bluuebunny/crossref_metadata_2025 huggingface dataset:
Adults with cystic fibrosis: meeting the challenge!
Authors: Dobbin C. J. , Bye P. T. P.
Published: December 2003

Abstract

The number of adults with cystic fibrosis (CF) is increasing. They are striving for independence and a fulfilling life with focus on career, relationships, education and finances at a time when lung function is likely to be declining and complications of this multi‐system disease are increasing. Maintaining the quality and improving the duration of life are continuing challenges for the ­clinician and the patient. Increased hope and greater expectations have been provided by a number of recent clinical advances and active research into novel treatments, including gene therapy.

There has been increased recognition of the necessity for early diagnosis, adequate monitoring and effective intervention for complications such as diabetes and osteo­porosis. Research into multi‐resistant bacteria and clonal strains of Pseudomonas aeruginosa is ongoing and attention has focused on infection control policies. Although more high‐level evidence is required on many issues confronting people with CF, a considerable effort has been made over the last decade to provide a more evidence‐based approach to therapy with a number of large controlled clinical trials. For the adult with CF, there are also more decisions to be made. There is focus on reproductive health, with most couples enjoying the real possibility of having children. For those with advanced disease, the option for lung transplantation is well established.

Maintenance of quality care will require adequate planning, effective transition programmes from paediatric to adult care, specialized training for doctors, nurses and allied health professionals and the allocation of sufficient resources to accommodate the inevitable increase in patient numbers. (Intern Med J 2003; 33: 593−597)
Cavernosal nerve mapping: current data and applications
Authors: Klotz L.
Published: December 2003

There are four reviews in this month's section, two relating to the technical aspects of treating prostate cancer, one to genetic instability and bladder cancer, and the final one about continence surgery in urogenital prolapse. The authors are from Canada, the USA, and the UK. The messages from all of the reviews are clear, and provide interesting reading. The contributions to this section continue to give considerable information, and there are many more to follow.

Although nerve‐sparing prostatectomy is widely practised, the results with respect to preserving potency often do not meet expectations. The concept of intraoperative cavernosal nerve stimulation is reasonable. Data that link the response to sildenafil after prostatectomy with bilateral nerve sparing has increased the importance of optimizing nerve sparing. The cavernosal nerves are often difficult to visualize and may have a variable course. A tumescent response to nerve stimulation can be shown consistently; the response may be subtle, and characterized by a minimal increase in penile circumference and blood flow. Immediately after prostatectomy, proximal nerve stimulation identifies whether neural continuity has been maintained, and is predictive of recovery of erectile function. The CavermapTM system (Uromed Corporation, Boston, MA, USA) was developed to permit intraoperative nerve stimulation with tumescence monitoring. An initial phase 2 and subsequent phase 3 single‐blinded, randomized, multicentre study that compared Cavermap‐assisted prostatectomy with conventional nerve sparing showed a significant benefit in terms of the duration of nocturnal tumescence at 1 year. Other approaches are being explored, including incorporating the device into sural or genito‐femoral nerve grafting, use of nerve stimulation during cystectomy or abdominal‐perineal resection, and direct corpus cavernosal pressure monitoring during nerve stimulation. These approaches warrant further evaluation.
Genetic instability and transitional cell carcinoma of the bladder
Authors: Catto J.W.F. , Meuth M. , Hamdy F.C.
Published: December 2003

The development of cancer occurs in a stepwise fashion, with each step representing the mutation in one of several key genes. However, the mutation rate of somatic cells is too low to account for the number of mutations required for a cell to undergo carcinogenesis. Thus, the development of genetic instability is a vital early step towards carcinogenesis. We review the evidence for genetic instability, with particular reference to transitional cell carcinoma of the bladder. Both microsatellite instability and chromosomal instability are present in this tumour, and we discuss their incidence and clinical implications.
Radiotherapy and hyperthermia in the treatment of patients with locally advanced prostate cancer: preliminary results
Authors: Van Vulpen M. , De Leeuw A.A.C. , Raaymakers B.W. , Van Moorselaar R.J.A. , Hofman P. , Lagendijk J.J.W. , Battermann J.J.
Published: December 2003

OBJECTIVE

To report an interim clinical evaluation of combined external beam irradiation (EBRT) and interstitial or regional hyperthermia in the treatment of locally advanced prostate cancer.

PATIENTS AND METHODS

From 1997 to 2001, 26 patients with T3‐4/NX/0M0 prostate carcinoma were treated with a combination of conformal EBRT and hyperthermia. Fourteen patients received five weekly regional hyperthermia treatments within an optimization (phase II) study, using the coaxial transverse electrical magnetic system. Twelve patients received one interstitial hyperthermia treatment within a feasibility study (phase I), using the multi‐electrode current source system. Irradiation was delivered using a conformal three‐field technique, administering 70 Gy in 2‐Gy fractions in 7 weeks.

RESULTS

The mean initial prostate‐specific antigen level was 26 ng/mL. Three patients had a T4 and 23 a T3 tumour; the tumours were classified as well (four), moderately (16) and poorly (six) differentiated. The mean follow‐up was 36 months. In the combined treatments there was no toxicity of more than grade 2. In regional hyperthermia the mean index temperature (T90and T50, i.e. exceeded by 90% and 50% of the measurements) was 40.2 °C and 40.8 °C, and for interstitial hyperthermia 39.4 °C and 41.8 °C, respectively. All patients survived; seven patients had a biochemical relapse (27%), three in the regional and four in the interstitial group. The actuarial probability of freedom from biochemical relapse was 70% at 36 months for all patients together, 79% for regional and 57% for interstitial. No factors were found that could be used to predict relapse.

CONCLUSIONS

The clinical outcome in these patients with advanced localized prostate cancer seems to compare favourably with most series using irradiation alone, and the treatment caused no severe complications.
Adjuvant goserelin improves clinical disease‐free survival and reduces disease‐related mortality in patients with locally advanced or localized prostate cancer
Authors: Akaza H.
Published: December 2003

This article reviews the clinical disease‐free survival (DFS) and disease‐related mortality (DRM) data from published prospective, randomized trials of goserelin, given alone as adjuvant treatment or combined with a nonsteroidal antiandrogen as neoadjuvant treatment in patients with locally advanced or localized prostate cancer. Four trials were of radiotherapy and one of radical prostatectomy. The five trials included > 3500 patients and the median follow‐up was 4.8–7.1 years. There were statistically significant improvements in clinical DFS with goserelin support relative to the control treatment in all five trials (each log‐rank P ≤ 0.004). Reductions in the risk of DRM were statistically significant with adjuvant goserelin vs no adjuvant treatment to support radiotherapy in one trial, and with adjuvant goserelin or bilateral orchidectomy vs no adjuvant treatment to support radical prostatectomy in another (each log‐rank P ≤ 0.001). Time‐point estimates of the rates of clinical DFS and DRM were in favour of goserelin support vs control in all five trials at 5 years and in the three trials for which data were available at 8 years. Goserelin support therefore improves clinical DFS and reduces DRM after radiotherapy or radical prostatectomy. Adjuvant goserelin may offer greater clinical benefits than neoadjuvant hormonal treatment.
Patients’ preferences for communicating a prostate cancer diagnosis and participating in medical decision‐making
Authors: Davison B.J. , Parker P.A. , Goldenberg S.L.
Published: December 2003

OBJECTIVES

To assess patients’ preferences about how physicians’ deliver news of a prostate cancer diagnosis, and patients’ preferred participation in medical decision‐making, with a secondary objective being to validate the Measure of Patients’ Preferences (MPP) scale with these patients.

PATIENTS AND METHODS

Eighty‐seven men (mean age 62.4 years) referred to an ultrasound/radiology department for their first transrectal ultrasonography (TRUS)‐guided biopsy completed the MPP and Control Preferences measures. Patients were asked to identify how they would like to be told about a potential prostate cancer diagnosis by their physician, and what role they would like in making treatment‐related decisions with their physicians.

RESULTS

Most patients wanted either an active (43%) or collaborative (47%) role in medical decision‐making if the TRUS showed prostate cancer. Men rated content items (what and how much information is provided by their physician) as more important than supportive (emotional support during interaction) or facilitative (setting and context variables) items. Men who preferred a collaborative role in the patient–physician interaction wanted significantly (P = 0.04) more content (detailed information on available treatments and the effect of these treatments on their quality of life) than men who had a preference for either an active or passive role in medical decision‐making. Demographic characteristics were not indicative of either preferred role in decision‐making or communication preferences. The MPP was shown to be reliable.

CONCLUSIONS

Men have expectations about how physicians disclose a diagnosis of prostate cancer and how they wish to participate in making treatment decisions. These results underline the importance of identifying patient preferences before embarking on treatment discussions, as the way ‘bad news’ is disclosed has previously been identified as a predictor of the outcome of the patient‐physician interview.
A randomized trial of choice of treatment in prostate cancer: the effect of intervention on the treatment chosen
Authors: Auvinen A. , Hakama M. , Ala‐Opas M. , Vornanen T. , Leppilahti M. , Salminen P. , Tammela T.L.J.
Published: December 2003

OBJECTIVE

To determine whether different approaches in the choice of treatment affect the treatment chosen by the patient for prostate cancer.

PATIENTS AND METHODS

We conducted a randomized trial with 210 men who had a histologically confirmed diagnosis of prostate cancer in 1993–94 at four major hospitals in Finland. After obtaining informed consent the men were randomized either to an intervention arm, in which there was greater patient participation in the choice of treatment following a structured procedure, or a control arm in which the standard approach, i.e. a standardized treatment protocol, was used. The main outcome measure of the analysis was the primary treatment chosen for prostate cancer.

RESULTS

In the enhanced participation arm patients not eligible for radical prostatectomy chose orchidectomy less frequently and favoured nonsurgical endocrine treatment than in the treatment protocol arm. Radical prostatectomy was the most commonly chosen treatment option in both arms among men with operable cancer. The way treatment options were presented affected the treatment chosen for prostate cancer.

CONCLUSION

Patients with prostate cancer are willing and able to take an active role in making decisions. The preferences of patients with prostate cancer in the choice of treatment may differ from the priorities of the physicians.
Significance of cancer detection in the anterior lateral horn on systematic prostate biopsy: the effect on pathological findings of radical prostatectomy specimens
Authors: Miyake H. , Sakai I. , Ishimura T. , Hara I. , Eto H.
Published: December 2003

OBJECTIVE

To clarify the significance of cancer detection in the anterior lateral horn (ALH) on systematic prostate biopsy in relation to its effect on the pathological findings from retropubic radical prostatectomy (RRP) specimens.

PATIENTS AND METHODS

The study included 84 consecutive patients who underwent RRP at our institution between January 1999 and December 2002, after being diagnosed as having prostate cancer, based on systematic prostate biopsies that included the areas taken by standard sextant biopsies and the bilateral ALHs. Several clinicopathological factors of these patients were analysed in relation to the presence or absence of cancer in the ALH on systematic biopsy.

RESULTS

Of the 84 patients, cancer was detected in the ALH in 44 (group A), but not in the remaining 40 (group B). There were no significant differences in age, preoperative serum prostate‐specific antigen level, or prostate volume between the groups. However, the incidence of bilateral positive cores and the percentage of positive biopsy cores in group A were significantly higher than those in group B. Pathological examinations of RRP specimens showed no significant differences in the incidence of lymphatic invasion, vascular invasion and perineural invasion, or Gleason score between the groups, but group A had a significantly larger tumour volume and higher incidence of extraprostatic disease than group B.

CONCLUSIONS

Despite similar biological tumour characteristics and irrespective of the cancer location in the ALH, advanced and extensive disease frequently involves the ALH. Therefore, more aggressive treatment should be considered if cancer is detected in the ALH by systematic prostate biopsy.
T1G3 transitional cell carcinoma of the bladder: recurrence, progression and survival
Authors: Peyromaure M. , Zerbib M.
Published: December 2003

OBJECTIVES

To report our experience with T1G3 bladder tumours over the last 10 years.

PATIENTS AND METHODS

We analysed the outcome of 74 consecutive patients treated for a T1G3 bladder cancer between 1991 and 2001. Fifty‐seven patients (77%) were treated with transurethral resection (TUR) plus six weekly instillations of bacillus Calmette‐Guérin (BCG) therapy. Ten patients (13.5%) with contraindications to BCG or with a small T1a tumour were treated with TUR plus mitomycin‐C, and seven (9.5%) were treated with TUR alone because of their age. Patients treated with BCG had systematic biopsies taken at the end of the first course. Patients with residual tumour received a second course of six weekly instillations. Patients with negative biopsies received maintenance BCG therapy consisting of intravesical instillations each week for 3 weeks given 3, 6, 12, 18, 24, 30 and 36 months after the first course.

RESULTS

The median follow‐up was 53 months. The overall recurrence rate was 46% and the overall progression rate 19%. The rate of delayed cystectomy was 8% and that of disease‐specific survival 91%. In patients who received BCG therapy, the recurrence and progression rates were 42% and 23%, respectively. In this group the rate of disease‐specific survival was 88%.

CONCLUSION

This study confirms that maintenance BCG therapy is an effective treatment for T1G3 bladder tumours, with an acceptable rate of bladder preservation.
Does extended lymphadenectomy increase the morbidity of radical cystectomy?
Authors: Brössner C. , Pycha A. , Toth A. , Mian C. , Kuber W.
Published: December 2003

OBJECTIVE

To report the events during and after radical cystectomy and urinary diversion for bladder cancer, in terms of major and minor complications, comparing a minimal with an extended lymphadenectomy, as more lymph nodes obtained during radical cystectomy may improve staging and thus the outcome.

PATIENTS AND METHODS

We reviewed 92 consecutive patients who underwent radical cystectomy from March 1998 to February 2002; 46 had a minimal (group A) and 46 an extended lymphadenectomy (group B). Cases were selected according to the American Society of Anesthesiologists classification, only including those graded 2 or 3. We specifically evaluated the incidence and type of complications within 30 days after surgery.

RESULTS

Because of extending the lymphadenectomy the operative duration was a median of 63 min longer in group B (P < 0.01). Complications requiring surgical interventions occurred in four (9%) patients in group A and five (11%) in group B (P = 0.28). Complications requiring no surgical intervention were also similar in both groups. Three patients died, two in group A and one in group B (P = 0.57).

CONCLUSION

Extended lymphadenectomy in radical cystectomy does not increase the morbidity within 30 days of surgery.
Laparoscopic radical nephrectomy for T1 renal cancer: the gold standard? A comparison of laparoscopic vs open nephrectomy
Authors: Makhoul B. , De La Taille A. , Vordos D. , Salomon L. , Sebe P. , Audet J.F. , Ruiz L. , Hoznek A. , Antiphon P. , Cicco A. , Yiou R. , Chopin D. , Abbou C.C.
Published: December 2003

OBJECTIVE

To evaluate the complication rate and clinical follow‐up of patients treated for T1 renal cancer by open or laparoscopic nephrectomy at the same institution, as this approach appears to be attractive for treating small renal cancers.

PATIENTS AND METHODS

Between 1995 and 2002, 39 patients underwent retroperitoneal laparoscopic and 26 transperitoneal open radical nephrectomy for T1 renal cancer (TNM 1997). Variables before during and after surgery, e.g. cancer recurrence, were compared between the groups.

RESULTS

There were no differences between the laparoscopic and open groups in age, sex ratio, weight, height, fitness score, operative duration (134 vs 133 min), minor or major complications, tumour diameter, Fuhrman grade or length of follow‐up. Patients who underwent laparoscopic surgery had less blood loss (133 vs 357 mL, P < 0.001), less need for transfusion (none vs 150 mL, P = 0.04), a lower consumption of analgesia drugs, and shorter hospitalization (5.5 vs 8.8 days, P < 0.001). With a mean follow‐up of 20.4 months there was no recurrence or tumour progression.

CONCLUSION

Laparoscopic radical nephrectomy for patients with T1 renal cancer is a safe, reliable procedure that decreases hospitalization time and bleeding, and ensures the same cancer control as open nephrectomy.
A randomized crossover study to evaluate Ro 115–1240, a selective α1A/1L‐adrenoceptor partial agonist in women with stress urinary incontinence
Authors: Musselman D.M. , Ford A.P.D.W. , Gennevois D.J. , Harbison M.L. , Laurent A.L. , Mokatrin A.S. , Stoltz R.R. , Blue D.R.
Published: December 2003

OBJECTIVES

To investigate the potential therapeutic benefits of the selective α1A/1l‐adrenoceptor partial agonist Ro 115–1240 in women with mild‐to‐moderate stress urinary incontinence (SUI).

PATIENTS AND METHODS

Thirty‐seven women with mild‐to‐moderate SUI were enrolled in a randomized, placebo‐controlled crossover study. Patients received 1.5 mg Ro 115–1240 twice daily or matching placebo for 2 or 4 weeks. Voiding diaries were used to record the number of SUI episodes, urge incontinence episodes and pads used. Sitting blood pressures and heart rate were recorded at each visit.

RESULTS

Ro 115–1240 was associated with a significantly lower mean weekly number of SUI episodes than placebo (8.4 vs 6.0; P= 0.0079), a 28% relative improvement over placebo. There was also a significantly lower mean number of pads used and wet pads changed/week with Ro 115–1240 than with placebo (P = 0.0055 and 0.0066, respectively). The most frequently reported treatment‐emergent adverse events were scalp tingling, headache, chills, piloerection, and pruritus. Generally these events were transient and mild to moderate. There was a slightly lower mean sitting heart rate with Ro 115–1240 than with placebo, but no difference in mean systolic or diastolic blood pressure between treatments.

CONCLUSIONS

This study suggests that selective α1A/1l‐adrenoceptor partial agonists have the potential to improve the symptoms of SUI with little or no cardiovascular effect. These results are encouraging and a randomized controlled trial of Ro 115–1240 in a larger population with SUI is warranted to substantiate these findings.
Solifenacin appears effective and well tolerated in patients with symptomatic idiopathic detrusor overactivity in a placebo‐ and tolterodine‐controlled phase 2 dose‐finding study
Authors: Chapple C.R. , Araño P. , Bosch J.L.H.R. , De Ridder D. , Kramer A.E.J.L. , Ridder A.M.
Published: December 2003

Early results using two new agents to treat urinary incontinence are published. The use of Ro 115–1240 in women with stress urinary incontinence is presented, with encouraging results. This will lead to further studies in more patients. Solifenacin was evaluated in a dose‐finding study and the results presented here; the results of the phase III study appear next month.

OBJECTIVES

To evaluate the dose‐response relationship and safety/tolerability of solifenacin succinate (YM905) in the treatment of overactive bladder (OAB), and to compare its efficacy and safety/tolerability with tolterodine 2 mg twice daily.

PATIENTS AND METHODS

This multicentre study included a 2‐week single‐blind placebo run‐in, a 4‐week double‐blind placebo‐controlled active treatment phase, and a 2‐week follow‐up. Men and women with an OAB and urodynamic evidence of detrusor overactivity were randomized to placebo or solifenacin 2.5, 5, 10 or 20 mg once daily, or tolterodine 2 mg twice daily.

RESULTS

Of 265 patients enrolled, 225 were randomized and 192 completed the study. Solifenacin 5, 10 and 20 mg produced statistically significant (P < 0.05) improvements in voids/24 h vs placebo, whereas tolterodine did not; the mean change with tolterodine was between those with solifenacin 2.5 and 5 mg. The outcome was similar for the mean change from baseline to endpoint in mean volume voided/void. For incontinence and urgency episodes/24 h the solifenacin dose groups showed numerically superior changes vs placebo; the mean effects with tolterodine were generally smaller than with solifenacin. Most of the efficacy effect of solifenacin was evident at 2 weeks. Quality‐of‐life outcomes supported the efficacy results. Solifenacin 5 and 10 mg were well tolerated; there were no serious treatment‐related adverse events. The incidence of dry mouth was 14% for solifenacin 5 and 10 mg, 2.6% for placebo and 24% for tolterodine.

CONCLUSION

In this study, the 5‐ and 10‐mg doses of solifenacin appeared to be the most clinically effective for treating OAB, considering the balance between efficacy, quality of life and tolerability. From the results of this study solifenacin 5 and 10 mg were selected for further evaluation in large‐scale phase 3 studies.
Management of acute urinary retention secondary to benign prostatic hyperplasia in the UK: a national survey
Authors: Manikandan R. , Srirangam S.J. , O'Reilly P.H. , Collins G.N.
Published: December 2003

OBJECTIVE

To analyse current practice in the management of acute urinary retention (AUR) secondary to benign prostatic hyperplasia (BPH) in the UK, and to assess how much of this is evidence‐based.

METHODS

In all, 410 consultant urologists practising in UK hospitals were sent a questionnaire about the management of AUR secondary to BPH. Data were collected on practice relating to initial management, trial without catheter (TWOC), the use of α‐blockers and the follow‐up. The need for a uniform guideline in the management of AUR secondary to BPH was also assessed.

RESULTS

We received 270 (66%) replies, of which six were excluded because they were from subspeciality interests (e.g. paediatric urology) or had ambiguous answers; 264 (64%) were therefore available for analysis. Urethral catheterization was the initial management of choice (98%), failing which a suprapubic catheter was inserted. Two‐thirds (65.5%) admitted the patient after catheterization. Most consultants initiated α‐blockers (70.5%), with 64% (118) of these using a TWOC 2 days after starting them. One failed TWOC was an indication for transurethral resection of the prostate for 192 (72.8%), with 136 (49.8%) re‐admitting the patient for surgery later. Routine follow‐up after a successful TWOC was advocated by 77.3%. Just over half the respondents (52.6%) felt that there was no need for uniform guidelines in the management of AUR secondary to BPH.

CONCLUSION

This survey identified a reasonable national uniformity in managing AUR secondary to BPH in the UK, but significant aspects of current practice are not evidence‐based.
Prostaglandin E2 and bethanechol in combination for treating detrusor underactivity
Authors: Hindley R.G. , Brierly R.D. , Thomas P.J.
Published: December 2003

OBJECTIVE

To test the hypothesis, in a prospective randomized double‐blind study, that the combination of intravesical prostaglandin E2 (PGE2) and oral bethanechol chloride (BC) are additive or synergistic in improving bladder emptying, as they have been used alone for treating impaired detrusor contractility with little clinical benefit.

PATIENTS AND METHODS

Nineteen patients with detrusor underactivity (17 men and two women) were eligible and randomized to one of two treatments. All had postvoid residual urine volumes (PVR) consistently of > 300 mL, most being reliant on clean intermittent self‐catheterization (CISC). The experimental treatment group (nine patients) received once‐weekly intravesical PGE2 (1.5 mg in 20 mL 0.9% saline) plus BC 50 mg four times daily, for a total of 6 weeks. The second group of 10 patients received a once‐weekly instillation of saline together with placebo tablets, again for 6 weeks.

RESULTS

Before treatment the median (interquartile range) PVR was 426 (405–480) mL for those receiving both drugs; this decreased to 325 (290–352) mL after completing the treatment (P < 0.015). In the placebo group the respective values were 576 (539–777) and 538 (350–775) mL (P = 0.09). Four of the patients receiving the active combination reported symptomatic improvement and were able to reduce the frequency of CISC.

CONCLUSION

Although there was evidence of a pharmacological effect, BC and PGE2 had a limited therapeutic effect compared with placebo. Whilst we would not recommend this treatment as routine, it may be considered for the occasional treatment of a patient with detrusor underactivity.
The impact of sildenafil citrate on sexual satisfaction profiles in men with a penile prosthesis in situ
Authors: Mulhall J.P. , Jahoda A. , Aviv N. , Valenzuela R. , Parker M.
Published: December 2003

This section includes three papers, two of which describe the use of drug treatment for erectile dysfunction in special situations. The authors from New York and Chicago write about sildenafil in patients with a penile prosthesis in situ. Authors from Zurich have used apomorphine in patients with spinal cord injury and erectile dysfunction. It is often helpful to readers with an interest in the area of erectile problems to explore the use of commonly prescribed drugs in somewhat less common situations.

OBJECTIVE

To assess the efficacy of sildenafil in increasing penile glans tumescence and improving patient satisfaction in men with a penile prosthesis, as this remains a major treatment for erectile dysfunction but a common complaint is the lack of glans engorgement.

PATIENTS AND METHODS

To determine whether sildenafil combined with a penile prosthesis improves satisfaction, patients used an implant alone for at least 1 month, after which they completed the International Index of Erectile Function (IIEF) questionnaire. The same patients were then given sildenafil citrate and completed the IIEF questionnaire after using the sildenafil/implant combination.

RESULTS

Patients who responded to sildenafil with glans engorgement reported significantly greater satisfaction scores than with an implant alone.

CONCLUSION

We currently offer sildenafil citrate after implantation to all men who have a penile prosthesis placed.
Apomorphine sublingual as primary or secondary treatment for erectile dysfunction in patients with spinal cord injury
Authors: Strebel R.T. , Reitz A. , Tenti G. , Curt A. , Hauri D. , Schurch B.
Published: December 2003

OBJECTIVES

To evaluate the effectiveness of apomorphine sublingual (SL) 3 mg, as a primary or secondary treatment for erectile dysfunction (ED) in patients with spinal cord injury (SCI), and to determine possible differences in efficacy considering clinical, urodynamic and neurophysiological findings.

PATIENTS AND METHODS

The study included 22 patients with chronic SCI and neurogenic ED who were examined physically and by a video‐urodynamic evaluation. A neurophysiological evaluation included somatosensory evoked potentials of the pudendal nerve, palmar and plantar sympathetic skin responses and bulbocavernous reflex recordings. Thereafter the patients received 8 tablets of apomorphine SL 3 mg and were asked to complete the International Index of Erectile Function questionnaire before and after treatment. Side‐effects, subjective efficacy compared with other treatments and satisfaction with the SL administration were recorded.

RESULTS

Of the 22 men, 11 had upper motor neurone lesions (six complete, five incomplete), eight lower motor neurone lesions (seven complete, one incomplete) and three had mixed lesions. In all, 12 patients took sildenafil citrate and five alprostadil intracavernosally beforehand, and five had used nothing to treat their ED. Seven patients had some response and reported that the drug helped them to obtain an erection, but only two reported erections sufficient for intercourse and would agree to continue apomorphine SL as their standard treatment; all the others reported being disappointed. Nine patients reported side‐effects. There were no significant correlations for electrophysiological or urodynamic findings and treatment success. Of the 22 patients 20 preferred SL rather than the normal administration.

CONCLUSIONS

Apomorphine SL, a D1/D2 dopamine agonist, facilitates erectile function in a heterogeneous group of patients with no significant relationship with any of the assessed urodynamic or electrophysiological variables. The overall low rates of response either for primary or secondary treatment suggests that apomorphine will have limited applicability in patients with SCI.
Treatment of penile curvature with Essed‐Schröder tunical plication: aspects of quality of life from the patients’ perspective
Authors: Van Der Horst C. , Martínez Portillo F.J. , Seif C. , Alken P. , Juenemann K.P.
Published: December 2003

OBJECTIVES

To investigate retrospectively the long‐term functional results and quality of life of patients undergoing the Essed‐Schröder procedure (a simple plication of the tunica albuginea) to correct penile deviation, using a standardized questionnaire.

PATIENTS AND METHODS

Between 1998 and 2001, 59 patients had surgery in our hospital to correct penile deviation (mean age 40 years at the time of surgery; mean follow‐up 30 months for this study). All 59 patients received a standardized questionnaire via mail, of which 50 could be assessed as valid.

RESULTS

Of the 50 patients, 22 had a congenital penile deviation and 28 Peyronie's disease. In all patients the penis was completely straightened. The proportion of patients capable of sexual intercourse was significantly higher after surgery (90%) than before (62%). The frequency of pain during intercourse was halved. Of the 50 patients, 60% would have the same operation again, 32% were undecided and 8% would not; 22% were dissatisfied with the results. None of the patients had complete erectile dysfunction after surgery; 74% reported a decrease in penile length and 78% of the patients’ partners were satisfied with the outcome.

CONCLUSIONS

The tunical plication procedure is simple and minimally invasive for correcting penile deviation. In the opinion of most patients the Essed‐Schröder method provides a significant improvement in sexual function and quality of life with maximum protection of erectile function.
Exaggerated primary endoscope deflection: initial clinical experience with prototype flexible ureteroscopes
Authors: Johnson G.B. , Grasso M.
Published: December 2003

The arrival of the flexible ureteroscope has been of great value to urologists, allowing access to virtually all parts of the collecting system. Authors from two centres in the New York area and Taiwan write in this section about their experience with new types of flexible ureteroscopes. Their views are sure to be of interest to readers.

OBJECTIVE

To increase the clinical usefulness of the actively deflectable flexible ureteroscope by making sequential changes in design and then using these prototypes clinically; and to develop a clinical series using the optimum prototype and contrast it with an extensive database of patients treated with the traditional flexible ureteroscope.

METHODS

A series of prototypic flexible ureteroscopes was developed and used clinically. The active deflection of the prototype ureteroscope was evaluated with and with no accessories in the working channel, and compared with a standard 7.5 F ureteroscope. Clinical data were then accrued and compared with a previously published database.

RESULTS

The progression of prototypes led to a final version which incorporated > 300° primary active deflection, shaft miniaturization (8.4 F) and an increase in endoscope shaft stiffness. The prototype flexible ureteroscope had significantly greater active deflection than the standard ureteroscope, especially when working channel accessories were used. In all, 115 endoscopic procedures were carried out, the indications for which included endoscopic lithotripsy for distal calculi (51), treatment of upper tract urothelial carcinoma (27), diagnostic endoscopy (26) and retrograde endopyelotomy (three). No guidewire was required to place the flexible ureteroscope into the upper urinary tract in 27% of patients. Active intramural dilatation for access was only required in 3% of the procedures. All lower pole calyces were accessed with this instrument.

CONCLUSIONS

Adding exaggerated deflection is a timely advance in flexible ureteropyeloscopy. This and the other changes in design facilitated complex retrograde endoscopic procedures and increased the therapeutic potential of the instrument.
Are new‐generation flexible ureteroscopes better than their predecessors?
Authors: Chiu K.‐Y. , Cai Y. , Marcovich R. , Smith A.D. , Lee B.R.
Published: December 2003

OBJECTIVE

To compare two newly designed flexible ureteroscopes with their respective predecessors, to determine whether design advances have overcome the limitation of tip deflection, which may interfere with diagnosis and treatment of lower pole renal pathology.

MATERIALS AND METHODS

Two new‐generation flexible ureteroscopes, the DUR‐8 Elite (ACMI, Southborough, MA, USA) and 11278AU (Karl Storz Endoscopy, Culver City, CA, USA) were compared with their previous models, the ACMI DUR‐8 and the Storz 11274AAU. Active tip deflection and irrigation flow rates with and without various endoscopic tools were assessed. Specifications, purchase prices and repair costs were obtained from each manufacturer. The field of view and screen image size of each ureteroscope were also compared.

RESULTS

The ACMI DUR‐8 Elite and the Storz 11278AU had improvements of 79° and 144°, respectively, from their respective older models. Although the tip deflection of all ureteroscopes was compromised by inserting different endoscopic tools, these new instruments were less affected. With a 3 F basket inside the working channel, the ACMI DUR‐8 Elite and the Storz 11278AU had only 0.7% and 2.8% loss of upward tip deflection, compared with their older models, at 9.6% and 5.0%, respectively. However, the flow rates of these new instruments were decreased.

CONCLUSION

The new flexible ureteroscopes have significantly better active tip deflection than previous models, both with and without endoscopic instrumentation inserted. However, improved flexibility is at the expense of decreased flow rates and higher purchase costs.
Metabolic risk factors in patients with renal stones in KwaZulu Natal: an inter‐racial study (Asian and Whites)
Authors: Abdel Goad E.H. , Bereczky Z.B.
Published: December 2003

OBJECTIVE

To identify any differences between Whites and Indians in KwaZulu Natal province, South Africa, in the metabolic risk factors which predispose them to urinary stone formation.

PATIENTS AND METHODS

Urinary stone disease is often a manifestation of an underlying metabolic disorder in most patients. Intrinsic and extrinsic factors affect the susceptibility of an individual to develop urinary stones. Although South African‐born Indians and Whites in KwaZulu Natal share some of the same extrinsic factors, diet and genetic factors differ between the groups. In a study from April 1999 until April 2001, 140 patients were included who had a radiological diagnosis of renal calculi; they were evaluated metabolically using previously recommended methods.

RESULTS

All the patients had at least one identifiable metabolic risk factor; the prevalence of the common metabolic risk factors was similar in the two groups. The prevalence of complete renal tubular acidosis (type 1) was significantly higher in the Indian patients. The most common metabolic abnormalities were hypomagnesuria and hypocitraturia, followed by low urinary volume. Hypercalciuria was not significant in this population. While Indians had lower urine volumes than Whites, Whites had significantly higher urinary calcium excretion than Indians.

CONCLUSION

There were a few variations in the metabolic risk factors between Indians and Whites, and the differences could be attributed to genetic or dietary habits. The high incidence of renal tubular acidosis in Indian patients could explain the higher prevalence of urinary stone disease in this group than in other racial groups.
Rhabdomyosarcoma of the bladder, prostate or vagina: the role of surgery
Authors: Filipas D. , Fisch M. , Stein R. , Gutjahr P. , Hohenfellner R. , Thüroff J.W.
Published: December 2003

Rhabdomyosarcoma of pelvic organs is not common enough for many people to develop large series. However, the authors from Mainz retrospectively analysed 107 children with this condition, and suggest that primary chemotherapy followed by radical surgery yields excellent cure rates.

OBJECTIVE

To retrospectively analyse the outcome of children with rhabdomyosarcoma (RMS) of the bladder, prostate or vagina who were treated with chemotherapy, with or without radical surgery or additional radiotherapy, at our institution since 1968.

PATIENTS AND METHODS

From a total of 107 children with RMS seen between 1968 and December 2001, 22 (mean age 5.9, range 0.5–18) had RMS of bladder/prostate or vagina. Twenty of the patients received primary polychemotherapy (vincristine, actinomycin D, cyclophosphamide, adriamycin, and more recently including etoposide and ifosfamide), two had primary surgery and seven had additional radiotherapy. Fourteen patients had radical cystoprostatectomy, with continent cutaneous urinary diversion with an ileocaecal pouch in seven, in one each a transverse colonic pouch, orthotopic ileocaecal bladder substitution, a rectal reservoir and rectosigmoid pouch and a colonic conduit diversion in two patients.

RESULTS

After a mean (range) follow‐up of 8.6  (1.0–26) years, 17 patients had no evidence of disease. Five patients presenting initially with advanced tumour stages died from progressive RMS. Two patients with a continent urinary diversion required ureteric reimplantation for stenosis. In two patients severe bladder contraction after radiotherapy required bladder augmentation.

CONCLUSION

Primary chemotherapy followed by radical surgery of RMS of the prostate and/or bladder allows complete tumour resection in most cases, and yields excellent cure rates.
A comparison of palpable and impalpable cryptorchid testes using CD‐99 immunohistochemistry
Authors: Abrahams H.M. , Kallakury B.V.S. , Sheehan C.E. , Kogan B.A.
Published: December 2003

OBJECTIVE

To compare the clinical and morphological features of impalpable and palpable cryptorchid testes, as there is debate about how much effort is appropriate to bring an impalpable undescended testicle into the scrotum.

PATIENTS AND METHODS

We reviewed retrospectively 189 cases of undescended testicles in 168 patients who were explored surgically by one surgeon between August 1997 and September 2000. Operative findings of palpability, testicular size and location were collected. The mean tubular diameter (MTD), tubular fertility index (TFI) and mean number of germ cells per tubule (MGCT) were calculated using immunohistochemistry for CD‐99, a Sertoli‐cell marker, to classify germ cells more accurately.

RESULTS

Sixty‐three testes (33%) were impalpable; the median age at the time of surgical exploration was 23 months for both groups. The mean (sd) testicular volume for the impalpable and palpable groups were 0.83 (0.38) and 1.22 (0.54) mL, respectively. Using fitted curves of size vs age, impalpable testes were smaller than palpable testes at all ages, with the difference nearly statistically significant (P < 0.06). The MTD, TFI and MGCT decreased with age in both groups, with no statistically significant differences between the groups. A sub‐analysis of abdominal and extra‐abdominal testes confirmed no significant differences.

CONCLUSION

Impalpable testes are smaller at the time of exploration than palpable cryptorchid testes. However, histological factors predict that impalpable testes have a significant chance of future fertility and therefore orchidopexy is appropriate. CD‐99 immunohistochemistry makes objective morphological information easier to obtain.
Genital sensation after feminizing genitoplasty for congenital adrenal hyperplasia: a pilot study
Authors: Crouch N.S. , Minto C.L. , Laio L.‐M. , Woodhouse C.R.J. , Creighton S.M.
Published: December 2003

OBJECTIVE

To assess sensation in the clitoris and vagina in women with congenital adrenal hyperplasia (CAH) who have previously had genital surgery, and to evaluate sexual function in this group as the latter, and particularly the experience of orgasm, appear to be closely related to sensitivity.

PATIENTS AND METHODS

Six women were recruited from a multidisciplinary clinic specialising in intersex conditions, and representing an initial cohort from a larger ongoing study. The patients were asked to complete a postal questionnaire with a specialized sexual function assessment. Thermal, vibratory and light‐touch sensory thresholds were assessed in the clitoris and vagina using a genito‐sensory analyser and Von Frey filaments.

RESULTS

All six women had highly abnormal results for sensation in the clitoris. Only three of them had an introitus capable of admitting the vaginal probe, and the vaginal sensory data of all three were within the validated ranges. A self‐administered sexual function assessment was completed by the five women who were sexually active. The scores indicated sexual difficulties, particularly in the areas of infrequency of intercourse and anorgasmia.

CONCLUSIONS

The sensory data for all six women were outside the normal range for the clitoris. The results for the upper vagina, which had not had surgery, were within normal ranges. These findings suggest that genital surgery may disrupt sensory input. Sexual function also appears to be impaired and this may relate to the compromised sensitivity and restricted introitus. The possibility that women with CAH have deficient clitoral sensation ab initio cannot be excluded. These striking findings must be evaluated further in the light of the controversy about the issue of genital surgery in children with CAH.
Expanded PTFE bladder neck slings for incontinence in children: the long‐term outcome
Authors: Godbole P. , Mackinnon A.E.
Published: December 2003

OBJECTIVE

To assess the long‐term outcome of circumferential expanded PTFE (Gore‐texTM, WL Gore Associates, Scotland) bladder neck slings for achieving urethral continence in children with a neuropathic bladder.

PATIENTS AND METHODS

The records were reviewed of 19 children undergoing bladder reconstruction (most with a neuropathic bladder) who had a Gore‐tex sling placed circumferentially at the bladder neck, over a 5‐year period. Of these, seven had spina bifida; two each spinal dysraphism, surgery for anorectal anomalies and an idiopathic neuropathic bladder; five who developed a neuropathic bladder from other causes, and one born with bladder exstrophy. All children had an uncompliant bladder with a low urethral leak‐point pressure on preoperative urodynamics. In all children conventional clean intermittent catheterization and pharmacotherapy had failed. Four had had previous augmentation surgery while 15 had concomitant bladder augmentation and formation of a Mitrofanoff stoma. The main outcome measure was achieving dryness. The original intention of the procedure was also to maintain urethral catheterization.

RESULTS

Full details of the follow‐up were available in 17 patients. Despite initial good short‐term results, at a median follow up of 7 years, in 14 patients the sling had to be removed because of erosion, often with transient urethral leakage before the bladder neck subsequently closed. A bladder calculus was associated with each case of erosion except one.

CONCLUSION

Although in the short term this technique had favourable results, it was not a useful technique in the long term.
The phosphatidylinositol‐3 kinase pathway regulates bladder cancer cell invasion
Authors: Wu X. , Obata T. , Khan Q. , Highshaw R.A. , De Vere White R. , Sweeney C.
Published: December 2003

Three of the studies described in this section relate to bladder cancer. The first of these concerns the PI‐3 kinase pathway, which has been a topic of interest in cancer in general. The authors from Sacramento suggest that it may regulate cancer cell invasion, and hope that this may lead to translational therapeutic uses.

Another study describes the pharmacological characteristics of Ro115‐1240, which is a selective alpha1A/1L adrenoceptor partial agonist, a compound which may have a future in treating stress urinary incontinence.

OBJECTIVES

To investigate the role of the phosphatidylinositol (PI)‐3 kinase pathway in the invasion of bladder cancer cell lines, and to assess the activation of this pathway in primary human bladder tumours.

MATERIALS AND METHODS

Human bladder cancer cells were treated with pathway specific inhibitors or were transfected with PI‐3 kinase pathway components. The invasion of cultured bladder cancer cells was analysed by an invasion assay. Bladder cancer cells lines and primary human bladder tumours were analysed for pathway activation by western blotting.

RESULTS

A specific inhibitor of PI‐3 kinase enzyme activity, Ly294002, potently suppressed the invasive properties of three highly invasive bladder tumour cell lines. Restoration of the PTEN gene to invasive UM‐UC‐3 bladder tumour cells or expression of a dominant‐negative version of the PI‐3 kinase target, Akt, also potently inhibited invasion, indicating a central role for the PI‐3 kinase/Akt pathway in this process. In addition, 55% of primary tumours from patients with bladder cancer had markedly high levels of phosphorylated Akt.

CONCLUSION

Pharmacological or biochemical inhibition of the PI‐3 kinase pathway drastically reduced the invasive capacity of bladder cancer cell lines; over half of primary human bladder tumours had high Akt phosphorylation, suggesting that the aberrant activation of this pathway may contribute to the invasion of a significant subset of bladder cancers.