Teuvo Tammela

Postoperative Urinary Retention: I. Incidence and Predisposing Factors

198 (3.8% comprising 4.7% of the males and 2.9% of the females) out of 5220 surgical patients developed total urinary retention postoperatively. The frequency of this condition increased with age and was highest after thoracotomies and endoprosthetic surgery of the hip joints. Voiding history was abnormal in 80% of the patients affected. Subclinical obstructive bladder dysfunction, over-distension of the bladder during the operation and in the recovery room after the operation, sympathomimetic and anticholinergic medication during or after anaesthesia, and an inability to stand or sit after surgery were common causes of retention. Premedication, type of anaesthesia, nature of the liquids given and postoperative analgetics seemed not to affect the incidence of retention. Postoperative urinary retention is an underestimated and mostly avoidable complication. Every patient should be asked for a urinary history before an elective operation. Infravesical obstruction should be relieved before any other elective surgical procedures are undertaken. In cases of emergency surgery prophylactic catheterization to prevent postoperative retention is recommended for patients with obstructive symptoms.

Postoperative urinary retention. II. Micturition problems after the first catheterization.

198 out of 5220 surgical patients were catheterized because of unexpected postoperative urinary retention. In 39% of cases micturition succeeded after the first catheterization of the overdistended bladder, but 61% (58% of the males and 66% of the females) developed more copolicated voided problems. The volume of fluids given intravenously during anaesthesia, the volume of primary urinary retention and increasing age were predisposing factors for prolonged micturition difficulties. Hospitalization was protracted because of postoperative urinary retention in 21 patients, and for 20 males prostatic surgery was necessary to relieve persistent retention.

Urodynamic Effects of Finasteride in the Treatment of Bladder Outlet Obstruction due to Benign Prostatic Hyperplasia

Urodynamic effects of the 5-alpha-reductase inhibitor, finasteride, were studied in the treatment of patients with bladder outlet obstruction due to benign prostatic hyperplasia (BPH). A total of 36 patients was randomly assigned in a double-bind manner to receive either 5 mg. finasteride daily (19) or placebo (17) for 6 months. The possible relief of bladder outlet obstruction was monitored with uroflowmetry and repeated urodynamics. The mean flow rate, detrusor opening pressure, detrusor pressure at maximum flow and maximum detrusor pressure improved significantly in the patients treated with finasteride. There were no significant differences in the improvement of symptom score or peak flow rate, or in the reduction of residual urine between the finasteride and placebo groups. The treatment resulted in 30% average decrease in prostatic size and 46% decrease in prostate specific antigen concentration. The efficacy of finasteride in relief of bladder outlet obstruction caused by BPH seems to be of the same degree as that achieved by chemical castration therapy but without any significant side effects. There were wide variations among BPH patient response to finasteride treatment. Further studies are needed to define the responders who benefit from this treatment.

P53 Accumulation, Deoxyribonucleic Acid Ploidy and Progression of Bladder Cancer

PURPOSE The alterations in deoxyribonucleic acid (DNA) ploidy and p53 expression during progression of bladder cancer were determined. MATERIALS AND METHODS p53 Expression and DNA ploidy were studied in 51 patients with transitional cell carcinoma of the bladder (mean followup 5 years). Of 29 primarily superficial tumors (stages Ta and T1) 17 became subsequently invasive (greater than stage T2) within an average of 4 years (group 2) and 12 recurred superficially with no sign of progression during a mean followup of 10.8 years (group 1). Of the patients 22 had metastatic disease (group 3). Samples of tumors at diagnosis and recurrence or progression were analyzed by immunohistochemistry and flow cytometry. RESULTS p53 Accumulation was detected at diagnosis in 29 of the 51 patients (57%), including 3 of 12 (25%) in group 1, 5 of 17 (29%) in group 2 and 14 of 22 (64%) in group 3. The p values for the differences between groups 1 and 3, and 2 and 3 were 0.07 and 0.054, respectively. Abnormal DNA contents were noted in 3 of 12 (25%), 11 of 17 (65%) and 16 of 22 (73%) patients in groups 1 to 3, respectively, and the differences between groups 1 and 2, and 1 and 3 were statistically significant. Using these 2 genetic markers, we found genetic progression to be uncommon in groups 1 and 3, whereas in group 2 an initially negative p53 staining became positive at invasion into the muscle in 5 of 12 patients (42%). CONCLUSIONS The tumors in patients with superficial recurrences are mostly diploid and negative for p53, and those with metastasis are nondiploid and positive for p53 from the beginning, while further genetic progression is uncommon. However, p53 tends to accumulate frequently when the tumor begins to invade the muscle. There seems to be a need for caution against under staging an apparent stage T1 tumor that is positive for p53.

Intrascrotal adenomatoid tumors.

Adenomatoid tumors are regarded as uncommon neoplasms of the paratesticular tissues, probably of mesothelial origin. The majority of cases reported have involved the epididymis. We report our experience with 8 cases of testicular tumors and 11 of epididymal adenomatoid tumors during a 13-year period, and review the relevant literature. The incidence of adenomatoid tumors relative to all tumors in the testis was 6.9% (8 of 116), exceeding that of Leydig cell tumors, which were previously believed to be the most common benign testicular neoplasms. The adenomatoid tumors included 38% epididymal tumors (11 of 29). The clinical course of the tumors was benign, without recurrences. Local excision is regarded as the treatment of choice for epididymal and testicular adenomatoid tumors.

Colocystoplasty for the Treatment of Severe Interstitial Cystitis

Twelve patients with end-stage interstitial cystitis and intractable symptoms resistant to conservative measures underwent supratrigonal cystectomy and colocystoplasty, comprising 7 right colocystoplasties and 5 open-loop sigmoidocystoplasties. Mean follow-up was 4.7 years. Ten patients had complete relief of pain and a decrease in frequency, while 2 patients required cystectomy and urinary diversion because of persistent symptoms or infection and incontinence. Bladder function was evaluated urodynamically in 11 patients. The bladder capacities in the right colocystoplasties were between 325 and 800 ml (mean 495), compared with 180 and 500 ml (mean 345) in the sigmoideocystoplasties. Two patients suffered from mild urge incontinence. All the patients retained their sensation of bladder fullness and voided without difficulty. In only 3 cases was a procedure needed to lower the bladder outflow tract resistance. Most patients did not need long-term antibiotics. No impairment in renal function was noted. In view of the good results achieved colocystoplasty can be recommended more often for the treatment of interstitial cystitis, detubularized right colocystoplasty being the operation of choice.

Ethanolamine Oleate Sclerotherapy for Hydroceles and Spermatoceles: A Survey of 158 Patients with Ultrasound Followup

Sclerotherapy with 5% ethanolamine oleate was used to treat 102 hydroceles in 100 patients and 63 spermatoceles in 58 patients. Scrotal ultrasound examination was performed before the sclerotherapy and at each followup visit. Of the hydroceles 98% were cured completely and 68% were cured after only 1 sclerosant instillation, while 60% of the spermatoceles resolved completely and 33% partially, with 7% failures. No hydroceles recurred during an average followup of 43 months, whereas spermatocele recurred in 4 patients more than 1 year after successful treatment, with a mean followup of 46 months. Approximately half of the patients experienced pain after treatment, 3 had infection and 2 had hematoma. No changes in the structure or size of the testicles were found by ultrasound during followup. Ethanolamine oleate sclerotherapy is a safe, effective and economical form of outpatient therapy that can be recommended as primary treatment for hydroceles in adults and as an alternative to surgery for spermatoceles with 1 to 3 cysts in elderly men in whom fertility is not important.

Intravesical epirubicin with and without verapamil for the prophylaxis of superficial bladder tumours

Seventy-five patients with recurrent bladder carcinoma were randomized after electroresection to receive either epirubicin (E) or epirubicin + verapamil (E + V) instillation of the bladder at regular intervals for 2 years. Samples of the bladder wall, tumour tissue and peripheral blood were taken from 20 patients. The average follow-up period was 21 months. Fifty per cent of the patients in the E group and 37% in the E + V group developed recurrent tumours. Recurrence rates (RR) were 6.3 and 4.7, respectively. Before the instillation therapy the RR was 16.0. There was a highly significant reduction of RR during the instillation therapies; in group E p less than 0.005 and in group E + V p less than 0.001. The difference between the treatment groups was not statistically significant. Verapamil increased epirubicin concentrations in both the bladder wall and the tumour tissue, but did not affect concentrations in the peripheral blood. Side effects were few and did not lead to discontinuation of treatment.

Sarcoidosis of the Bladder: A Case Report and Literature Review

A case of bladder sarcoidosis in a woman with known systemic involvement of this disease is reported. The lesion improved and ureteral obstruction was relieved after transurethral resection and systemic corticosteroid treatment. Sarcoidosis and malacoplakia are believed to represent distinct disease processes in the bladder.

Relationship Between Blood Groups and Tumour Grade, Number, Size, Stage, Recurrence and Survival in Patients with Transitional Cell Carcinoma of the Bladder

Blood group was correlated with the tumour grade, number, size, stage and recurrence rate and with survival in 261 consecutive patients with bladder cancer analyzed at least five years after diagnosis of the disease. The distribution of blood groups did not differ from that in the general population. There were no significant differences in the incidence of invasion at the time of diagnosis or later, in the number of the tumours or in the recurrence rate. A tendency for high-grade and large-sized tumours was observed in the blood groups O(H) and B. Differences in mortality were not observed until eight years after diagnosis, so that 28% of the patients with blood group A and 40% of those with blood group O had died of bladder cancer by ten years after diagnosis. Since the differences are small, the clinical significance of blood groups as a prognostic factor in bladder cancer patients is minimal. However, there seems to be a need for further research of the significance of genetic background in the natural history of bladder cancer.