Aggressive angiomyxoma of the perineum: a rare presentation in a male with 4 years follow up.

Angiomyxoma are rare myxoid cells tumours that occur predominantly in women in the fourth decade. They are classified as the less aggressive superficial and the deeper aggressive variety commonly called aggressive angimyxomas. We report a rare perineal aggressive angiomyxoma in a 79-year-old male presenting with a painless perineo-scrotal mass. Radiological investigations confirmed a lobulated well-defined mass separate from the testicles and histology following wide local excision confirmed aggressive angiomyxoma. He remains recurrence free at 4 years of surveillance which is the among longest reported follow-up for perineal angiomyxoma.

Pain related and overall morbidity with TRUS guided prostate biopsy--a prospective study.

OBJECTIVE: To assess analgesia requirement after trans-rectal ultrasound guided prostate biopsy(TRUSBx) for appropriate counselling. MATERIALS AND METHODS: Prospectively, successive patients undergoing TRUSBx between July 2009 and November 2011 were given questionnaires prior to procedure. Standard 12-core TRUSBx under peri-prostatic block (10 mL of 1% lidocaine) and antibiotic prophylaxis (oral ciprofloxacin, intravenous gentamicin and metronidazole suppository) were performed. Pain perception was assessed using a Visual Analogue Score (VAS). RESULTS: Mean (range) age of the 405 patients was 67.3 years (48-88). Mean VAS during the procedure was 2.93 and 2.20 on reaching home. Mean maximum VAS for the cohort on day 1 and day 2 were 1.27 and 0.7 respectively. 140 (35%) were independent with some or minimal discomfort. 14 patients required assistance for some of their basic daily needs. 9 patients (2.2%) were hospitalised due to sepsis. 131 patients (32.4%) required additional oral analgesia following TRUSBx on days 0, 1 and 2. These patients were generally younger with a mean age for this group of 63.6 years (46-88). The difference in the mean age between those self-medicating and not was not statistically significant (p > 0.005). This group had mean VAS during the procedure of 4 and when patients reached home was 3.5. Mean maximum VAS on day 1 and 2 was 2.1 and 1.3 respectively. 11 patients required assistance from another adult. CONCLUSION: A third of patients required self-medicated analgesia post-procedure. Age alone cannot be used as a criterion to identify patients who will subsequently require analgesia post-procedure, but a higher VAS during the procedure may be indicative. These patients must be counselled appropriately.

Pain related and overall morbidity with TRUS guided prostate biopsy a prospective study

Objective To assess analgesia requirement after trans-rectal ultrasound guided prostate biopsy(TRUSBx) for appropriate counselling. Materials and Methods Prospectively, successive patients undergoing TRUSBx between July 2009 and November 2011 were given questionnaires prior to procedure. Standard 12-core TRUSBx under peri-prostatic block (10 mL of 1% lidocaine) and antibiotic prophylaxis (oral ciprofloxacin, intravenous gentamicin and metronidazole suppository) were performed. Pain perception was assessed using a Visual Analogue Score (VAS). Results Mean (range) age of the 405 patients was 67.3 years (48-88). Mean VAS during the procedure was 2.93 and 2.20 on reaching home. Mean maximum VAS for the cohort on day 1 and day 2 were 1.27 and 0.7 respectively. 140 (35%) were independent with some or minimal discomfort. 14 patients required assistance for some of their basic daily needs. 9 patients (2.2%) were hospitalised due to sepsis. 131 patients (32.4%) required additional oral analgesia following TRUSBx on days 0, 1 and 2. These patients were generally younger with a mean age for this group of 63.6 years (46-88). The difference in the mean age between those self-medicating and not was not statistically significant (p > 0.005). This group had mean VAS during the procedure of 4 and when patients reached home was 3.5. Mean maximum VAS on day 1 and 2 was 2.1 and 1.3 respectively. 11 patients required assistance from another adult. Conclusion A third of patients required self-medicated analgesia post-procedure. Age alone cannot be used as a criterion to identify patients who will subsequently require analgesia post-procedure, but a higher VAS during the procedure may be indicative. These patients must be counselled appropriately. .

Intraoperative red blood cell salvage and autologous transfusion during open radical retropubic prostatectomy: a cost-benefit analysis.

INTRODUCTION: Open radical retropubic prostatectomy (RRP) has an average blood loss of over 1,000 ml. This has been reported even from high volume centres of excellence. We have looked at the clinical and financial benefits of using intraoperative cell salvage (ICS) as a method of reducing the autologous blood transfusion requirements for our RRP patients. MATERIALS AND METHODS: Group A comprised 25 consecutive patients who underwent RRP immediately prior to the acquisition of a cell saver machine. Group B consisted of the next 25 consecutive patients undergoing surgery using the Dideco Electa (Sorin Group, Italy) cell saver machine. Blood transfusion costs for both groups were calculated and compared. RESULTS: The mean postoperative haemoglobin was similar in both groups (11.1 gm/dl in Group A and 11.4 gm/dl in Group B). All Group B patients received autologous blood (average 506 ml, range: 103-1,023 ml). In addition, 5 patients (20%) in Group B received a group total of 16 units (average 0.6 units) of homologous blood. For Group A the total cost of transfusing the 69 units of homologous blood was estimated as £9,315, based on a per blood unit cost of £135. This cost did not include consumables or nursing costs. CONCLUSIONS: We found no evidence that autologous transfusions increased the risk of early biochemical relapse or of disease dissemination. ICS reduced our dependence on donated homologous blood.

Implications of pacemakers and implantable cardioverter defibrillators in urological practice.

PURPOSE: Pacemakers and implantable cardioverter defibrillators are widely used and often encountered in urology practices worldwide. Safety and performance during electrosurgery, extracorporeal shock wave lithotripsy, magnetic resonance imaging, positron emission tomography and radiotherapy are not clearly defined. We reviewed the literature on their use and implications in urological practice. MATERIALS AND METHODS: We performed a PubMed® search and all relevant articles were studied to understand the basic functioning of these devices along with the technological advances designed to reduce electromagnetic interference. RESULTS: A modern permanent pacemaker is comprised of a generator and leads connecting to the atrial or ventricular myocardium with sensing and pacing functions. Implantable cardioverter defibrillators respond to episodes of ventricular tachycardia and fibrillation by discharging a defibrillating current. From a device perspective, several protective mechanisms have been developed in the permanent pacemaker/implantable cardioverter defibrillator to reduce the effects of electromagnetic interference. These involve generator material changes, lead modification, and better sensing and pacing algorithms. Magnetic resonance imaging compatible pacemakers have now been developed and are approved for use in Europe. From a urologist's perspective 5 procedures require the close monitoring of permanent pacemaker/implantable cardioverter defibrillator function. 1) For electrosurgery modifications in the device and in the methods of use have been recommended. 2) For extracorporeal shock wave lithotripsy the European Association of Urology provides some guidance with regard to patients with these devices. 3) During positron emission tomography the pulse generator and the lead area should be covered with lead to protect the device. 4) Magnetic resonance imaging is contraindicated but currently trials are under way for a new pacing system for safe use in the magnetic resonance imaging environment. 5) Patients can undergo radiotherapy with standard precautions but those with an abdominal permanent pacemaker/implantable cardioverter defibrillator require careful planning. Finally, implanted devices should have a full evaluation before and after the procedure. CONCLUSIONS: Clear guidelines are essential given the rapid advances in technology to enhance patient safety. Magnetic resonance imaging should be avoided in patients without a magnetic resonance imaging compatible device. However, patients can undergo extracorporeal shock wave lithotripsy, radiotherapy and positron emission tomography as long as the device is not in the path.

Bipolar technology for transurethral prostatectomy.

Bipolar electrosurgical technology has gained worldwide attention with various companies introducing devices, such as the Gyrus PlasmaKinetic™ Tissue Management System (Gyrus ACMI, MN, USA) and the Olympus(®) UES-40 Surgmaster generator (Olympus, Tokyo, Japan), which is aimed at minimizing the morbidity of standard monopolar transurethral resection of the prostate (TURP), whilst also maintaining efficacy and durability. The Gyrus PlasmaKinetic System effectively controls bleeding, resulting in a clear operative field; it greatly reduces risk of transurethral resection syndrome, thus providing a new option among minimally-invasive surgical treatments for benign prostatic hyperplasia. In a meta-analysis of head-to-head comparisons between the monopolar and bipolar TURP, the operation times, transfusion rates, retention rates after catheter removal and urethral complications did not differ significantly. Irrigation and catheterization duration was significantly longer with monopolar TURP.

Emphysematous pyelonephritis.

Emphysematous pyelonephritis (EPN) is a severe necrotizing infection of the renal parenchyma. The clinical course of EPN can be severe and life-threatening if not recognized and treated promptly. Most of the information has been from case reports, a few large series have also been reported. Using an evidence-based approach, this review describes the pathogenesis, classification, complications, and management of EPN. Emphysematous pyelonephritis (EPN) is an acute severe necrotizing infection of the renal parenchyma and its surrounding tissues that results in the presence of gas in the renal parenchyma, collecting system, or perinephric tissue. The cause for mortality in EPN is primarily due to septic complications. Up to 95% of the cases with EPN have underlying uncontrolled diabetes mellitus. The risk of developing EPN secondary to a urinary tract obstruction is about 25-40%. There are three classifications of EPN based on radiological findings. Acute renal failure, microscopic or macroscopic haematuria, severe proteinuria are other positive findings in EPN. Escherichia coli is the most common causative pathogen with the organism isolated on urine or pus cultures in nearly 70% of the reported cases. A plain radiograph shows an abnormal gas shadow in the renal bed raising the suspicion whereas an ultrasound scan or computed tomography (CT) will confirm the presence of intra-renal gas thus supporting the diagnosis of EPN. Gas may extend beyond the site of inflammation to the sub capsular, perinephric and pararenal spaces. In some cases, gas was found to be extending into the scrotal sac and spermatic cord. Subsequent case studies have shown patients being successfully treated with PCD when used in addition to medical management, with significant reduction in the morality rates. PCD should be performed on patients who have localized areas of gas and functioning renal tissue is present. The treatment strategies include MM alone, PCD plus MM, MM plus emergency nephrectomy, and PCD plus MM plus emergency nephrectomy. In small proportion of patients managed with MM and PCD, subsequent nephrectomy will be required and in these patients the reported mortality is 6.6% Nephrectomy in patients with EPN can be simple, radical or laparoscopic.

Cost benefits of intraoperative cell salvage in radical cystectomy.

OBJECTIVE: We have looked into the clinical and financial benefits of using intra-operative cell salvage (ICS) as a method to reduce the amount of autologous blood transfusion (ABT) requirement for our radical cystectomy (RC) patients. MATERIALS AND METHODS: Fifteen consecutive patients undergoing radical cystectomy received cell salvaged blood (ICS), while 15 did not (NCS). The cost of using the cell saver, number of homologous transfusions, survival, and recurrences were recorded and compared using paired t-test and chi-square test between the two groups. A Dideco Electa® (Sorin Group, Electa, Italy) cell saver machine was used for all the patients in the ICS group and leukocyte filters were used on the salvaged blood before the autologous transfusion. RESULTS: The mean age was 63 years (53-72 years), 66 years (46-79 years) in ICS and NCS groups, respectively (P = 0.368). All 15 (100%) patients in the NCS group required an allogenic transfusion compared to 9/15 (60%) in the ICS group (P = 0.08). There was a significant reduction in the mean volume of allogenic blood transfused with the use of cell saver. Median follow-up was 23 and 21 months in the ICS and NCS group with 10 and 4 patients alive at last follow-up, respectively. There was a saving of 355 pounds per patient in the ICS group compared to the NCS group. CONCLUSION: Our initial study shows that cell savage is feasible and safe in patients undergoing radical cystectomy. It does not adversely affect the medium term outcome of patients undergoing RC and is also cost effective.

Medical management of overactive bladder.

Overactive bladder (OAB), as defined by the International Continence Society, is characterized by a symptom complex including urinary urgency with or without urge incontinence, usually associated with frequency and nocturia. OAB syndrome has an incidence reported from six European countries ranging between 12-17%, while in the United States; a study conducted by the National Overactive Bladder Evaluation program found the incidence at 17%. In Asia, the prevalence of OAB is reported at 53.1%. In about 75%, OAB symptoms are due to idiopathic detrusor activity; neurological disease, bladder outflow obstruction (BOO) intrinsic bladder pathology and other chronic pelvic floor disorders are implicated in the others. OAB can be diagnosed easily and managed effectively with both non-pharmacological and pharmacological therapies. The first-line treatments are lifestyle interventions, bladder training, pelvic floor muscle exercises and anticholinergic drugs. Antimuscarinics are the drug class of choice for OAB symptoms; with proven efficacy, and adverse event profiles that differ somewhat.