Robotic sacrocolpopexy with medial umbilical ligament autologous graft to treat neovaginal prolapse in a transgender woman

Vaginoplasty is commonly performed to treat gender dysphoria in transgender women. Neovaginal prolapse is a late complication of vaginoplasty, and there is minimal literature regarding its surgical management. We report a case of robotic sacrocolpopexy using medial umbilical ligament autologous graft to treat neovaginal prolapse in a transgender woman, which is a novel technique that has not been previously described. The procedure resulted in a good postoperative outcome for the patient. The innovative use of medial umbilical ligament autologous graft enabled the patient to benefit from a fully minimally invasive procedure whilst avoiding the risks associated with synthetic mesh.

mparing Urolift and tandard ransurethral resection of prostate head of adiotherapy in men with urinary symptoms secondary to prostate enlargement in Southwest London and North Cumbria (CO-STAR): a study protocol for a randomised feasibility study

INTRODUCTION

Patients undergoing prostate radiotherapy with an enlarged prostate can have short-term and long-term urinary complications. Currently, transurethral resection of the prostate (TURP) is the mainstay surgical intervention for men with urinary symptoms due to an enlarged prostate prior to radiotherapy. UroLift (NeoTract, Pleasanton, CA, USA) is a recent minimally invasive alternative, widely used in benign disease but is untested in men with prostate cancer.

METHODS AND ANALYSIS

A multicentre, two-arm study designed in collaboration with a Patient Reference Group to assess the feasibility of randomising men with prostate cancer and coexisting urinary symptoms due to prostate enlargement to TURP or UroLift ahead of radiotherapy. 45 patients will be enrolled and randomised (1:1) using a computer-generated programme to TURP or UroLift. Recruitment and retention will be assessed over a 12 month period. Information on clinical outcomes, adverse events and costs will be collected. Clinical outcomes and patient reported outcome measures will be measured at baseline, 6 weeks postintervention and 3 months following radiotherapy. A further 12 in-depth interviews will be conducted with a subset of patients to assess acceptability using the Theoretical Framework of Acceptability. Descriptive analysis on all outcomes will be performed using Stata (StataCorp V.2021).

ETHICS AND DISSEMINATION

The trial has been approved by the Research Ethics Committee (REC) NHS Health Research Authority (HRA) and Health and Care Research Wales (HCRW). The results will be published in peer-reviewed journals, presented at national meetings and disseminated to patients via social media, charity and hospital websites.

TRIAL REGISTRATION NUMBER

NCT05840549.

Predictors for adverse events following intravesical botulinum toxin injections in men

INTRODUCTION

Intravesical botulinum toxin A (BTX-A) has been long established as treatment for overactive bladder and neurogenic bladder dysfunction. However, most published data are reported among a female cohort. Adverse events such as intermittent self-catheterization (ISC) and urinary tract infections (UTIs) play a large role in discontinuation of therapy. There is currently limited information regarding predictive factors to appropriately counsel male patients.

MATERIALS AND METHODS

We retrospectively collected data on male patients undergoing their first intravesical BTX-A therapy from January 2016 to July 2021 in two high-volume centers. Data included demographics, past medical and surgical history, and urodynamic parameters. Patients were excluded if they had a long-term catheter or ISC before initiation of therapy.

RESULTS

A total of 69 men were included in the study with a median age of 66 years. There were 18 patients with neurogenic bladder dysfunction. Thirty men had urge incontinence secondary to radical prostatectomy or bladder outflow surgery. Overall rates of ISC were 43.5%. Predictors for ISC included a baseline postvoid residual (PVR) ≥ 50 mL (odds ratio [OR]: 4.2, 95% confidence interval [CI]: 1.36-13.03, p = 0.01), BTX-A dose >100 units (OR: 4.2, 95% CI: 1.36-13.0, p = 0.01). Stress urinary incontinence was protective against ISC (OR: 0.20, 95% CI: 0.04-1.00, p = 0.049) as well as history of prostatectomy/bladder outflow obstruction (BOO) surgery (OR: 0.16, 95% CI: 0.05-0.47, p < 0.001). A multivariable logistic regression model with these factors yielded a c-statistic of 0.80 (optimism-adjusted = 0.75). An enlarged prostate was the only predictor for UTI among our male cohort (OR: 8.0, 95% CI: 2.03-31.5, p = 0.003).

CONCLUSIONS

This is the first study assessing risk factors of adverse events among men following BTX-A injection. High PVR and BTX-A dose of >100U were predictors of requiring ISC after BTX-A. Stress incontinence, previous radical prostatectomy, and BOO surgery were all protective against needing ISC post-BTX-A. An enlarged prostate was associated with development of UTI. These factors can be used to assist in counseling male patients regarding their risk of ISC and UTI.

Robotic-assisted laparoscopic colposuspension for female stress urinary incontinence: a prospective series

The suspension of use of sub-urethral mesh in the UK in 2018 has seen the resurgence of colposuspension in female SUI surgery. Open and laparoscopic colposuspension techniques are well recognised. We present data from 28 robotic-assisted laparoscopic colposuspension (RALCp) procedures, reporting on technique, safety and efficacy. Approval was obtained from the hospital New and Novel Procedures Committee. All patients had urodynamic assessment prior to surgery. Data was prospectively gathered and 24-h pad usage and Urinary Incontinence Short Form Questionnaire (ICIQ-UI-SF) scores were used to assess symptom severity and quality of life. PGII scores were used to assess patient satisfaction after the procedure. Paired T test analysis was conducted. Since May 2019, robotic colposuspension has been performed in 28 patients. The mean age and BMI were 49 and 27 (kg/m²), respectively, with a mean follow-up period of 12 months. 67.9% of patients had pure urodynamic SUI and 32.1% of patients had previous anti-SUI surgery. Average operating time was 127 min, blood loss 20 ml and length of stay 2 days. There was a significant 73% improvement in mean 24-h pad usage (p = 0.001) and an improvement in mean ICIQ-UI-SF scores from 18.1 to 9.4 (p = 0.0001). Day 1 mean pain score was 5/10. This is the largest series of its kind. Robotic colposuspension is safe and feasible with significant improvements seen in quality of life scores and number of pads used per day. It presents a minimally invasive treatment option in female SUI, however needs larger volume evaluation and longer follow-up for further evaluation.

Management of men with lower urinary tract symptoms referred for prostate radiotherapy

Objective:

To report on the experience of the management of lower urinary tract symptoms (LUTS) in men referred for prostate radiotherapy (RT) in a large tertiary referral centre.

Methods:

Between February and November 2018, 156 men referred for radiotherapy were seen and assessed according to their LUTS history: International Prostate Symptom Score (IPSS), flow rate (FR) and post-void residual (PVR). Patients with LUTS were offered management options depending on severity including lifestyle advice, oral medication or surgery. A subset of patients ( n = 102) were reassessed post-RT, and univariate and multivariate logistic regression was performed to predict symptoms improvement.

Results:

Prior to referral for RT and assessment at our dedicated LUTS clinic, 65% of men had a documented history of LUTS, 14% had completed an IPSS questionnaire and only 13% had a urinary FR; 17% (27/156) had prior treatment in the form of medication or surgery. In our assessment, 77/156 (49%) had mild, 66/156 (42%) moderate and 13/156 (8%) severe LUTS determined by IPSS. Out of 156, 71 (46%) had a quality-of-life score >3. Of the men, 81% were offered lifestyle advice, 47 patients were started on alpha blockers and 20 (12.8%) went onto Transurethral Resection of the Prostate prior to RT; 6 weeks following RT, 61 (50%) patients had higher IPSS scores. Patients who were started on alpha blockers ( p = 0.022) or had TURP ( p = 0.015) were less likely to have an increase in IPSS score on multivariate analysis.

Conclusion:

Men undergoing RT for prostate cancer often have co-existing LUTS. Consideration and evaluation of their LUTS and offer of treatment either medication or surgery could improve urinary symptoms in men undergoing prostate radiotherapy in the short term. Longer term data are still needed to understand the full long-term impact on patient’s symptoms and quality of life. We recommend that patients have formal LUTS assessment pre-RT.

Level of evidence:

Not applicable.

Prevalence of chronic pain following suburethral mesh sling implantation for post-prostatectomy incontinence

PURPOSE

To evaluate postoperative pain and complications following AdVance™/AdVance™ XP male sling implantation.

MATERIALS AND METHODS

A multi-center retrospective medical notes review of patients implanted for bothersome post-prostatectomy incontinence was conducted. All patients were telephoned to provide further information on pain or further complications related to their surgery. Statistical evaluation utilized logistical regression analysis. Additionally, a literature review was conducted reviewing pain outcomes following AdVance™/AdVance™ XP implantation.

RESULTS

One-hundred and twenty-seven men were reviewed over an 8-year period. The mean age was 70 years, with mean follow up 52 months. Of those with mild stress urinary incontinence, 45 (79%) had a successful outcome compared to 42 (72%) in the moderate group. Twenty-nine (23%) men reported postoperative pain, with a mean maximal pain score of 6 (range: 0-10). The majority of pain resolved within 4 weeks (19/29 men). A further seven patients resolved by 3 months. Only three men (2.3%) had chronic pain greater than 3 months, which all resolved by 1 year. Men less than 65 years were more likely to suffer pain (p = 0.009). Acute urinary retention occurred in 23 (18%) men and correlated significantly with postoperative pain (p = 0.04). Overactive bladder symptoms, severity of incontinence or radiotherapy were not correlated with postoperative pain. In our cohort, there were no extrusions, divisions, or explantations.

CONCLUSION

Approximately a quarter of men experience pain in the early postoperative period. However, the severity and rates of chronic pain (>3 months) are low (2.3%) but all settle within a year.

Testicular rupture: Simplifying the diagnosis

Objective:

To review the use of ultrasound imaging in the diagnosis of testicular rupture and in relation to current guidelines.

Methods:

Data was retrospectively collected for all patients diagnosed with testicular rupture at a major trauma centre between 2011 and 2018. Data included patient demographics, mechanism of trauma, specific findings on ultrasound and outcomes. On review of ultrasound imaging, specific findings identified include a breach in the tunica albuginea (currently advised in guidelines), heterogenicity and contour loss.

Results:

Eight patients were identified with average age 37 years old, mechanism of trauma was 50%, 37.5% and 12.5% for motorcycle road traffic collision, sporting injury and workplace injury respectively. A breach of tunica albuginea was identified on ultrasound in 65% of cases, compared with 100% of cases showing contour loss and heterogenicity. Of the 87.5% patients who were managed surgically one needed orchidectomy (and later testosterone replacement).

Conclusion:

Guidelines have varied on how to use ultrasound imaging in diagnosing a clinically difficult condition. Our case series demonstrates that diagnosing testicular rupture by looking for more easily identifiable characteristics (heterogenicity and contour loss) than currently recommended in the guidelines (breech in the tunica albuginea) will aid diagnosis and patient pathway and improve outcomes.

Level of evidence:

5

The MIC-KEY button vesicostomy: a superior alternative for suprapubic drainage?

OBJECTIVES

To evaluate the MIC-KEY button vesicostomy as an alternative to indwelling suprapubic catheters (SPCs) for bladder drainage in adults.

PATIENTS AND METHODS

Phase II pilot study prospectively evaluating patients with indwelling SPCs that were converted to MIC-KEY buttons, or cystoscopic-guided de novo insertion, between November 2014 and February 2019. In all, 15 patients (14 female, one male) had indwelling SPCs that had conversion or attempted conversion to MIC-KEY button, and one (male) had a cystoscopic-guided de novo insertion with a history of previous suprapubic catheterisation. The mean (range) age was 44.2 (13-73) years. Catheter-related quality-of-life (C-IQoL) questionnaire data were collected at baseline and 3 months.

RESULTS

Two patients had attempted conversion but were abandoned perioperatively due to sizing issues and insertion difficulties, respectively. Three patients were subsequently converted back to a SPC; due to button sizing (18 days), leaking (3 months), and recurrent infection (13 months). The remaining 11 patients have remained well with continued drainage via the MIC-KEY button; mean (range) duration since conversion was 34.2 (5-105) months. The C-IQoL score improved 3 months after insertion, from 50.0 to 75.4. Changes were performed dependent on patient's personalised management, typically every 3 months, under local or general anaesthetic.

CONCLUSION

The MIC-KEY button is a safe alternative to SPC drainage in adults in the short- to medium-term, in a selected cohort.

Incidence, type and management of ureteric injury associated with vesicovaginal fistulas: Report of a series from a specialized center

OBJECTIVES

To report a large series of vesicovaginal fistula, and to assess the incidence of ureteric injury in association with vesicovaginal fistula.

METHODS

We retrospectively reviewed a prospective database of patients with vesicovaginal fistula referred to our center between 2004 and 2016. Data on patient demographics, fistula etiology, mode of repair, and any associated ureteric injury and its treatment were noted.

RESULTS

Overall, 116 patients (median age 49 years, range 23-88 years) were referred for management of vesicovaginal fistula during the study period. Four of these patients (3.4%) had associated ureteric injury, one of whom had bilateral injury. Ureteric obstruction alone was noted in two patients, ureterovaginal fistula alone in one patient, and bilateral ureteric obstruction and ureterovaginal fistula in one patient. All ureteric injuries were managed with simultaneous reimplantation into the bladder at the time of vesicovaginal fistula repair. Five patients had post-radiotherapy vesicovaginal fistula, and the remainder were post-surgical. Three patients with post-radiotherapy vesicovaginal fistula proceeded to primary diversion.

CONCLUSIONS

Ureteric injury is far less common than previously reported, occurring in <5% of patients presenting with vesicovaginal fistula. It can be successfully managed, and it remains the major indication for abdominal repair of vesicovaginal fistula.

The autologous rectus fascia sheath sacrocolpopexy and sacrohysteropexy, a mesh free alternative in patients with recurrent uterine and vault prolapse: A contemporary series and literature review

Introduction:

About 40% of women suffer pelvic organ prolapse (POP) in a lifetime. The current standard intervention for vault prolapse is a mesh sacrocolpopexy or sacrohysteropexy. However, patients and surgeons are increasingly hesitant to use mesh given recent the UK and Food and Drug Administration warnings and litigation. A possible alternative is to use autologous tissue to support the vault, as a mesh-free solution. We report the outcomes from an initial series of autologous rectus fascia sheath (RFS) sacrocolpopexy and sacrohysteropexy in patients with complex pelvic floor dysfunction.

Patients and Methods:

All patients had previous, multiple urological/gynecological surgery and declined standard mesh repairs. All had preoperative videourodynamics and defecating magnetic resonance imaging evaluation. The autologous POP repair was performed using 10–18 cm of rectus sheath with a similar technique to that employing mesh to support the anterior-posterior vaginal walls or encircle the cervix and secured to the sacral promontory.

Results:

Seven patients with a mean age of 52 (33–64) years underwent autologous RFS POP repair between 2014 and 2017. Mean follow-up is 16 (range 2–33) months. All patients have durable result at last follow-up. No significant complications are reported.

Conclusions:

This is the first report of patients with complex pelvic floor dysfunction and apical POP being managed with autologous RFS sacrocolpopexy/sacrohysteropexy, and only the second report of a free graft being utilized with success. Autologous RFS sacrocolpopexy/sacrohysteropexy avoids the 10%–15% risks of mesh-related complications. Further studies of long-term durability are needed.

Urethral Sphincter Injection of Botulinum Toxin A: A Review of Its Application and Outcomes

The first reported application of Botulinum toxin-A (BTX-A) into the urethral sphincter predates the first documented use in the bladder. The aim of this review is to describe the clinical indications of BTX-A injection into the urethral sphincter and its clinical efficacy. This review of the literature includes the larger more significant published studies that have reported on this use of BTX-A. Case reports and articles not published in English were excluded. There have been many published clinical studies describing the use of BTX-A in the urethral sphincter, four of which are randomized placebo controlled trials. These studies tend to include patients either in urinary retention or with obstructed voiding, both in the neuropathic and non-neuropathic populations. Studies tend to demonstrate improvements in urodynamic parameters and quality of life after injection. There have been many small clinical studies in this area, however larger placebo-controlled trials are needed to evaluate this treatment at higher levels of evidence.

Nocturia in Patients With Parkinson's Disease

Background

Waking up from sleep more than once to pass urine, known as nocturia, is an important nonmotor symptom in Parkinson's disease (PD). Very little is known about the cause for nocturia. The aim of this work was to evaluate lower urinary tract (LUT) symptoms in patients with PD reporting nocturia using standardized validated questionnaires and bladder diaries and to assess the impact of nocturia on quality of life and sleep.

Methods

Twenty-three consecutive patients with PD (17 males, 6 females; mean age: 68.5 years; range, 50-85) referred to a specialist uro-neurology clinic reporting nocturia according to the International Continence Society definition were included. Patients measured their daily fluid intake, urinary output per void, and recorded these with the timing of voids on a 3-day bladder diary. Standardized questionnaires were used to assess LUT symptoms (Urinary Symptom Profile, International Prostate Symptom Score, and Qualiveen Short Form) and sleep quality (Parkinson's Disease Sleep Scale).

Results

Mean duration of PD was 10.1 years, and mean severity on H & Y scale was 3.0 (range, 1.0-5.0). Median duration of LUT symptoms was 6.0 years. Mean night-time urinary frequency was 3.5 (range, 1.0-7.3), and mean nocturnal maximum voided volume was 242 mL. Mean Nocturnal Polyuria Index (NPi) was 0.4 (range, 0.13-0.75), and 13 patients (56.5%) had nocturnal polyuria (NPi > 0.33). Patients with nocturnal polyuria reported more-severe LUT symptoms that impacted quality of life and sleep.

Conclusions

In this preliminary study, nocturnal polyuria seems to be common in patients with PD reporting nocturia and appears to affect quality of life and sleep, though this was not statistically significant. The bladder diary is an essential tool in the assessment of nocturia in patients with PD.

SINGLE CENTRE RANDOMISED PILOT STUDY OF TWO REGIMENS (30 MINS DAILY OR 30 MINS WEEKLY FOR 12 WEEKS) OF TRANSCUTANEOUS TIBIAL NERVE STIMULATION USING A NOVEL DEVICE FOR TREATING MULTIPLE SCLEROSIS-RELATED OVERACTIVE BLADDER SYMPTOMS

Introduction

Percutaneous tibial nerve stimulation (PTNS) is effective for managing multiple sclerosis (MS)-related overactive bladder (OAB) symptoms. However the need for weekly clinic visits restricts its use. The purpose of this study was to evaluate safety and efficacy of a novel, self-applying device for managing OAB symptoms.

Study design, materials and methods

48 patients reporting OAB (MS n=24, idiopathic n=24), were randomized (1:1) to either daily or weekly treatments for 12 weeks with geko™, a novel device stimulating the tibial nerve transcutaneously. Efficacy was assessed using validated questionnaires (ICIQ-OAB, ICIQLUTS-QoL) and bladder diaries filled at weeks 4, 8, and 12. Urinary neurotrophins (Nerve growth factor (NGF) and Brain derived neurotrophic factor) were measured.

Results

34 patients (MS n=19) completed the study. 18 patients responded to treatment (53%); 72% of responders belonged to the MS cohort. Multilevel regression analysis suggested significant improvements in questionnaire scores (ICIQ-OAB –10.2 (–13.5 to –6.9; p=0.001), ICIQLUTS-QOL –40.8 (–57.4 to –24.3; p=0.000)), without differences between weekly and daily-treated arms. No significant adverse effects were reported and patients rated the treatment as easy to use and comfortable. NGF levels at baseline were significantly greater in non-responders (p=0.05).

Concluding message

In this pilot study, a patch device suitable for self-application at home appears to be an effective, safe and convenient alternative for managing MS-related OAB symptoms.

Bradykinin modulates spontaneous nerve growth factor production and stretch-induced ATP release in human urothelium

The urothelium plays a crucial role in integrating urinary bladder sensory outputs, responding to mechanical stress and chemical stimulation by producing several diffusible mediators, including ATP and, possibly, neurotrophin nerve growth factor (NGF). Such urothelial mediators activate underlying afferents and thus may contribute to normal bladder sensation and possibly to the development of bladder overactivity. The muscle-contracting and pain-inducing peptide bradykinin is produced in various inflammatory and non-inflammatory pathologies associated with bladder overactivity, but the effect of bradykinin on human urothelial function has not yet been characterized. The human urothelial cell line UROtsa expresses mRNA for both B1 and B2 subtypes of bradykinin receptors, as determined by real-time PCR. Bradykinin concentration-dependently (pEC50=8.3, Emax 4434±277nM) increased urothelial intracellular calcium levels and induced phosphorylation of the mitogen-activated protein kinase (MAPK) ERK1/2. Activation of both bradykinin-induced signaling pathways was completely abolished by the B2 antagonist icatibant (1μM), but not the B1 antagonist R715 (1μM). Bradykinin-induced (100nM) B2 receptor activation markedly increased (192±13% of control levels) stretch-induced ATP release from UROtsa in hypotonic medium, the effect being dependent on intracellular calcium elevations. UROtsa cells also expressed mRNA and protein for NGF and spontaneously released NGF to the medium in the course of hours (11.5±1.4pgNGF/mgprotein/h). Bradykinin increased NGF mRNA expression and accelerated urothelial NGF release to 127±5% in a protein kinase C- and ERK1/2-dependent manner. Finally, bradykinin up-regulated mRNA for transient-receptor potential vanilloid (TRPV1) sensory ion channel in UROtsa. In conclusion, we show that bradykinin represents a versatile modulator of human urothelial phenotype, accelerating stretch-induced ATP release, spontaneous release of NGF, as well as expression of sensory ion channel TRPV1. Bradykinin-induced changes in urothelial sensory function might contribute to the development of bladder dysfunction.

Neurogenic detrusor overactivity in patients with spinal cord injury: evaluation and management

Lower urinary tract dysfunction can have a significant impact on patients with spinal cord injury. Over the years, many treatment options have become available. This article reviews the assessment and management of neurogenic detrusor overactivity, with a particular focus on articles from the recent literature. Recent guidelines on the subject will be discussed. Management options include antimuscarinics and bladder emptying measures, botulinum toxin A, and neuromodulation in refractory cases and surgery for intractable cases. Recent and relevant publications in these areas will be summarized and discussed.

Axial torsion as a rare and unusual complication of a Meckel's diverticulum: a case report and review of the literature

Introduction

In 1809, Johann Friedrich Meckel described the embryology of a small bowel diverticulum, which now bears his name. Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract, with a prevalence ranging from 1% to 4% of the population. The majority are clinically silent and are incidentally identified at surgery or at autopsy. The lifetime risk of complications is estimated at 4%, with most of these complications occurring in adults. It is these cases that can cause problems for the clinician, as the diagnosis can be elusive and the consequences extremely serious.

Case presentation

We present the case of a 68-year-old Caucasian man with axial torsion of a Meckel's diverticulum around its base, a rare complication. He presented with acute, severe abdominal pain, and a clinical diagnosis of perforated acute appendicitis was made. Laparotomy revealed a torted Meckel's diverticulum with distal necrosis and perforation, which was resected. His recovery was uncomplicated, and he was discharged to home six days post-operatively.

Conclusion

Torsion is an extremely rare complication of Meckel's diverticulum. Its presentation can be elusive, and it can mimic a number of different, more common intra-abdominal pathologies. Imaging appears to be an unreliable diagnostic tool, and the diagnosis is usually made intra-operatively. Factors pre-disposing these patients to axial torsion of Meckel's diverticulum include the presence of mesodiverticular bands, a narrow base, excessive length, and associated neoplastic growth or inflammation of the diverticulum. The importance of searching for a diseased Meckel's diverticulum at laparotomy in appropriate circumstances is highlighted. Once identified, prompt surgical excision generally leads to an uncomplicated recovery.

Epidemiological and other studies in the assessment of factors contributing to cataractogenesis

Some problems of cataract epidemiology are briefly reviewed. Studies of the incidence and prevalence of cataract, and of economic status, measure social need but cannot, by themselves, point to possible causes. Information on geographical or regional distributions and medical, clinical and occupational studies permit the formulation of socially, medically or experimentally testable hypotheses concerning specific contributory factors. We have found several such factors to be significantly associated with cataract; they appear to be risk factors. Some risk factors are associated with subclinical deviations from the range of normal concentrations of certain plasma constituents, whereas clinically or experimentally acute deviations are known to be rapidly cataractogenic. Other risk factors include medical conditions and certain drugs. Although individuals may have several risk factors, controls have significantly fewer than cataract patients of the same age. This difference in the number of risk factors is also age-related, as is the degree of divergence from the normal range in the concentrations of several plasma constituents.

Serum growth hormone measurements in clinical practice: An audit of performance from the UK National External Quality Assessment scheme

The replacement of growth hormone (GH) radioimmunoassays with a variety of more specific immunometric methods in diagnostic service laboratories has led to a worsening of between-laboratory agreement, reflecting differences in method bias. Incorrect calibration and differences in specificity are important causes of method bias, but the impact of this on interpretation is not clear. In order to maximize the diagnostic reliability of GH testing for small stature, manufacturers should carefully calibrate their methods against the appropriate GH International Standard, and should use antibodies of broadly agreed specificity. Laboratories performing GH tests should participate in a reliable External Quality Assessment (EQA) scheme and guidelines for investigation that incorporate normal GH responses should be agreed.

Variation in biochemical screening for Down's syndrome in the United Kingdom

A questionnaire survey was undertaken of all 73 laboratories performing Down's syndrome screening in 1995. An estimated 352,000 tests were performed representing 47% of maternities. Three-quarters of these tests have ultrasound dating information at the time of testing. The majority of laboratories (70%) commenced screening at 15 weeks of gestation or later, and there was considerable variation in the upper limit of screening (17 to 24 weeks). Eighty-six percent of laboratories screened all women regardless of age. The reported Down's syndrome risk was based on term in 85% of laboratories. There was an inconsistent approach to determining and reporting high risk for trisomy 18 (Edwards' syndrome): 5% reported risks on report forms and 42% notified the clinicians if the risk was considered to be raised.

Some plasma constituents correlate with human cataract location and nuclear colour

AIMS

To look for differences in levels of various plasma constituents between pair-matched controls and patients who had cataracts classified by location and appearance of lens opacity and nuclear colour in order to identify systemic risk factors.

METHODS

One thousand patients were taken from the cataract waiting list of a specialist eye hospital. For each patient, a matched control of the same sex and half-decade of age but without cataract was taken from the patient-list of the family doctor of the patient; the control was the next alphabetically after the patient on the doctor's list. At an early morning visit to the homes of both patients and controls, fasting, a team of nurses performed venepunctures and collected information for a questionnaire. Eye examinations were performed by a team of ophthalmologists.

RESULTS

Predominantly nuclear cataract was significantly associated with raised plasma alanine aminotransferase and bilirubin, posterior subcapsular cataract with increased calcium and urea, cuneiform with reduced potassium, mature/hypermature with raised potassium and reduced total carbon dioxide. The following were consistently significantly associated with all forms of cataract; diabetes and raised plasma glucose (not in non-diabetics), use of steroid medication, raised levels of cortisol (steroid users excluded), albumin, alkaline phosphatase, gamma-glutamyl transpeptidase, sodium and total protein and reduced levels of cholesterol and albumin/(total protein-albumin) ratio (an approximation for the albumin/globulin ratio). The multivariate analysis indicated that the most important non-specific cataractogenic effects were those of increased total protein, diabetes and use of steroid medication.

CONCLUSION

This and other studies support, broadly, the conclusions that senile or age-related cataract is not merely caused by increasing age and also that various morphological types have different risk factors. The mechanisms underlying the biochemical associations with different patterns of lens opacification and the identification of the ultimate risk factors remain to be elucidated.

Why do immunoassays for tumour markers give differing results?--a view from the UK National External Quality Assessment Schemes

External Quality Assessment schemes can provide unique insight into how current methods are performing in the field. Results from the UK National External Quality Assessment Schemes, which monitor performance of immunoassays for a number of tumour markers and peptide hormones in serum, show that in spite of considerable improvements resulting from increased assay automation, major discrepancies in results obtained are still observed. Reasons for this include poor calibration, use of antibodies of differing specificity, and vulnerability to clinically relevant interferences. Variation in quoted reference ranges is also a cause of concern. Each of these important aspects of performance will require attention if improved between-method and between-laboratory agreement is to be achieved.

Some blood plasma constituents correlate with human cataract

AIMS

To look for differences between matched pairs of patients and controls in concentrations of various plasma constituents which might indicate dysfunctions associated with cataract.

METHOD

One thousand patients were taken from the cataract waiting list of a specialist eye hospital. For each patient a matched control of the same sex and half-decade of age but without cataract was taken from the patient list of the family doctor of the patient; the control was the next alphabetically after the patient on the doctor's list. The patients and controls were visited in their homes by a team of nurses who performed venepunctures and collected information for a questionnaire. Eye examinations were performed by a team of ophthalmologists.

RESULTS

Significant differences were found between the cataract and control groups in 10 of the 18 examined plasma constituents. A constellation of three--bilirubin, alkaline phosphatase, and gamma glutamyl transpeptidase--was significantly higher in the cataract group, suggesting subclinical liver dysfunction as a risk factor. Steroid treatment and diabetes increased cataract risk. Endogenous basal plasma cortisol levels were raised in the cataract group, irrespective of steroid use and diabetic status. Alkaline phosphatase, calcium, glucose, and sodium were all raised in the cataract group. Given the raised total protein and albumin also found in the cataract group, the lower albumin/(total protein-albumin) ratio (an approximation for albumin/globulin ratio) may imply an increase in globulin, suggestive of possible (chronic) infection. Total cholesterol was lower in the cataract group.

CONCLUSION

Human cataract in older age groups seems to be due to an accumulation of risk factors, even if individual mean concentrations are well within normal limits but, of course, differing significantly from the corresponding means in the control population.

Raised carcinoembryonic antigen level as an indicator of recurrent disease in follow up of patients with colorectal cancer

BACKGROUND

Serum carcinoembryonic antigen level is raised in 80% of patients undergoing colonic resection for cancer. Subsequent elevation in the follow-up period may precede signs and symptoms as an indicator of recurrent disease. there is little evidence that "classical" follow up of patients in the general surgical outpatient clinic improves either survival or quality of life. Regular carcinoembryonic antigen level estimation requested by the general practitioner, allied to day-case colonoscopic surveillance may be a more rational approach.

AIM

A study was undertaken to investigate the relationship between raised carcinoembryonic antigen level and the recurrence of colorectal cancer in patients following a curative primary resection.

METHOD

Retrospective analysis was carried out on the notes of 125 patients who had attended a dedicated hospital colorectal follow-up clinic between 1988 and 1992. Carcinoembryonic antigen level data were obtained by subsequent examination of the University of Edinburgh Department of Clinical Chemistry (immunoassay section) carcinoembryonic antigen database.

RESULTS

A single carcinoembryonic level result of more than 100 ul-1 (normal range less than 60 ul-1) was found to be a highly sensitive (87%), specific (89%), and accurate (88%) indicator of recurrent disease. Raised carcinoembryonic antigen level preceded symptoms in 72% of patients with recurrence of colorectal cancer.

CONCLUSION

Sequential laboratory estimation of carcinoembryonic antigen level organized by the general practitioner may represent an accurate method of detecting recurrent colorectal disease. Hospital review could be limited to colonoscopic surveillance and restaging of patients referred with evidence of recurrent disease.

Serological markers for metastatic breast cancer

Three serum markers, TPS, CA 15.3 and CEA, were used to monitor the response to treatment of 20 patients with metastatic breast cancer. At the time of the first evidence of metastases or at the time of progression of known metastatic disease, 84% of TPS values were above the reference limit, as compared to 74% for CA 15.3 and 84% for CEA. If the treatment instituted was effective, 60% of TPS values showed an early (within 2 or 3 weeks after commencement or change of therapy) reduction in level against only 27% of CA 15.3 and 27% of CEA levels. This suggests that TPS provides a more sensitive and earlier predictor of therapeutic response. In patients with clinical evidence of further progression of disease while on therapy, 86% of TPS values showed persistent elevation or increase, as compared to 71% of CA 15.3 levels and only 36% of CEA levels. It was also noted in these patients that TPS values rose earlier than either CA 15.3 or CEA. This indicates that TPS is a more reliable predictor of response to treatment than the other two markers. In addition, we found that, at the time of presentation, in women who had visceral metastases (liver, lung, or brain alone or in combination), 87% of TPS values were raised, as compared to 80% of CA 15.3 and 73% of CEA values. In women who had bone and soft tissue metastases at presentation, 75% of TPS values were elevated, against 50% of CA 15.3 and 75% of CEA values.(ABSTRACT TRUNCATED AT 250 WORDS)