Principles of ureteric reconstruction

The principles of ureteric reconstruction are not different from those of reconstructive urology in the rest of the urinary system. The importance of ensuring good vascular supply, complete excision of pathological lesions, good drainage and a wide spatulated and tension-free anastomosis of mucosa to mucosa remain paramount. Although time of diagnosis is the most single most adverse factor affecting outcome, the majority of ureteric injuries still present postoperatively, and delays in diagnosis are the rule rather than the exception. Successful management requires early and definitive intervention using endoscopic means or percutaneous drainage and stenting where possible. Failing this, a number of open surgical options to foreshorten the course of the ureter should be implemented. Most ureteric injuries below the pelvic brim can be treated easily with a ureteroneocystostomy using a bladder elongation procedure or a Boari flap. Mid and upper ureteric injuries above the pelvic brim, however, can be repaired with a spatulated ureteroureterostomy if the defect is small. In those with extensive ureteral loss, measures such as mobilizing the kidney, transureteroureterostomy, renal autotransplantation and ureteral substitution using small bowel may be required. Artificial ureteral substitutes may be an alternative in selected cases.

Role of PSA testing in multiphasic health screening

BACKGROUND

Although mass screening for prostate cancer does not meet the criteria for an effective screening programme, multiphasic screening which includes PSA testing is still being carried out.

AIM

We decided to study and evaluate the usefulness of PSA testing in multiphasic health screening and at the same time establish age-specific ranges of normal PSA values in our local population.

RESULTS

Six hundred and ninety five male patients who had their PSA levels tested during a multiphasic health screening from October 1992 to August 1995 were evaluated. Abnormal PSA levels were repeated and subjected to a DRE and TRUS biopsy if they were persistently high using age-specific PSA ranges. Our results showed 14 (4.1%) out of 695 patients who had an abnormal PSA of > 4 ng/mL. compared to 19 who had abnormal PSA levels using the age-specific PSA ranges. Of the patients who were < 40 yrs of age, no further investigations were done. Amongst those 80 years and older, none had abnormal age-specific PSA rates. No prostate cancers were picked up amongst all the patients investigated. Median age specific PSA values at the 95th percentile was calculated for each age group. A rise in the median PSA values with age was also noted.

CONCLUSION

We recommend that in patients less than 40 years of age, PSA should not be carried out as the probability of prostate cancer is almost zero. Similarly, in patients who are 80 years and above and asymptomatic, such screening may not be indicated given the limited options available. Age-specific rates are a better way to reduce the negative biopsy rates in the age-groups that are amenable to curative treatment. With a local set of age-specific PSA ranges, we hope to increase the positive predictive value of PSA for prostate cancers in our local population until more specific and equally sensitive tests are made available.

A comparative study of the distribution of ofloxacin and ciprofloxacin in prostatic tissues after simultaneous oral ingestion

OBJECTIVES

To determine the levels of two quinolones, ofloxacin and ciprofloxacin, potent broad-spectrum antibiotics with very good oral bioavailability and low minimum inhibitory concentrations (MICs) for most pathogens, in the prostates of patients who underwent transurethral resection of the prostate (TURP) after oral ingestion for surgical prophylaxis.

PATIENTS AND METHODS

Twenty-eight patients with BPH requiring a TURP ingested 250 mg of both drugs 2-4 h before operation. The levels of the drugs in the serum and prostate were measured using high-performance liquid chromatography and the levels of both drugs determined at the 6 and 9 o'clock positions in the prostate to examine any local variations in drug concentration.

RESULTS

Ofloxacin concentrations were significantly higher in the serum and prostatic tissues compared with ciprofloxacin for the same dose, but its penetrance into the prostate was lower. This mainly reflected its higher oral bioavailability. Both drugs were present in concentrations 50% higher at the 6 o'clock than at the 9 o'clock position but both exceeded the MICs for most Gram-negative organisms except Pseudomonas.

CONCLUSION

Ofloxacin has the advantage against ciprofloxacin of exceeding the MICs for Staphylococcus and Chlamydia. However, ciprofloxacin has the advantage of having prostate-to-serum ratios of unity, but for the same dose the prostatic concentrations of ofloxacin is significantly higher.

An unusual presentation of renal cell carcinoma with deep vein thrombosis of the calf

Renal cell carcinoma is a malignant tumour that involves the vena cava in 4% to 10% of patients undergoing radical nephrectomy. Of these only a third to half presented with symptoms of vena caval involvement. We present a case of renal cell carcinoma with vena caval involvement that presented with just a swollen right leg. The patient was staged and had a nephrectomy and resection of the inferior vena cava. Due to extensive collateral venous drainage renal function was not compromised and he was discharged well.

Extramammary Paget's disease: a report of three cases and review of the literature

Extramammary Paget's disease (FMPD) is a rare skin disease with a tendency to recur even in the face of adequate excision. It was first suggested by Weiner in 1937 to be a carcinoma of the apocrine sweat gland with intraepithelial excision. Thus, most cases of EMPD occur in the perianal, perigenital and axilla regions where sweat glands abound, with scrotal EMPD being the commonest. EMPD can occur in both benign or malignant form and is often confused with chronic dermatitis. Diagnosis can only be confirmed by an excision biopsy. The long-term survival in patients without an underlying carcinoma is good. However, EMPD associated with an underlying adnexal carcinoma tends to be more aggressive and the prognosis is poor in such cases. EMPD is also associated with other malignancies such as prostatic, rectal, cervical, breast, bladder and skin carcinomas. Incidences of up to 40% have been reported. Thus, patients with EMPD should be thoroughly screened for associated primary growths. The treatment of EMPD is essentially by surgical excision with clear margins. The options available for a clear margin include intraoperative frozen section,Moh's surgery and paraffin section with delayed re-excision. In this report, we present three cases of EMPD with markedly different outcomes and a review of the literature.

Haemospermia due to urethral haemangiomas--a report of two cases

Haemospermia is an extremely alarming symptom and patients with this condition often seek medical advice early. Classically, haemospermia can be divided into 2 types: those associated with genitourinary tract infection and those not associated with infection. In the latter group however, the cause is not often found and hence, it is considered as idiopathic. In this paper, we present 2 cases of haemospermia in which haemangiomas were found on urethrocystoscopy. These lesions were located at or just distal to the verumontanum and were easily diathermised with good results.

Gall bladder empyema--another good reason for early cholecystectomy

Over an 18-month period, 31 cholecystectomies were performed for empyema of the gall bladder. Analysis of these 31 cases showed that clinical features referable to the diagnosis and seriousness of this condition were few. The presence of a gall bladder mass was detected in only 35% of patients. In adopting a policy of early cholecystectomy for patients admitted for acute gall bladder disease, a low mortality rate of 3.2% was achieved for this group of patients with empyema of the gall bladder. Based on these results, we found that empyema of the gall bladder is another good reason to support early cholecystectomy.