Ilkka Paananen

Treatment of renal cysts with single-session percutaneous drainage and ethanol sclerotherapy: long-term outcome

OBJECTIVES To evaluate the safety, efficacy, and long-term outcome of single-session ethanol sclerotherapy for non-neoplastic renal cysts. METHODS In a prospective study, 32 patients with a simple renal cyst were treated with ultrasound-guided percutaneous aspiration, and no more than 100 mL sterile 99% ethanol was injected into the cyst. The procedure was performed under local anesthesia, and the patients were hospitalized overnight. The serum concentrations of alcohol immediately after the sclerotherapy and 1 hour later and the corresponding urine concentrations were measured. The mean follow-up period was 55 months (range 12 to 156). Control checkups were scheduled at 1, 3, 6, 9, and 12 months after the sclerotherapy. During the control visits, the patients underwent ultrasound measurement of the size of the cyst. The history concerning renal pain especially was evaluated by the urologist. The patients were asked if they did or did not have pain. The severity of pain was not evaluated. RESULTS Sclerotherapy with ethanol was performed successfully in all 32 patients with a simple renal cyst. The cyst disappeared completely in 7 patients (22%). The mean size of all cysts decreased from 7.8 cm (range 3 to 16) to 1.7 cm (range 0 to 9; P <0.0001). Before the sclerotherapy, 24 patients had symptoms due to the cyst, and 18 of these (75%) were asymptomatic after the ethanol sclerotherapy. In 2 patients the pain decreased, 2 patients were without change, and in 2 patients the pain increased. There was no correlation between the size of the cyst and the intensity of pain. No major complications occurred. The serum concentration of alcohol varied from 0 to 0.30 g/L and that in urine from 0.04 to 0.27 g/L. CONCLUSIONS Percutaneous aspiration and sclerotherapy with ethanol for simple renal cysts is simple, fast, safe, effective, and inexpensive. The results are comparable to those reported earlier. The treatment is without major complications. We propose sclerotherapy with 99% ethanol as the primary treatment of simple renal cyst. The treatment can be done in an outpatient clinic.

Increasing numbers of ureteric injuries after the introduction of laparoscopic surgery

Objective. There is an impression that ureteric injuries have become more common during the past decade, and therefore this study aimed to determine the incidence, aetiology, features, treatment and outcomes of ureteric injuries over an extended period. Material and methods. Records of patients treated for ureteric injury in 1986–2006, divided into three 7-year periods, were reviewed retrospectively. The numbers of open and laparoscopic gynaecological, surgical and endourological operations were ascertained. Results. All 72 ureteric injuries recorded were iatrogenic, being diagnosed in 60 females and 11 males (mean age 52 years). Only five injuries occurred during the first 7-year period (1986–1992), but the incidence was markedly higher during the following two 7-year periods, 28 (1993–1999) and 39 (2000–2006), respectively. The injuries were mostly secondary to gynaecological procedures (64%) or general surgery (25%). Only 11% occurred in association with a urological procedure. The cause was mostly laparoscopic (56%) or open surgery (33%), and the injury was in most cases located in the lower ureter (89%). The diagnosis was usually delayed (in 79%), with a median time to diagnosis of 6 days. The injuries were managed by ureteroneocystostomy (49%), a ureteral stent (19%) or end-to-end anastomosis (12%). The complication rate was 36%. Conclusions. Iatrogenic ureteric injuries have increased markedly during the past two decades. Gynaecological laparoscopic procedures account for more than half of the injuries, and the most common location is the lower ureter. Most injuries are treated by ureteroneocystostomy, but endourological treatment yields acceptable results. To improve the management of ureteric injury there must be a high index of suspicion, especially during laparoscopic operations.

Evaluation of health-related quality of life in patients with painful bladder syndrome/interstitial cystitis and the impact of four treatments on it

Objective. Painful bladder syndrome/interstitial cystitis (PBS/IC) is an inflammatory bladder disease of unknown origin. Symptoms of PBS/IC compromise patients’ quality of life (QoL). This study evaluated a health-related quality of life (HRQoL) questionnaire in PBS/IC. Material and methods. 151 patients with PBS/IC filled in the HRQoL questionnaire before and after the treatment. Of these, 87 patients participated in a 3-month randomized study testing intravesical dimethyl sulfoxide (DMSO) and bacille Calmette–Guérin (BCG) and 64 patients took part in a 6-month randomized study evaluating oral cyclosporine A (CyA) and pentosan polysulfate sodium (PPS). The changes in HRQoL questionnaire were evaluated with respect to the changes in global response assessment (GRA). Results. The results of the HRQoL questionnaire reflected well the post-treatment GRA. Patients responding to their treatment had improved QoL. CyA treatment had more impact on emotional well-being, social functioning, activity limitation days, pain and physical capacity than PPS treatment (p<0.05). More patients responded to DMSO than BCG treatment according to GRA (p<0.01), but the results in HRQoL questionnaire were equal after DMSO and BCG treatments. Conclusions. The HRQoL questionnaire can be used in evaluating QoL in PBS/IC patients. Treatment of PBS/IC had obvious effects on QoL.

The rationale behind recommendations for follow-up after urinary diversion: An evidence-based approach

Departments of Urology, Haukeland University Hospital, Bergen, Norway, Aarhus University Hospital, Skejby Sygehus, Aarhus, Denmark, Sahlgrenska University Hospital, Göteborg, Sweden, Landspitali University Hospital, Reykjavik, Iceland, University Hospital, Lund University, Lund, Sweden, Oulu University Hospital, Oulu, Finland, Rikshospitalet University Hospital, Oslo, Norway, State University Hospital, Copenhagen, Denmark, and Kuopio University Hospital, Kuopio, Finland

Retrospective Analysis of Long-Term Outcomes of 64 Patients Treated by Endopyelotomy in Two Low-Volume Hospitals: Good and Durable Results

BACKGROUND AND PURPOSE Endopyelotomy is an option for the management of ureteropelvic junction (UPJ) obstruction, but long-term outcome data are lacking. The purpose of this study was to evaluate the long-term outcome of endopyelotomy. PATIENTS AND METHODS We retrospectively collected data from all endopyelotomies performed in two low-volume hospitals in Finland between 1987 and 2007. The diagnosis was based primarily on urography results. We also conducted a patient survey during the fall of 2007 for the subjective outcome of the operation. There were 18, 17, and 29 patients with a mean follow-up time 152.2, 67.1, and 77.6 months treated by percutaneous antegrade endopyelotomy, Acucise endopyelotomy, and retrograde endopyelotomy, respectively. RESULTS Reoperation for recurrent UPJ obstruction was required for 0, 1 (6%) and 5 (17%) of the patients, the radiographic outcome of the operation was better in 17 (94%), 13 (76%), and 18 (62%) of the patients, and 0, 2 (12%), and 5 (17%) of the patients experienced no relief in pain after percutaneous antegrade endopyelotomy, Acucise endopyelotomy, and retrograde endopyelotomy, respectively. Complications necessitating intervention were recorded for 7 (38.9%), 4 (23.5%), and 4 (13.8%) patients after antegrade endopyelotomy, Acucise endopyelotomy, and retrograde endopyelotomy, respectively. According to the patient survey, 15 (100%), 11 (73%), and 19 (86%) of the respondents were satisfied with the results of the operation after antegrade endopyelotomy, Acucise endopyelotomy, and retrograde endopyelotomy, respectively. The patients were mainly monitored by radiologic examinations, not by renography. CONCLUSIONS Endopyelotomy offers good and durable results in the long-term. Complications were common, however, and laparoscopic pyeloplasty may be a recommended option for management of primary UPJ obstruction.

Functional results after orthotopic bladder substitution: a prospective multicentre study comparing four types of neobladder.

Abstract Objective. The aim of this study was to evaluate enterocystometry, voiding pattern and urine leakage of four types of orthotopic bladder substitute. Material and methods. At eight urological departments, 78 consecutive men were studied: 66 with an ileal neobladder [30 Studer pouches (S), 24 Hautmann pouches (H) and 12 T-pouches (T)] and 12 with a right colonic [Goldwasser type (G)] neobladder. Enterocystometry, determination of residual urine, micturition protocol and 24 h pad weight test were performed 6 and 12 months postoperatively. Results. Colonic neobladders had higher pouch pressure at first desire, normal desire and strong desire than ileal neobladders (except at first and normal desire at 12 months) (p < 0.02) and contraction was present more often at both 6 and 12 months (p < 0.01 and p < 0.01). Compliance was good in all types of pouch. Intermittent self-catheterization was more common in H patients at 6 months (p = 0.033). All patients with colonic neobladders used pads during the day and night. In patients with ileal pouches 32% used pads during the day and 70% during the night at 12 months. Urine leakage was higher in patients with colonic bladders at 6 and 12 months during the day (mean/median of 98/31 ml and 82/16 ml versus 10/0 ml and 4/0 ml, p < 0.001). T-pouches had excellent day-time continence, but nocturnal leakage was high. Conclusions. The Hautmann pouch and the Studer pouch behaved similarly at enterocystometry and clinically, and continence was good in the majority of patients. The low number of patients with the other two types of pouch precludes definitive statements.

Changing trends in symptomatology, diagnostics, stage and survival of prostate cancer in Northern Finland during a period of 20 years

BackgroundProstate cancer is the most common cancer among men in many countries. The aim of the present study was to find out how the symptoms leading to a diagnosis, diagnostic procedures and stages of the disease among prostate cancer patients have changed over a period of 20 years.MethodsThis retrospective chart review consisted of 421 prostate cancer patients whose treatment was started in the years 1982, 1987, 1992, 1997 and 2002 at the Oulu University Hospital. Earlier prostatic disorders, specific urological symptoms, diagnostic procedures, the TNM classification and histological grade were recorded.ResultsThe number of symptom-free prostate cancer patients increased over the 20 years, as did the number of men suffering from chronic prostatitis, although the latter increase was not statistically significant. A drop in the number of clinical T4 cases and increase of clinical T1 and clinical T2 cases was recorded but no clear change in the histological distribution occurred. The 5-year prostate cancer-specific survival improved significantly over the 20 years. The urologist was found to be the person who was contacted first most often.ConclusionsOur data indicate that the number of prostate cancer patients has increased hugely over the period from 1982 to 2002 and although the clinical T stage has moved towards earlier stages, the proportion of well differentiated cancers remains low, so that most patients have clinically significant cancer with the need of some form of therapy. Further, prostate cancer-specific survival improved significantly over the period.

Initiation of robot-assisted radical prostatectomies in Finland: Impact on centralization and quality of care

Abstract Objective The aim of this study was to analyze the impact of introduction of robot-assisted prostate surgery and its quality measures in Finland from 2008 to 2012. Materials and methods Registry data were collected for time trends and national distribution of prostate cancer surgery in Finland, while preoperative, operative and follow-up data were collected for quality measures. Results The number and proportion of robot-assisted laparoscopic radical prostatectomies (RALPs) increased rapidly and they accounted for 68% of all radical prostatectomies in 2012. The number of centers performing prostatectomies diminished from 25 to 20 at the expense of low-volume centers. In total, 1996 patients were operated on in the four RALP centers in 2008–2012. As anticipated, the learning curve was uniform between the centers, as were mean blood loss (212 ml), hospitalization (1.8 days) and catheterization times (10.6 days). At 3 and 12 months, 49.4% and 71.2% of patients, respectively, were totally continent (no pads). After unilateral nerve-sparing surgery, 9.9% and 5.1% had partial or normal erection at 3 months postoperatively and 14.8% and 20.4% at 12 months, respectively. If bilateral nerve sparing was done, the figures were 13.0% and 13.5% at 3 months and 14.6% and 34.9% at 12 months. Clavien–Dindo grade 3, 4 or 5 complications were seen in 0.3%, 0.3% and 0.1% of patients, respectively. Limitations of the study include non-standardized collection of outcome parameters. Conclusions This report shows that the main impact of adoption of RALP on a national level was rapid spontaneous centralization of prostate cancer surgery. The main advantages of minimally invasive prostatectomy, i.e. low blood loss and short hospitalization, are easily achieved, while continuous effort is necessary for improvements in surgical outcomes.