H. Motiwala

Does intraprostatic inflammation have a role in the pathogenesis and progression of benign prostatic hyperplasia

To compare the incidence of acute and/or chronic intraprostatic inflammation (ACI) in men undergoing transurethral resection of the prostate (TURP) for urinary retention and lower urinary tract symptoms (LUTS), as recently a role was suggested for ACI in the pathogenesis and progression of BPH, and urinary retention is considered an endpoint in the natural history of this condition.

The discovery of prostate-specific antigen.

The discovery of prostate‐specific antigen (PSA) was beset with controversy; as PSA is present in prostatic tissue and semen, it was independently discovered and given different names, thus adding to the controversy. In this review we document the early research in this field to describe the chronology of the discovery of PSA. Using a comprehensive Medline search of the historical aspects of PSA, all relevant papers were reviewed; communication with the scientists involved in the discovery of PSA was an invaluable contribution. In 1960, Flocks was the first to experiment with antigens in the prostate and 10 years later Ablin reported the presence of precipitation antigens in the prostate. In 1971, Hara characterized a unique protein in the semen fluid, γ‐seminoprotein. Li and Beling, in 1973, isolated a protein, E1, from human semen in an attempt to find a novel method to achieve fertility control. In 1978, Sensabaugh identified semen‐specific protein p30, but proved that it was similar to E1 protein, and that prostate was the source. In 1979, Wang purified a tissue‐specific antigen from the prostate (‘prostate antigen’). PSA was first measured quantitatively in the blood by Papsidero in 1980, and Stamey carried out the initial work on the clinical use of PSA as a marker of prostate cancer. Thus the discovery of PSA is interesting and surrounded by controversy. Although the credit for purifying PSA goes to Wang, other eminent scientists published research on this antigen. The initial work on PSA in semen was to asses its properties as a forensic marker for rape victims, but soon its potential as a marker for prostate cancer became evident.

Adult paratesticular tumours

Most masses encountered within the scrotal sac are within the testis and neoplastic. However, a subset of these tumours are extratesticular and mostly arise from paratesticular tissue. The paratesticular region is a complex anatomical area which includes the contents of the spermatic cord, testicular tunics, epididymis and vestigial remnants, e.g. the appendices epididymis and testis [1]. Histogenetically, this area is composed of a variety of epithelial, mesothelial and mesenchymal elements. Neoplasms arising from this region therefore form a heterogeneous group of tumours with different behavioural patterns. On rare occasions, tumours from distant sites may metastasize to the paratesticular region [2]. Tumours occurring in the paratesticular region may be clinically indistinguishable from testicular tumours, thus resulting in initial misdiagnosis. Most tumours of this region present as a scrotal mass or swelling, which may or may not be painful and is occasionally accompanied by a hydrocele. The preoperative distinction between the benign and malignant paratesticular tumour is rarely made, as there may be no specific finding, which results in difficulty in diagnosis and management. Paratesticular tumours, although infrequent, have a high incidence of malignancy; it has been estimated that 70% of paratesticular tumours are benign and 30% are malignant. Although it is often difficult to determine with certainty the exact site of origin of paratesticular tumours, it is thought that the spermatic cord is the most common, accounting for 90% [3]. With the exception of cystadenomas of the epididymis, occasional dermoid cysts of the spermatic cord and rare papillary tumours, most tumours involving the testicular adnexal structures are of mesenchymal origin [4]. Paratesticular tumours are commonly either soft-tissue neoplasms or are mesothelial in origin. Benign and malignant soft-tissue tumours accounted for 58 of 111 (52%) paratesticular tumours submitted to the Canadian Reference Centre for Cancer Pathology from 1949 to 1987 [5]. The exact incidence of paratesticular soft-tissue neoplasms is difficult to estimate, and this is particularly true for benign tumours, which may often go unreported [6]. In this article benign and malignant paratesticular tumours are reviewed. Most of the benign tumours in this region frequently occur in other anatomical sites so the review concentrates on those tumours which are more specific to the paratesticular region.

Publication rate of abstracts presented at the British Association of Urological Surgeons Annual Meeting

To determine the number of peer‐reviewed publications arising from the abstracts presented at the annual meetings of the British Association of Urological Surgeons (BAUS), and to assess urological trainees’ attitudes to research in relationship to the pursuit of Specialist Registrar (SpR) training numbers and their perception of academic urology in the UK.

Voiding dysfunction after tension-free vaginal tape: a conservative approach is often successful

The published literature has focused mainly on the efficacy of tension-free vaginal tape (TVT) in correcting stress incontinence with few reports of complications. We report our experience with the first 52 cases of TVT, specifically assessing voiding dysfunction after the procedure. We carried out a retrospective study of patients undergoing TVT surgery for stress urinary incontinence (SUI) between April 2001 and July 2003. Data were collected on period of catheterization, voiding and storage symptoms, their duration and management. Fifty-two women with a mean age 54xa0years (36–77) were included. Postoperatively, the urethral catheter was removed routinely within 12xa0h. Twelve patients (23%) failed to void spontaneously and needed recatheterization. Ten of them (83%) were able to resume spontaneous voiding within 3xa0months. Twenty patients (38%) complained of storage symptoms postoperatively. Sixteen (80%) responded to conservative treatment. Transient urinary symptoms after TVT sling for SUI are common but can usually be managed conservatively.

Occlusion Angiography Using Intraoperative Contrast-enhanced Ultrasound Scan (CEUS): A Novel Technique Demonstrating Segmental Renal Blood Supply to Assist Zero-ischaemia Robot-assisted Partial Nephrectomy

BACKGROUNDnRecent innovations in technology and operative techniques have enabled safe performance of robot-assisted zero-ischaemia partial nephrectomy (PN), thus preventing the deleterious effect of warm ischaemia time.nnnOBJECTIVEnTo describe a novel technique of occlusion angiography using intraoperative contrast-enhanced ultrasound scan (CEUS) for zero-ischaemia robot-assisted PN (RAPN).nnnDESIGN, SETTING, AND PARTICIPANTSnWe used a prospective cohort evaluation of five patients who had imaging suspicious of renal cell carcinoma (RCC) treated at a single centre.nnnSURGICAL PROCEDUREnWe used computed tomography with three-dimensional reconstruction to identify renal arterial anatomy and its relationship to the tumour. Then, RAPN was performed with selective clamping and demonstration of a nonperfused segment of kidney (occlusion angiography) using intraoperative CEUS.nnnOUTCOME MEASUREMENTS AND STATISTICAL ANALYSISnWe prospectively collected data on baseline, perioperative, and postoperative parameters.nnnRESULTS AND LIMITATIONSnWe describe the effects seen on ultrasound contrast administration. Contrast flare is seen in the segment of the kidney that is perfused. When selective clamping is performed, a watershed (line of demarcation) between the perfused and nonperfused segments of the kidney is clearly seen, allowing excision of the tumour in a relatively avascular plane and ensuring an adequate oncologic margin, when feasible. The mean age was 68.2 yr of age (range: 36-85), and the mean tumour size was 29.6mm (range: 20-42). The mean intraparenchymal extension of the tumour was 22.6mm (range: 12-30). Three tumours were located on the right kidney and two on the left. The mean blood loss was 420ml (range: 200-1000). The histology revealed clear cell RCC in two patients, oncocytoma in two patients, and type 1 papillary RCC in one patient. All the surgical specimens had negative surgical margins. The mean decrease in glomerular filtration rate was 8.4ml (range: 0-24). The mean follow-up was 6.4 mo (range: 5-8), with no evidence of recurrence in any patient. The only limitation in adopting this technique is the need for an intraoperative ultrasound probe with a CEUS mode. However, most specialists who perform minimally invasive surgery for small renal tumours believe that intraoperative ultrasound scan imaging is essential to achieving adequate resection margins.nnnCONCLUSIONSnIntraoperative CEUS can be a useful adjunct in determining whether zero-ischaemia RAPN is feasible by delineating the area of nonperfusion. This technique has several advantages over the currently available techniques, such as indigo carmine green and Doppler probes.

LOW-COST TELEMEDICINE

Telemedicine has become an integral and multi-faceted part of current medical practice. Real-time video and information transfer offers the ability to interact with colleagues and patients at remote sites and has been used since the 1970s [1]. Many cross-site specialist multidisciplinary team meetings in the UK employ this technology, allowing expertise to be available more widely and helping to balance out disparities in access and quality of care and hopefully to improve outcomes.

Self-Introduction of Foreign Body into Urinary Bladder

A 142-cm knotted electric cable was removed cystoscopically from a 12-year-old girl. Psychiatric evaluation revealed normal childhood curiosity and inquisitiveness and no pathological mental process. Both a urologist and a psychiatrist need to be involved in the management of such patients.

Incisional hernia around the suprapubic catheter: an unusual complication

Hernia through the suprapubic catheterization (SPC) site is rare. Attention is required for such hernias as they get obstructed due to the narrow neck. We report this rare presentation in an elderly gentleman with obstructed incisional hernia through the SPC site, which was reduced and subsequently had a successful mesh repair.

Role of i.v. urography in patients with haematuria.

Objective: Traditionally, patients presenting with haematuria undergo a series of investigations, including urine cytology, cystoscopy, i.v. urography (IVU) and renal tract ultrasound (US). Studies have suggested that the omission of IVU as a routine investigation for painless haematuria does not dramatically reduce the detection rate of malignant conditions. In this large retrospective study we evaluated the impact of the omission of IVU on the diagnosis of renal tract malignancies and other non‐malignant but significant conditions. Material and Methods: A retrospective analysis of all patients attending our haematuria clinic between January 2000 and August 2002 was carried out. The diagnostic yields of IVU and a US scan were compared and the significance of abnormalities missed by either modality was assessed with regard to the overall management of patients. Diagnoses were divided into those that were significant and potentially harmful [e.g. tumour, pelvi‐ureteric junction (PUJ) obstruction, hydronephrosis] and those that were insignificant and harmless (e.g. simple cyst, non‐obstructing calculus). Liddells exact test for matched pairs was used to test for statistical significance and to give the relative risk of a positive result. Results: A total of 1211 patients were included in the study. When cytology, cystoscopy and US were normal, IVU did not detect any additional malignant pathology. Performing IVU instead of a US scan would have resulted in 74 non‐malignant conditions remaining undiagnosed. Similarly, US alone would have missed 64 non‐malignant lesions. Six non‐malignant but significant conditions, including PUJ obstruction (nu2005=u20055) and benign ureteric stricture with hydronephrosis (nu2005=u20051), were missed by US but detected by IVU. Conclusion: In this cohort of retrospectively studied patients attending a haematuria clinic, IVU could safely have been omitted without decreasing the overall detection of malignant pathologies. Nevertheless, significant non‐malignant pathologies would have remained undiagnosed. The authors suggest that US combined with a MAG III renogram could be considered as a first‐line investigation instead of IVU. This is likely to result in maximum detection of malignant and non‐malignant conditions, while reducing the radiation exposure to the patient.