P. Javle

GRADING OF BENIGN PROSTATIC OBSTRUCTION CAN PREDICT THE OUTCOME OF TRANSURETHRAL PROSTATECTOMY

PURPOSE We investigate whether urodynamic grading of benign prostatic obstruction and detrusor contractility predicts the outcome of transurethral prostatectomy. MATERIALS AND METHODS A total of 53 patients who were suitable candidates for transurethral prostatectomy completed an assessment protocol before and 3 months after surgery, which included International Prostate Symptom Score, uroflowmetry, ultrasonography (prostatic size and residual urine volume) and standard pressure flow study. The results of the pressure flow study were analyzed to grade obstruction (unequivocal, equivocal or no obstruction) and detrusor contractility (weak or normal) using our simplified pressure flow nomogram. RESULTS Analysis of the pressure flow study data demonstrated that the efficiency of detrusor contraction was weak in 6 of 27 men with unequivocal, 11 of 23 with equivocal and 2 of 3 with no obstruction. Treatment outcome was significantly better in patients with unequivocal obstruction and normal detrusor contractility. Treatment failure occurred in 80% of patients with equivocal obstruction and impaired detrusor contractility, and 100% of the unobstructed group. Urodynamic grading of obstruction and detrusor contractility predicted treatment outcome with a sensitivity of 87%, specificity 93% and positive predictive value 95%. CONCLUSIONS Urodynamic grading of benign prostatic obstruction and detrusor contractility can reliably predict treatment outcome and, therefore, enable the urologist to identify a subgroup of patients who would not benefit from surgery.

Orthotopic Neobladder versus Ileal Conduit Urinary Diversion after Cystectomy – A Quality-of-Life Based Comparison

INTRODUCTION Radical cystectomy remains the gold standard in treatment of muscle invasive bladder cancer. Evolution of pathological guidelines has empowered centres to offer orthotopic substitution (OBS) to patients undergoing radical cystectomy. We compared health-related quality of life (HRQoL) between patients who underwent OBS or ileal conduit urinary diversion (ICD) following radical cystectomy. PATIENTS AND METHODS A total of 57 patients who underwent cystectomy were assessed pre-operatively using Karnofsky performance scale (KPS). Of these, 52 patients (28 OBS and 24 ICD) who responded to a postal questionnaire consisting of SF-36 and a functional index questionnaire were included. RESULTS Median age of patients was 70 years. Pre-operative KPS scores were similar. All eight HRQoL scales were favourable in both groups. OBS patients had significantly better physical functioning. In the cohort, 42% of men with OBS and 25% of diversions could maintain an erection to varying degrees. Of the OBS patients, 85% were continent with two patients reporting reduced QoL with pad usage. Of ICD patients, 63% felt less complete and 42% were embarrassed due to the stoma, with 58% apprehensive of stomal leakage. Of OBS patients, 96% had significant relationships and a more active life-style. CONCLUSIONS In a similar age-group population, there was no significant difference in most QoL indices but body image issues persist in ICD patients. OBS patients had significantly better physical function, continuing to have a more active lifestyle. They attained urethral voiding with good continence. A detailed discussion of long-term functional outcome would engender a realistic expectation allowing better adaptation.

Is a digital rectal examination necessary in the diagnosis and clinical staging of early prostate cancer

To assess the role of a digital rectal examination (DRE) in the clinical diagnosis of prostate cancer and in predicting the pathological stage, as the diagnosis of early prostate cancer usually comprises prostate‐specific antigen (PSA) testing, a DRE and transrectal ultrasonography (TRUS)‐guided biopsies.

Defining the minimum hospital case-load to achieve optimum outcomes in radical cystectomy

To define ‘high‐’ and ‘low‐’ volume hospitals for radical cystectomy, and the minimum caseload required for a hospital to achieve optimum outcomes, as a relationship between increasing surgical case volume and improved outcomes in radical urological surgery has been suggested in recent North American studies.

Effect of peripheral biopsies in maximising early prostate cancer detection in 8-, 10- or 12-core biopsy regimens

To assess the cancer detection rate per individual core biopsy in a 12‐core protocol and develop an optimal biopsy regimen for detecting early prostate cancer.

Importance of peripheral biopsies in maximising the detection of early prostate cancer in repeat 12-core biopsy protocols

To assess cancer‐detection rates in repeat 12‐core biopsy protocols, as extended multicore prostate biopsy protocols have become standard when investigating men with a raised prostate‐specific antigen (PSA) level, but repeat prostate biopsy protocols are still developing.

The benefits of radical prostatectomy beyond cancer control in symptomatic men with prostate cancer

To evaluate lower urinary tract symptoms (LUTS) and the symptom‐associated quality of life (QoL) after radical prostatectomy.

Radical cystectomy: defining the threshold for a surgeon to achieve optimum outcomes

Background: The reorganisation of cancer services in England will result in the creation of specialist high volume cancer surgery centres. Studies have suggested a relationship between increasing surgical volume and improved outcomes in urological pelvic cancer surgery, although to date, they have pre-defined the definition of “high” and “low” volume surgeons. Aim: To derive the minimum caseload a surgeon requires to achieve optimum outcomes and to examine the effect of the operating centre size upon individual surgeon’s outcomes. Methods: All cystectomies performed for bladder cancer in England over 5 years were analysed from Hospital Episode Statistics (HES) data. Statistical analysis was undertaken to describe the relationship between each surgeon’s annual case volume and two outcome measures: in-hospital mortality rate, and hospital stay. The surgeon’s outcomes were then analysed with respect to the overall level of activity in their operating centre. Results: A total of 6308 cystectomies were performed; the mean number of surgeons performing them annually was 327 with an overall mortality rate of 5.53%. A significant inverse correlation (−0.968, p<0.01) was found between case volume and mortality rate. Applying 95% confidence interval estimation, the minimum caseload required to achieve the lowest mortality rate was eight procedures per year. Increasing caseload beyond eight operations per year did not produce a significant reduction in mortality rate. Conclusion: Analysis of HES data confirms an inverse relationship between surgeon’s caseload and mortality for radical cystectomy. A caseload of eight operations per year is associated with the lowest mortality rate.

Trends in prostate cancer incidence and survival in various socioeconomic classes: a population-based study.

Objectives: Prostate cancer is currently the commonest cancer in men of all ages in UK, but robust demographic data of its distribution in various socioeconomic classes is lacking. We aimed to analyze its incidence, mortality and survival trends in West Midlands, England, from 1986 to 2000 in terms of socioeconomic deprivation.

Site of local anaesthesia in transrectal ultrasonography-guided 12-core prostate biopsy: does it make a difference?

To prospectively compare the efficacy of bi‐basal vs bi‐apical periprostatic nerve block (PPNB) during 12‐core prostate biopsy guided by transrectal ultrasonography (TRUS), and to evaluate the pain experienced on inserting the probe compared to the biopsy procedure, as PPNB with lignocaine local anaesthesia has been used for over a decade for minimizing pain during prostatic biopsy.