O. Karim

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.

Trans-rectal ultrasound guided biopsy of the prostate: nationwide diversity in practice and training in the United Kingdom.

Introduction: TRUS-guided needle biopsy of the prostate is the standard technique in the diagnosis of prostate cancer. However the practice is highly variable across the United Kingdom. We survey the standard approaches to TRUS biopsy of prostate, highlighting the nationwide diversity of practice and training. Methods: One hundred and eighty questionnaires were sent out to specialist registrars, investigating the number of prostate biopsy cores taken, the use of prophylactic antibiotics, rectal preparation and local analgesia in TRUS biopsy of the prostate. One hundred and fourteen trainees (63%) returned the questionnaires. Twenty-three percent reported sextant biopsy as standard, 36% taking eight-core and 26% taking 10 or more cores. There is no standard regime for antibiotic prophylaxis. Eighteen percent also reported rectal preparation as routine. Thirty-eight percent of the patients receive local anaesthesia prior to the biopsy. Overall, 42% of the TRUS biopsies are carried out by urologists, 29% by radiologists and 21% by both. Six percents have nurse practitioners’ involvement. Fifty-six percent of trainees are involve in the TRUS biopsy, 68% do not think they received enough training to carry out the procedure. Conclusions: TRUS-guided needle biopsy of the prostate is the standard technique in the diagnosis of prostate cancer. Our survey highlights nationwide diversity in practice in the UK with respect of the number of cores taken, antibiotic prophylaxis and local anaesthesia utilisation. This raised the issue of standardising the practice. More urologists are also actively taking part in this procedure, making the structured training increasingly important.

Safety and detailed patterns of morbidity of transrectal ultrasound guided needle biopsy of prostate in a urologist-led unit

Objective: We prospectively evaluate the safety, morbidity and characteristics of complications for transrectal ultrasound guided needle biopsy of prostate carried out solely by urologists in a single unit. This will help to counsel patient prior to the biopsy. Patients and methods: One hundred consecutive patients were recruited to complete questionnaires prospectively, 2 weeks and 3 months after TRUS and prostate biopsy. Haematospermia, haematuria and rectal bleeding characteristics were evaluated. Pain, analgesia requirement, infection and urinary retention rates were also assessed. Results: Ninety-two patients (92%) returned questionnaires 2 weeks and 63 patients (63%) three months after the biopsy. At 2 weeks questionnaire, 58 patients (63%) experienced haematuria and 9 patients (10%) for more than 1 week. Eighty-five percent of the 58 patients who had haematuria described it as mild and intermittent. Twenty-three (25%) patients experienced a rectal bleed and none for more than four days. Only 1 patient experienced clots with the rectal bleeding. Twelve (13%) patients had difficulty passing urine but the symptoms resolved by day four. Acute urinary retention did not occur. Thirty-five (38%) patients had some degree of discomfort and only one patient had pain for more than three days. Twenty-five (27%) patients took analgesia between 1 and 8 days (Mean 3 days). Two patients had a urinary tract infection despite prophylactic antibiotics. At three months, 4 patients (6%) had experienced secondary haematuria 3 weeks after the biopsy. Two patients experienced more rectal bleeding 2 weeks after the biopsy and 1 patient had residual discomfort 2 weeks after the procedure. Thirteen patients (21%) had haematospermia between day 6 and 56 (Mean 21 days). Conclusions: Transrectal ultrasound guided biopsy of the prostate is generally well tolerated with minor pain and morbidity in our urologist-led service. Our data will assist counselling of patients prior to the procedure.

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

BACKGROUND Recent 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. OBJECTIVE To describe a novel technique of occlusion angiography using intraoperative contrast-enhanced ultrasound scan (CEUS) for zero-ischaemia robot-assisted PN (RAPN). DESIGN, SETTING, AND PARTICIPANTS We used a prospective cohort evaluation of five patients who had imaging suspicious of renal cell carcinoma (RCC) treated at a single centre. SURGICAL PROCEDURE We 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. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We prospectively collected data on baseline, perioperative, and postoperative parameters. RESULTS AND LIMITATIONS We 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. CONCLUSIONS Intraoperative 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.

Role of intra-operative contrast-enhanced ultrasound (CEUS) in robotic-assisted nephron-sparing surgery

This review examines studies of intra-operative contrast-enhanced ultrasound (CEUS) and its emerging role and advantages in robotic-assisted nephron-sparing surgery. Contrast-enhanced ultrasound is a technology that combines the use of second-generation contrast agents consisting of microbubbles with existent ultrasound techniques. Until now, this novel technology has aided surgeons with procedures involving the liver. However, with recent advances in the CEUS technique and the introduction of robotics in nephron-sparing surgery, CEUS has proven to be efficacious in answering several clinical questions with respect to the kidneys. In addition, the introduction of the microbubble-based contrast agents has increased the image quality and signal uptake by the ultrasound probe. This has led to better, enhanced scanning of the macro and microvasculature of the kidneys, making CEUS a powerful diagnostic modality. This imaging method is capable of further lowering the learning curve and warm ischemia time (WIT) during robotic-assisted nephron-sparing surgery, with its increased level of capillary perfusion and imaging. CEUS has the potential to increase the sensitivity and specificity of intra-operative images, and can significantly improve the outcome of robotic-assisted nephron-sparing surgery by increasing the precision and diagnostic insight of the surgeon. The purpose of this article is to review the practical and potential uses of CEUS as an intra-operative imaging technique during robotic-assisted nephron-sparing surgery.

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.

Cutaneous myiasis of Cordylobia anthropophaga.

We report on a case of glans penis cutaneous myiasis with Cordylobia anthropophaga acquired from Somalia. The mode of transmission and preventative measures are discussed.