Unusual presentation of a periurethral abscess following infection with Neisseria gonorrhoea

We describe an unusual case of a male patient presenting with penile and testicular swelling following an unprotected and traumatic sexual encounter. It was suspected that an isolated penile injury occurred during intercourse; however, ultrasound imaging identified an intact tunical layer and right-sided epididymo-orchitis. Following screening for sexually transmitted infections (STIs), he was discharged with antibiotics and advice to attend the Sexual Health Centre for contact tracing. He represented with a periurethral abscess and an antimicrobial-resistant (AMR) strain of Neisseria gonorrhoea was identified. Appropriate antibiotic treatment was initiated. Examination-under-anaesthesia, following abscess drainage, revealed a contained collection with no urethral fistula; however, a flat urethral lesion was seen during urethroscopy. Repeat urethroscopy and biopsy of the lesion indicated polypoid urethritis. Periurethral abscess secondary to gonococcal urethritis is a rare complication, but one that we should be suspicious of, especially with the growing incidence of AMR-STIs.

Complications of percutaneous nephrostomy in a district general hospital

OBJECTIVE

Percutaneous nephrostomy (PCN) is one of the commonest procedures performed. There are currently no European recommendations on the accepted rate of complications. The aim of the present study is to report the complication rate of PCN with the specific emphasis on sepsis and septic shock, the causative organisms, sensitivities to antibiotics, and associated risk factors.

MATERIAL AND METHODS

Retrospectively collected data on patients undergoing acute or elective PCN at the Department of Radiology, Countess of Chester Hospital (COCH), in the UK between January 2014 and December 2016 were analyzed after the study was approved by Local Audit Department at COCH.

RESULTS

A total of 66 patients underwent 90 acute or elective PCNs. Three patients developed major post-PCN complication (two patients developed septic shock and the third suffered a hemorrhagic episode requiring blood transfusion). Nephrostomy tube complications (blockage, leaking, fracturing and kinking of the catheter) occurred in 4 patients. Complications were more common when the PCN was performed out of working hours (71.4% [10/14], and 17.3% [9/52] for PCNs performed within, and out of working hours, respectively: p<0.001). The age of the patients did not seem to correlate with the development of complications (p<0.001). Of all 25 patients, in whom septicemia was diagnosed prior to PCN tube insertion, 12 developed septic shock and 13 had signs of sepsis for longer than 24 h. Fifteen patients had positive urine cultures. The most common organism isolated was Escherichia coli. Blood culture isolates included: Escherichia coli, Eggerthella lenta, Enterococcus, Proteus mirabilis, Pseudomonas aeruginosa and Streptococcus pneumonia.

CONCLUSION

Our complication rates were within United States proposed target ranges. Our data may help to serve as a baseline for outcome targets in the European centres.

Uretero-Arterial Fistula - Not So Rare?

The first uretero-arterial fistula (UAF) was reported in 1908 by Moschcowitz. In 2009, a systematic review identified 139 cases. Since then a further 23 cases were described with 19 cases originating from a single center. It has been recognized as a very rare condition in the past. However, more recently, the increasing incidence of UAF has led us to believe that this condition is more frequent than previously described. Aging population, improved cancer survival and extensive multimodal pelvic cancer treatments have been recognized as culprits for the increased incidence of UAFs. We have reviewed literature on UAFs, identified risk factors, patho-physiology and treatment options. Also, we present a case of fistulous communication between the internal iliac artery and ureter in a patient with a potential risk factor previously not described in the literature.

An Annual Urology Tutorial For Junior Doctors; Results Of A Multi-Centre Study

This article was migrated. The article was not marked as recommended. IntroductionUrology accounts for a significant proportion of acute surgical admissions. The current undergraduate and postgraduate teaching curriculum does not place a large emphasis on urology teaching or placement which is concerning. With the use of questionnaires, our multi-centre study aims to observe junior doctor's perceived confidence level in management of urological condition after the inclusion of a urology interactive tutorial in the postgraduate program.MethodsFoundation and core trainee across four district general and teaching hospitals in the UK were invited to attend a urology tutorial. Prior to the tutorial, all participants were given a questionnaire to explore their previous urology teaching exposure and their confidence level in managing urological conditions. An interactive tutorial was conducted which covered emergency urological presentations and some ward based problems. A post-tutorial questionnaire was given with the intention to observe any improvement in confidence level.ResultsA total of 68 junior doctors participated. Only 4% (n=3) had received adequate urology teaching previously. Only 1 person felt confident to competently manage all urological problems while 34% (n=23) felt capable to manage most urological presentations. All participating junior doctors were keen on extra urology teaching, with 97% (n=66) wanted the teaching to focus on emergency urology conditions. 62% (n=42) felt this will help to improve patient care and aid their future training jobs. Positive feedbacks were received after the teaching, with 93% (n=63) finding it very useful and 97% (n=66) reported an increased in confidence level. DiscussionThis multi-centre study provided supporting evidence that junior doctors do not feel adequately prepared to manage urological conditions in the acute setting. We observed that junior doctor's confidence level in managing such presentations can be improved with an inclusion of a teaching supplementation. We propose the inclusion of urology teaching in the foundation program teaching curricula.

The changes in prostate cancer and its management in the North West of England over a 10-year period

Objectives:

Our aim was to evaluate changes in prostate cancer diagnosis and management and to examine changes in the stage and grade of newly diagnosed prostate cancer in the North West of England over a 10-year period.

Materials and methods:

Data was collected concerning the diagnosis (including stage and grade) and management of newly diagnosed prostate cancer in the North West of England. There were three time points: 2003, 2007 and 2011 including a total of 648 patients. For assessment of median time changes Spearman’s Rank correlation test was used, for the assessment of changes in Gleason grade and clinical stage Mann–Whitney U test was used, and assessment of positive margin rates was done with Fisher’s test.

Results:

Median time from management decision to surgery has reduced from 46 (2003), 34 (2007) to 27 days (2011) ( p=0.074). The proportion of patients managed with active surveillance has remained relatively constant over time (18%, 16% and 21% respectively). More minimally invasive, nerve-sparing prostatectomies are now performed, and positive margin rates have significantly reduced from 53% (2003) to 23% (2011) ( p<0.001). Gleason grade significantly increased over time ( p<0.001); Gleason 7 disease was diagnosed in 23% of patients in 2003, 32% in 2007 and 49% in 2011 ( p<0.001). There was an increase in Gleason 8 disease; 6% (2003) to 8.6% (2011), but this was not significant ( p=0.27). Increase in clinical stage was also noted over time; identification of T3 disease rose from 2% (2003 and 2007) to 5% (2011) ( p=0.045) (excluding cases with non-recorded stage).

Conclusion:

Prostate cancer management in the North West of England has evolved over the last decade, with overall improvements in management quality. We have demonstrated an increase in the presenting stage and grade of prostate cancer over a 10-year period.

Prevalence of prostatic calcification subtypes and association with prostate cancer

OBJECTIVE

To evaluate the prevalence and to classify prostatic calcification on transrectal ultrasonography (TRUS) and correlate the findings with histology.

METHODS

A prospective, blinded study of men undergoing TRUS and prostatic biopsy was designed. A standardized reproducible technique was used with a BK 7.5- to 12.5-MHz multiplanar probe. Representative images of the calcification in the sagittal and transverse planes were captured. Blind analysis by an experienced observer was performed. TRUS findings were categorized using a novel classification and correlated with histologic data.

RESULTS

A total of 274 patients (58.8%) had prostate cancer, 88 patients (18.9%) inflammation, and 104 patients (22.3%) had benign pathology. Interface calcification was present in 42.3% of patients. Peripheral or transitional zone calcification was unusual (6.8% and 9.0%, respectively). Of the peripheral zone calcification group patients, 78.1% had cancer on histology examination (P = .020).

CONCLUSION

Prevalence and characteristics of prostatic calcification have been described using this novel and practical classification. Although interface calcification is common and not associated with any particular pathology, peripheral zone calcification appears to be strongly associated with prostate cancer.

Diethylstilboestrol (1 mg) in the management of castration-resistant prostate cancer

OBJECTIVE

To investigate the efficacy of diethylstilboestrol (DES) in patients with advanced prostate cancer refractory to androgen suppression.

METHODS

This retrospective study comprises 194 patients with prostate cancer treated with DES (1 mg daily) between 1976 and 2010. Study outcome parameters included demographic data, tumour characteristics, treatment history, prostate-specific antigen (PSA) responses, radiologic studies, adverse events and overall survival.

RESULTS

At initiation of oestrogen therapy the mean patient age was 69 years (range: 48-89) and the median PSA was 96 ng/ml (range: 1.9-9,500). The median duration of prior prostate cancer treatment was 29 months (range: 1-365). DES was the second-line treatment in 58 patients and the third/fourth-line therapy in 136 men. A formal (≥50%) PSA response was observed in 95 patients (48.9%) and the median time to progression (TTP) was 250 days (95% CI, 180-360) for this group. An additional 62 patients (31.9%) had a partial PSA response with a median TTP of 150 days (95% CI, 92-180). Thirty-seven patients (19.1%) did not have a PSA response and the median TTP was 90 days (95% CI, 90-97). The median overall survival from the start of oestrogen therapy for the entire cohort was 576 days (95% CI, 482-690). The median overall survival of patients who had a formal (≥50%), partial (<50%) and no PSA response was 756 (95% CI, 670-1,429), 428 (95% CI, 340-630) and 329 (95% CI, 287-510) days, respectively. Thirty-nine patients (20.1%) were still alive at the end of the study. No treatment-related deaths occurred.

CONCLUSIONS

In the age of chemotherapy this study highlights the efficacy of oestrogen therapy in castration-refractory prostate cancer. The optimal point in the therapeutic pathway at which DES should be prescribed remains to be established.

Embryology and adult urology - Not always mutually exclusive: A case report on true hermaphroditism at an adult urology clinic

True hermaphrodite (TH) is one of the rarest varieties of disorders of sexual differentiation. Most patients present early in the life and are managed by pediatricians. We present a rare case of an adult TH which was first diagnosed by a urologist. We discuss the pathology of TH and its clinical relevance. Knowledge and awareness of embryology are vital to all specialties.

A rare case of testicular metastasis of bladder transitional cell carcinoma

Metastases from bladder transitional cell carcinoma (TCC) to the testis are very rare. These are usually found on autopsy and occur in advanced or metastatic bladder cancers. More common, known primary tumors that metastasize to the testis include prostate, lungs, melanoma, gastro-intestinal tract and the kidney. We report a rare case of solitary and synchronous metastatic TCC of the bladder to the testis, discovered on histological examination. This case illustrates that metastatic neoplasm to uncommon sites should be considered in the differential diagnosis for patients with a history of advanced bladder TCC.

Acute urinary retention in women due to urethral calculi: A rare case

We present a case of a 51-year-old woman with acute urinary retention caused by a urethral calculus. Urethral calculi in women are extremely rare and are usually formed in association with underlying genitourinary pathology. In this case, however, no pathology was detected via thorough urological evaluation. We discuss the pathogenesis, clinical presentation and treatment of urethral calculi. To our knowledge, this is the second reported case of a primary urethral calculus in a female with an anatomically normal urinary tract and the first in a middle-aged Caucasian female.

Diethylstilboestrol for the treatment of prostate cancer: past, present and future

The aim of this review was to discuss the most recent data from current trials of diethylstilboestrol (DES) to identify its present role in advanced prostate cancer treatment as new hormonal therapies emerge. The most relevant clinical studies using DES in castration-refractory prostate cancer (CRPC) were identified from the literature. The safety, efficacy, outcomes and mechanisms of action are summarized. In the age of chemotherapy this review highlights the efficacy of oestrogen therapy in CRPC. The optimal point in the therapeutic pathway at which DES should be prescribed remains to be established.

Bladder neck sparing in radical prostatectomy

The role of a bladder neck sparing (BNS) technique in radical prostatectomy (RP) remains controversial. The potential advantages of improved functional recovery must be weighed against oncological outcomes. We performed a literature review to evaluate the current knowledge regarding oncological and functional outcomes of BNS and bladder neck reconstruction (BNr) in RP. A systematic literature review using on-line medical databases was performed. A total of 33 papers were identified evaluating the use of BNS in open, laparoscopic and robotic-assisted RP. The majority were retrospective case series, with only one prospective, randomised, blinded study identified. The majority of papers reported no significant difference in oncological outcomes using a BNS or BNr technique, regardless of the surgical technique employed. Quoted positive surgical margin rates ranged from 6% to 32%. Early urinary continence (UC) rates were ranged from 36% to 100% at 1 month, with long-term UC rate reported at 84-100% at 12 months if the bladder neck (BN) was spared. BNS has been shown to improve early return of UC and long-term UC without compromising oncological outcomes. Anastomotic stricture rate is also lower when using a BNS technique.

Metastatic prostate cancer in transsexual diagnosed after three decades of estrogen therapy

The incidence of prostate cancer in transsexual patients is very low with only few reported cases. Many years before presenting with prostate cancer, these patients receive hormone ablation as a part of their gender therapy. Their disease is already defined as castrate resistant, and the treatment and follow-up of such patients remains a challenge. We report a case of a male-to-female transgender woman who was diagnosed with metastatic prostate cancer, 31 years post-feminization.

Ureteric stricture: an unusual presentation of metastatic prostate adenocarcinoma

We describe an unusual case of a prostatic adenocarcinoma presenting with a ureteric stricture secondary to a discrete metastatic lesion. A 76-year-old man presented with a short history of right loin pain. Initial examination was unremarkable, digital rectal examination was normal and prostate specific antigen was within normal range. Computed tomography showed right hydronephrosis and a distal ureteric stricture. A distal ureteric transitional cell carcinoma was thought to be most likely. A nephroureterectomy was carried out and histology revealed a skipped lesion of a metastatic prostate adenocarcinoma. Metastatic lesions to the ureters due to prostate cancer are rare. It was believed to be secondary to a transitional cell carcinoma as there was no evidence initially to suggest prostatic disease as the cause. A prostatic adenocarcinoma should be considered in the differential diagnosis of any lesions in the ureter believed to have a malignant origin.