P. H. Powell

Outcome of elective prostatectomy.

OBJECTIVES--To determine the symptomatic and urodynamic outcome of elective prostatectomy and to establish whether the outcome is influenced or can be predicted by preoperative urodynamic measurements. DESIGN--Prospective non-randomised study with follow up at a mean of 11 months after operation. Most men were assessed jointly by a urologist and a general practitioner. SETTING--Department of urology in a teaching hospital serving a large district population. PATIENTS--253 Men listed for elective prostatectomy because of symptoms and low urinary flow rates (less than 15 ml/s) and excluding those already on a waiting list or with acute urinary retention, clinically apparent prostatic cancer, and neurological or cerebrovascular disease; 217 (86%) were followed up. INTERVENTION--Elective prostatectomy. MAIN OUTCOME MEASURE--Classification on the basis of relief of symptoms assessed by patients and urologist and general practitioner and of symptom scores obtained by questionnaire. RESULTS--Of the 217 men followed up, 171 (79%) had a satisfactory subjective review and 155 (72%) had a satisfactory review and also low symptom scores. An unsatisfactory outcome was associated with preoperative symptoms of urge incontinence, small prostatic size and resected weight, low voiding pressures, and low urethral resistance. Preoperative maximum urinary flow rates did not predict outcome. Men with poor outcome could be classified into two groups: those with irritative symptoms who were more likely before operation to have had urge incontinence and detrusor instability and men with symptoms of poor urinary flow who were more likely before operation to have had a small prostate, low voiding pressures, and low urethral resistance. In patients in the second group flow rates or voiding pressures improved little after operation. Men with stable detrusors and either low urethral resistance or low voiding pressures were less likely to do well after prostatectomy, but despite these associations preoperative urodynamic measurements were unable to predict outcome accurately. CONCLUSIONS--Prostatectomy was satisfactory in relieving symptoms and improving urodynamic measurements in most men, but even in those with classic symptoms and low urinary flow rates a substantial minority experienced little improvement afterwards and urodynamic measurements did not accurately predict outcome in individual patients.

Treatment of Carcinoma In Situ With Intravesical Bacillus Calmette-Guerin Without Maintenance

Purpose: Data concerning the relative efficacy of intravesical bacillus Calmette-Guerin (BCG) on subgroups of carcinoma in situ of the bladder are limited. We report the outcome of primary carcinoma in situ and carcinoma in situ associated with Ta or T1 transitional cell carcinoma of the bladder treated with BCG.Materials and Methods: Between 1987 and 1997, 135 patients (median age 70 years) with biopsy proven bladder carcinoma in situ underwent a standard course of 6 BCG instillations. Patients were divided into group 1–23 patients with primary carcinoma in situ, group 2–37 with carcinoma in situ associated with Ta transitional cell carcinoma and group 3–75 with carcinoma in situ associated with T1 transitional cell carcinoma.Results: Median followup was 41 months. For groups 1 to 3, complete response rates at 3 months were 74% (17 of 23 cases), 70% (26 of 37) and 75% (56 of 75), respectively. The overall progression rates at 5 years were 20% (3 of 15 cases), 18% (4 of 22) and 49% (25 of 51). Cancer spec...

The Use of Duplex Ultrasound in the Assessment of Arterial Supply to the Penis in Vasculogenic Impotence

Impotence may be caused by arterial disease affecting the vessels supplying the corpora cavernosa. Color duplex ultrasound was used to measure the peak systolic velocity and systolic rise time in the deep penile arteries in 22 impotent men following papaverine stimulation. The results were compared with the findings of selective internal pudendal pharmaco-arteriography. A further comparison was made using color duplex ultrasound with 37 impotent men who all responded well to papaverine. A systolic rise time of 110 msec. or more was found to be the best discriminant of disease in the arteries supplying the corpora giving a positive predictive value of 0.92. A long systolic rise time in a papaverine responder may indicate that the arterial supply is borderline or that the arterial flow is maximal and that the problem lies on the sinusoidal-venous side. It appears that in the absence of a pathological condition there is a large surplus arterial supply.

Pan-urethral warts as a cause of acute retention of urine

torily. He has now been on 6-monthly surveillance for Case report 3 years. When recurrence was evident, a further course (four doses at weekly intervals) of self-administered 5-FU A 41-year-old man presented with a 3-day history of diBculty in micturition. His medical history included was prescribed. He is currently asymptomatic with no voiding diBculties. immunosuppression therapy (cyclosporin, prednisolone and azathioprine) for a transplanted kidney, and diathermy of penile warts. A physical examination suggested acute retention of urine; the penile warts on the Comment glans penis did not involve the urethral meatus. Urethral catheterization drained >400 mL of urine and cystoUrethral warts usually aCect the skin or external meatus, less commonly aCecting the distal penile urethra where urethroscopy on the following day showed extensive warty lesions extending from the urethra to the bladder they are associated with dysuria, urethral bleeding and infection [1]. Those aCecting the anterior urethra are neck (Fig. 1). Biopsy of the lesions revealed no evidence of dysplasia and supported a diagnosis of condyloma usually single and rarely multiple. Extensive urethral warts presenting as acute retention of urine has not acuminata. 5-Fluorouracil (5-FU) cream (6–8 mL of 5%) was injected into the urethra and milked proximally, been described previously. Immunosuppressed and immunocompromised individuals are at risk of followed by the application of a penile clamp for 5 min. A urethral catheter was replaced at the end of the developing extensive urethral warts. With better survival in these groups of patients, urethral warts may be procedure and removed within 24–48 h. This treatment was repeated three times once a week and then patches encountered more often in urological practice. Topical 5-FU is the treatment of choice [2], but may need to be of residual warts were removed by cystodiathermy using the diathermy electrode. There was a marked improverepeated and additional treatment with cystodiathermy may be necessary. ment (Fig. 2) and the patient managed to void satisfac-

Treatment of carcinoma in situ with intravesical bacillus calmette-guerin without maintenance.1: J Urol 2002;167:2408–12.

PURPOSE Data concerning the relative efficacy of intravesical bacillus Calmette-Guerin (BCG) on subgroups of carcinoma in situ of the bladder are limited. We report the outcome of primary carcinoma in situ and carcinoma in situ associated with Ta or T1 transitional cell carcinoma of the bladder treated with BCG. MATERIALS AND METHODS Between 1987 and 1997, 135 patients (median age 70 years) with biopsy proven bladder carcinoma in situ underwent a standard course of 6 BCG instillations. Patients were divided into group 1-23 patients with primary carcinoma in situ, group 2-37 with carcinoma in situ associated with Ta transitional cell carcinoma and group 3-75 with carcinoma in situ associated with T1 transitional cell carcinoma. RESULTS Median followup was 41 months. For groups 1 to 3, complete response rates at 3 months were 74% (17 of 23 cases), 70% (26 of 37) and 75% (56 of 75), respectively. The overall progression rates at 5 years were 20% (3 of 15 cases), 18% (4 of 22) and 49% (25 of 51). Cancer specific survival rates were 83% (10 of 12 patients), 86% (12 of 14) and 59% (17 of 29), and the numbers of patients alive with the bladder intact were 60% (9 of 15), 58% (11 of 19) and 30% (12 of 40). Patients in group 3 treated with BCG had progression significantly earlier than those in groups 1 and 2 (log-rank test p = 0.013). A complete response to BCG in group 3 patients significantly delayed time to progression (Cox regression p = 0.001) but did not reduce death from transitional cell carcinoma. Indeed, only 38% (8 of 21) of complete responders were alive with the bladder intact at 5 years. CONCLUSIONS A single course of BCG is remarkably effective for primary carcinoma in situ and carcinoma in situ associated with Ta transitional cell carcinoma but is suboptimal in patients with carcinoma in situ associated with T1 transitional cell carcinoma. Better outcomes in each of the 3 groups may have occurred with maintenance BCG.