Claes R. Nyman

Psychosocial Adjustment and General State of Health In Patients With Ileal Conduit Urinary Diversion

The psychosocial adjustment and general state of health were investigated in 66 patients (40 males, 26 females) who had been subjected to an ileal conduit urinary diversion on account of bladder cancer (44 patients) or incontinence or bladder dysfunction (22 patients). Seventy per cent of the patients reported unchanged, overall, social activity (OSA) after the operation. Twenty per cent reported less and 10% more activity. Bladder-cancer patients were more likely to curtail their social activities compared with the patients with incontinence or bladder dysfunction. Appliance-related problems were mentioned by half of the patients who reported decreased OSA. One-third of the patients considered accidental leakage or fear of such leakage as the most negative aspect of surgery. Factors related to an altered body image were the most common negative aspect reported by females. Despite psychosocial problems, the majority of the patients (80%) considered their health to be good. Males, individuals working full-time and patients with unchanged OSA scored higher on a Health Index, i.e. considered themselves healthier than the rest of the patients.

Diagnostic Methods in the Detection of Prostate Cancer: A Study of a Randomly Selected Population of 2,400 Men

We investigated the value of digital rectal examination, transrectal ultrasonography and prostatic specific antigen (PSA) analysis as aids in general clinical practice and in the early detection of prostate cancer. Of a randomly selected population of 2,400 men 55 to 70 years old who were offered examination with digital rectal examination, transrectal ultrasound and PSA analysis, 1,782 (74%) accepted and prostate cancer was detected in 65 (3.6%). When the transrectal ultrasound results were also considered the detection rate of digital rectal examination (2.3%) was increased by 50% and the number of stage T2A or less tumors was doubled. At reexamination due to markedly high PSA values (7 micrograms/l. or more) only a few additional cancers (5%) were detected. However, it is noteworthy that 80% of the detected cancers were found among the subgroup with abnormal PSA values (4 micrograms/l. or more) and comprising 17% of the study population, which suggests the possibility of selecting a risk group at mass screening. Moreover, the positive predictive value increased from 4% (when only digital rectal examination was positive) to 71% for the combination of positive digital rectal examination, positive transrectal ultrasound and an increased PSA concentration (that is 7 micrograms/l. or greater).

Bipolar transurethral resection of the prostate causes less bleeding than the monopolar technique: a single-centre randomized trial of 202 patients

Study Type – Therapy (RCT)
Level of Evidence 1b

DOUBLE-BLIND RANDOMIZED STUDY OF SYMPTOMS ASSOCIATED WITH ABSORPTION OF GLYCINE 1.5% OR MANNITOL 3% DURING TRANSURETHRAL RESECTION OF THE PROSTATE

PURPOSE We studied which irrigating fluid, glycine 1.5% or mannitol 3%, is associated with the most favorable adverse effects profile when absorbed by the patient during transurethral resection of the prostate. MATERIALS AND METHODS Irrigating fluid bags containing mannitol 3% or glycine 1.5%, both with added ethanol 1% as an indicator of fluid absorption, were used in a randomized double-blind fashion during 394 transurethral prostatic resections. The incidence of 13 symptoms was studied in 52 patients (13%) who absorbed more than 500 ml. fluid. RESULTS The incidence of circulatory symptoms did not differ between the fluids but the risk of neurological symptoms, such as nausea, after transurethral prostatic resection was 4.8 times higher when glycine 1.5% was absorbed (p <0.04). An increase of 1,000 ml. in the volume of irrigant absorbed increased the overall risk for circulatory symptoms by a factor of 3.4 (p <0.03) and the risk of neurological symptoms by a factor of 4.4 (p <0.02). CONCLUSIONS Absorption of mannitol 3% during transurethral prostatic resection is associated with fewer neurological symptoms than glycine 1.5%.

Deoxyribonucleic Acid Profile and Tumor Progression in Primary Carcinoma in Situ of the Bladder: A Study of 63 Patients with Grade 3 Lesions

In 63 patients with primary grade 3 carcinoma in situ of the bladder flow cytometric deoxyribonucleic acid (DNA) analysis was performed at diagnosis and during an average followup of 63 months. The results of DNA measurements were related to disease progression, that is invasive tumor and/or metastatic disease. The DNA histograms were classified as diploid (2 patients) or aneuploid (61). A total of 3 categories of aneuploid tumors with different prognostic significance could be defined: 1) carcinoma in situ with 1 aneuploid cell population at diagnosis and with no change to multiple aneuploid cell populations throughout observation, 2) carcinoma in situ with 1 aneuploid cell population at diagnosis but with a later change to multiple aneuploid cell populations and 3) carcinoma in situ with multiple aneuploid cell populations already at diagnosis. At 5 years the progression-free survival for the 3 categories was 94%, 43% and 20%, respectively. Over-all, of the patients with multiple aneuploid cell populations (categories 2 and 3) 76% had progression, in contrast to 19% of those in category 1 (p less than 0.0005). In category 2 development of multiple aneuploid cell populations preceded progression in 8 of 11 progressive cases by an average of 20 months. Therefore, the occurrence of multiple aneuploid cell populations must be considered as a sign of high aggressiveness. We conclude that flow cytometric DNA analysis is a potent predictor of prognosis in cases of primary carcinoma in situ of the bladder.

Prognostic significance of mucosal aneuploidy in stage Ta/T1 grade 3 carcinoma of the bladder

In a prospective series of 71 patients with newly detected grade 3, stages Ta and T1 bladder carcinoma tumor characteristics, including the results of deoxyribonucleic acid (DNA) analysis as well as morphological and DNA characteristics of the grossly normal urothelium, were investigated and related to progression-free survival. The mean duration of followup was 57 months, with a minimum of 24 months. Of the 71 patients 24 underwent primary cystectomy, and 47 were conservatively treated with transurethral resection alone, or followed by instillation therapy or irradiation therapy. Of the cystectomy and conservatively treated patients 2 (8%) and 16 (34%), respectively, died of bladder carcinoma. Among the 47 conservatively treated patients tumor progression could not be predicted by the initial characteristics of tumor stage, papillary or nonpapillary growth, tumor multiplicity, tumor size, existence of 1 or multiple aneuploid cell populations, S phase value, carcinoma in situ and atypia or aneuploidy in the mucosal biopsies. Neither was progression predicted by the recurrence rate during year 1 of observation. However, a change to or persistent mucosal aneuploidy and a change to or persistent morphological abnormality of the mucosa during year 1 of observation were predictive for tumor progression (p = 0.001 and 0.045, respectively). When compared in stepwise regression analysis (Coxs proportional hazard model), DNA aneuploidy in the mucosa at 12 months after diagnosis was a highly significant predictor, whereas morphology added no further prognostic information. Therefore, progression is related to gross chromosomal abnormalities of the mucosa. High risk patients can be identified by evaluation of the grossly normal mucosa, which should be done as part of the initial diagnosis and during followup in conservatively treated patients with stages Ta and T1, grade 3 bladder carcinoma.

Classification of peristomal skin changes in patients with urostomy

Peristomal skin lesions in patients with ileal conduit urinary diversion have been reported in frequencies ranging from none to occurrence in 100% of patients. In previous studies skin lesions often are referred to in unspecific terms, which has made it impossible to compare results with those of other studies. Thus a classification of peristomal skin (CPS) has been developed on the basis of macroscopic peristomal findings. It defines what can be accepted as ordinary findings, as well as two different types of skin lesions, erythematous-erosive and pseudoverrucous. Each of these is divided into two subgroups. Such a classification is a prerequisite for a meaningful comparison of the type, incidence, and severity of skin lesions in different groups; it also may allow a more reliable clinical evaluation of new ostomy appliances and skin care products. In addition, CPS may also facilitate communication among professionals who are responsible for the care of ostomy patients.

Prostate-specific Antigen (PSA), PSA Density and Age- adjusted PSA Reference Values in Screening for Prostate Cancer A Study of a Randomly Selected Population of 2,400 Men

Prostate cancer screening with DRE, TRUS, and PSA testing was offered to 2,400 randomly selected men 55-70 years old. Among 1,782 examined, 65 (3.6%) men with prostate cancer were diagnosed. The PSA results were correlated to the diagnosis, the mens age, and the prostate volume. Least square regression analysis was used to calculate the 95% upper confidence intervals for PSA in each year of age in men without prostate cancer. The PPV was calculated for: (i) PSA > 4 ng/ml, (ii) PSAD > 0.15, (iii) PSAD > 0.20 and (iv) age-adjusted PSA reference values. A significant correlation was found between PSA and prostate volume, between PSA and age, and between the prostate volume and age. The calculated annual growth of the prostate was 1.6% and the annual increase in PSA was 2.4%. The age-adjusted upper PSA reference values for the three age categories studied (55-59, 60-64 and 65-70 years) were 5.2, 5.8, and 6.7 ng/ml, respectively. The PPVs for PSA > 4 ng/ml, PSAD > 0.15, PSAD > 0.20, and the age-adjusted PSA reference values were 17%, 14%, 22%, and 27%, respectively. Age-adjusted PSA or PSAD may increase the PPV compared to PSA > 4 ng/ml. The detection rate is, however, inadequate. A PSA cut-off at 4 ng/ml could therefore be maintained in men 55-70 years old. The median PSA values and median prostate volumes calculated for men with benign findings may serve as a reference in future studies.

Complications and Clinical Outcome 18 Months After Bipolar and Monopolar Transurethral Resection of the Prostate

PURPOSE To compare bipolar resection with the conventional monopolar transurethral resection of the prostate (TURP) with respect to peri- and postoperative complications and long-term outcome. PATIENTS AND METHODS Patients with consecutive benign prostatic hyperplasia needing surgery (n=185) from the hospitals waiting list were randomized to TURP using either a bipolar or a monopolar system. Peri- and postoperative parameters were monitored, complications were registered, and timed micturition/International Prostate Symptom Score (TM/IPSS) forms were collected at 3 and 6 weeks and at 6 and 18 months. RESULTS Bipolar surgery was followed by a 16% to 20% higher percentage of the patients reporting ongoing improvement (fractional IPSS change >2) at 3 and 6 weeks after the surgery (p<0.05). There were fewer readmissions in the bipolar group than in the monopolar (5 vs. 13, p<0.05). No differences between the groups with respect to hospital stay and catheter duration was recorded. Bipolar and monopolar TURP resulted in marked and sustained improvements of IPSS, bother score, and TM. CONCLUSIONS Bipolar TURP, using the transurethral resection in saline (TURis) system, resulted in significantly fewer postoperative readmissions, faster postoperative recovery, and equally long-lasting good results in TM/IPSS and bother score, as in monopolar TURP.

Comparative flow cytometric deoxyribonucleic acid studies on exophytic tumor and random mucosal biopsies in untreated carcinoma of the bladder.

In 290 patients with untreated carcinoma of the bladder the deoxyribonucleic acid properties, as measured by flow cytometry, of 3 random mucosal biopsies were studied and compared to those of the exophytic tumors. Mucosal aneuploidy was found with few exceptions in aneuploid tumors only, and in a significantly lower frequency in aneuploid tumors of grade 2 than grade 3. The individual specificity of bladder tumors is emphasized by the observation that the level of ploidy was mostly the same in aneuploid mucosal biopsies as in the exophytic tumor. This is underlined further by the occurrence of cell populations of the same ploidy in different parts of the bladder mucosa. However, S-phase values of the concomitant intraurothelial lesions were significantly lower than those of the exophytic tumors. Therefore, we concluded that the process of evolution from malignantly transformed lesions, confined to the urothelium, to an exophytic or invasive tumor is dependent on a further elevated proliferation of the urothelial lesions.