V. Mishra

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.

Sacral neurostimulation for urinary retention: 10‐year experience from one UK centre

To report our 10‐year experience of sacral neurostimulation (SNS) for women in urinary retention, comparing the original one‐stage with the newer two‐stage technique, as SNS therapy is a well‐established treatment for urinary retention secondary to urethral sphincter overactivity (Fowler’s syndrome).

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.

Voiding dysfunction after tension-free vaginal tape: a conservative approach is often successful

The published literature has focused mainly on the efficacy of tension-free vaginal tape (TVT) in correcting stress incontinence with few reports of complications. We report our experience with the first 52 cases of TVT, specifically assessing voiding dysfunction after the procedure. We carried out a retrospective study of patients undergoing TVT surgery for stress urinary incontinence (SUI) between April 2001 and July 2003. Data were collected on period of catheterization, voiding and storage symptoms, their duration and management. Fifty-two women with a mean age 54xa0years (36–77) were included. Postoperatively, the urethral catheter was removed routinely within 12xa0h. Twelve patients (23%) failed to void spontaneously and needed recatheterization. Ten of them (83%) were able to resume spontaneous voiding within 3xa0months. Twenty patients (38%) complained of storage symptoms postoperatively. Sixteen (80%) responded to conservative treatment. Transient urinary symptoms after TVT sling for SUI are common but can usually be managed conservatively.

Role of repeated prostatic massage in chronic prostatitis: a systematic review of the literature.

r w s N m i m rostatitis is a significant health problem, with a prevalence of 11%-16%. This results in more than 2 million office visits per year in the United tates and each Canadian urologist seeing an average of 62 prostatitis patients every year. Up to 50% of men ay be affected by it at some stage in their life, and for ndividual patients, the negative impact on quality of life s comparable to that of active Crohn’s disease or a recent yocardial infarction. Chronic prostatitis/chronic pelvic pain syndrome is a linical syndrome characterized by pain in the perineum, elvis, suprapubic area, or the external genitalia, with a ariable degree of voiding or ejaculatory disturbance. rach et al. were the first to use a systematic approach o the diagnosis and management of patients with sympoms of prostatitis, based on the microscopic examination nd cultures of segmented urogenital tract specimens. ajor breakthroughs in the study of prostatitis were made n the 1990s, resulting in the currently used classificaion that includes acute bacterial prostatitis (type I), hronic bacterial prostatitis (type II), chronic prostatitis/ hronic pelvic pain syndrome (type III), and asymptomtic inflammatory prostatitis (type IV). Type III is further ubdivided into type IIIA (inflammatory) and type IIIB noninflammatory). A validated outcome measure has been eveloped in the form of the National Institutes of Health hronic Prostatitis Symptom Index (NIH-CPSI). This is n internationally accepted tool, used in standard clinical ractice, which has been recommended as the “gold tandard” outcome measure for future research. A myriad of etiopathologic mechanisms for chronic rostatitis—some not even involving the prostate land— have been postulated, ranging from infections, ysfunctional voiding, intraductal reflux, and chemical nflammation to autoimmunity and neuromuscular disurbances. The response to the often empiric convenional multipronged treatment strategy is uncertain, re-

Chronic prostatitis: Current concepts

Purpose: Chronic prostatitis (CP) is a common condition. It causes significant suffering to the patients and constitutes a sizeable workload for the urologists. The purpose of this review is to describe the currently accepted concepts regarding the aspects of CP. Materials and Methods: Relevant papers on the epidemiology, etiology, diagnosis, evaluation and management of CP were identified through a search of MEDLINE using text terms “prostatitis”, “chronic prostatitis” and “chronic pelvic pain syndrome”. The list of articles thus obtained was supplemented by manual search of bibliographies of the identified articles and also by exploring the MEDLINE option “Related Articles”. Results: The salient points of the relevant articles on each aspect of CP have been summarized in the form of a non-systematic narrative review. Conclusion: Chronic prostatitis is caused by a variety of infective and non-infective factors and is characterized by a rather long remitting and relapsing clinical course. The diagnosis is based on symptoms comprising pain and nonspecific urinary and/or ejaculatory disturbances and microbiological tests to localize bacteria and/or leucocytes in segmented urinary tract specimens. The contemporary classification was proposed by the National Institutes of Health/National Institute of Diabetes Digestive Kidney Diseases (NIH/NIDDK). National Institutes of Health - Chronic Prostatitis Symptom Index (NIH-CPSI) is the patient evaluation tool used extensively in clinical practice and research. Management should be individualized, multimodal and of an appropriate duration.

Ureteric Obstruction Caused by Pelvic Actinomycosis

Ureteric obstruction is a well-known complication of actinomycosis, however its management in previous case reports has been very variable and sometimes mutilating. We report a rare case presenting with ischiorectal abscess that was successfully treated by JJ stenting and penicillin.

Role of i.v. urography in patients with haematuria.

Objective: Traditionally, patients presenting with haematuria undergo a series of investigations, including urine cytology, cystoscopy, i.v. urography (IVU) and renal tract ultrasound (US). Studies have suggested that the omission of IVU as a routine investigation for painless haematuria does not dramatically reduce the detection rate of malignant conditions. In this large retrospective study we evaluated the impact of the omission of IVU on the diagnosis of renal tract malignancies and other non‐malignant but significant conditions. Material and Methods: A retrospective analysis of all patients attending our haematuria clinic between January 2000 and August 2002 was carried out. The diagnostic yields of IVU and a US scan were compared and the significance of abnormalities missed by either modality was assessed with regard to the overall management of patients. Diagnoses were divided into those that were significant and potentially harmful [e.g. tumour, pelvi‐ureteric junction (PUJ) obstruction, hydronephrosis] and those that were insignificant and harmless (e.g. simple cyst, non‐obstructing calculus). Liddells exact test for matched pairs was used to test for statistical significance and to give the relative risk of a positive result. Results: A total of 1211 patients were included in the study. When cytology, cystoscopy and US were normal, IVU did not detect any additional malignant pathology. Performing IVU instead of a US scan would have resulted in 74 non‐malignant conditions remaining undiagnosed. Similarly, US alone would have missed 64 non‐malignant lesions. Six non‐malignant but significant conditions, including PUJ obstruction (nu2005=u20055) and benign ureteric stricture with hydronephrosis (nu2005=u20051), were missed by US but detected by IVU. Conclusion: In this cohort of retrospectively studied patients attending a haematuria clinic, IVU could safely have been omitted without decreasing the overall detection of malignant pathologies. Nevertheless, significant non‐malignant pathologies would have remained undiagnosed. The authors suggest that US combined with a MAG III renogram could be considered as a first‐line investigation instead of IVU. This is likely to result in maximum detection of malignant and non‐malignant conditions, while reducing the radiation exposure to the patient.

Extra-anatomical complications of antegrade double-J insertion.

Introduction: Insertion of a double-J (JJ) stent is a common procedure often carried out in the retrograde route by the urologists and the antegrade route by the radiologists. Reported complications include stent migration, encrustation, and fracture. Extra-anatomic placement of an antegrade JJ stent is a rare but infrequently recognized complication. Materials and Methods: We performed a retrospective audit of 165 antegrade JJ stent insertions performed over three consecutive years by a single interventional radiologist. All renal units were hydronephrotic at the time of nephrostomy. All procedures were performed under local anaesthetic with antibiotic prophylaxis. Results: Antegrade stent insertion was carried out simultaneously at the time of nephrostomy in 55 of the 165 cases (33%). The remainder were inserted at a mean of 2 weeks following decompression. In five (3%) patients, who had delayed antegrade stenting following nephrostomy, the procedure was complicated by silent ureteric perforation and an extra-anatomic placement of the stent. These complications had delayed manifestations, which included two retroperitoneal abscesses, a pelvic urinoma, a case each of ureterorectal fistula, and ureterovaginal fistula. Risk factors for ureteric perforation include previous pelvic malignancy, pelvic surgery, pelvic radiation, and a history of ureteric manipulation. Conclusion: Antegrade ureteric JJ stenting is a procedure not without complications. Extra-anatomic placement of the antegrade stent is a hitherto the infrequently reported complication but needs a high index of suspicion to be diagnosed. Risk factors for ureteric perforation at the time of stent insertion have to be considered to prevent this potential complication.

Primary localized amyloidosis of the ureter with osseous metaplasia

An 83-year-old man presented with a brief history of right loin pain, frequency and urgency of urination, and microscopic haematuria. Ultrasonography showed a hydronephrotic right kidney, which on a subsequent IVU was not excretory. The left kidney on imaging was normal and there were no malignant cells on urine cytology. A right retrograde ureterogram showed a complete block in the mid-ureter. On ureteroscopy an impacted ureteric calculus was found which did not fragment with electrohydraulic lithotripsy. Subsequently the patient underwent right nephrostomy and antegrade ureterography, which showed a filling defect with an ‘apple core’ appearance in the mid-ureter (Fig. l). CT showed a densely calcified lesion in the right ureter and a MAG3 scan confirmed a non-functioning right kidney. The diagnosis was of ureteric TCC with calcification. At operation a 2-cm calcified mid-ureteric lesion was found and a right nephroureterectomy with removal of a cuff of bladder was carried out. Histology confirmed amyloidosis of the ureter with the presence of eosinophilic material and osseous metaplasia at the periphery of the lesion (Fig. 2). Immunohistochemical staining showed AA type amyloid fibrils consistent with a diagnosis of primary amyloidosis.