Patrick H. O’Reilly

Iohexol Clearance for the Determination of Glomerular Filtration Rate in Clinical Practice: Evidence for a New Gold Standard

X-ray fluorescence analysis provides a simple method of measuring glomerular filtration rate from the clearance of ordinary unlabeled radiographic contrast media. To measure the accuracy of iohexol clearance using a clinically simple 2-sample single injection technique, a comparison was made in 30 patients with classical continuous infusion techniques for plasma (y = 1.03x - 0.015, r = 0.981) and renal (y = 0.950x + 7.26, r = 0.964) iohexol clearance. A comparison was made with classical inulin clearance. The renal clearance of iohexol and inulin was virtually identical (y = 0.998x + 2.31, r = 0.986). Single injection iohexol clearance agreed closely with the renal inulin clearance (y = 0.947x + 4.92, r = 0.983) as did clearance based on a single 3-hour sample (y = 0.875x + 12.63, r = 0.962). Iohexol clearance using x-ray fluorescence is a simple, rapid and accurate alternative to inulin clearance for clinical and research purposes.

Functional Outcome of Pyeloplasty for Ureteropelvic Junction Obstruction: Prospective Study in 30 Consecutive Cases

In a prospective study of 50 consecutive patients with urographic renal pelvic dilatation, 30 with genuine ureteropelvic junction obstruction identified by 123iodine-hippurate diuretic renal scanning (renography) were treated by dismembered pyeloplasty. One patient with reduced preoperative function required secondary nephrectomy. Three patients with normal function in solitary kidneys had unchanged postoperative function. In the remaining 26 patients preoperative function measured by diuretic renal scanning was compared to 6-month postoperative values. If split function changes of less than 5 per cent were considered insignificant, to allow for inherent statistical errors of renal scanning, preoperative function was decreased in 18 patients, improved postoperatively in 10 and remained the same in 8. In 8 patients preoperative function was normal and remained so postoperatively. Drainage improved in 22 of the 26 patients and was unchanged in 4. Analysis of functional change by Students t test and the Wilcoxon paired sums test showed significant improvement in mean and median function (p less than 0.001), with the degree of improvement being greatest in patients with the most severely depressed preoperative levels. In addition to producing significant improvement in drainage in ureteropelvic junction obstruction, pyeloplasty arrests functional deterioration in almost every case and improves function significantly in the majority.

Measurement of the plasma clearance of urographic contrast media for the determination of glomerular filtration rate.

Further experience with a new method to determine glomerular filtration rate is presented. The method depends on measurement by an x-ray fluorescence technique of the plasma disappearance of the injected iodine in standard nonionic radiographic contrast media used during excretory urography. The results of comparison of contrast clearance with 99m technetium-diethylenetriaminepentaacetic acid clearance in 33 cases showed excellent agreement with a correlation coefficient of 0.95. Reproducibility of the contrast clearance method was confirmed by repeated examination of 10 plasma samples at weekly intervals for 6 weeks, the results of which showed no significant differences. The contrast clearance technique for the measurement of glomerular filtration rate during excretory urography is simple, quick and accurate, and merits further development.

Diethylstilboestrol versus Bicalutamide in Hormone Refractory Prostate Carcinoma: A Prospective Randomized Trial

Objective: To compare the efficacy of diethylstilboestrol (DES) with bicalutamide in the treatment of hormone refractory prostate cancer in relation to its effect on prostate-specific antigen (PSA) and survival. Methods: Patients on LHRH analogues for prostate carcinoma with evidence of biochemical or clinical progression were randomized into one of the treatment arms (n = 58). The first group (group A, n = 26) received 1 mg of DES with 75 mg of aspirin per day in addition to the primary hormonal treatment. The second group (group B, n = 32) received bicalutamide at a dose of 50 mg/day in addition to the primary treatment. Patients were followed up every 3 months with their PSA being checked and were also monitored for any clinical progression and adverse effects as a result of treatment. Any adverse event occurring after patients were started on treatment was attributed to the drug and patients were clinically assessed at each visit. Failure of treatment was defined as a 50% or greater increase in PSA after commencing treatment. Once randomized, all patients were followed up for survival regardless of failure of second-line hormonal manipulation. Results: The mean age of the patients was 76.7 years (60–88, SD 7.4) in group A and 76 years (67–86, SD 6.9) in group B. Twelve patients in each group had metastatic disease. The median follow-up periods for both groups were 24 months (range 6–48 in group A, range 3–54 in group B). 65% of the patients in group A (17/26) and 43.5% (14/32) in group B had a fall in their PSA levels (p = 0.08, Fisher’s exact test) with 23% (6/26) and 31% (10/32) having a >50% response respectively (p = 0.34, Fisher’s exact test). Mean PSA nadir in those who responded were 20.6 ng/ml (range 1.6–59.4) and 7.41 ng/ml (range 0.1–42.6) in groups A and B respectively. The median duration of response was 9 months (3–18 months) for group A and 12 months (3–18 months) for group B. Seven patients in group A and 6 in group B experienced adverse events. Three of the 7 in the group A experienced cardiovascular related adverse effects (1 congestive cardiac failure, 1 pulmonary embolism and 1 stroke). At the end of the study period, 14 (54%) of group A patients were alive and 12 (46%) were dead. In group B, 15 (47%) were alive, 16 (50%) were dead and 1 (3%) lost to follow-up. At the completion of the study, 3 patients in each group were still on treatment. Conclusion: Low-dose DES and 50 mg of bicalutamide per day are equally effective in hormone refractory prostate carcinoma with respect to biochemical response, although DES has more severe adverse effects. This is a small sample and larger multicentre trials are needed to give us a definite conclusion.

Nephroptosis: seriously misunderstood?

Nephroptosis has been one of the most controversial and often debated urological diagnoses for more than a century. Anatomically, it is defined as a significant descent ( > 5 cm or two vertebral bodies on IVU) of the kidney as the patient moves from supine to erect [1]. The kidney might move into an abnormal position but is capable of moving back into a normal anatomical site, which differentiates it from an ectopic kidney, which would constantly remain in an abnormal position. The gross downward displacement of the kidney can give rise to symptoms either due to effects on the ureter or the renal hilar vessels.

The short‐term prostate‐specific antigen velocity before biopsy can be used to predict prostatic histology

Objectives To evaluate whether the short‐term prostate‐specific antigen (PSA) velocity before biopsy can be used to predict prostatic histology, and to assess the role of a second PSA measurement before prostate biopsy.

Bicornuate and Unicornuate Uterus Associated with Unilateral Renal Aplasia and Abnormal Solitary Kidneys: Report of 3 Cases

We present 3 cases of a genital abnormality associated with unilateral renal aplasia in which the single kidney was abnormal. Renal aplasia associated with unicornuate uterus or uterus didelphia is rare but it has been reported previously. However, except for vesicoureteral reflux the single kidney usually is normal. Modern methods of evaluating renal function and urodynamics will be helpful when abnormal kidneys are found and will avoid unnecessary surgery. It is mandatory to suspect abnormalities of the urinary tract when genital maldevelopment is encountered and vice versa.

Over expression of metallothionein predicts resistance of transitional cell carcinoma of bladder to intravesical mitomycin therapy

PURPOSE Metallothionein, a low molecular weight intracellular protein, binds mitomycin with high affinity protecting the tumor DNA. We prospectively studied the relationship of metallothionein expression in bladder transitional cell carcinoma and resistance to intravesical mitomycin. MATERIALS AND METHODS A series of 45 consecutive patients with superficial transitional cell carcinoma treated with intravesical mitomycin were studied. Resected tumor tissues were stained with metallothionein monoclonal antibody E9. Two pathologists scored staining intensity and distribution. All patients were followed with regular flexible cystoscopy. RESULTS Median patient age was 73 years (range 44 to 89). Tumor grade was 1 to 3 in 6, 33 and 6 cases, respectively. In 20 patients (44.44%) tumor recurred after mitomycin therapy. Median cytoplasmic staining scores for recurrent and nonrecurrent tumors were 5 (range 0 to 61) and 0 (0 to 14), respectively. Median nuclear staining scores for recurrent and nonrecurrent tumors were 3 (range 0 to 56) and 0 (0 to 11), respectively. Median followup of patients without recurrence was 18 months (range 12 to 36). Nuclear and cytoplasmic staining scores were significantly higher in recurrent than in nonrecurrent tumors. There was no significant relationship of metallothionein expression with tumor grade. CONCLUSIONS Over expression of metallothionein predicts the resistance of bladder transitional cell carcinoma to intravesical mitomycin therapy.

The effect of intravesical single-dose Mitomycin C in recurrent superficial bladder cancer

Objectives: This study was designed to evaluate the efficacy of the intravesical instillation of single-dose Mitomycin C post-ablation of purely recurrent tumours. Patients and methods: Two patient groups with small-volume, low-grade (1 or 2), superficial (pTa) recurrent disease were studied. Sixty-seven patients at one institution received a single intravesical dose of Mitomycin C following tumour ablation using a Holmium YAG Laser. The other institution provided a control patient group of 68 patients treated with laser ablation alone. Patients were reviewed with regular flexible cystoscopies throughout the study period. Results: The groups were matched for age and the number and grade of tumours. Recurrence rates were lower, yet not to statistical significance, in the group receiving Mitomycin C post-intervention (48% vs. 62% (p= 0.14) at 12 months and 76% vs. 82% at 24 months (p = 0.64)). The observed beneficial effect at 12 months appeared to depreciate by 24 months. There was no significant improvement in the recurrence-free interval for the Mitomycin C group (log rank test p = 0.28). Conclusions: This study has failed to demonstrate a beneficial trend for the use of single-dose of Mitomycin C after ablation of recurrent superficial bladder cancer. Further evaluation in the form of a prospective trial is indicated.

Visually directed high-intensity focused ultrasound for organ-confined prostate cancer: a proposed standard for the conduct of therapy.

The inability of patients to recall information given to them during the consent process is a well-recorded phenomenon. Not surprisingly, patients’ recall of information is best immediately after signing a consent form and deteriorates from then on [7]. The findings of Masood et al. , that patients remember so little of the detail of the process of consent, particularly when questioned some days afterwards, is not new. Poor recall some time after the process of consent has taken place does not in anyway mean that informed consent had not been obtained; it might simply be due to the capricious nature of human memory. We must be very clear about this, for misinterpretation of this study could lay us all open to the threat of suit. Many patients will simply have forgotten what they have been told, even though they acknowledge understanding during the consent consultation, arguing later that they were not informed.