Innominate Salter osteotomy using resorbable screws: a retrospective case series and presentation of a new concept for fixation

PURPOSE

The Salter innominate osteotomy (SIO) in children is traditionally stabilized by Kirschner-wires, which have issues regarding stability, infection and the need to be extracted. To counter these disadvantages, we present a surgical method to stabilize SIO with modern resorbable poly lactic-co-glycolic acid screws. Using a case series of 21 patients treated with SIO for developmental dysplasia of the hip or Legg-Calvé-Perthes disease we evaluate the feasibility of the method.

METHODS

The integrity of the osteotomy was interpreted by radiological measurements of acetabular index, centre-edge angle and Reimer's index. Perioperative and postoperative complications were evaluated.

RESULTS

Radiographic evaluation revealed a stable osteotomy and favourable development in all measured parameters with the exception of one patient who fell out of bed the first day postoperatively. No other perioperative surgical complications were observed and there were no local reactions to the resorbable screws.

CONCLUSION

Modern resorbable screws carry multiple benefits both for the patient and the surgeon. In our case series the implants provided sufficient stability and the implants caused no local reactions. The use of resorbable implants gave the surgeon a wider range of possible screw placements and avoided the need for implant removal.

LEVEL OF EVIDENCE

Level IV - Case series.

Cardiovascular outcomes among sildenafil users: results of the International Men's Health Study

AIM

To assess the incidence of serious cardiovascular disease (CVD) events [i.e. myocardial infarction (MI) and stroke] and all-cause mortality in men with erectile dysfunction (ED) who received prescriptions for sildenafil.

METHODS

The International Men's Health Study (IMHS) was a prospective, observational cohort study of patients with ED and a new or existing prescription for sildenafil. Baseline and follow-up questionnaires provided information on demographics, CVD risk factors and ED. Postevent questionnaires were mailed to patients following possible nonfatal CVD events to collect information related to exposure to sildenafil/ED treatments before the event.

RESULTS

Thirty-five CVD events were reported in 30 patients in the analysis set (n = 3813). The incidence of all-cause mortality, MI and stroke was 0.4, 0.6 and 0.1 per 100 patient-years of observation respectively. Among the six men who reported using sildenafil in the month before a nonfatal CVD event, two reported use in the 24 h before the event.

CONCLUSION

The results of the IMHS support previous reports that ED and CVD are often comorbid and share risk factors.

The results of routine evaluation of adult patients with haematuria analysed according to referral form information with 2-year follow-up

OBJECTIVE

With the principal aim of determining how often investigation of haematuria results in a malignancy diagnosis, the referrals (n = 581) during one year to a department of urology (catchment area 250,000 inhabitants) where haematuria was mentioned in the referral form have been registered and analysed. The case records were evaluated after two years.

RESULTS

The tumours detected were mainly bladder tumours (n = 43) and prostate cancers (n = 31). Only three upper urinary tract tumours were diagnosed. The incidence of malignancies was high in patients with macroscopic haematuria (24%), especially if it was asymptomatic (32%). The incidence was lower in microscopic haematuria (9%), especially if it was asymptomatic (5%). The incidence of malignancies was strongly age- and sex-related; in no female under 70 years and in no male under 45 years of age with microscopic haematuria was a malignant tumour detected.

CONCLUSION

Macroscopic haematuria, especially in older patients, is often associated with a malignancy and the investigation must be given high priority. The incidence of malignant tumours in patients with symptomatic microscopic haematuria also warrants an investigation. In the case of asymptomatic microhaematuria. the risk is so low, especially in women that the need for a work-up must be strongly questioned.

[When is it meaningful to investigate hematuria? Macroscopic hematuria--investigate always. Microscopic hematuria--symptoms and age decide]

All patients (n = 578) referred during one year and for whom hematuria was mentioned in the referral form were monitored following urological evaluation including urography and cystoscopy. Evaluation of macroscopic hematuria was often associated with significant findings at both urography (stones) and cystoscopy (bladder tumors). The situation was the same even if not as pronounced for evaluation of microscopic hematuria with concomitant urinary tract symptoms. The evaluation of asymptomatic microscopic hematuria was, however, very rarely associated with significant findings, which were moreover totally lacking among women and younger males.

Urine tissue-polypeptide-specific antigen (TPS) as a marker for bladder cancer

OBJECTIVES

To determine the sensitivity and specificity of urine tissue-polypeptide-specific antigen (TPS) for bladder carcinomas and to evaluate whether urine TPS is influenced by tumour size, number, grade and stage.

PATIENTS AND METHODS

A total of 260 patients entered the study, one group (n = 151) with known bladder cancer disease (79 with recurrent tumour and 72 with no tumour at cystoscopy). The other group (n = 109) consisted of patients without previously known bladder tumour disease, 55 with newly detected bladder tumour(s) and 54 investigated for microhematuria found to be idiopathic. TPS in urine was measured using an ELISA-kit, a solid phase two-site immunosorbent assay with polyclonal antibodies against cytokeratin 18.

RESULTS

Urine TPS was significantly higher in patients with bladder tumours (p < 0.001). There was a significant correlation between TPS and tumour size (p = 0.004), grade (p = 0.001) and stage (p = 0.001). Tumour number was not significantly correlated to urine TPS (p = 0.75). With TPS 42 as a cut-off level, the sensitivity was 73% for newly detected tumours and 50% for recurrences; the specificity was 70% and 63% respectively. With a 95% specificity, the sensitivity for newly detected tumours was 33% and for recurrences 18%. The lower sensitivity and specificity for recurrences was mainly explained by differences in tumour size, grade and stage between the recurrences and the newly detected tumours.

CONCLUSIONS

Urine TPS is a marker for bladder carcinoma correlated to size, grade and stage. The sensitivity and specificity for newly detected tumours are quite comparable with other markers. Its clinical usefulness is however not established and it appears less useful in the follow-up of patients with known bladder tumour disease.

[Both major breakthroughs and stagnation in urology. Industry, together with clinicians, are responsible for most innovations]

Urology is a specialty with many branches, including urological oncology with 25% of all cancers. Development in certain areas been very rapid, for instance with the introduction of minimally and non-invasive methods such as ESWL and phosphodiesterase inhibitors, innovations which have brought obvious improvements and have been promptly adopted in clinical practice. In other areas such as chronic abacterial prostatitis and renal cancer, progress has been very limited. Still other areas have seen useful but less spectacular improvements for which it has taken time, clinical experience and a multitude of clinical studies before they have been embraced in daily clinical practice. Examples of these more gradual developments are hyperthermia for the treatment of benign prostatic hyperplasia and transrectal ultrasound in prostate cancer.

The importance of glucose for the Escherichia coli mediated citrate depletion in synthetic and human urine

OBJECTIVE

Escherichia coli has previously been shown to reduce urine citrate and influence urine pH. In this study the influence of glucose on the E. coli mediated citrate decrease has been investigated.

MATERIAL AND METHODS

In synthetic urine, a glucose concentration of > or = 1 mmol/l was a prerequisite for bacteria to grow and lower citrate. At glucose concentrations > or = 5 mmol/l an E. coli mediated pH decrease correlated to urine glucose was observed.

RESULTS

In human urine, variations in urine glucose influenced the citrate decrease and addition of glucose accelerated the E. coli mediated citrate decrease, which in certain urines could be very pronounced.

CONCLUSIONS

Citrate has a pronounced effect on the activity product of calcium oxalate and calcium phosphate and the E. coli mediated decrease in urine citrate may be involved in the formation of urinary tract stones and catheter encrustations.

Stage progression in Ta papillary urothelial tumors: relationship to grade, immunohistochemical expression of tumor markers, mitotic frequency and DNA ploidy

PURPOSE

We studied 363 patients with stage Ta bladder tumors during long-term followup who were classified according to the 1998 WHO and International Society of Urological Pathology consensus classifications. We determine whether various immunohistochemical and molecular markers could predict tumor progression.

MATERIALS AND METHODS

A total of 680 patients in western Sweden with a first diagnosis of bladder carcinoma in 1987 and 1988 were registered and followed for at least 5 years. There were 363 (53%) tumors that were papillary stage pTa. The tumors were classified as papillary urothelial neoplasm of low malignant potential in 95 patients, low grade papillary urothelial carcinoma in 160 and high grade carcinoma in 108. Of the patients in the latter group 95 were subdivided into WHO grade 2 and 13 into WHO grade 3. Tissue from the primary tumors that progressed in stage during followup was further analyzed with immunohistochemical methods (p21, p53, Ki67 and pRb), DNA ploidy and mitotic frequency. The results were compared with those in matched controls (nonprogressors).

RESULTS

Recurrence developed in 35% of patients with papillary urothelial neoplasm of low malignant potential compared to 71% with low grade urothelial carcinoma and 73% with high grade carcinoma (p <0.0001). No papillary urothelial neoplasm of low malignant potential progressed in stage. Disease progressed in 4% of patients with low grade compared to 23% with high grade carcinoma (p <0.0001). Of the patients with WHO grade 3 disease progressed in 45% compared to grade 2 in 20% (p <0.0011). At first diagnosis p53 score was significantly higher (p <0.0022) among patients with WHO grade 2 carcinoma which later progressed compared to that in matched controls but there was no significant difference regarding the other markers. In contrast to grade 2 most grade 3 carcinoma was aneuploid, had high mitosis frequency, high p53 and Ki67 scores as well as loss of retinoblastoma gene expression.

CONCLUSIONS

The 1988 WHO and International Society of Urological Pathology consensus classifications divide noninvasive papillary bladder tumors into 3 subgroups with different clinical behavior, which seems to be an advantage compared with the 1973 WHO classification. A disadvantage is that the high grade carcinoma group contains 2 subgroups with different progression rates and immunohistochemical marker profiles, corresponding to the 1999 WHO grades 2 and 3. Grade 2 tumors in patients that progressed in stage years later seem to have different immunohistochemical and molecular marker profiles compared to those in matched controls.

[Viagra is first choice preparation in the treatment of erectile dysfunction. Access to a variety of methods makes individual treatment possible]

Several pharmacological treatments for erectile dysfunction (ED) have recently been introduced. This study performed during 1999 shows that in Sweden mostly men in their 60's, often with circulatory disease and/or diabetes, where the ones who were treated for ED. The most frequently used drug (80%) is sildenafil (Viagra). The mean consumption is 4.8 tablets per month, the same consumption as for intracavernous prostaglandin injections. The pattern of prescription doesn't differ between general practitioners and urological surgeons. No evidence for "overconsumption" became evident in the study. Presently, the majority of men who seek help for ED are middle-aged, have circulatory disease and are prescribed sildenafil (Viagra).

Prospective registration of all patients in a geographical region with newly diagnosed bladder carcinomas during a two-year period

OBJECTIVE

To report the age, stage and grade of all patients with newly diagnosed bladder carcinoma in a well-defined geographical region and to compare this cohort with previous reports which come mainly from large referral centres.

MATERIAL AND METHODS

All newly diagnosed bladder carcinoma patients (n = 701) in Western Sweden were prospectively registered during a 2-year period (1987-88). The histopathological material was re-examined by a reference pathologist. All the original clinical records were reviewed by one urologist 5-7 years after diagnosis. Demographic data, tumor grade, stage, multiplicity, presence of carcinoma in situ and lymphatic invasion are presented.

RESULTS

The mean age at diagnosis was 70.5 years. Grade and stage increase with age. The proportion of non-invasive tumors (55%) is higher than in any previous Scandinavian report. The age-standardized incidence in bladder carcinoma among men in the largest city (Göteborg) is 55% higher than in the rest of the region (p<0.0001). Deviations between the primary pathologist and the reviewer with regard to tumor grade were particularly seen in tumors of grades I and II.

CONCLUSIONS

Differences in mean age, stage and grade distribution were found between the present report, which included all patients with newly diagnosed bladder carcinoma in a geographical area, and other reports, which mainly comprised patients from large treatment centres. These differences can probably and mainly be explained by selection factors such as various degrees of inclusion of low-grade papillary tumors.

Recurrence and progression in low grade papillary urothelial tumors

PURPOSE

We report long-term followup data on patients with World Health Organization (WHO) grade I bladder tumors, and determine whether histopathological subgrouping as papillary neoplasm of low malignant potential and low grade papillary carcinoma is of clinical value.

MATERIALS AND METHODS

All 680 patients in western Sweden with first diagnosis of bladder carcinoma in 1987 to 1988 were registered and followed for at least 5 years. Of the tumors 255 (37.5%) were stage Ta, WHO grade I. Tumors were further classified as papillary neoplasm of low malignant potential in 95 patients and low grade papillary carcinoma in 160 according to WHO and the International Society of Urological Pathology consensus classification of urothelial (transitional cell) neoplasms of the bladder.

RESULTS

Mean age of patients at first diagnosis of low grade papillary carcinoma was 69.2 years, which was 4.6 years higher than those with papillary neoplasm of low malignant potential (p<0.005). During a mean observation time of 60 months our 255 patients underwent 577 operations for recurrences and had 1,858 negative cystoscopies. The risk of recurrence was significantly lower in patients with papillary neoplasm of low malignant potential compared to those with low grade papillary carcinoma (35 versus 71%, p<0.001). The risk of recurrence was higher in patients with multiple tumors at first diagnosis as well as those with recurrence at the first followup after 3 to 4 months. Stage progressed in 6 patients (2.4%), all with low grade papillary carcinoma at diagnosis.

CONCLUSIONS

More than 90% of patients with stage Ta, WHO grade I have a benign form of bladder neoplasm, and few have truly malignant tumors. Future research should focus on reducing the number of recurrences and followup cystoscopies, and finding methods to identify malignant tumors so that pertinent treatment can be instituted. Subgrouping of WHO grade I bladder tumors as papillary neoplasm of low malignant potential and low grade papillary carcinoma seems to add valuable prognostic information.

Long-term followup of a bladder carcinoma cohort: routine followup urography is not necessary

PURPOSE

We evaluate whether routine excretory urography is needed in the long-term followup of patients with bladder carcinoma.

MATERIALS AND METHODS

A total of 680 patients with an initial diagnosis of bladder carcinoma from 1987 to 1988 in western Sweden were prospectively registered and followed for at least 5 years. All carcinomas of the kidney, renal pelvis and ureter, and all surgically treated cases of ureteral stricture were registered.

RESULTS

During followup renal pelvic or ureteral carcinoma developed in 16 patients, renal cell carcinoma was diagnosed in 2 and 6 underwent surgery for benign obstruction of the distal ureter.

CONCLUSIONS

The low annual incidence of malignant upper urinary tract and renal tumors as well as ureteral strictures supports our opinion that routine imaging of the upper urinary tract is not indicated during followup of patients with bladder carcinoma. We recommend urography at initial diagnosis of bladder carcinoma, when tumor progression occurs and when symptoms or signs raise suspicion of upper urinary tract disease.

Stone fragmentation pattern of piezoelectric shockwave lithotripsy in vitro

Whole stones (N = 64; largest diameter 5-15 mm) were treated in vitro with piezoelectric shockwaves using the Edap LT-01 lithotripter with 2.5 Hz at either 100% or 54% power. The number of fragments larger than 2 mm was counted after every 30 seconds. The stones were defined as totally broken when all fragments were < 2 mm. Total fragmentation time was correlated with the energy level and the size of the stone. The number of large fragments did not correlate with the energy level but rather with the original size of the stone.

Irradiation of localized prostatic carcinoma with a combination of high dose rate iridium-192 brachytherapy and external beam radiotherapy with three target definitions and dose levels inside the prostate gland

PURPOSE

Localized prostate cancer was treated with combined external beam radiotherapy and high dose rate Ir-192 brachytherapy with the purpose of a high dose. The technical aspects of a modified treatment are described.

METHODS

The brachytherapy was given in two sessions preceded and succeeded by external beam radiation. The radioactive source was temporarily implanted by a remote afterloading device through six to 15 needles inserted transperineally guided by transrectal ultrasound. The entire prostate gland was included in the clinical target volume. The urethra and the tumour volume could be defined and irradiated to different dose levels in more than 90% of the patients.

RESULTS

Fifty-four patients were treated. The total dose to the prostate was approximately 70 Gy and to the tumour volume 80 Gy. By calculating the corresponding dose given by 2.0 Gy fractions, considering the radiobiology by using the LQ formula and assuming an alpha/beta value for prostate tissue of 10, the dose to the prostate was approximately 84 Gy and to the tumour volume 112 Gy. For the late effects to the urethra an alpha/beta value of 3 was used, which corresponds to 85 Gy. The brachytherapy could be given with accuracy except when the dorsal border of the prostate was concave. The dose distribution then tended to be less satisfactory. Post-treatment calculations showed that the maximum dose to the rectum was 67 Gy (radiobiologically corrected to 88 Gy), given in a small volume. The early side effects from the brachytherapy were minimal. The treatment could not be performed as intended in four patients; three patients had a narrow pelvis and in one patient the prostate was unusually resilient, preventing the needles from being positioned properly.

CONCLUSIONS

This modification of a previously reported brachytherapy technique for prostate carcinoma permits a high radiation dose to the tumour and to the prostate gland, which ultimately may improve local control.

Palliative effect of intravesical bacillus Calmette-Guerin in elderly patients with advanced bladder carcinoma

PURPOSE

Intravesical bacillus Calmette-Guerin (BCG) was used to palliate severe local symptoms in patients with invasive carcinoma.

MATERIALS AND METHODS

Four patients with unresectable bladder carcinoma who were unfit for radical cystectomy because of age and poor performance status were treated with a 6-week course of BCG followed by monthly instillations.

RESULTS

Urgency and frequency were reduced in 3 patients and the improvement lasted for 9 to 19 months. All 4 patients ultimately died of bladder carcinoma.

CONCLUSIONS

The results of palliative BCG treatment were encouraging, but further experience is necessary.

Combined treatment with temporary short-term high dose rate iridium-192 brachytherapy and external beam radiotherapy for irradiation of localized prostatic carcinoma

PURPOSE

To evaluate the treatment outcome after radical radiotherapy of localized prostate cancer in 50 patients (38 patients with stage T1-2 and 12 patients with stage T3) after a median follow-up time of 45 months (range 18-92 months).

METHODS

The treatment was given by combination of external beam radiotherapy (50 Gy) and brachytherapy (2 x 10 Gy). The brachytherapy was given using TRUS-guided percutaneously inserted temporary needles with a high dose rate remote afterloading technique with Ir-192 as the radionuclide source. Three target definitions and dose levels inside the prostate gland were used. Local control was evaluated by digital rectal examination, TRUS-guided biopsies and serum PSA evaluations.

RESULTS

Clinical and biopsy verified local control was achieved in 48 of the 50 (96%) patients; for stage T1-2 in 37 of 38 (97%) patients and for stage T3 in 11 of 12 (92%) patients. A posttreatment serum PSA level < or =1.0 ng/ml was seen in 42 (84%) patients, values from >1.0 to < or =2.0 ng/ml were seen in four (8%) patients and values exceeding 2.0 were seen in four (8%) patients. The late toxicity was minimal.

CONCLUSION

The local control results and the minimal toxicity after the combined radiotherapy treatment are promising. However, long term results are necessary before general use.

Analysis of the local control in lymph-node staged localized prostate cancer treated by external beam radiotherapy, assessed by digital rectal examination, serum prostate-specific antigen and biopsy

OBJECTIVE

To describe local disease control after radical external beam radiotherapy of prostatic carcinoma, as judged by digital rectal examination (DRE), transrectal ultrasonography (TRUS)-guided biopsies and estimates of serum prostate-specific antigen (PSA).

PATIENTS AND METHODS

The study comprised 175 patients (mean age 67.5 years, range 49-82; > 90% aged > or = 60 years) with localized prostatic carcinoma (T1-T3C, N0, M0) who underwent external beam radiation therapy (70 Gy), and were then regularly followed with a DRE, measurements of serum PSA and TRUS-guided biopsies to determine the outcome.

RESULTS

The DRE revealed four patients with evidence of residual cancer in the prostate and biopsies showed no evidence of residual cancer in 131 (75%) of the patients. There was no correlation of residual cancer with tumour stage or grade but tumour size, as estimated by TRUS, correlated with the results of the biopsy. The nadir serum PSA level was < or = 1.0 ng/mL in 116 (66%) of the patients, of whom 76 (43%) had a nadir serum PSA level of < or = 0.5 ng/mL. The median time to the nadir level was 11 months. Serum PSA progression (> 4.0 ng/mL) at the latest PSA measurement after reaching the nadir occurred in 13% of the patients with a nadir PSA of < or = 0.5 ng/mL and in 25 of the 29 (86%) patients with a nadir serum PSA > 2.0 ng/mL. Cox regression analysis showed that tumour size and rectal irradiation dose were the most important factors for local control.

CONCLUSIONS

Radiotherapy is effective in achieving local control in small prostate cancer tumours but less effective in large tumours. Tumour size and dorsal extension of the irradiated target, the rectal dose, were the two important factors for local control. A serum PSA level of < or = 1.0 ng/mL was associated with a higher chance of prolonged disease control.

Long-term followup of all patients with muscle invasive (stages T2, T3 and T4) bladder carcinoma in a geographical region

PURPOSE

We studied the relationship between long-term survival and treatment of stages T2, T3 and T4 bladder carcinoma in an unselected patient population.

MATERIALS AND METHODS

A total of 680 patients with the initial diagnosis of bladder carcinoma in 1987 to 1988 in Western Sweden was prospectively registered and followed until 1994. Of these patients 107 had stage T2 to T3 and 41 had stage T4 disease.

RESULTS

Of the patients with stage T2 to T3 disease 30 (mean age 66) underwent radical cystectomy, 33 (mean age 75) full dose radiotherapy and 44 (mean age 81) nonradical therapy (mainly transurethral resection of the bladder). The 5-year crude survival rates were 33, 15 and 14%, respectively. Of the patients with stage T4 disease 6 (mean age 61) underwent radical cystectomy, 9 (mean age 73) full dose radiotherapy and 26 (mean age 81) nonradical therapy (mainly transurethral resection of the bladder). All except 1 patient died of disease within 4 years.

CONCLUSIONS

More than 60% of the patients in the cohort were considered unsuitable for radical cystectomy and their survival was poor, whether treated with full dose radiotherapy or transurethral resection of the bladder alone.

Radiotherapy of localised prostate cancer. Analysis of late treatment complications. A prospective study

PURPOSE

To describe the late side-effects of radical radiotherapy of prostatic carcinoma and to analyse how pretreatment and treatment-related factors contribute to the toxicity.

MATERIALS AND METHODS

184 patients have regularly been followed after terminated radical external beam radiotherapy treatment (70 Gy) for a mean of 46 (range 24-96) months. For registration of toxicity a modified RTOG scale was used. The Cox regression model was used for multivariate analysis.

RESULTS

37% of the patients had no late side-effects at all. Mild complications were reported by 53%, mainly gastrointestinal (42%) and urogenital (23%). A persistent improvement of the mild toxicity was seen in nearly half of the patients with gastrointestinal or nocturnal frequency side-effects. Only 16 (9%) patients had moderate or severe complications. The multivariate analysis revealed that the risk of posttreatment complications was strongly correlated to pretreatment presence of symptoms from the organs at risk. Posttreatment complications presenting first 3 years after irradiation were rare.

CONCLUSIONS

Radical external beam radiotherapy (70 Gy) can be given with a low risk of severe complications. It appears reasonable to assume that the risk can be further reduced by excluding patients with gastrointestinal and urinary tract disease or symptoms.

Long-term followup of a bladder carcinoma cohort: questionable value of radical radiotherapy

PURPOSE

We studied the outcome of radical radiotherapy for bladder carcinoma in all patients from a well-defined region.

MATERIALS AND METHODS

All 701 cases with a new bladder carcinoma between 1987 and 1988 in Western Sweden were prospectively documented and followed until 1994. Between 1987 and 1994, 74 of the 701 patients (mean age 73 years, range 54 to 88) were treated with external beam radiotherapy (60 Gy. or more).

RESULTS

At least 84% of the patients had persistent tumor, a local recurrence or a symptomatic contracted bladder after external beam radiotherapy. Seven patients (9.5%) died of early or late treatment related complications. Of only 8 long-term survivors 6 had undergone radical transurethral resection before external beam radiotherapy.

CONCLUSIONS

Full dose external beam radiotherapy in patients with bladder carcinoma was associated with high local recurrence and serious complication rates. It must be questioned whether elderly patients actually benefit from full dose radiotherapy.

The importance of the depth of invasion in stage T1 bladder carcinoma: a prospective cohort study

PURPOSE

We studied the depth of invasion in the lamina propria in all patients with primary stage T1 bladder cancer in a geographical region and related the findings to the long-term prognosis.

MATERIALS AND METHODS

All 121 primary stage T1 tumors diagnosed in western Sweden between 1987 and 1988 were analyzed with respect to the depth of invasion in relation to the lamina muscularis mucosae. All clinical records were reviewed in 1994 and 1995.

RESULTS

More than 90% of the histopathological specimens could be separated into superficially (pT1a) or deeply (pT1b) invasive stage T1 tumors. Grade 3 tumors were significantly more common among patients with stage pT1b disease (79 versus 40%, p < 0.001). Patients with stage pT1b grade 3 cancer had a higher progression rate (58 versus 36%, p > 0.05) and an almost doubled risk of dying of bladder carcinoma compared to those with stage pT1a grade 3 disease (45 versus 23%, p > 0.05). Carcinoma in situ at the primary operation was associated with an impaired prognosis in patients with grade 3 tumors regardless of the depth of invasion in the lamina propria.

CONCLUSIONS

The prognosis is poor in patients with deep lamina propria invasion (stage pT1b) treated with transurethral resection alone. Patients treated with radical cystectomy had excellent survival regardless of the depth of invasion in the lamina propria. Radiotherapy was associated with poor survival.

[Outpatient treatment of bladder cancer--lower cost and satisfied patients]

Transurethral resection of bladder tumours and recurrences accounts for a substantial part of the workload at a urology unit. With the aim of reducing costs, since 1992 we have performed transurethral resection as an out-patient procedure if possible. Transurethral resection as day surgery in selected patients has been enabled by the use of extirpation and fulguration under cover of intravesical lignocaine (lidocaine) anaesthesia or submucosal lignocaine injection. Before the introduction of the out-patient treatment policy, around 270 transurethral resections of bladder tumours were performed annually at a cost of SEK 5.7 million. During 1994 and 1995, almost half of the procedures could be performed in an out-patient setting, with minimal complications and a very high level of patient acceptance, the respective reductions in costs being SEK 2.4 million and SEK 3.2 million.

Concrement formation and urease-induced crystallization in urine from patients with continent ileal reservoirs

OBJECTIVES

To study the relationship between urinary tract infection, urine composition and concrement formation in patients with continent ileal reservoirs for urinary diversion.

PATIENTS AND METHODS

The study comprised 27 patients (seven men and 20 women, mean age 47 years, range 23-76) with continent ileal reservoirs who were followed for a mean of 67 months (range 13-146) by annual reservoiroscopy, intravenous urography and urine culture; at the final follow-up, a sample of their morning urine was analysed for a range of compounds and the number and size of any particles present or produced in response to incubation with urease.

RESULTS

The presence of urease-producing bacteria was associated with the formation of concrement. However, a few patients in whom an infection with urease-producing organisms was not detected also formed concrement. Urine from those patients forming stones tended to have a high calcium and a low citrate concentration. After incubation with urease, significantly more and larger particles were formed in the urine from stone formers. There was a strong correlation (r = 0.8) between urinary calcium content and urinary pH when the urease-induced precipitation commenced, and between urinary calcium and the size and volume of the crystals developed (r = 0.9) after 4 h of incubation.

CONCLUSIONS

There are many factors which might influence the formation of concrement, e.g. outflow conditions, the presence of staples or infection in the reservoir, and the composition of the urine is also important. It thus appears appropriate to determine if measures to reduce urinary calcium and increase urinary citrate can decrease the episodes of stone formation in those patients with continent ileal reservoirs for urinary diversion who frequently form stones.

Effect of indomethacin on N-[4-(5-nitro-2-furyl)-2-thiazolyl]formamide-induced urinary tract carcinogenesis

The effects of indomethacin on the urinary bladder and renal pelvis in rats treated with N-[4-(5-nitro-2-furyl)-2-thiazolyl]formamide (FANFT) were studied. Two hundred female Sprague-Dawley rats were divided into four groups. Group 1 received control diet without added chemicals. Group 2 was treated with indomethacin (1 mg/kg per day) in the drinking water throughout the experiment. Groups 3 and 4 received 0.2% FANFT in the diet for seven weeks followed by control diet. In addition to FANFT, Group 4 received indomethacin, 1 mg/kg per day, for the entire experiment. The rats were sacrificed after 92 weeks. There were no urothelial tumors in the control group, one renal pelvic tumor in the indomethacin group, 4 tumors in the FANFT group and 10 urothelial tumors in the FANFT + indomethacin group. The difference between Groups 3 and 4 was statistically significant (P < 0.05). Moderate and severe hyperplasia of the renal pelvic and papillary epithelium was found in 15 of 48 rats in Group 2 (indomethacin only) as compared with 6 of 49 control rats (P < 0.05). Moderate and severe hyperplasia was equally frequent in Groups 3 and 4 (14 and 17 animals in each group, respectively). Twenty-four rats in Group 2 had mammary tumors as compared to 12 animals in Group 1 (P < 0.01). Five of the tumors in Group 2 were adenocarcinomas. There was no difference between the number of mammary tumors in Groups 3 and 4 (36 and 32 animals in each group, respectively). The results suggest that indomethacin enhances FANFT-induced urinary tract carcinogenesis. Indomethacin also seems to exert some tumorigenic activity in the mammary gland.

The relationship among multiple recurrences, progression and prognosis of patients with stages Ta and T1 transitional cell cancer of the bladder followed for at least 20 years

A retrospective study was done on 176 patients with primary stages Ta and T1 bladder cancer treated between 1963 and 1972. One patient was lost to followup after 6 years, while the remainder were followed to death or for at least 20 years. In 1993, 13 patients had no evidence of disease, 39 died of bladder cancer and 123 died of intercurrent disease. Of 77 patients with a primary noninfiltrating tumor and 99 with a primary lamina propria invasive tumor 9 (11%) and 30 (30%), respectively, died of bladder cancer. Recurrences were noted on 10 or more cystoscopic studies in 16 patients and 10 died of bladder cancer 3.5 to 19 years after the primary transurethral resection. A total of 14 patients received repeated thiotepa instillations, all continued to have recurrences and 10 subsequently died of bladder cancer. Only 1 upper tract tumor was diagnosed on routine followup excretory urography. Invasive transitional cell carcinoma of the bladder developed in only 1 of 59 patients who had been tumor-free for 5 years. The results indicate that patients with recurrences on 10 or more cystoscopic studies will continue to have recurrences until death or cystectomy. Recurrence more than 4 years after the primary tumor operation is another ominous sign. Repeated thiotepa instillations did not influence the course of the disease in patients with a history of multiple recurrences. Followup cystoscopy may be discontinued 5 to 10 years after the last recurrence, at least in patients with a solitary low grade primary tumor. Routine followup urographic studies are neither cost-effective, clinically indicated nor justified in patients with superficial bladder cancer.

Laparoscopic obturator lymph node dissection in patients with prostatic cancer

The result of 33 laparoscopic obturator lymph node dissections in patients with locally confined prostatic cancer are presented and compared with open surgery dissections. The hospitalization time was 3 days with the laparoscopic technique, a reduction by 50% compared with open surgery. The operation time was increased from 60 to 100 minutes. No serious complications were encountered. The postoperative recovery was fast and uneventful. The number of glands dissected out was slightly lower than that at open surgery. Obturator lymph node metastases were found in 15% of the patients in the laparoscopic series.

The effects of sodium citrate and oral potassium citrate on urease-induced crystallization

OBJECTIVES

To study the effects of citrate on urease-induced crystallization in human urine.

MATERIALS AND METHODS

Urine samples were collected from seven healthy volunteers with no history of urinary tract infection or stone disease. Citrate was removed from the urine samples by decomposition with citrate lyase. Citrate was then added to the urine in increasing concentrations. Oral potassium citrate was given to the volunteers and their urine was collected. The samples were incubated with urease and the crystallization induced was observed by the Coulter counter technique, by using an optical microscope and by precipitated material analysis.

RESULTS

The initiation of crystallization was markedly delayed by both the addition of citrate to the urine and after the ingestion of citrate. Crystal growth and the resulting precipitation of both calcium and magnesium showed a concentration-dependent reduction when citrate was added up to a concentration of 4 mM. Crystal growth and precipitation of calcium and magnesium were also significantly decreased by oral citrate intake.

CONCLUSION

Citrate added to the urine or taken orally markedly delays urease-induced crystallization in human urine.

Long-term studies of urease-induced crystallization in human urine

Urine samples were inoculated with viable Proteus mirabilis or purified Jack bean urease. The subsequent pH increase and crystallization were followed for 2 weeks. Particle formation was detected much earlier and at a lower pH in urines inoculated with Proteus, in which a higher end pH was also reached. The crystal configuration in bacteria and urease inoculated samples was different. Crystal aggregation was also much more pronounced in the Proteus mirabilis inoculated samples. The total precipitation was markedly increased in the Proteus mirabilis inoculated samples. The presence of live Proteus mirabilis thus has a profound influence on urease-induced crystallization in human urine. Despite the formation of rather large crystal aggregates in the Proteus-inoculated urines, no firm aggregates of a "prestone" type were observed.

Unique ability of the Proteus mirabilis capsule to enhance mineral growth in infectious urinary calculi

Struvite (MgNH4PO4.6H2O) calculi are a common complication of Proteus mirabilis urinary tract infections. Although urease is a major virulence factor in calculus formation, the polysaccharide capsule (CPS) of this organism also enhances struvite crystallization and growth in vitro (L. Clapham, R. J. C. McLean, J. C. Nickel, J. Downey, and J. W. Costerton, J. Crystal Growth 104:475-484, 1990). We obtained purified CPS, of known structure and varying anionic character, from P. mirabilis ATCC 49565 and several other organisms. Artificial urine was added to CPS, and the pH was elevated from 5.8 to 8.5 by the addition of urease or titration with 0.25 M NH4OH to induce struvite crystallization. Crystallization was measured by particle counting (Coulter counter), and the morphology (crystal habit) was examined by phase-contrast microscopy. In the presence of partially anionic P. mirabilis CPS, struvite formation occurred at a lower pH than in the absence of CPS or in the presence of other neutral, partially anionic, or anionic CPS. At pH 7.5 to 8.0, significantly more struvite crystals formed in the presence of P. mirabilis CPS than under other experimental conditions. With the exception of one polymer (curdlan) which did not bind Mg2+, enhancement of struvite formation by CPS polymers was inversely proportional to their Mg2+ binding ability. We speculate that the structure and partial anionic nature of P. mirabilis CPS enable it to enhance struvite formation by weakly concentrating Mg2+ ions during struvite crystal formation. This illustrates a new virulence aspect of bacterial CPS during infection.

Laparoscopic ligature of the spermatic veins. A comparison between outpatient and hospitalised treatment

The preferable operation for varicocele is ligation of all venous trunks of the spermatic vein above the internal orifice of the inguinal canal, traditionally performed by a retroperitoneal approach. An alternative method is laparoscopic ligature of the spermatic veins. To evaluate this procedure and to see if it can be done on an outpatient basis, 24 patients were operated upon laparoscopically. The patients were allocated to two series, one scheduled to be operated upon on an outpatient basis and one hospitalised. In 22 out of 24 patients the varicocele had disappeared completely at follow-up 1-3 months after the operation. Three of the patients operated upon late during the day in the outpatient group had to stay overnight. No complications occurred. The costs were more than 50% lower in the outpatient group. Laparoscopic ligature of the spermatic veins seems to be an attractive way to treat varicoceles, with good postoperative results and, if performed on an outpatient basis, with a substantial reduction of costs.

Extirpation and fulguration of multiple superficial bladder tumour recurrences under intravesical lignocaine anaesthesia

OBJECTIVE

To register the results, complications and patient acceptance of bladder tumour operations under local anaesthesia.

PATIENTS AND METHODS

Intravesical lignocaine was the anaesthesia used in 30 patients with multiple bladder tumour recurrences. The largest tumour was extirpated with large flexible biopsy forceps and the others were fulgurated.

RESULTS

All visible tumours were extirpated or fulgurated except in one patient, where the operation had to be terminated due to unsatisfactory anaesthesia. All left the hospital within 2 h of surgery. Complications were minor and patient acceptance was very high.

CONCLUSION

These operations have previously been performed under spinal anaesthesia in this department and the present modification reduced costs by approximately 70%. Patients who had only minor discomfort associated with routine cystoscopy under urethral anaesthesia were well suited for extirpation and fulguration of multiple small tumours under intravesical lignocaine.

Multiple bladder biopsies under intravesical lignocaine anaesthesia

OBJECTIVE

To study biopsy quality, complications and patient acceptance when urinary bladder biopsies were taken under local anaesthesia.

PATIENTS AND METHODS

Multiple large cold-cup urinary bladder biopsies were taken under topical lignocaine anaesthesia in 20 patients who had previously undergone transurethral resection for superficial bladder cancer.

RESULTS

The procedures were carried out at the outpatient clinic with 0.5-2 h post-operative observation. Patient acceptance was very high and complications were minimal. The quality of the biopsies was consistently high and influenced treatment in the majority of the patients.

CONCLUSION

In our department multiple bladder biopsies (mapping) have previously always been performed as a transurethral resection under general or spinal anaesthesia. Operation under intravesical lignocaine anaesthesia with 2 h post-operative observation reduced the costs by 70%.

Analysis of stone fragility in vitro and in vivo with piezoelectric shock waves using the EDAP LT-01

A total of 100 whole stones was fragmented in vitro at 3-minute intervals with piezoelectric shock waves using the EDAP LT-01 device until all fragments were less than 2 mm. Larger stones and stones with a high computerized tomography attenuation needed longer treatments for fragmentation. Smoothly bulging stones with an even structure according to plain x-ray films were also more resistant to the shock wave treatment. Calcium oxalate monohydrate stones were not more difficult to break than other types of calculi. Stone fragments from 100 patients after extracorporeal shock wave lithotripsy were also analyzed. The average size of the fragments collected was less than 1 mm. Larger stones produced larger fragments and required more treatment sessions.

Citrate and urease-induced crystallization in synthetic and human urine

The effects of citrate on the different phases of urease-induced crystallization were studied using Coulter counter techniques and optical microscopy. Citrate increased urine pH and markedly delayed the initiation of the crystallization (nucleation) in both human and synthetic urine. In synthetic urine, particle aggregation and especially particle growth were delayed and inhibited by citrate. In human urine, aggregation was distinctly inhibited by citrate. It appears that the susceptibility of urine to form crystals in the presence of urease activity is influenced by its citrate concentration.

Serum concentration of prostate-specific antigen in relation to prostate volume in 50 healthy middle-aged men

Fifty men without symptoms of prostatic disease, aged 40 to 66 years, were studied with respect to serum concentration of prostate-specific antigen (PSA) and volume of the prostate gland. PSA was determined with two immunometric assays, one using a radioactive label, the other a nonisotopic label. Prostate volume was determined by transrectal ultrasound examination using two different modes of evaluation and assessed by rectal examination. The simpler "ellipsoid method" underestimated the volume by 20% compared to planimetry of several sections but they were well correlated to each other. It was found that prostate volume increased by 0.4 ml per year of age increase. There was a curvilinear relationship between serum PSA concentration and prostate volume determined by ultrasound; no statistically significant relationship was found between PSA concentration and prostate volume by rectal examination. The results indicate that the diagnostic value of serum PSA, for prostatic malignancy, will increase if values are related to prostate volume determined by ultrasound examination.

Crystal adherence to rat bladder epithelium after long-term E. coli infection

The normal urothelium is covered by a mucous coat which acts as an unspecific barrier against the adhesion of bacteria, cancer cells and crystals. Acute bacterial infections cause disruptions of the mucous coat and impairment of its anti-adherent property. The effect of long-term infection is, however, not known. Live E. coli were inoculated into rat urinary bladders and a persisting infection was obtained by creating a small bladder diverticulum. After 2, 10 and 21 days a crystal adhesion assay showed a twofold increased adherence to the urinary bladder in the infected rats compared to control (p < 0.001). One possible explanation could be an injury to the mucous coat.

Influence of Escherichia coli on urease-induced crystallisation in human urine

Urease was added to urines inoculated with Escherichia coli 24 hours earlier and to control urines not inoculated with E. coli. The inoculation did not change the concentration of the measured urine components. The urease-induced ammonium ion production and pH increase was reduced in E. coli-inoculated urines compared to control urines. This suggests that E. coli can inhibit urease. The precipitation of both phosphate and magnesium on glass rods inserted in the urine was reduced with 40-50% in the E. coli-inoculated urines. The results demonstrate that E. coli can influence urease-induced crystallisation.

Effect of long-term oral testosterone undecanoate treatment on prostate volume and serum prostate-specific antigen concentration in eugonadal middle-aged men

Testosterone undecanoate (160 mg/day) or placebo was given orally in a double-blind fashion for 8 months to 23 middle-aged men without urinary tract symptoms. Testosterone was found to increase the mean prostate volume by 12% (P < .012). The treatment suppressed the serum concentrations of sex-hormone-binding globulin and follicle stimulating hormone. The observed decrease in the mean serum concentration of luteinizing hormone was not statistically significant. The serum concentrations of prostate-specific antigen did not change as measured by two different well-validated immunometric assays. No changes in micturition habits or urine flow charts were reported.

The influence of pH and urine composition on urease enzymatic activity in human urine

It is reasonable to assume that the rate of pH increase in urine induced by urease-producing microorganisms is one of the factors which determine whether crystallisation with subsequent stone formation will occur or not. To evaluate how the time needed to increase urine pH varies between different urine samples and how it depends on urine composition, a standardised amount of urease was added to different human urine samples. The incubations were performed in a pH-stat. This allowed simultaneous study of how urease enzymatic activity depends on urine pH and how it varies between different urines. The enzymatic activity was found to be negatively correlated to urine pH and to vary between different urines. The rate of the pH increase varied markedly between different urines. Small pH increases depended on the native urine pH and urease enzymatic activity. Higher pH increases up to the levels of phosphate crystallisation depended more on urine phosphate, the major urine buffer. The results presented show that urine composition influences the urease-induced pH increase. This might have clinical implications.

Urease-induced precipitation of phosphate salts in vitro on indwelling catheters made of different materials

The urease-induced precipitation of phosphate salts on indwelling catheters was studied in an experimental in vitro model. The precipitation was strongly pH-related and was much higher in synthetic urine than in human urine. In the latter, it was significantly lower on silicone catheters than on latex catheters, including those with a hydrophilic coating. The precipitation on silicone catheters that had been in situ was not increased as compared with that on unused catheters, in contrast to latex catheters with a hydrophilic coating, among which the precipitation on used catheters was higher.

Studies of urease-induced crystallisation in undiluted human urine using the Coulter counter technique

Urease-induced crystallisation was studied in different human urine samples after urease incubation. The studies were performed using the Coulter counter technique, which enables determination of the number and size of particles in a solution and calculation of the total particle volume. The crystallization took place in three consecutive but overlapping steps: (1) nucleation, (2) growth and (3) aggregation. The maximal number of particles obtained in the different samples varied little, but there was a great variation in particle size and total particle volume. The variation in particle size appeared to be mainly due to differences in particle growth, a factor that might be of importance for stone formation.

Relationship between urease-producing bacteria, urinary pH and encrustation on indwelling urinary catheters

In 11 patients with long-term indwelling catheters the amount of catheter encrustation and urinary pH were measured and the urine regularly cultured over a prolonged period of time (median of 7 periods of 3 weeks). The mean urinary pH was related to the persistent presence of urease-producing micro-organisms (P. mirabilis) and urinary pH governed the precipitation of catheter encrustation. The critical pH appeared to be around 6.8. In patients with a mean urinary pH below this level the encrustation was minute (less than or equal to 2.9 mg phosphate). In patients with a mean urinary pH above 6.8 it was considerable but with a marked interindividual variation (35.5-138.7 mg phosphate). The composition of the encrustation was also strongly pH-related, with a much higher proportion present as magnesium ammonium phosphate in patients with a mean urinary pH above 6.8. The persistent presence of urease producers was not associated with a high pH or a more pronounced precipitation of phosphate in all patients. The amount of encrustation thus appears to depend not only on the presence of urease-producing micro-organisms but also on individual factors such as urinary composition.