High incidence of severe urologic complications following radiotherapy for cervical cancer in Japanese women

BACKGROUND

Good results have been obtained with radiation therapy for cervical cancer, but many patients suffer radiation-induced complications of adjacent organs. Some authors have reported that about 10% of patients treated with radiotherapy experience radiation-induced complications. We have previously reported that the incidence of spontaneous rupture of the urinary bladder is high in Japan but extremely low in the United States and Europe. In this study, we examined whether incidence or type of radiation-induced complications differs between Japan and the United States and Europe.

METHODS

A retrospective study was performed to determine the incidence among Japanese women of severe complications requiring surgical intervention following radiotherapy for cervical cancer. A total of 271 patients were treated at Kobe City General Hospital using external-beam therapy from December 1981 to March 1989. In 232 external-beam therapy was combined with high-dose-rate intracavitary brachytherapy with a remotely controlled afterloading system (RALS). The incidence and type of radiation-induced complications of the urinary tract, rectum, and intestine were determined following exclusion of 74 patients with evidence of disease recurrence or progression.

RESULTS

A total of 16 patients (8.1%) had urologic complications that required surgical intervention following irradiation, while a total of 26 patients (13.2%) had complications of the rectum or intestine that required surgical intervention following irradiation. Urologic complications occurred significantly later than those of the rectum and intestine (6.4 and 2.2 years, respectively) (P < 0.0001). The overall incidence of severe complications was comparatively higher than reported in the United States and Europe. The incidence of spontaneous rupture of the urinary bladder was particularly high (2.0%) in Japan.

CONCLUSIONS

The incidence of severe complications following radiotherapy is comparatively higher in Japan than in the United States and Europe. In particular, spontaneous rupture of the urinary bladder is common in Japan. This might be due to the use of high-dose-rate brachytherapy. Since brachytherapy is currently being used for prostate cancer, urologists and radiologists must consider the possibility of a high incidence of such severe complications, especially when using high-dose-rate brachytherapy.

[High intensity focused ultrasound (HIFU) in urology]

INTRODUCTION

Focused ultrasound is now well known to urologists in the context of its validated application in extracorporeal lithotripsy. High Intensity Focused Ultrasound (HIFU) represents a potential therapeutic modality for tissue destruction due to its very high energy and its capacity to precisely reach a target with a very short emission time. The authors review the current state of art of HIFU in urology at a time when its indication in prostate cancer is being defined.

MATERIAL AND METHOD

After a brief description of the main physical principles of ultrasound and the main data determining focussing of high energy ultrasound, the main machines available (research and clinical) are described. The published clinical literature concerning the tissue destructive action in urology is reviewed.

RESULTS

HIFU has been used in urology to treat renal, vesical, prostatic (BPH and cancer), and external genital organ lesions. Purely extracorporeal machines are gradually being replaced by intracorporeal procedures, especially transrectal techniques for prostatic lesions. The quality of ultrasound detection of the target still limits the use of this minimally invasive modality. The intervening tissues are spared with a good therapeutic efficacy on the target tissues, provided optimal firing parameters are used.

CONCLUSION

HIFU has a demonstrated potential in the treatment of prostate cancer and studies conducted by several teams have defined the technique and its efficacy. Other indications have been studied, but must be validated by further clinical trials. The future will probably see the design of machines adapted to a specific target tissue rather than a single multidisciplinary extracorporeal machine.

Use of new technology in endourology and laparoscopy by american urologists: internet and postal survey

OBJECTIVES

To assess the use of new technology by American urologists.

METHODS

Using the American Urological Association directory, surveys were sent via the U.S. postal service to 1000 randomly selected American urologists and 3065 urologists who had an Internet address listed in the directory.

RESULTS

Responses were received from 601 urologists (415 postal, 186 Internet). Overall, 81% of survey respondents reported performing fewer or the same number of percutaneous procedures as compared with 3 to 4 years ago and 84% reported carrying out more or the same number of ureteroscopic procedures in the treatment of patients with stone disease. Open dismembered pyeloplasty (43%) and Acucise endopyelotomy (42%) were most frequently reported as the preferred treatment for adult patients with symptomatic ureteropelvic junction obstruction. Although 60% of respondents reported that they have taken a laparoscopy course, 67% currently do not perform any laparoscopy in their practice. In addition, only 7% of urologists stated that laparoscopy comprises more than 5% of their practice. When stratified by the number of years in practice, those in practice less than 10 years were more likely than those in practice 10 to 20 years and those in practice longer than 20 years to have performed an endopyelotomy (77%, 60%, and 48%, respectively, P <0.001) and to be currently performing laparoscopy (49%, 36%, and 18%, respectively, P <0.001).

CONCLUSIONS

Compared with 3 to 4 years ago, American urologists are performing more ureteroscopy and fewer percutaneous stone procedures. Although most urologists have taken laparoscopy courses, this modality has not been widely incorporated into their practices at present.

Are coagulation studies necessary before percutaneous nephrostomy?

PURPOSE

Performance of coagulation studies for patients undergoing percutaneous nephrostomy (PCN) has been advocated by some investigators. We performed a retrospective study to assess this practice.

MATERIALS AND METHODS

The medical records of 180 patients subjected to PCN for various reasons between October 1991 and July 1998 were reviewed. This represents a subset of patients in whom PCN was performed by an experienced interventional radiologist at our institution. Patients were excluded if they had a history of active liver disease, hematologic or bleeding disorder, current use of heparin or warfarin, or platelet count <100,000. The remaining 160 patients were separated into two groups. Group 1 consisted of 153 patients with a normal prothrombin time (PT) and partial thromboplastin time (PTT). Group 2 comprised 7 patients with an abnormal PT or PTT. Demographic and laboratory data including PT, PTT, complete blood, and platelet counts were analyzed to determine if a hemorrhagic complication could be predicted by an abnormal PT or PTT.

RESULTS

In group 1 the mean PT was 12.2 seconds and the mean PTT was 25.0 seconds; in group 2 the mean PT was 13.9 seconds and the mean PTT was 30.3 seconds. The hemorrhagic complication rates were not statistically different between the two patient cohorts (p = .203). Demographic and standard laboratory data were not predictive of abnormal coagulation parameters.

CONCLUSIONS

Screening coagulation studies are unnecessary in the standard patient subjected to PCN.

Future trends in neurourology

Attention is drawn to the fact that neurourology should be a regular subspecialty within urology. The urologist should consider himself an organ specialist for the lower urinary tract, meaning that he has the knowledge and the skills to perform diagnostic procedures, as well as all treatment options - either by medication, exercise, operations or electrical stimulation techniques. Beyond general urological knowledge and skills, the requirements for a neurourologist are briefly outlined.

Exorcisms used for treatment of urinary tract diseases in Greece during the Middle Ages and Renaissance

Using an unpublished 16th century manuscript as a pilot case, we examined the role of the formal Christian rituals and of hybrid semi-Christian semi-pagan exorcistic writings in curing renal ailments. It was found that in spite of the changing religious and cultural orthodoxy in the lands around the Eastern Mediterranean Basin, people did adhere to their belief in divine intervention when they were suffering from renal and/or other afflictions. We traced the origin of these beliefs at least to the preclassical period, and its continuation well beyond the Renaissance. The same practice applied both to nephrological diseases of humans (clergy and laymen alike) and of animals. We also present several interesting works of art from the palaeo-Christian to the post-Byzantine era supporting our theses.

Urinary tract masses

Disorders of the urinary tract account for the majority of abdominal masses in infants. The most common causes of a flank mass in a neonate are a hydronephrotic kidney followed by a multicystic kidney. An increasing number of disorders resulting in hydronephrosis are diagnosed by prenatal ultrasound scan, and their natural history continues to be elucidated. This review will examine the common anatomic and functional causes of fetal and neonatal hydronephrosis as well as the diagnosis and treatment of solid and cystic urinary tract masses.

A giant urinoma in a neonate without obstructive uropathy

We report a neonate with a giant urinoma and renal failure. A 7-day-old boy had a giant abdominal mass of 6.5 cm x 8 cm in the right quadrant, gastroesophageal reflux, and renal failure caused by the compression from the mass. Radiological observations revealed a multiseptated cyst and neither kidney could be detected. To relieve these symptoms percutaneous drainage was performed. The contents of the fluid were similar to the patient's urine. The symptoms were improved by the drainage, and we found the left kidney to be absent and the right kidney small. Four prenatal ultrasound scans detected no cystic lesions in his abdomen. Neonatal urinomas are commonly complicated by obstructive uropathy, such as posterior urethral valves or ureteropelvic junction obstruction. These obstructive uropathies were ruled out by retrograde pyelography and voiding cystourethrography. A severely dilated upper pole of a double collecting system was also ruled out by intravenous pyelography and direct observation of the kidney during an open biopsy. The cause of the urinoma is still uncertain, but trauma during delivery and the dysplastic right kidney may be involved.

Urologic emergencies in the cancer patient

Urologic emergencies are common in the cancer patient and relate mainly to complications of bladder hemorrhage, upper or lower urinary tract obstruction, urinary tract infection, and priapism. Hemorrhagic cystitis is commonly due to bladder injury from radiation therapy, viral infection, or metabolites of chemotherapeutic agents. Treatments aimed at ameliorating the effects of theses metabolites, such as mesna and intravenous (IV) hydration, coupled with cystoscopy, evacuation of clots, and formalin instillation, have given clinicians an effective means of avoiding exsanguinating hemorrhage from the bladder. Malignant ureteral obstruction is an ominous sign in the cancer patient and may be due to tumor compression, retroperitoneal adenopathy, or direct tumor invasion. The endourologic procedures of ureteral stenting and percutaneous nephrostomy are effective means of palliation; however, complications of infection, stent obstruction, and stent migration can result in hospital admission and a decline in quality of life. Median survival for patients with malignant ureteral obstruction is less than 7 months, regardless of the tumor of origin. Bladder outlet obstruction leading to urinary retention can be due to mechanical factors involving the bladder neck or prostate, or to a breakdown in the neurophysiologic function of the bladder. Every attempt is made to avoid surgical intervention or the placement of chronic in-dwelling catheter in these often debilitated patients. Patients are often effectively treated with a variety of pharmacologic agents, such as alpha-adrenergic receptor blockers or by the initiation of chronic intermittent catheterization. Urinary tract infections are particularly dangerous in neutropenic and bone marrow transplant patients, with bladder catheters the most common portal entry. The colonization and later infection by resistant nosocomial organisms, such as Pseudomonas aeruginosa and Candida albicans, can rapidly lead to life-threatening sepsis. On rare occasions, emergency surgical intervention with adequate open drainage or nephrectomy is required to control such infections. Priapism can be caused by hematologic malignancy with hypercoagulation, metastatic disease involving the corpora cavernosa with thrombosis of the venous outflow from the penis, or rarely from intracavernous injections used for the treatment of impotence. If effective treatment exists for the primary tumor, improvement or resolution of the state of priapism may occur. Radiation therapy may be required to decrease the pain associated with malignant priapism, but surgical shunting procedures are rarely effective.

[Which urologic treatment alternatives are there for the hemophiliac patient?]

OBJECTIVE

Urological procedures are hazardous for hemophilic patients. The aim of this work is to report the treatment of 22 hemophilic patients in order to define prognosis factors and treatment options.

MATERIAL AND METHODS

22 patients have been treated: 8 had severe hemophilia, 5 A (FVIII < 1%), 3 B (F IX < 1%), 2 had moderate hemophilia A (FVIII 2 to 6%) and 10 minor hemophilia A (F VIII 7 to 30%). Two had acquired hemophilia with auto-anti-FVIII antibodies (ab). Four patients were HIV+. Eighteen patients were first referred to our hospital, and 3 were transferred from an other institution for persistent hematuria: one with anuria, one after bladder neck incision, and the other following suprapubic prostatectomy.

RESULTS

For patients without FVIII ab, a sufficient level of FVIII or IX (> 60%), could be achieved pre-operatively and maintained post operatively (4 to 20 days, according to the surgical procedure) by injections of FVIII, FIX or by injections of desmopressin. For one haemophilia A patient with anti-F VIII ab, transferred for uncontrollable bleeding after bladder neck incision, selective arterial embolization was successful. But for 2 patients with acquired haemophilia, improvement of the coagulation was insufficient, with human or porcine FVIII, activated prothombic complex concentrates or recombinant activated FVII. In spite of surgical procedures and arterial embolizations the 2 patients died.

CONCLUSION

The urological treatment of haemophilic patients needs to be performed in specialised centers. For patients without FVIII ab, classical urological procedures can be performed. But for patients with FVIII ab when alternative treatments (radiotherapy, LHRH agonists) can be used, the surgical procedures must be delayed; in emergency if hemostasis cannot be achieved arterial embolization could be useful.

Ureteral dilation using a tapered dilator: a cost-effective approach

BACKGROUND AND PURPOSE

The 6/12 AQ hydrophilically coated tapered dilator is a newly developed device for ureteral dilation prior to rigid and flexible ureteroscopy.

PATIENTS AND METHODS

To evaluate the efficacy, safety, and cost-effectiveness of this device, it was used to gain ureteral access in 80 consecutive patients undergoing ureteroscopy for diagnostic purposes, stone treatment, or stricture dilation.

RESULTS

In all 80 cases, the ureteral orifice and intramural ureter were dilated successfully. One complication occurred: an embedded stone was extruded through the ureteral wall. Each dilation procedure using the 6/12 AQ tapered dilator costs 20% of a balloon dilation, a saving of approximately $764 per dilation.

CONCLUSION

Ureteral dilation with the 6/12 AQ tapered dilator is a safe, effective, and inexpensive alternative to traditional dilation techniques.