British Journal of Medical & Surgical Urology - Articles in Press

Neurourology: A review - Corrected Proof

Mahreen Hussain, Julian Shah, Rizwan Hamid — 2012-05-17

Neuropathic bladder dysfunction (NBD) is generally accompanied by abnormalities in other autonomic and somatic systems. Hence, an holistic approach in a multidisciplinary setting using the expertise of a rehabilitation consultant, neuro-urologist, continence nurses, physiotherapists and occupational therapists is required.

Supine percutaneous nephrolithotomy with endoscopic combined intra-renal surgery – Results of the first one hundred patients from a single UK centre - Corrected Proof

Ninaad S. Awsare, Maneesh Ghei, Vellore Rajkumar, Paul A. Jones — 2012-05-07

Summary: Objective: To review our experience using combined supine PCNL and simultaneous ureterorenoscopy (ECIRS: endoscopic combined intra-renal surgery) to treat renal calculi.Patients and methods: Retrospective analysis of operative times, anaesthetic and surgical complications, and stone-free rates in patients who underwent PCNL and ECIRS in the Galdakao Modified Supine Valdivia position at a single centre between September 2007 and November 2011 was undertaken. Outcomes for those patients with BMI>30 and those with high ASA grade were compared to the remaining patient group.Results: One hundred patients underwent 103 PCNL procedures. Thirty-one (31%) patients had BMI>30 while 48 (48%) had ASA grade III or IV. Mean±S.D. operative time and hospital stay was 111.34±36.92min and 49.5±18.6h respectively with no demonstrable increase in either parameter for patients with high ASA grade or BMI. The overall PCNL stone-free rate was 87% with 13 needing a secondary procedure. Six patients had postoperative complications (three transfusions, two post-operative fever and one ITU admission for sepsis).Conclusions: Supine PCNL incurs minimal anaesthetic morbidity. The GMSV position enables PCNL to be performed in the obese safely with high stone-clearance rates when combined with ECIRS thus decreasing the need for ancillary procedures such as ESWL.

Antibody interference leading to serum PSA overestimation in a post-radical prostatectomy patient: Lesson learnt - Corrected Proof

D. Church, P. Barker, G. Basnett, K. Taylor, D. Halsall, N. Shah — 2012-05-07

A 61-year-old man was referred to a urology tertiary referral centre with a serum total prostate specific antigen (TPSA) concentration of 5.6μg/L (Abbott Architect®, Abbot Laboratories, IL, USA). The clinical stage was T1c, Gleason 3+3=6 with adenocarcinoma confirmed within the left lobe only on biopsy. Magnetic resonance imaging demonstrated localised disease. The patient underwent robotic assisted laparoscopic radical prostatectomy with bilateral pelvic lymph node dissection. Histology confirmed unifocal Gleason 3+3=6, with negative margins (pT2aN0Mx).

Synchronous presentation of acute appendicitis and left ureteric stone - Corrected Proof

2012-05-03

Acute appendicitis is common and urolithiasis is a rare cause of abdominal pain in children. However, synchronous presentation of both pathologies is very rare and to our knowledge only three cases of acute appendicitis and right ureteric stone have been reported in the English literature. We describe a first case report of acute appendicitis and left ureteric stone presenting simultaneously.

Importance of local data on occurrence and outcomes of renal cell cancer - Corrected Proof

2012-04-26

Summary: Background: In comparatively socioeconomically deprived areas male cancer mortality is often above the national average. Given this, we explored the pattern of presentation and outcomes of men with conventional clear cell renal cell carcinoma (CCRCC) undergoing nephrectomy at a North East of England regional tertiary referral centre.Patients and methods: A retrospective review of CCRCC patients treated with nephrectomy between 2004 and 2008 was performed. Risk of progression for men and women was calculated using Mayo, Memorial Sloan-Kettering (MSK) and Kattan prognostic scores. Outcomes of disease free progression and overall survival were measured.Results: 292 patients with complete local follow up were identified that had undergone radical nephrectomy for conventional clear cell histology. The median (range) follow up was 36 months (10–65 months), and men accounted for 64% of these cases. At presentation, 45% of cases presented with stage III–IV (>T2, N0/1, M0/1) disease compared with 32% nationally (BAUS cancer registry). At diagnosis men had more advanced tumours compared with women (54% vs. 22% for stage >T2, N0/1, M0/1; p<0.001) and had higher risk of progression based on prognostic scores (p<0.01) despite similar risk factors and clinical symptoms. Early outcome analysis comparing men to women revealed both lower disease-free survival (82% vs. 89%) and overall survival (87% vs. 93%) in men at 24 months (p<0.01). However, stage for stage comparisons between men and women demonstrated no significant difference in survival.Discussion: Men in the North East of England presented later with more advanced CCRCC. The reason for this remained undefined in this study. This pattern is consistent with reports of adverse male cancer-related outcomes in deprived areas and highlights the importance of local data in planning local health care.

Vesico-peritoneal fistula: A rare cause of chronic abdominal pain - Corrected Proof

W.L. Ooi, B.T. Sherwood, J. Stanley, S. Baskaranathan — 2012-04-12

A 31-year-old lady was referred to the Urologists with a history of relapsing lower abdominal pain on micturition. One year prior to the onset of her symptoms, she had undergone an emergency caesarean section for foetal bradycardia. No immediate complications were noted intra-operatively and her recovery and discharge from hospital were uneventful. Her additional medical history included previous open and laparoscopic surgery for ovarian dermoid cysts.

Penile strangulation by a substantial metal napkin ring: Successful removal with Medtronic Midas Rex(r) legend(r) Stylus(r) Drill System - Corrected Proof

S. Roushias, R. Veeratterapillay, S. McCracken, R. Heer — 2012-04-05

Summary: We report the case of a 34 year old with penile constriction by a large solid steel ring napkin holder in whom attempts of removal by conventional techniques failed. Standard instruments available in urology and general surgical theatres proved too weak to sever the ring and those offered by the fire services were grossly oversized and dangerous to use around the genitalia. Orthopaedic staff offered an instrument not previously used within the urology department: the Medtronic Midas Rex© Legend EHS Stylus High-Speed Surgical Drill. This intricate electronic powered drill allowed quick, controlled and safe incision of the metal ring, relieving the constriction. In addition to this first report of a metal penile constriction device removed using the Medtronic Midas Rex(r) Legend(r) Drill System, we review the literature on penile constriction and management strategies.

Torsion of both ipsilateral testicles in a polyorchid male - Corrected Proof

2012-04-03

A 13-year-old pubescent boy presented to the Accident and Emergency Department with a ten day history of intermittent left testicular pain which had significantly worsened 48h prior to attendance. He suffered from attention deficit hyperactivity disorder, treated with Concerta; prior to attendance he was otherwise well. Clinical examination was consistent with a testicular torsion and associated reactive hydrocoele; examination of the right hemiscrotum was normal. In view of his presentation and examination findings he was rapidly taken to theatre for scrotal exploration.

Hyperammonaemic encephalopathy secondary to an infected perinephric urinoma - Corrected Proof

2012-03-29

A previously healthy 31 year old vegan female developed lower back pain following a fall 4 weeks prior to presentation. A MRI scan demonstrated a large complex left perinephric collection fistulating to the posterior-lateral abdominal wall with a complex intra-peritoneal collection and large staghorn calculus (). Following admission an emergency radiological drainage of the perinephric collection was performed. Cultures from this aspirate grew Escherichia coli. Within 72h the patient became septic again and a CT-scan confirmed a large urinoma (). A retrograde JJ Stent was inserted to drain the kidney. Cultures at this stage grew Proteus mirabilis. The patient's stay was complicated by low oral intake and hypoalbuminemia. On day 17 the patient developed a reactive pleural effusion () requiring percutaneous drainage. On admission the patient was commenced initially on intravenous (IV) Cefuroxime and Amoxicillin. Based on further culture and sensitivities the antibiotics were changed to IV Piperacillin/Tazobactam and Meropenem subsequently. A summary of the source of the microbiology culture and treatment commenced is presented in .

Intravesical botulinum toxin for overactive bladder syndrome without detrusor overactivity - Corrected Proof

B.L. Jackson, F. Burge, E. Bronjewski, R.J. Parkinson — 2012-03-16

Abstract: Objective: To report our experience of intravesical botulinum toxin for idiopathic overactive bladder syndrome (OAB) without detrusor overactivity (DOA) on urodynamic assessment.Patients and methods: Data regarding presentation, diagnosis, urodynamic findings, date and dose of treatment, and outcomes were recorded prospectively for 94 patients undergoing intravesical botulinum toxin injection for idiopathic overactive bladder syndrome at our institution. The cohort included 19 patients without DOA on urodynamics. A positive response to treatment was defined as patient-reported improvement without the need for further treatment. ICIQ-OAB and UI scores, and bladder diary parameters were also recorded. Rates of urinary retention requiring intermittent or indwelling catheterisation were noted.Results: The overall response rate to treatment was 82% (n=94). Patients without DOA (n=19) had a response rate of 89%, which compared favourably with a response rate of 81% in patients with DOA (n=75).Overall, 29% of patients who were voiding normally prior to treatment required intermittent self-catheterisation after the procedure. The requirement for self-catheterisation did not appear to be influenced by urodynamic findings.Conclusion: These preliminary, non-randomised data suggest that intravesical botulinum toxin injection may be efficacious in patients with OAB symptoms without DOA. Further evaluation by means of a randomised, controlled trial is suggested.

A case of ureteric obstruction, secondary to debris, following laparoscopic cryotherapy for a right renal cell tumour - Corrected Proof

J. Jelski, H. Burden, M. Speakman — 2012-03-16

A 74 year old gentleman with known polycystic disease was diagnosed with bilateral renal tumours. Imaging with a computed tomography (CT) contrast scan confirmed these to be a 4cm×3cm right upper pole renal tumour and a 2cm×1.8cm left renal tumour (). These were both confined within the renal capsule and with no evidence of metastatic spread. DMSA scans showed 50/50 split function and serum EGFR was 45mls/min/1.73m2.

Factors influencing patients’ treatment selection for localised prostate cancer: A systematic review - Corrected Proof

L.A. Robles, S. Chou, O. Cole, A. Hamid, A. Griffiths, K. Vedhara — 2012-03-07

Summary: Objective: Men diagnosed with localised prostate cancer (LPCa) are usually offered a range of treatment options. Patients’ beliefs about their illness and treatments have been shown to be influential in treatment selection for chronic conditions. The aim of this systematic review was to examine the role of these beliefs in influencing treatment selection in LPCa.Methods: A systematic review of the literature was conducted in electronic journal databases and major charity, government and dissertation databases. Content experts were contacted for recommendations of studies of relevance.Results: The search yielded 10 published papers; six of which used a qualitative approach. Content analysis was performed to identify the factors frequently associated with treatment decisions. The salient beliefs influencing each of the most common treatment choices for LPCa, including the factors external to the patient that inform these beliefs, were reported.Conclusion: Patients’ treatment choices are influenced by their beliefs, and the beliefs of others, regarding the disease, the effectiveness of treatment and the severity of possible side effects. The findings of this review highlight that psychosocial interventions may be necessary to challenge erroneous beliefs and ensure that patients are making informed decisions regarding their treatment.

Bilateral orchidectomy for germ cell tumours in cryptorchid testis in Down's syndrome: A case report - Corrected Proof

L.C.E. Martin, T.G. Rashid, M. Ruston — 2012-03-05

A fifty year-old patient with Down's Syndrome (DS) presented with a right groin lump discovered by his carers. He had severe learning difficulties and coronary stent insertion following myocardial infarction. Ultrasound revealed bilateral inguinal cryptorchid testes with extensive bilateral testicular microcalcification (TM). The right testis showed a well-defined suspicious looking mass measuring 7mm×7mm. Tumour markers revealed elevated lactate dehydrogenase and alpha fetoprotein. Beta Human Chorionic Gonadotrophin was normal. His severe learning and behavioural difficulties meant surveillance of the left testis would be challenging, and his cardiac history posed high general anaesthetic risk. Considering his co-morbidities, the assumed difficulties involved in surveillance of the left testis and high risk of bilateral tumours (based on the extensive micro-calcification in cryptorchid testes), the multi-disciplinary-team decided on simultaneous bilateral orchidectomy.

Voiding dysfunction after left medial frontal lobe infarction - Corrected Proof

L.F. Derbyshire, M. Jones, S. Bromage, C. Tawadros, C.D. Betts — 2012-02-23

A 37-year-old right handed man was admitted to hospital after developing sudden onset weakness of his right arm and leg. At admission, he complained of urinary frequency and incontinence, with no prior urinary symptoms. His motor function returned to normal within 36h.

Effect of a suspension suture in addition to a total anatomical reconstruction in robot assisted laparoscopic prostatectomy: Does it help early continence? - Corrected Proof

Taimur Tariq Shah, Shabnam Undre, Jim Adshead — 2012-02-10

Summary: Introduction: Continence post robotic assisted laparoscopic radical prostatectomy (RALP) is approximately 90% and many reconstructive techniques have been described to improve early continence. We assessed whether a peri-urethral suspension stitch in addition to a total anatomical repair (TAR) improved early continence.Materials and methods: We describe our procedure and assessed 68 consecutive RALP's over a two-year period. Complete data were collected on continence rates and incontinence modular questionnaire (ICIQ) scores in 55 patients.Results: In the “no suspension stitch” (NoSS) group continence rates at 2 weeks, 6 weeks and 3 months were 11%, 48% and 81% respectively whilst in the “suspension stitch” (SS) group continence rates were 11%, 46% and 75% respectively (lowest p-value=0.26 seen at 2 weeks). Average ICIQ scores in the NoSS group were 9.8, 6.6 and 4.3 and in the SS group were 9.4, 6.4 and 4.8 at each time frame (lowest p-value=0.63 at 6 weeks).Conclusions: No significant difference in continence or ICIQ scores was seen between the two groups. Overall our continence rates were comparable to the published literature. The addition of a suspension stitch did not add any further benefit in improving early continence when performing a total anatomical reconstruction.

Early recurrence of non-muscle invasive bladder cancer as a clinical marker of a poor prognosis and cancer-specific survival - Corrected Proof

P.J.S. Charlesworth, R.H.R. Gray, C. Blick, N. Kilbey, A. Protheroe, J.P. Crew — 2012-02-10

Abstract: Objective: To determine whether early recurrence of non-muscle invasive bladder cancer confers prognostic value with respect to bladder cancer-specific survival.Patients and methods: Following local ethics committee approval, all patients that underwent TURBT for a bladder tumour within the Oxford Radcliffe Trust between 1997 and 2007 were entered into the local Cancer Research Uro-Oncology Database (CRUD©). The rate of positive histological recurrence of non-muscle invasive bladder cancer at first cystoscopy (<4 months) following the index TURBT was calculated and the cancer-specific survival calculated using data from the National Cancer Intelligence Network.Results: Median positive early recurrence of (NMIBC) non-muscle invasive bladder cancer was 18.9% for the period of 1997 to 2007 (mean 20.3%; range 13.9–28.3%). Positive early recurrence was associated with significantly worse survival, with 5-year cancer specific survival falling from 82.3% (first cystoscopy negative) to 69.4%, (first cystoscopy positive), Log Rank p=0.02.Conclusions: Our results suggest that if histological recurrence is present at first cystoscopy then the patient is more likely to die from bladder cancer, with 5-year cancer specific mortality of 18% if first cystoscopy clear, compared to 31% if histological recurrence (relative risk 1.7). With the growing demand for surgical outcome measures, our study suggests that ‘positive recurrence at first cystoscopy’ is both simple to measure and a valid predictor of patient outcome.

Development and validation of a UK-specific prostate cancer staging predictive model: UK prostate cancer tables - Corrected Proof

Thomas B.L. Lam, Olivier Regnier-Coudert, John McCall, Sam McClinton — 2012-02-01

Summary: Objectives: To construct new prostate cancer staging lookup tables based on a dataset collated by the British Association of Urological Surgeons (BAUS) and to validate them and compare their predictive power with Partin tables.Patients and methods: Complete data on 1701 patients was collated between 1999 and 2008 across 57 UK centres. Lookup tables were created for prediction of pathological stage (PS) using PSA level, biopsy Gleason score (GS) and clinical stage, replicating Partin's original approach.Tables were generated using logistic regression (LR) and bootstrap resampling methods and were internally validated and externally validated using concordance indices (CI) and area under the receiver operating characteristic curve (AUROC) respectively.Results: The CI and AUROC analyses indicate that Partin tables performed poorly on UK data in comparison with US data.The UK prostate cancer tables performed better than Partin tables but the predictive power of all models was relatively poor.Conclusion: The study shows that the predictive power of Partin tables is reduced when applied to the UK population.Models generated using LR methodology have fundamental limitations, and we suggest alternative modelling methods such as Bayesian networks.

Tumour multiplicity as a risk factor for the development of bladder tumours after primary upper urinary tract cancer - Corrected Proof

Hideaki Ito, Nobuyuki Oyama, Katsuki Tsuchiyama, Osamu Yokoyama — 2012-02-01

Summary: Objective: To determine the independent risk factors for intravesical tumour recurrence in patients with primary urothelial cancer of the upper urinary tract.Patients and methods: Of the 60 patients who underwent nephroureterectomy for urothelial cancer of the upper urinary tract, the data from 49 patients were retrospectively reviewed. Patients with a previous history or concomitance of bladder cancer were excluded from the study. Multivariate analysis by Cox's proportional hazards model was used to determine independent risk factors for intravesical tumour recurrence.Results: Of the 49 patients reviewed, 22 (44.9%) experienced subsequent intravesical tumour recurrence during a mean follow-up period of 26 months (range 3–103). On multivariate analysis, tumour multiplicity had a statistically significant impact on the risk of intravesical tumour recurrence (P<0.01).Conclusion: Neither the pathology of the upper urinary tract cancers nor the method of treatment was associated with recurrent bladder cancers. Only tumour multiplicity had a significant impact on the incidence of intravesical tumour recurrence.

A retrospective multi-centre study on the outcome of laparoscopic simple nephrectomies - Corrected Proof

Jihène El Kafsi, Mark Sullivan, Adam Jones — 2012-01-24

Summary: Objective: A review of our experience in laparoscopic simple nephrectomies from May 2003 to May 2011 in the Urology Departments in Oxford and Reading.Method: A total of 100 patients, median age 46years (IQR=27, range 17–82) underwent a laparoscopic simple nephrectomy for benign disease in the 8-year period reviewed. Data on patient demographics, pre-operative diagnosis, operating time, operative approach, estimated blood loss, in hospital post-operative complications and length of stay were collected from electronic databases held in the departments and regularly updated.Results: 100 laparoscopic simple nephrectomies were performed between May 2003 and May 2011. Median operating time was 180min (IQR=60min, range 75–375min). Median estimated blood loss was 50ml (IQR=50ml, range 10–1000ml). Median length of stay was 3days (IQR=3, range 2–14days). No patients suffered from significant changes in renal function. Three patients were transfused between 2 and 3 units. 26 complications were recorded for 22 patients. Four were Clavien grade IIIb and 22 were grades I–II.Conclusion: Although laparoscopic simple nephrectomy is feasible and confers the usual benefits of laparoscopy it is often a technically challenging procedure. We used the Clavien Classification to standardise complications of laparoscopic simple nephrectomies. The term “simple” nephrectomy is misleading and should be changed.

Prostate cancer incidence in patients on 5α-reductase inhibitors for lower urinary tract symptoms: A 14-year retrospective study - Corrected Proof

I. Ahmad, D.R. Small, N.S. Krishna, M.N. Akhtar, H.Y. Leung — 2012-01-24

Summary: There is still much debate regarding the long-term effect of 5α-reductase inhibitors (5-ARI) on the development of prostate cancer (PC). We tested the incidence of prostate cancer and the tumour Gleason grading in a non-screened population who were prescribed 5-ARIs for lower urinary tract symptoms (LUTS). Data from a prostatic biopsy database were analysed in a retrospective study, and included a period of 14 years (01/01/1997 to 01/01/2011). Those patients who were on 5-ARIs with either finasteride or dutasteride for less than 1 year were excluded. Patients who presented with LUTS and underwent diagnostic prostatic biopsies were included in this study. This patient cohort was further categorised according to their history of 5-ARIs medication.The incidence of PC in the 5-ARI treated group was 15.4% (n=22/143), comparable to that of the untreated group (16.7%, n=332/1990) (p=0.7318). Mean Gleason sum score and respective grade was the same (7=3+4) (median sum score 7 (range 6–10)). Average age at the time of PC diagnosis was similar regardless of 5-ARIs treatment: 72 (range 50–84) and 73 (45–84) years for treated and untreated groups, respectively.In this retrospective study, patients treated with 5-ARIs for LUTS had similar risk in developing PC when compared to those who did not receive 5-ARIs. The Gleason sum scores for the cancers were similar in the two groups.

A five year review of the management of acutely presenting epididymo-orchitis in a single UK institution - Corrected Proof

T.J. Dutton, J.J. Aning, J.S. McGrath — 2012-01-20

Summary: Introduction: This audit compared the management of epididymo-orchitis within our institution against the 2010 guidelines issued by the British Association of Sexual Health and HIV.Methods: A Retrospective casenote analysis was performed on all patients diagnosed with epididymo-orchitis between August 2004 and August 2009. Patients were identified using Hospital Episode Statistics (HES) data. Data analysed included patient's age, investigations performed, treatment given, and patient follow-up.Results: In total, 232 patients were identified (mean age 41 years, range 1–96). A mid-stream urine was performed in 105 (45%) patients, 12 (5%) had a urethral swab and 82 (35%) had an ultrasound scan. Twenty patients were surgically explored to exclude torsion. The mean length of stay was 1 night (range 0–9). Antibiotics were prescribed in 94% of patients. Sexual history and advice to attend a genito-urinary clinic was documented in 16% and 4% of cases respectively. Referral for follow-up in the urology outpatient clinic occurred for 24% of patients.Conclusions: The management of epididymo-orchitis in patients referred for secondary care review is an area for significant improvement in clinical practice. Implementation and dissemination of clear local guidelines are essential to ensure appropriate patient management and minimise unnecessary in-patient admissions and outpatient follow-up.

Inguinal lymphadenectomy for squamous cell cancer of the penis—Experience of a UK supra-regional network - Corrected Proof

Thomas G. Martin, Jonathan C. Goddard, Tim R. Terry, Duncan J. Summerton — 2012-01-18

Summary: Objective: To present a case series of patients undergoing inguinal lymphadenectomy (IL) for squamous cell cancer (SCC) of the penis within an UK Supra-Regional Network (SRN).Patients and methods: Retrospective case note analysis was undertaken of all patients who underwent IL following referral from the network units across a wide region. Information was cross-referenced from clinician, pathology and hospital episode databases.Results: A total of 79 modified ILs and 11 radical ILs were performed in 49 patients over 5 years. Metastatic involvement was found in 59.1% of patients. Of these 58.6% were found to have extranodal spread at the time of operation. The finding of extranodal spread significantly impacted upon survival. One year survival rates post IL were 100% for pN0 and pN1, compared with 67% for pN3.Kaplan–Meier curves were plotted and showed a significant difference in survival from primary surgery on log rank comparison between pN0/pN1 and pN3 nodal categories. As in most series, IL has a considerable morbidity rate. No perioperative mortality was seen.Conclusions: This case series emphasizes the negative prognostic impact of finding extranodal spread (pN3) at IL. In those with unilateral intranodal metastases (pN1), IL is curative for the majority of patients.

Acute lower limb ischaemia following radical cystectomy - Corrected Proof

Todd Smith, Andrew Chetwood, Anoop Prasad, Ian Franklin, David Hrouda — 2012-01-06

A seventy-nine-year old man was admitted to hospital for an elective radical cystectomy and ileal conduit formation for a G3pT2 transitional cell carcinoma of the bladder (TCC). Previous medical history included hypertension and peripheral vascular disease. He had previously undergone a left femoro-popliteal bypass using great saphenous vein in 2005 for severe calf claudication. He represented in 2007 with recurrence of his symptoms and was found to have a 50% stenosis of his left common iliac artery. He was managed medically and in 2009 he was discharged from the care of the vascular surgeons with an improved walking distance.

Benign renal Schwannoma: Case report and review of the literature - Corrected Proof

J.A. Raju, G. Kingston, A. Jones — 2011-12-05

Schwannomas are tumours originating from Schwann cells of nerve sheaths and are most commonly found in the head, neck, limbs and mediastinum. They are typically benign but in rare cases can demonstrate malignant change . Retroperitoneal Schwannomas are uncommon, accounting for 0.3–3.2% of cases while visceral involvement is even rarer. Only 21 cases of benign renal Schwannoma have been reported . We present the clinico-pathological features of an additional case and review the literature.

Acute pancreatitis induced by an obstructing left ureteric calculus - Corrected Proof

C. Dospinescu, T.B.L. Lam, L. Kurban, N.P. Cohen, S.K. Swami — 2011-12-05

Summary: A 55-year-old woman with acute left-sided renal colic developed acute focal pancreatitis secondary to perinephric inflammation caused by an obstructive 6mm left upper ureteric calculus.

Germ cell tumors of undescended vs. descended testes: Population-based clinical and outcomes data - Corrected Proof

Norleena P. Gullett, Timothy A. Masterson, Peter A.S. Johnstone — 2011-12-02

Summary: Objective: Testicular cancer has been associated with undescended testes (UDT) for decades, with a relative risk of testicular cancer in cryptorchidism at 2.75–8. Tumors of UDT are infrequently encountered in clinical practice and no population-based prior analysis has described clinical patterns of care in their case.Methods: Information on malignant testicular lesions was retrieved from the population-based Surveillance Epidemiology and End Results (SEER) data for the period 1983–2005. Site codes C62.0 (UDT) were compared with C62.1 (descended testis; DT), using appropriate surgical codes for the era reported. Analysis was made of the seminomatous histology codes (ICD-03 9061–9063) vs. the nonseminomatous germ cell tumor codes (ICD-03 9065–9085). Further analysis was stratified by presenting extent of disease (local, regional, or distant).Results: 462 cases of tumors of UDT were documented; 416 (90%) were germ cell tumors (GCT). In this timeframe, 7414 cases of DT GCT were described. UDT lesions were more frequently seminoma (74.7% vs. 60.8%; p<0.0001), and diagnosed at a more advanced stage than DT lesions (χ2=18, p=0.0001). Similar frequency of RT was noted for localized seminoma, whether UDT or DT, after RadOrch (p=0.13), and was rarely delivered for NSGCT. 5-yr observed (5YOS) and relative survival (5YRS) of seminomas did not differ between the DT and UDT cohorts, or between the DT and UDT NSGCT cohorts.Conclusions: Our results support recent literature revealing seminomas are more frequent in cryptorchid testes. RT was equally used between localized UDT and DT seminomas. Penetrance of RadOrch is similar in local and regional disease by histology. Survival is equivalent for UDT compared to DT lesions in both seminomatous and NSGCT histologies.

Re: Use of the Dundee technique to relieve penile strangulation [Br. J. Med. Surg. Urol. (4) (2011) 213–215] - Corrected Proof

D. Nasralla, R. Kinder — 2011-11-03

I read with interest the recent article by Pastides et al. . We encountered a 51-year-old gentleman in a similar predicament recently in our institution. He had managed to squeeze his penis through a 5cm segment of narrow copper piping () and presented with a grossly swollen, incarcerated glans. By the time the surgical team were called the emergency department had already tried, and failed, to remove the pipe using ring-cutters. The fire brigade had also been called to review the situation but had nothing further they could offer. As suggested by the authors, the Dundee technique was attempted with a penile block administered and multiple fenestrations made in the glans to aid decompression, but all to no avail. Shortly after his presentation, the patient was taken to theatre. Under a general anaesthetic further attempts were made to decompress the glans using the Dundee technique and direct, prolonged pressure, with little improvement seen. The orthopods were called who could only suggest using a plaster cutting saw, but this only scored the surface and looked likely to injure the friable looking tissue of the swollen glans. Bone nibblers, bolt cutters and even a hacksaw all failed to make an impression and so we had to return to 1st principles. We placed a tight tourniquet around the base of the penis to occlude arterial inflow as well as venous return. Then, 2 large bore cannulae were inserted through the glans into the corpus spongiosum, through which we were able to aspirate 30ml of blood. The effect was immediate and plain to see—the glans deflated to almost its normal size. Then, with only a small amount of additional compression and manipulation, we were able to extract it from the pipe. Remarkably, after this whole traumatic experience, the penis appeared to emerge relatively unscathed. A urethral catheter was inserted to allow the patient and his genitalia to rest for 24h, after which it was removed and he was discharged. As Pastides et al. described, innovative methods often have to be employed to deal with patients in unusual predicaments. Penile incarceration is a well recognised entity and often falls into this category. Helpfully, Bhat et al. described a grading system for these injuries in 2002 which categorises them as shown below:

Utility of renal mass biopsy in a UK tertiary referral centre - Corrected Proof

2011-11-03

Abstract: Objective: To determine the value of percutaneous biopsy in a UK cohort of patients with renal mass lesions, with particular reference to its utility for the prediction of histological cell-type, Fuhrman nuclear grade and necrosis.Patients and methods: From May 1999 to September 2009, 71 patients underwent renal mass biopsy (RMB), most for indeterminate renal masses or in those with a mass lesion and extrarenal malignancy. Approximately one-third were for small renal masses (≤4cm). Biopsy results were correlated with final surgical specimen pathology or with the outcome of surveillance in those not receiving surgery.Results: Of 71 biopsies, there were 65 (91.5%) considered diagnostic biopsies, of which 59 (90.8%) were malignant and 6 (9.2%) were benign. 30 patients with biopsy-proven malignancy underwent extirpative surgery, with a diagnostic accuracy for biopsy of 100%. Accuracy of RMB for histological sub-type, Fuhrman nuclear grade and tumour necrosis was 80.0%, 52.3% and 80.0%, respectively. Bleeding complications were seen in 2 (2.8%) patients, and there were no cases of needle track seeding.Conclusion: RMB is a safe and accurate method for determining underlying malignancy, with an acceptable non-diagnostic rate. Although concordance for histological tumour sub-type and necrosis was reasonable, values for nuclear grade were less reliable.

PSA velocity and doubling time in diagnosis and prognosis of prostate cancer - Corrected Proof

Andrew J. Vickers, Simon F. Brewster — 2011-10-05

Summary: Cancer is a growth process and it is natural that we should be concerned with how the routinely used marker of prostate cancer tumour burden – PSA – changes over time. Such change is measured by PSA velocity or PSA doubling time, described in general as “PSA kinetics”. However, it turns out that calculation of PSA velocity and doubling time is far from straightforward. More than 20 different methods have been proposed, and many of these give quite divergent results. There is clear evidence that PSA kinetics are critical for understanding prognosis in advanced or relapsed prostate cancer. However, PSA kinetics have no value for men with an untreated prostate: neither PSA velocity nor doubling time have any role in diagnosing prostate cancer or providing a prognosis for men before treatment.

Transvaginal cystectomy for complete bladder prolapse - Corrected Proof

Hashim U. Ahmed, Dan Wood, David Griffin, Frederick Banks — 2011-08-11

A 29 year old woman presented with an introital mass that had increased in size over a number of weeks. At age 5 years, primary incontinence, as a result of non-ambulant spina bifida, resulted in formation of an ileal conduit urinary diversion. She had subsequently undergone a right nephrectomy for intractable infections secondary to nephrolithiasis. On examination under anaesthesia, the mass measured approximately 10cm by 4cm with a smooth pale appearance. It was reducible and was in place of her urethral meatus (). A diagnosis was made of remnant bladder prolapse with complete eversion through her urethral meatus.

Analgesic ketamine use leading to cystectomy: A case report - Corrected Proof

K. Shahzad, A. Svec, O. Al-koussayer, M. Harris, S. Fulford — 2011-07-26

Ketamine has been used for the induction and maintenance of anaesthesia since 1965 . It is also used in the management of chronic pain and recently has been proposed as a fast acting anti-depressant (reviewed by ).