Improved artificial urinary sphincter outcomes using a transcorporal cuff placement in patients with a "fragile urethra"

INTRODUCTION

The artificial urinary sphincter (AUS) is the most effective treatment option for incontinence after prostate cancer treatment. However, patients with a "fragile urethra" (defined as prior radiotherapy, previous failed AUS, or previous urethroplasty) are at increased risk of AUS failure. The aim of this study was to evaluate outcomes using standard and transcorporal cuff placement in this group of patients.

METHODS

A retrospective review was performed on patients with a fragile urethra who underwent AUS insertion between 2004 and 2017. The primary outcome was the need for AUS revision. Secondary outcome measures included change in pad use, patient satisfaction, continence (≤1 pad/day), improvement (≥50% change in pad use), and cuff erosion rates.

RESULTS

Seventy-six patients met the criteria for inclusion, with a mean age of 71.6 years and a mean followup of 37.9 months. A total of 42.1% had prior radiotherapy, 56.6% had a history of failed AUS, and 19.7% had previous urethroplasty. Transcorporal cuff placement was performed in 31.6% (n=24). These patients had lower revision (20.8% vs. 36.5%; p=0.05) and erosion rates (8.3% vs. 17.3%; p=0.09). There was no significant difference in functional outcomes such as continence (66.7% vs. 73.1%; p=0.57), improvement (100% vs. 90.4%;p=0.17), or satisfaction (82.6% vs. 69.4%; p=0.26), nor for 90-day complications (4.2% vs. 9.6%; p=0.41).

CONCLUSIONS

AUS insertion is an effective treatment option for post-prostatectomy incontinence in the setting of a fragile urethra. Transcorporal cuff placement in this subset of patients may be recommended, as it is associated with lower revision and erosion rates compared to standard cuff placement.

Strategies to maximise patient comfort during extracorporeal shockwave lithotripsy - A randomised controlled trial

BACKGROUND/PURPOSE OF STUDY

We aim to assess if distraction techniques improve patient comfort tolerability of SWL.

METHODS

We carried out a prospective randomised controlled trial of SWL-naïve patients attending for treatment. Patients were randomised into three groups and offered oral analgesia as standard of care. Group 1 (n = 19) received stress balls to squeeze during treatment. Group 2 (n = 19) listened to music during treatment. Group 3 (n = 17) received standard of care only. All patients completed a validated health anxiety inventory score prior to treatment. All patients completed a validated pain questionnaire and visual analogue scale (VAS) after treatment. Primary outcomes were completion of SWL treatment and pain score results.

RESULTS

55 patients attending for SWL were randomised. There was no difference in stone size or position, presence of a stent, height or weight between the groups. VAS scores were lower in controls compared to Group 1 (1.93 vs 3.69, p = 0.08). On subgroup analysis of non-anxious patients, pain questionnaire scores were lower in controls compared to Group 1 (2.58 vs 4.77, p = 0.06). VAS scores were lower in patients who received optional analgesia alone than in patients who received stress balls alone (1.92 vs 4.07, p = 0.05). Across all subgroups, pain scores were lower in the control group compared to the distraction groups, but did not achieve significance.

CONCLUSIONS

In conclusion, distraction techniques should not replace standard of care for analgesia during SWL. This study was registered with clinicaltrials.gov (identifier NCT03379922).

Paediatric urology training: what does the future hold?

BACKGROUND

Paediatric urology training is not a mandatory part of higher surgical training in urology in Ireland. It is predicted there will be a shortfall of surgeons trained in paediatric surgery in the coming years leading to a reliance on specialist paediatric surgical centres.

AIM

The aim of this study was to assess the attitudes of urological trainees regarding the current state of paediatric urology training and to address the potential future changes to training structures.

METHODS

A voluntary anonymous internet-based survey was emailed to all urological trainees. Parameters assessed included sex, level of training, attitudes towards paediatric urology training and levels of competence regarding core paediatric urological procedures.

RESULTS

69.2 % (n = 18) responded to the survey. 94.4 % (n = 17) would favour mandatory paediatric training-of these, 52.9 % (n = 9) would favour this in a dedicated paediatric hospital with a paediatric urologist. 66.7 % (n = 12) would like to provide a paediatric urology service as a consultant. 55.6 % (n = 10) felt they were competent to perform circumcision or scrotal exploration independently and manage all associated complications. No trainee felt themselves to be competent to perform orchidopexy independently and manage all complications.

CONCLUSION

Our study demonstrates a promising desire to provide paediatric services in the future. A greater emphasis on structured paediatric urology training is required to maintain the standard currently offered by adult urologists.

Filling the void: a case of sepsis following the injection of a penile bulking agent

Many cosmetic procedures are now performed by non-medical personnel. Owing to the wide coverage of aesthetic procedures by the media, patients may be less informed of the serious complications that can be seen when impure materials are injected by less-skilled practitioners. The authors present a case of sepsis following the injection of a non-medical grade penile bulking agent. Although penile augmentation is under-reported in the literature, public interest in such procedures is increasing. The growing demand for such procedures needs to be addressed by the medical community.

Livestock Services and the Poor

This paper reviews the economic framework for the delivery of livestock services to the poor. It is argued that the demand for livestock products is likely to increase rapidly and the ability of the poor to participate in the opportunities presented by this growth is linked critically to the availability of good service support, both on the input and output side. Governments therefore have a responsibility to supply the necessary public goods (including the institutions and legal frameworks), and the market infrastructure for facilitating the emergence of efficient markets for livestock services. The paper further argues that the dynamics of public policy in developing countries are much more complex than the simple application of economic logic. It is the larger political economy that often dictates policy choices. It is therefore important to integrate political economy and governance issues into the economic debate on livestock service delivery. The paper also reviews the context in which the markets for livestock services will need to function. Different countries are facing very different sets of issues, and the identification of possible interventions in livestock service markets would require careful field research and analysis. In this context, the paper suggests the elements of a research agenda for the next few years.

Monte Carlo-based treatment planning for boron neutron capture therapy using custom designed models automatically generated from CT data

PURPOSE

A Monte Carlo-based treatment planning code for boron neutron capture therapy (BNCT), called NCTPLAN, has been developed in support of the New England Medical Center-Massachusetts Institute of Technology program in BNCT. This code has been used to plan BNCT irradiations in an ongoing peripheral melanoma BNCT protocol. The concept and design of the code is described and illustrative applications are presented.

METHODS AND MATERIALS

NCTPLAN uses thin-slice Computed Tomography (CT) image data to automatically create a heterogeneous multimaterial model of the relevant body part, which is then used as input to a Monte Carlo simulation code, MCNP, to derive distributions within the model. Results are displayed as isocontours superimposed on precisely corresponding CT images of the body part. Currently the computational slowness of the dose calculations precludes efficient treatment planning per se, but does provide the radiation oncologist with a preview of the doses that will be delivered to tumors and to various normal tissues, and permits neutron irradiation times in Megawatt-minutes (MW-min) to be calculated for specific dose prescriptions. The validation of the NCTPLAN results by experimental mixed-field dosimetry is presented. A typical application involving a cranial parallel-opposed epithermal neutron beam irradiation of a human subject with a glioblastoma multiforme is illustrated showing relative biological effectiveness-isodose (RBE) distributions in normal CNS structures and in brain tumors. Parametric curves for the MITR-II M67 epithermal neutron beam, showing the gain factors (gain factor = minimum tumor dose/maximum normal brain dose) for various combinations of boron concentrations in tumor and in normal brain, are presented.

RESULTS

The NCTPLAN code provides good computational agreement with experimental measurements for all dose components along the neutron beam central axis in a head phantom. For the M67 epithermal beam the gain factor for 1, boronophenylalanine for a small midline brain tumor under typical distribution assumptions is 1.4-1.8 x . Implementation of the code under clinical conditions is demonstrated.

CONCLUSION

The NCTPLAN code has been shown to be well suited to treatment-planning applications in BNCT. Comparison of computationally derived dose distributions in a phantom compared with experimental measurements demonstrates good agreement. Automatic superposition of isodose contours with corresponding CT image data provides the ability to evaluate BNCT doses to tumor and to normal structures. Calculation of gain factors suggests that for the M67 epithermal neutron beam, more advantage is gained from increasing boron concentrations in tumor than from increasing the boron tumor-to-normal brain ratio.

Methimazole-induced cholestatic liver injury, mimicking sclerosing cholangitis

Cholestatic jaundice caused by imidazole derivates is a rare complication of antithyroid therapy. Only 20 such cases have been reported in the literature since the introduction of methimazole in 1949 and of carbimazole in 1953. We present a further case of methimazole-induced cholestatic liver injury, mimicking sclerosing cholangitis, where the etiology has been proven by a clear chronological relationship and the lack of other causative factors.

Bone disorders following total gastrectomy

Bone disorders following gastrectomy were studied by measuring absolute and relative bone mineral density of the Wards triangle, serum 1,25-(OH)2-D, alkaline phosphatase, and total serum calcium. The subjects were 20 males who had undergone total gastrectomy not more than three months previously (group A1). Seventeen of these patients were reviewed three years later (group A2). Absolute and relative bone density were significantly lower in group A2 than in A1 (0.52 +/- 0.011 g/cm2 versus 0.6 +/- 0.014 g/cm2, P < 0.01 and 85.5 +/- 1.4% age-matched control versus 95 +/- 1.3%, P < 0.01). 1,25-(OH)2-D was significantly lower in group A2 than in group A1 (14.3 +/- 0.97 pg/ml versus 20.6 +/- 1.02 pg/ml, P < 0.01). There was no difference in alkaline phosphatase and calcium serum concentration. The mean weight loss was 6.26 +/- 0.57% over the follow-up period, and weight loss correlated with absolute and relative bone density (r = -0.74, P < 0.01). There was a positive correlation between 1,25-(OH)2-D and absolute or relative bone density (r = 0.67, r = 0.62 and P < 0.01). These data suggest that bone density decrease has already occurred three years after total gastrectomy and is positively correlated to 1,25-(OH)2-D deficiency. As no differences in serum alkaline phosphatase and serum calcium concentration were found, these factors are of little value for the early detection of postgastrectomy bone disorders, whereas weight loss is a valuable screening parameter.

Altered antroduodenal motility after cholecystectomy

BACKGROUND

Persistent nonspecific symptoms such as epigastric pain, bloating, nausea, and bilious vomiting are common following cholecystectomy. The etiology of these symptoms is unknown, but abnormal antroduodenal motility associated with duodenogastric reflux (DGR) is a possible cause.

PATIENTS AND METHODS

Sixteen postcholecystectomy patients and 19 healthy volunteers ("normals") were studied. Ten of the patients were asymptomatic and 6 were symptomatic. The study consisted of a 4-hour 99mTc-DISIDA (diisopropyl imidodiacetic acid) infusion and gastric aspiration, 24-hour intragastric pH monitoring, and 24-hour ambulatory antroduodenal manometry.

RESULTS

The postcholecystectomy patients showed increased DGR of the infused 99mTc-DISIDA. The data are given as coulter counts x 10(6)/min. The increase was more marked in symptomatic postcholecystectomy patients (2.54 +/- 0.15) compared to asymptomatic patients (1.21 +/- 0.46) or normals (0.26 +/- 0.15). Postcholecystectomy patients had increased percentage of time with intragastric pH > 3. In the supine period in particular, the pH was > 3 in symptomatic patients 25.4% +/- 7.7% of the time versus 8.1% +/- 4.3% for asymptomatic patients (P < 0.01). The antral phase III frequency after cholecystectomy was 2.5 +/- 0.09 cycles/min compared to 3.2 +/- 0.08 cycles/min in normals (P < 0.0001). Furthermore, propagation of the phase III front in the duodenum was significantly slowed to 0.14 +/- 0.02 cm/s after cholecystectomy compared to 0.27 +/- 0.02 cm/s in normals (P < 0.001). The duration of phase III in the proximal duodenum after cholecystectomy was also decreased to 4.3 +/- 0.27 min compared to 5.9 +/- 0.35 min in normals (P < 0.005).

CONCLUSIONS

Fasting antroduodenal motility is altered after cholecystectomy. The abnormality is associated with increased DGR, which is more marked in symptomatic patients.

Lymphangitis carcinomatosis of the lesser omentum: a prognostic factor in gastric cancer

A series of 126 patients with gastric cancer who underwent radical gastrectomy with systemic lymph node dissection revealed 9 patients who survived for a median time of only 3 months. Of these 9 patients, 4 were classified by the UICC system as stage II and 5 as stage III, all of whom had lymphangitis carcinomatosis of the lesser omentum. These data suggest that although lymphangitis carcinomatosis of the lesser omentum is an uncommon finding, if it is present, curative surgery is impossible and an operation should therefore be limited to tumor palliation.

The timing, specificity and clinical prediction of tricyclic drug effects in depression

This research was aimed at studying the rate of action of tricyclic drugs in depressive disorders, specifying the behavioural effects associated with recovery, and predicting clinical response. The research design involved comparison of a recovered group with a group treated for the equivalent four weeks, who showed minimal to no response. The findings indicated significant differences in baseline characteristics between responders and non-responders. Further, the drugs were found to act early in the responders, within the first week of treatment. Specific changes at one week which distinguished responder and non-responder groups occurred in the disturbed affects, and in cognitive functioning. Improvements also occurred in somatic symptoms, but these latter changes were general and not associated with later recovery. At 2 1/2 weeks, all facets of the depressed condition showed positive change in the responders. Implications of the results for assessing rate of tricyclic drug actions, their effects on the interaction of affect and neurochemistry, and the practical application of the results for the clinical situation, are discussed.