualized with ultrasound. An assessment of priapism can also be made using spectral Doppler waveform technology. Furthermore, dynamic assessment of cavernosal arterial changes after pharmaco-stimulation allows diagnosis of arterial and venogenic causes for impotence. This pictorial review illustrates the range of diseases encountered with ultrasound of the penis.

Distribution of vascular endothelial growth factor (VEGF) in prostate disease.

Vascular endothelial growth factor (VEGF) is a heparin-binding polypeptide growth factor. It is a potent mitogen for endothelial cells. Immunohistochemical localisation of VEGF was performed on 25 moderate to poorly differentiated stage T4 M+ prostate cancer specimens and 30 benign prostatic hyperplasia (BPH) specimens. A positive result was indicated by area staining >25% and +2 or +3 staining intensity. Positive epithelial staining was observed in 50% of BPH specimens and 56% of cancer specimens, while positive stromal staining was observed in 73% of BPH specimens and 30% of cancer specimens. This may reflect an active role for stromal VEGF in the pathological process of BPH.

Laparoscopic removal of multicystic dysplastic pelvic kidney.

A patient presented to us with a symptomatic, polycystic, nonfunctioning, pelvic kidney, which was removed laparoscopically. Laparoscopic removal of multicystic pelvic kidney has not been reported in an adult. The technique we adopted is described, and the relevant literature is reviewed.

Have stent-related symptoms anything to do with placement technique?

PURPOSE: To determine whether incorrect placement of an indwelling stent plays any role in the causation of irritative voiding symptoms and loin pain. PATIENTS AND METHODS: Sixty patients with ureteral calculous disease were prospectively requested to analyze the symptoms that they encountered 1 week after stent insertion via a questionnaire handed out at their discharge from the hospital. The answers were analyzed with reference to the intravenous urogram performed at presentation and the plain radiograph taken immediately after stent insertion. RESULTS: Stents crossing the midline in the bladder and having incomplete loops at the lower end give rise to higher morbidity. CONCLUSION: The present series suggests that the position and completeness of the lower loop do influence symptom severity. Proper attention to detail whilst placing a stent should help reduce the incidence and severity of stent-related symptoms.

Acute segmental testicular infarction: differentiation from tumour using high frequency colour Doppler ultrasound.

Segmental testicular infarction is rare, of variable aetiology but usually idiopathic. B-mode ultrasound may demonstrate a focal mass indistinguishable from a testicular tumour, with confirmation only achieved following surgery. We report a case of segmental testicular infarction presenting as a heterogeneous mass on B-mode ultrasound, confidently diagnosed as an area of infarction on high frequency colour Doppler ultrasound and proven on histology. The pre-operative differentiation of tumour from segmental infarction allows testis-sparing surgery.

Validity of PSA, free/total PSA ratio and complexed/total PSA ratio measurements in men with acute urinary retention.

The reliability of serum prostate specific antigen (PSA) measurements in men with acute urinary retention is unclear. Total PSA, free and complexed PSA were measured, and the free/total (f/t) PSA and complexed/total (c/t) PSA ratios calculated, prior to catheterisation and at 48 and 72 h post-catheterisation in 39 men with acute retention. Subsequent histology showed 12 patients had prostate cancer and 27 benign prostatic hypertrophy. Serum free and total PSA fell following catheterisation, while complexed PSA rose during the first 48 h then subsequently fell. The f/t PSA and c/t PSA ratios provided the best discrimination at 48-72 h with 100% sensitivity and 75-82% specificity.Prostate Cancer and Prostatic Diseases (2001) 4, 167-172.

The detection of prostate cells by the reverse transcription-polymerase chain reaction in the circulation of patients undergoing transurethral resection of the prostate.

OBJECTIVE: To determine whether prostate cells are disseminated into the circulation of patients after transurethral resection of the prostate (TURP), as assessed by a reverse transcription-polymerase chain reaction (RT-PCR) assay for prostate specific antigen (PSA) mRNA. PATIENTS AND METHODS: Fifty-one patients, comprising 34 with benign prostatic hyperplasia (BPH) and 17 with prostate cancer who were undergoing routine TURP, had blood samples taken before and 30 min after surgery. The blood mononuclear cell layer was isolated by density-gradient centrifugation and total RNA extracted. Complementary DNA was synthesized by RT of the RNA. The target PSA sequence was amplified by PCR with specific PSA primers and the product detected on agarose-gel electrophoresis with ethidium bromide staining. RESULTS: Five patients (all with prostate cancer) were positive on PSA RT-PCR before surgery and remained positive after TURP. Of the remaining 46 patients, five (11%; three with BPH and two with cancer) changed from a negative to a positive result after TURP. CONCLUSION: In a proportion of patients TURP causes the dissemination of prostate cells into the circulation which are then detectable by RT-PCR of PSA mRNA.