Epididymectomy in the management of intrascrotal disease: a critical reappraisal

OBJECTIVE

To assess the outcome of epididymectomy as a method of treating epididymal pathology.

PATIENTS AND METHODS

Forty-one patients who underwent epididymectomy between 1990 and 1995 were analysed retrospectively; their clinical records were reviewed and their satisfaction with the outcome and relief of symptoms assessed using a questionnaire and/or telephone interview.

RESULTS

Twenty-nine patients with pain were subdivided into three categories depending on the indication for epididymectomy, i.e. post-vasectomy epididymal engorgement (eight patients), complex cystic disease (11) or 'chronic epididymitis' (10). The outcome was satisfactory in 27 of the 29 patients. The best results were obtained in the group who underwent epididymectomy after vasectomy, where seven of eight improved after the procedure. Those with chronic epididymitis had the least favourable outcome, with only seven reporting any improvement in symptoms.

CONCLUSIONS

Epididymectomy has a valuable role in the management of epididymal pathology in appropriately selected patients.

The role of orchiectomy in the management of postpubertal cryptorchidism

PURPOSE

Owing to the risk of future malignancy, many postpubertal male subjects presenting with unilateral cryptorchidism undergo orchiectomy rather than orchiopexy. We examined the incidence of spermatogenesis and carcinogenesis in whole orchiectomy specimens removed from postpubertal cryptorchid male subjects. We review the concept that orchiectomy is justifiable in these patients.

MATERIALS AND METHODS

A total of 52 patients with postpubertal cryptorchidism (unilateral in 48, bilateral in 4) were retrospectively analyzed from 1984. Patient age ranged from 15 to 66 years (mean 26). Six patients presented with primary infertility (unilateral in 3, bilateral in 3). The undescended testicles were palpable in 32 cases (62%). All patients underwent unilateral orchiectomy and whole specimens were examined histologically.

RESULTS

Histology showed normal spermatogenesis in only 1 orchiectomy specimen, while 15 had maturation arrest, 6 testicular agenesis and 30 seminiferous tubular atrophy and/or Sertoli-cell-only syndrome with no spermatogenesis. The location of the undescended testis was the superficial inguinal pouch in 32 cases, inguinal canal in 6 and inside the deep ring in 8. Absent spermatogenesis was significantly associated with a high level of maldescent and with increasing age. Two patients (4%) had carcinoma in situ of the testicle. Torsion of an undescended testicle occurred in 1 patient (2%).

CONCLUSIONS

This analysis of cryptorchid testes in postpubertal male subjects confirms that the majority cannot contribute to fertility, have significant malignant potential and may undergo torsion. Therefore, orchiectomy remains the treatment of choice for the majority of postpubertal male subjects presenting with unilateral cryptorchidism.

Prognostic factors in squamous cell carcinoma of the penis and implications for management

OBJECTIVE

To determine the clinical and pathological features, methods and outcome of management in squamous cell carcinoma of the penis (SCCP).

PATIENTS AND METHODS

A retrospective study was carried out of 42 patients (mean age 63 years, range 28-86) with a histological diagnosis of SCCP. The disease stage, grade, treatment of primary tumour, lymph node disease and survival were recorded; the mean follow-up was 4 years (range 1.5-25).

RESULTS

The disease stage was T1 in 24 patients (57%), T2 in 14 (33%), T3 in three (7%) and T4 in one (2%); the tumour grade was well differentiated in 20 (47%), moderately differentiated in 14 (33%) and poorly differentiated in three (7%). Eight patients had histologically confirmed inguinal node disease at presentation, six of whom underwent lymph node dissection, while two underwent radiotherapy. Five patients developed inguinal node disease during follow-up (mean 10 months, range 4-21). Three of these patients were irradiated and two underwent lymph node dissection. Six patients (14%) had local recurrence, five of whom were managed surgically. One patient developed a local recurrence 11 years after initial surgery. Seven patients died from their disease (17%); four died within 2 years, being patients with high-stage and/or high-grade disease.

CONCLUSIONS

Modern management should include a standard staging classification and treatment protocols to maximize survival.

Double pigtail ureteric stent versus percutaneous nephrostomy: effects on stone transit and ureteric motility

OBJECTIVES AND METHODS

The effects of double pigtail ureteric catheters (JJS) and percutaneous nephrostomies (PN) on ureteric motility and artificial stone transit was assessed in 12 dogs. Each animal underwent bilateral nephrostomies and an artificial stone insertion into each upper ureter (n = 20). A 4-Fr JJS was inserted on one side (group 1) while a PN was left on the contralateral side (group 2). In 4 stone-only 'control' ureters (group 3), the PN was sealed after 72 h. Stone passage was assessed by plain x-rays. Pelvic and ureteric motility was assessed prior to stone insertion and again at 2 weeks.

RESULTS

In group 1, only 1 of 8 stones (12.5%) passed completely. Four reached the midureter, 3 remained static. Six of 8 stones (75%) in group 2 passed completely. Two stones remained in the distal ureter. All 4 stones (100%) in group 3 passed by day 3 postoperatively. At laparotomy the J-stented ureters were dilated and both pelvic and ureteric contractions were diminished. Ureteric diameter was normal on the PN side. The ureters contracted with normal amplitude, but diminished rate of contraction above the stones in the ureters with residual calculi (n = 2), and in the 6 ureters from which spontaneous stone passage had occurred. A similar pattern was found in the 4 group 3 ureters.

CONCLUSIONS

Double J stents are associated with ureteric dilatation, diminished peristalsis and impaired stone passage. APN preserves ureteric peristalsis and facilitates stone passage. In the initial phase, raised hydrostatic pressure appears to the most important factor determining stone passage.

The fate of the defunctioned bladder following supravesical urinary diversion

OBJECTIVE

To determine the nature, incidence and severity of bladder complications after supravesical urinary diversion without cystectomy and to identify preventative risk factors.

PATIENTS AND METHODS

A retrospective study of the last 25 years identified 35 patients who had supravesical urinary diversion without concomitant cystectomy (33 ileal loop diversions and two cutaneous ureterostomies). Urinary diversion was performed for a variety of lower urinary tract pathologies. Patients with urinary tract neoplasia were excluded. There were 15 males (mean age 41 years, range 13-72) and 20 females (mean age 49 years, range 15-81) with a mean follow-up of 5.2 years (range 1-25).

RESULTS

There were bladder complications in 10 patients (28%) including pyocystis (one mild and two severe), haemorrhage (two mild and one severe) and pain/spasm (four mild and three severe). Patients with interstitial cystitis, bladder outflow obstruction and/or a vesical fistula appeared to have a higher risk of complications. Four patients required cystectomy to treat severe symptoms while the remaining six achieved control of symptoms with no surgery. No patient developed carcinoma during the follow-up.

CONCLUSION

We recommend that cystectomy is considered at the time of supravesical urinary diversion, particularly in patients with interstitial cystitis, bladder outflow obstruction or a chronically infected bladder and especially in those with a vesical fistula.

Some aspects of the safety of high speed catamarans

A high speed catamaran was involved in an accident off Jersey. No one was injured as a result of the actual accident itself but there were a number of serious injuries sustained by passengers during the evacuation of the vessel. A number of deficiencies in the design of the vessel were identified as a result of the accident and the evacuation of passengers and crew. Access routes and the number of exits were important causes of concern. Lifejackets and life rafts were found to have problems in their use and their specification seemed not to be well adapted to their possible use. Life rafts in particular were found not to be sufficiently robust. The low crew to passenger ratio required passengers to take on roles for which they had neither the expertise nor the training. Crew and passengers all responded to the best of their ability but unnecessary strain was placed on all due to lack of sufficient trained people being available. Hypothermia was not a major problem but if the rescue had taken much longer then there would have been a rapidly increasing number of people affected. Rescue equipment should be improved to cope with this life threatening condition.

Antigen-pulsed, interleukin-4-treated B cells activate primed T cells in vitro but not naive T cells in vivo

The ability of B cells to act as effective antigen-presenting cells is a source of debate which centres on the degree of activation of either B cells or T cells. We have investigated whether B cells treated with interleukin 4 (IL-4) can express the two signals required to activate T cells: MHC Class 2/antigenic peptide complexes(signal 1) and the costimulatory molecules B7-1 and B7-2 (signal 2). We have also determined whether these cells could activate antigen-experienced T cells in vitro and whether they could prime naive T cells in vivo. We found that B cells expressed abundant MHC Class 2 molecules and moderate levels of B7-2 after 24 h culture in IL-4 with or without purified protein derivative (PPD) but B7-1 was not detectable. PPD-pulsed, IL-4 treated B cells induced antigen-experienced T cells to proliferate in vitro but these cells failed to prime naive T cells in vivo when injected into mice. We conclude that signals, in addition to those induced with IL-4, are required for B cells to initiate an immune response to antigen.

Is there a role for in vivo methylene blue staining in the prediction of bladder tumour recurrence?

OBJECTIVE

To assess the role of in vivo staining with intravesical methylene blue in predicting tumour recurrence.

PATIENTS AND METHODS

Thirty-nine patients (27 men and 12 women, age range 43-75 years) newly diagnosed with bladder tumours were prospectively studied and followed for a minimum of 2 years. Potential biopsy sites were identified by staining intravesically with a 1% methylene blue solution and compared with random biopsy sites.

RESULTS

Biopsy directed by methylene blue staining detected carcinoma in situ more often than random biopsy. Rates of recurrence were similar in both stained and unstained groups.

CONCLUSION

Methylene blue staining does not add significantly to the management of patients presenting with bladder tumours.

'Firm' versus 'soft' double pigtail ureteric stents: a randomised blind comparative trial

It is generally considered that 'firm' double pigtail ureteric catheters, while easier to insert and less prone to migration, may cause more patient discomfort than the 'softer' variety of stent. Objective support for these perceptions is however lacking. The aim of this study was to compare firm and soft stents regarding their ease of insertion, positional stability, biocompatibility and patient tolerance. 155 patients were randomised to receive 'firm' (polyurethane, n = 78) or 'soft' (Sof-Flex, n = 77) stents. Ease and mode of insertion was recorded at time of initial placement. Positional stability, degree of bladder inflammation, stent encrustation and patient tolerance were recorded at the time of removal. Patient tolerance was assessed by symptom score in double-blind fashion. Results showed no significant difference in ease of insertion, positional stability, degree of bladder inflammation or stent encrustation between the two groups. There was a significantly higher incidence of dysuria, renal and suprapubic pain in the firm stent group. There was no significant difference in the incidence of urgency, frequency, nocturia or haematuria. Normal activity and return to work were reported in 67 and 45% of patients with soft and firm stents, respectively. The data indicates that patient tolerance appears to be related to the softness of the stent material.

Out-of-hospital resuscitation in East Sussex: 1981 to 1989

OBJECTIVE

To assess the impact of extended training in advanced life support on the outcome of resuscitation.

DESIGN

Analysis of the successful resuscitations from 1981 to 1989.

SETTING

Brighton and East Sussex.

RESULTS

248 patients were resuscitated from cardiac or respiratory arrest in the community and subsequently survived to leave hospital. Their mean age was 64 years and one year survival was 77%. In most cases the cause of collapse was cardiac but 38 (15%) suffered a respiratory arrest. In 140 of the successful resuscitations (56%) collapse occurred before the arrival of the ambulance. Basic life support, with ventilation and chest compression where necessary, was sufficient to revive 35 (14%) of the patients. Defibrillation was also required in 107 patients (43%), and in a further 106 patients (43%) who had prolonged cardiorespiratory arrest requiring endotracheal intubation and the use of several drugs. Review of ambulance forms and case notes showed that in 87 cases (35%) the abilities of the paramedical ambulance staff in advanced resuscitation techniques contributed decisively to the success of resuscitation. These skills are illustrated by eight case reports.

CONCLUSIONS

Extended training for ambulance staff increases the likelihood of successful resuscitation from out-of-hospital cardiopulmonary arrest. Though instruction in defibrillation must have the highest priority, full paramedical training can bring appreciable additional benefits.

Comparison of reagent strip (dipstick) and microscopic haematuria in urological out-patients

Dipstick (reagent strip) and microscopic urine analysis for haematuria was performed prospectively on 1000 consecutive urine samples taken from urological out-patients. Haematuria was present in 185 samples (18.5%) and absent in 687 (68.7%) using both tests; 98 samples (9.8%) had dipstick haematuria that was not confirmed by microscopy and 30 samples (3%) had microscopic haematuria that was missed on dipstick urine analysis. Dipstick urine analysis had a sensitivity of 86.1% and a specificity of 85%. This study confirms that reagent strip testing for haematuria has both false positive and false negative results and indicates that cytoscopy should be considered in all patients with suspected haematuria.

Haemospermia: how to proceed?

Haemospermia is an alarming symptom but does it signify serious disease and how should it be investigated? A retrospective review of 44 men showed no evidence of malignancy and infection as the commonest cause. Standard investigation with midstream specimen of urine, intravenous pyelogram and cystoscopy is unhelpful. Microscopy and culture of a first stream specimen of urine or expressed prostatic secretions is the investigation of choice. Cystoscopy should be reserved for patients with recurrent haemospermia.

Is retrograde ureterography indicated in pelviureteric junction obstruction?

The role of retrograde ureterography in the management of pelviureteric junction (PUJ) obstruction remains controversial and it has recently been reiterated that visualisation of the entire ureter on the affected side is mandatory owing to the high incidence of other ureteric abnormalities. In a review of 119 consecutive adult pyeloplasties carried out over a 9-year period, only 2 ureteric abnormalities were found in association with PUJ obstruction (duplex ureter/3-cm proximal stricture). Other anatomical abnormalities included aberrant vessels, fascial bands and renal anomalies. Most secondary abnormalities were undiagnosed prior to surgery and all were easily dealt with per-operatively.

Treatment strategy for piezoelectric shock wave lithotripsy of upper ureteral calculi

In situ piezoelectric lithotripsy monotherapy for upper ureteral stones is an attractive option because it can be conducted on an outpatient basis. Difficulty in calculus localization with ultrasound is the limiting factor. We reviewed our experience with 99 patients treated for upper ureteral calculi with the EDAP LT.01 lithotriptor. For stones above the lower renal border we achieved a 53% stone-free rate compared to 25% for calculi below the lower renal border. In situ piezoelectric lithotripsy of upper ureteral calculi may be considered for stones above the lower renal border.

Ureterocolic fistula: a unique complication of extracorporeal shock wave lithotripsy

A unique case of ureterocolic fistula at the site of stone fragment impaction after piezoelectric shock wave lithotripsy is described. Pathological examination of the nephroureterectomy specimen indicated xanthogranulomatous pyelonephritis with the process extending into the ureter and fistulous tract.

Radiology of the AS 800 artificial urinary sphincter; normal appearances and complications

Thirteen adult male patients who had an AS 800 artificial urinary sphincter inserted are reviewed. Five have had malfunction, and in four the causes were diagnosed radiologically. These included: fistula formation, leakage of hydraulic fluid, air in the system, and inadequate deflation of the cuff. Since the sphincter is filled with contrast medium, it is ideally suited to radiological assessment.