Prostatic urethral lift (UroLift): a real-world analysis of outcomes using hospital episodes statistics

BACKGROUND

To determine real-world outcomes of prostatic urethral lift (UroLift) procedures conducted in hospitals across England.

METHODS

A retrospective observational cohort was identified from Hospital Episode Statistics data including men undergoing UroLift in hospitals in England between 2017 and 2020. Procedure uptake, patient demographics, inpatient complications, 30-day accident and emergency re-attendance rate, requirement for further treatment and catheterization were captured. Kaplan-Meier and hazard analysis were used to analyse time to re-treatment.

RESULTS

2942 index UroLift procedures from 80 hospital trusts were analysed; 85.3% conducted as day-case surgery (admitted to hospital for a planned surgical procedure and returning home on the same day). In-hospital complication rate was 3.4%. 93% of men were catheter-free at 30 days. The acute accident and emergency attendance rate within 30 days was 12.0%. Results of Kaplan Meier analysis for subsequent re-treatment (including additional UroLift and endoscopic intervention) at 1 and 2 years were 5.2% [95% CI 4.2 to 6.1] and 11.9% [10.1 to 13.6] respectively.

CONCLUSIONS

This real-world analysis of UroLift shows that it can be delivered safely in a day-case setting with minimal morbidity. However, hospital resource usage for catheterization and emergency hospital attendance in the first 30 days was substantial, and 12% required re-treatment at 2 years.

Non-Transecting Anastomotic Bulbar Urethroplasty For Urethral Stricture Disease-Experience From A Highvolume Specialist Centre

BACKGROUND

Urethral stricture disease has significant economic impact throughout world. The bulbar urethra is the commonest site for urethral strictures (Approx 50%) followed by penile urethra in most of the published literature. In developing countries trauma (road traffic accident and iatrogenic) is the leading cause of urethral stricture disease. Younger patients have usually idiopathic type as compare to old age group, which present more frequently with iatrogenic and trauma related urethral strictures.

METHODS

This Qausi Experimental study was conducted from May2012-June2016 of duration at Liaquat National Hospital Karachi. All the patients diagnosed with short urethral strictures related to bulbar urethra were included in this study. All the patients underwent non transecting bulbar urethroplasty. All patients were assessed preoperatively, peri-operatively and postoperatively and on follow-up visits as; on 2nd, 8th and 24th week. All the data regarding outcome was recorded on the Performa and analyzed on SPSS V20.

RESULTS

Total of 179patients were included, mean age was 38±SD15.3years (range 20- 65years). Anatomically bulbar urethra was affected in 52% of the cases followed by bulbopenile, bulbomembranous region. Etiologically idiopathic type was found in 40% cases, while trauma 21%, iatrogenic injury 26% and UTI 13% were also reasons. Stricture length was mean1.1±SD 1.4 cm (range 0.5-2.5cm). Preoperative Uroflowmetry revealed mean Qmax of 10.5±SD 5.3 ml/sec. Mean operative time was 35±SD 4.6 minutes, 7 patients had conversion to other procedures (3.91%), Postoperative complications were minimal. Mean follow up was 12±SD 21 months (range 6 months to 3 years). On initial follow up at 8th week and 24th week, Qmax was significantly improved. Only 3 patients required DVIU after the 24th week. Initial success rate after 24th week was 98.3% and eventually 100% at the long-term follow-up.

CONCLUSIONS

non-transecting anastomotic bulbar urethroplasty (NTABU) is a new standard of care for the short bulbar urethral stricture up to 2.5cm. Idiopathic aetiology, iatrogenic and posttraumatic urethral strictures in selective patients can safely be operated with this technique.

[Surgical treatment of metastatic penile cancer - what is the scientific rationale?]

The treatment of metastases of penile cancer is confined to lymphatic metastases. Limited lymph node metastasis in penile cancer can be cured by radical lymph node surgery if complete removal of all lymph nodes of the region is achieved. Adjuvant chemotherapy is recommended. This approach applies to the regional lymph nodes of the inguinal and pelvic regions. Applying this concept to retroperitoneal lymph node metastases may also be reasonable in selected cases. The individual prognosis depends on the extent of lymphatic spread.

Surgical site infection of scrotal and inguinal lesions after urologic surgery

To clarify the incidence of surgical site infection (SSI) after urological scrotal and inguinal surgical procedures and the preventive effect of antimicrobial prophylaxis for SSI, retrospective analysis was performed. The patients who underwent scrotal and inguinal operations from 2001 to 2010 were included in this analysis. A first or second generation cephalosporin was administered as antimicrobial prophylaxis just before the start of surgery and no additional prophylaxis was conducted. The surgery was classified into 76 (38%) cases with testicular sperm extraction (TESE), 72 (36%) with radical orchiectomy, 29 (14.5%) with bilateral orchiectomy (surgical castration) and 23 (11.5%) with other scrotal and inguinal operations. The median age and age range were 36 years and 18-81 years, respectively. SSI occurred in 7 (3.5%) cases. The frequencies of SSI were 6.5% in the patients with urological inguinal surgery and 1.6% in those with scrotal surgery. The frequency of SSI in the patients with urological inguinal surgery was not negligible even though it is considered a clean operation, and further analysis is warranted to prevent SSI.

The GMS hypospadias score: assessment of inter-observer reliability and correlation with post-operative complications

OBJECTIVE

An agreed upon method for describing the severity of hypospadias has not been established. Herein we assess the inter-observer reliability of the GMS hypospadias score and correlate it with the risk of a post-operative complication.

METHODS

A 3-component method for grading the severity of hypospadias was developed (GMS). Eighty-five consecutive patients presenting for hypospadias repair were graded independently by at least 2 surgeons using the GMS criteria. Scores were compared statistically to determine agreement between the observers. The outcomes of these patients were then reviewed to determine how the GMS score correlates to the risk of a surgical complication.

RESULTS

The G, M, and S scores had excellent agreement between observers. The GMS total score was exactly the same or differed by one point in 79/85 (93%) of patients. The complication rate was 5.6% for patients with a GMS score of 6 or less, but was 25.0% for patients with a GMS score greater than 6.

CONCLUSIONS

The GMS score provides a concise method for describing the severity of hypospadias and appears to have high inter-observer reliability. The GMS score also appears to correlate with the risk of a surgical complication.

Current practice in paediatric hypospadias surgery; a specialist survey

AIM

To undertake an online survey of current hypospadias surgery practice among those specialists attending the IVth World Congress of the International Society for Hypospadias and Disorders of Sex Development (ISHID), 2011.

MATERIALS AND METHODS

An online survey covering 22 separate questions relating to proximal and distal hypospadias surgery was set up, and all delegates registered for the conference were invited to complete this questionnaire anonymously. The data was analysed by three of the authors.

RESULTS

A total of 162 delegates registered for the conference of whom 74% were paediatric surgeons, paediatric urologists, plastic surgeons and adult/adolescent urologists. 93 delegates completed the online survey, and most of them (57%) were from Europe. The majority of surgeons see over 20 new patients/year (90%) and perform primary hypospadias surgery in over 20 patients/year (76%). The tubularized incised plate (TIP) repair is the most frequent technique used for the management of distal hypospadias (59%); other techniques used included Mathieu, onlay and TIP with graft. A variety of techniques are used for proximal hypospadias, but nearly half of the respondents (49%) preferred a staged approach. Self reported complication rates for distal hypospadias surgery are favourable (less than 10%) for 78% of the respondents. However, proximal hypospadias complication rates are higher.

CONCLUSIONS

With a majority of paediatric urologists and European delegates responding to our survey, the results suggest that there are differences in the management of proximal and distal hypospadias between surgeons, yet no differences were observed according to the region of their practice. Variations in long-term outcomes appear to be in keeping with the current literature.

[Treatment of idiopathic varicocele: comparative study of three techniques about 128 cases]

BACKGROUND

Several modalities of varicocele treatment are available, however, no therapeutic technique showed its superiority with regard to the other one.

AIM

To compare the results of three techniques of varicocelecomy.

METHODS

Retrospective Analytical and comparative study of 128 patients treated by of three techniques of varicocelectomy: the open surgery by retro peritoneal way for 42 patients (GI), the varicocelectomie coelioscopique for 41 patients (GII) and the antegrade scrotal sclerotherapy done for 45 patients (GIII), between march 2001 and January 2009.The mean age was 28 years. The main motive for consultation was represented by the painful varicocele in 67 % of the cases, followed by the hypofertility in 20.3 % of the cases and the association both in 12,5 % of the cases. The varicocele was in leftsider in 71.1 % of the cases, to the right side in 5.4 % of the cases and was bilateral in 23.43 % of the cases. Varicocele was infra-clinical at 6 patients, grade 1 in 16 sides, grade 2 in 105 sides and grade 3 in 31 sides. The numeration, the mobility as well as the morphology of sperm cells were comparable between the three groups Results: The global rate success was 81.2 %, with the highest rate found in the group III which was treated by antégrade scrotal sclerotherapy (84.4 %). The improvement of the parameters of the spermogramme was noted in the three groups, however a statistically significant difference was found only in patients treated by antégrade scrotal sclerotherapy; it mainly concerned numeration and the mobility of spermatozoides. The highest rate of pregnancy was recorded in patients treated by antégrade scrotal sclerotherapy (13.3%). The main postoperative complications were hydrocele (16%) followed by testicular hypotrophy (3 patients).

CONCLUSION

Three techniques of varicocele treatment, offer either a similar success rate, and improvement of parameters of the sperm cells. However, antegrade scrotal sclerotherpy seem to be the best treatment of first intention in proposed, regarding its efficiency, of the ease of its realization, its moderate cost and its feasibility in case of recurrence if varicocele was treated with open way'GIII).

Nomogram to preoperatively predict the probability of requiring epididymovasostomy during vasectomy reversal

PURPOSE

Up to 6% of men who undergo vasectomy may later undergo vasectomy reversal. Most men require vasovasostomy but a smaller subset requires epididymovasostomy. Outcomes of epididymovasostomy depend highly on specialized training in microsurgery and, if predicted preoperatively, might warrant referral to a specialist in this field. We created a nomogram based on preoperative patient characteristics to better predict the need for epididymovasostomy.

MATERIALS AND METHODS

We evaluated patients who underwent primary vasectomy reversal during a 5-year period. Preoperative and intraoperative patient data were collected in a prospectively maintained database. We evaluated the ability of age, years since vasectomy, vasectomy site, epididymal fullness and granuloma presence or absence to preoperatively predict the need for epididymovasostomy in a given patient. The step-down method was used to create a parsimonious model, on which a nomogram was created and assessed for predictive accuracy.

RESULTS

Included in the study were 271 patients with a mean age of 42 years. Patient age was not positively associated with epididymovasostomy. Mean time from vasectomy to reversal was 9.7 years. Time to reversal and a sperm granuloma were selected as important predictors of epididymovasostomy in the final parsimonious model. The nomogram achieved a bias corrected concordance index of 0.74 and it was well calibrated.

CONCLUSIONS

Epididymovasostomy can be preoperatively predicted based on years since vasectomy and a granuloma on physical examination. Urologists can use this nomogram to better inform patients of the potential need for epididymovasostomy and whether specialist referral is needed.

[Elective simultaneous operations in elderly and senile urological patients]

Surgeons of Samara Regional Veterans' Hospital made elective-simultaneous operations in 229 presenile and senile patients. Surgery was performed in the urological department in 1995-2010. It is shown that over 12% patients of urological geriatric departments need elective situltaneous operations, of them 8.7% are mild, 78.6%--moderate and 12.7%--severe. The results of simultaneous operations in 133 patients and staged operations in 60 control patients (adenomectomy and Vinkelman) differed insignificantly (p > 0.05). Such achievement was realized due to advanced prophessional education of all medical personnel of the department, introduction of new techniques in examination and treatment: accurate definition of absolute and relative contraindications for simultaneous surgery, effective preoperative preparation, low-invasive operations, different variants of non-endotracheal anesthesia. In addition to a positive clinical effect, new technology of simultaneous operations reduces 2.3-fold economic costs vs staged surgery, improves significantly quality of life of the above patients.

Trends in stricture management among male Medicare beneficiaries: underuse of urethroplasty?

OBJECTIVES

To analyze the trends in male urethral stricture management using the 1992-2001 Medicare claims data and to determine whether certain racial and ethnic groups have a disproportionate burden of urethral stricture disease.

METHODS

We analyzed the Medicare claims for fiscal years 1992, 1995, 1998, and 2001. The "International Classification of Disease, 9th revision," diagnosis codes were used to identify men with urethral stricture. The demographic characteristics assessed included patient age, race, and comorbidities, as measured using the Charlson index. Treatments were identified using the Physician Current Procedural Terminology Coding System, 4th edition, procedure codes and stratified into 4 treatment types: urethral dilation, direct vision internal urethrotomy, urethral stent/steroid injection, and urethroplasty.

RESULTS

The overall rates of stricture diagnosis decreased from 10,088/100,000 population in 1992 to 6897 in 2001 (from 1.4% to 0.9%). The stricture prevalence was greatest among black and Hispanic men, although the urethroplasty rates were greatest among white men. Direct vision internal urethrotomy was the most common treatment, followed by urethral dilation, urethral stent/steroid injection, and urethroplasty. The urethroplasty rates remained stable, but quite low (0.6%-0.8%), during the study period.

CONCLUSIONS

The overall rates of stricture diagnosis decreased from 1992 to 2001. Despite the poor overall efficacy of urethrotomy and urethral dilation relative to urethroplasty and despite the known complications of stent placement in this setting, the urethroplasty rates were the lowest of all treatments. Although we could not determine the treatment success with these data, these findings suggest an underuse of the most efficacious treatment of urethral stricture disease, urethroplasty.

Is objective assessment of cosmetic results after distal hypospadias repair superior to subjective assessment?

OBJECTIVE

To evaluate whether systematic scoring of pictures is really superior to subjective evaluation in the assessment of cosmetic results of distal hypospadias surgery, and whether any differences exist in subjective evaluation among the operating surgeon, the parents of the child, and a third party not previously involved in the care of the patient.

PATIENTS AND METHODS

Twenty-seven patients undergoing distal hypospadias repair by either the Snodgrass or Mathieu technique were enrolled. Cosmetic results of surgery were scored from 0 to 10 by one of each child's parents and by three surgeons. The latter assessed the results blindly on pictures taken during the outpatient visits; one used a systematic scoring system while the other two including the operating surgeon used subjective scoring. The four scores were compared using the Kendall W coefficient of concordance.

RESULTS

Overall, there was excellent concordance among the four observers (P<0.0001). The Snodgrass repair allowed for significantly better cosmetic results overall.

CONCLUSION

In distal hypospadias, subjective evaluation of overall penile appearance can be as reliable as an evaluation made using a systematic scoring system. There seems to be excellent concordance among the subjective evaluations of different observers.

Genito-urinary reconstruction in southern Nigeria

BACKGROUND

Urologic cases constitute about 25% of a busy surgical practice in Nigeria with up to 50% of these cases being genito-urinary abnormalities in adults and children. As most urologic surgery in Nigeria is done by general surgeons, a knowledge of the disease pattern and effective techniques in management would be helpful in surgical training.

OBJECTIVE

To describe the disease pattern and surgical outcomes in patients undergoing genito-urinary reconstruction in southern Nigeria

METHODS

We retrospectively reviewed the medical records of patients who underwent genito-urinary reconstructive procedures by two urologists and one paediatric surgeon over a 7-year (1991-1998) period at two tertiary referral centres in southern Nigeria. We extracted data such as age, sex, nature of pathology, surgical therapy and outcomes. Patients with a follow up of 12 months were excluded. The pattern of genito-urinary disease, type and outcome of surgical therapy, and complications were determined.

RESULTS

Two hundred and twenty seven patients (121 men, 39 women, and 67 children) underwent genito-urinary reconstruction during the seven years spanning 1991-1998. The study population consisted of 160 adults and 67 children (< 15 years old). Mean patient age was 43 years with a range of 18-87 years for adults and three years (range 18 months-13 years) for children. Mean follow up duration was 15 months, (range--13 months-seven years). Urethral abnormalities comprised 69% (98/ 227) of the lesions. The most common abnormality was urethral stricture in 98 (43%) patients. Urethral strictures were reconstructed as follows; primary anastomosis 83 (84.6%), pedicled penile skin island 6 (6.1%), Blandy 2 stage, 4 (4%), meatoplasty three (3%) and meatotomy, two (2%). The overall complication rate for repair of urethral strictures was 4.08%. There were 79 (35%) congenital lesions, including hypospadias 62 (27%), pelvi-ureteric junction obstruction 13 (6%), bladder exstrophy 2 (0.8%), chordee without hypospadias, 2 (0.9%), and concealed penis 1 (0.4%). These were managed using the following techniques; MAGPI, 30 (48.3%), urethroplasty, 22 (10%) single stage 10 (45%), two-stage 12 (55%), and urethral mobilization 10 (16%). Vesico-vaginal fistula complicating obstructed labour and pelvic surgery was the main cause of urinary fistulae. Ten patients underwent microsurgical epididymo-vasostomy for obstructive azoospermia resulting in three pregnancies.

CONCLUSION

Lower urinary tract reconstruction represents a major proportion of urologic surgery in southern Nigeria. Management by urologic specialists results in good outcomes, therefore urologic training in this area should include a large component of lower urinary tract reconstruction.

Penile fracture: experience at Ayub Teaching Hospital

BACKGROUND

Penile fracture is a relatively rare traumatic rupture of the tunica albuginea of one or both corpora cavernosa of an erect penis. It is a real urological emergency which needs early assessment and surgical management.

METHODS

Twelve (12) cases of penile fracture were reviewed from July, 1997 to July, 2007 in the Department of Urology, Ayub Teaching Hospital Abbottabad. All cases presented with classical history of penile fracture and the diagnosis was made on the basis of history and clinical examination only.

RESULTS

All the patients underwent immediate surgical repair with well preserved potency and excellent overall results.

CONCLUSION

Penile fracture has typical signs. Standard treatment consists of immediate surgical repair of penile fracture with a low incidence of late complications. Post op complications including urethral strictures and erectile dysfunction should be ruled out by regular follow-up.

Reduction in the number of orchidopexies for cryptorchidism after recognition of acquired undescended testis and implementation of expectative policy

BACKGROUND

Since the mid-1990s, acquired undescended testis has gradually been recognised as a separate entity for which the efficacy of prepubertal surgery has not been univocally been demonstrated. Therefore, in our hospital, orchidopexy was no longer routinely performed for acquired undescended testis.

AIM

To investigate the effect of expectative policy in our hospital on the number of orchidopexies.

METHODS

Two 5-year periods were compared. Period A (1991-1995), in which undescended testis was treated surgically, and period B (2000-2004), in which prepubertal orchidopexy in our hospital was no longer performed for acquired undescended testis. In addition, a comparison was made between the percentage reduction in hospital and national figures.

RESULTS

In period B, the number of orchidopexies in our hospital was reduced by 61.8% (from 387 to 148), mainly in the age group >6 years. Nationally, during the same period, the number of orchidopexies decreased only by 2.4% (from 18 024 to 17 591).

CONCLUSION

The results of this study confirm that recognition of acquired undescended testis is crucial for reducing the high number of (late) orchidopexies.

Orchiopexy practice patterns in New York State from 1984 to 2002

PURPOSE

Cryptorchidism is the most common genital anomaly identified at birth, and endocrine disrupters in the environment may be causing an increase in this entity. To determine whether the rate of surgery for undescended testes is increasing, we evaluated all documented orchiopexies performed in New York State during a 19-year period.

MATERIALS AND METHODS

We used the New York State Statewide Planning and Research Cooperative System database to identify all orchiopexies performed between 1984 and 2002. Orchiopexies performed for torsion were excluded.

RESULTS

A total of 36,484 boys were included in the study, of whom 26,575 were outpatients and 9,909 were inpatients. The overall rate of orchiopexy in our population (number of orchiopexies performed divided by number of live births during the study period) was 1.39%, and remained fairly constant throughout the study. Most orchiopexies were performed on an inpatient basis early in the study (92% in 1984) but by 2002 only 3% of repairs were done in inpatients. Early in the study (1984 to 1988) only 20% of orchiopexies were performed in patients younger than 2 years. However, between 1999 and 2002, 37.8% of orchiopexies were done before age 2.

CONCLUSIONS

Orchiopexy is being performed at an earlier age today than 2 decades ago. However, the majority of orchiopexies are not performed until after the recommended patient age of 2 years. The rate of orchiopexy is substantially higher than the accepted rate of 0.8% to 1.1%. Delayed referral to a surgeon, repair of retractile testicles and truly ascending testicles may account for these findings.

Trends in in-patient Hospital Utilization and Surgical Procedures for Breast, Prostate, Lung and Colorectal Cancers in Canada

OBJECTIVE

To analyse population-based trends of in-patient surgical procedures for breast (female), prostate, lung and colorectal cancers.

METHODS

The Hospital Morbidity Files supplied hospital data and the Canadian Cancer Registry, incidence data. Age-adjusted rates were standardized to the 1991 Canadian population.

RESULTS

All four cancers showed major changes in trends of surgical procedures. For breast cancer, the rate of in-patient breast conservation surgery (BCS) increased from 1981 to the early 1990s while the rate of mastectomy decreased. Because day surgery was not included, the subsequent in-patient BCS rate stayed level. For prostate cancer, the rate of transurethral prostatectomy was initially high but decreased after 1990, while the rate of radical prostatectomy increased rapidly, only minimally affected by the PSA-related peak in incidence. The lung cancer lobectomy rate in men remained at 10/100,000 after 1986, but in women rose from 3/100,000 to 7/100,000, reflecting increasing lung cancer incidence. For colorectal cancer, right hemicolectomies and anterior resections increased, especially in men.

CONCLUSIONS

Surgery trends reflected changes in incidence and treatment preferences. Canadian trends were generally similar to US trends, although the timing of some of the changes differed. Canadians tended to use less invasive procedures such as BCS and anterior resection.

The Estimated Prevalence of Hypospadias in Hokkaido, Japan

BACKGROUND: Hypospadias is one of the most common congenital anomalies in the world. Recently, increases in the prevalence of hypospadias have been reported in various countries including Japan. In this study, we examined whether the prevalence of hypospadias in Hokkaido, Japan, increased or not, using standardized diagnostic criteria. We also investigated the degree of its severity.

METHODS: We calculated prevalence of hypospadias using hospital records of hypospadias repair in Hokkaido. The prevalence from 1985 through 1997 by dividing the number of patients obtained from hospital records by the number of births.

RESULTS: The average prevalence of hypospadias in Hokkaido was 3.9 per 10,000 births, and did not significantly changed (p=0.7). The average proportions of distal, proximal and chordee alone were 56.7%, 39.6% and 3.7%, respectively. The decrease in the proportion of the proximal type was statistically significant (p=0.05) for the entire time period, whereas the proportion of the distal type did not have a significant upward trend for the observed 13 years (p=0.1).

CONCLUSION: No significant changes in the prevalence of hypospadias existed in Hokkaido.

Variations Among Individual Surgeons in the Rate of Positive Surgical Margins in Radical Prostatectomy Specimens

PURPOSE

Cancer at the resection margin (a positive surgical margin) after radical prostatectomy is associated with an increased risk of recurrence even after adjusting for other known risk factors, including pretreatment serum prostate specific antigen (PSA), clinical stage, grade and pathological stage (level of extracapsular extension, seminal vesicle invasion and pelvic lymph node status). Of these prognostic factors only surgical margin status can be influenced by surgical technique. We examined variations in the rate of positive surgical margins among surgeons after controlling for the severity of disease and volume of cases per surgeon.

MATERIALS AND METHODS

A total of 4,629 men were treated with radical prostatectomy by 1 of 44 surgeons at 2 large urban centers between 1983 and 2002 for clinical stage T1-T3NxM0 prostate cancer. Patients were excluded if they had previously received androgen deprivation therapy or radiation therapy to the pelvis. Positive surgical margins were defined as cancer at the inked resection margin. Other risk factors analyzed were serum PSA, grade (Gleason sum), extracapsular extension level (none, invasion into the capsule, present [not otherwise specified], focal extracapsular extension or established extracapsular extension), seminal vesicle invasion, pelvic lymph node metastases, surgery date, surgeon and volume of cases per surgeon.

RESULTS

For the 26 surgeons who each treated more than 10 patients in the study the rate of positive surgical margins was 10% to 48%. On multivariable analysis higher serum PSA, extracapsular extension level, higher radical prostatectomy Gleason sum, surgery date, surgical volume and surgeon were associated with surgical margin status after controlling for all other clinical and pathological variables.

CONCLUSIONS

While the clinical and pathological features of cancer are associated with the risk of a positive margin in radical prostatectomy specimens, the technique used by individual surgeons is also a factor. Lower rates of positive surgical margins for high volume surgeons suggest that experience and careful attention to surgical details, adjusted for the characteristics of the cancer being treated, can decrease positive surgical margin rates and improve cancer control with radical prostatectomy.

General anaesthesia or spinal anaesthesia for outpatient urological surgery

BACKGROUND AND OBJECTIVE

A variety of drugs and techniques have been introduced into ambulatory anaesthesia. The technique as well as the drugs used may hasten or delay home discharge. We compared recovery profiles and side-effects of spinal anaesthesia and total intravenous anaesthesia.

METHODS

Forty unpremedicated ASA I-II patients (18-65 yr) undergoing varicocele repair were randomly divided into two groups. Spinal anaesthesia (26-G atraumatic needle) with hyperbaric bupivacaine 0.5% 5 mg and fentanyl 25 microg were given to patients in Group Spinal (n = 20). Patients in Group TIVA (n = 20) received total intravenous anaesthesia with propofol and remifentanil given by continuous infusion; a laryngeal mask was used to secure the airway. The duration of surgery, time to home readiness and side-effects were recorded.

RESULTS

The two groups were comparable with respect to patients' characteristics and duration of surgery. The times to achieve ambulation were similar between groups (Spinal = 78.4 +/- 40.9 min, TIVA = 75.9 +/- 13.8 min). Urinary voiding was a requirement for discharge after spinal anaesthesia and the time for home readiness was longer in Group Spinal (158.0 +/- 40.2 versus 94.9 +/- 18.8 min) (P < 0.05). Two patients reported pruritus and one reported postdural puncture headache in Group Spinal, whereas two patients reported nausea in Group TIVA. Patients in Group TIVA had a greater need for analgesia postoperation (P < 0.05).

CONCLUSIONS

In healthy unpremedicated men undergoing minor urological operations, total intravenous anaesthesia with remifentanil and propofol provided as safe and effective anaesthesia as spinal block with the advantage of earlier home readiness.

Tubeless Barcat: a patient-friendly hypospadias procedure

OBJECTIVES

To determine whether the distinct advantages of a catheter-free hypospadias repair can be obtained with a Barcat procedure without an adverse effect on surgical outcome.

METHODS

A retrospective review was performed on consecutive patients who had undergone a catheter-free Barcat repair from July 1998 to May 2002. Patient records were examined for information regarding age, meatal location, primary or secondary procedure, operative time, postoperative follow-up, and complications.

RESULTS

Thirty-six consecutive catheter-free Barcat hypospadias repairs were performed in the review period. Patient age ranged from 6 months to 9 years (mean 26 months). All patients either had a coronal meatus or a subcoronal meatus. Thirty-three patients (92%) underwent a primary repair. Three patients (8%) underwent the repair as a secondary procedure after a previous failed procedure. The mean follow-up was 25 months. One patient required a single catheterization in the immediate postoperative period for urinary retention. Another patient had glans separation and meatal retrusion requiring a revision procedure. All the other patients achieved a satisfactory cosmetic result with an orthotopic slit-like meatus.

CONCLUSIONS

The Barcat hypospadias repair may be performed in patients with distal hypospadias without the use of a postoperative urethral catheter. Foregoing a catheter had no adverse effect on the surgical outcome with reduced patient discomfort.

Recurrence of condylomata acuminata of the urethra after conventional and fluorescence-controlled Nd:YAG laser treatment

OBJECTIVES

To report our experience with conventional and fluorescence-controlled neodymium:yttrium-aluminum-garnet (Nd:YAG) laser therapy of urethral condylomata. Urethral condylomata can sometimes only be reached by endoscopy and are in general very susceptible to recurrence. They must therefore be considered as a therapeutic problem that has not yet been resolved.

METHODS

One hundred sixty-eight patients with urethral condylomata were treated with the Nd:YAG laser (93 men using conventional white-light endoscopy and 75 men using fluorescence control after topical application of 5-aminolevulinic acid). The relapse characteristics were investigated according to the location and extent of the urethral lesions and with regard to the different endoscopy techniques.

RESULTS

Of all patients, 35.7% developed recurrences of urethral condylomata after laser therapy. These were mainly located on the meatus and in the distal urethra. Only 4.8% of patients had proximal condylomata, and this was only seen in people with distal urethral involvement. Extensive, complete, or semicircularly arranged condylomata developed recurrence and complications (eg, strictures) more frequently after laser therapy. Significantly fewer recurrences (21.3% versus 47.3%) were observed in fluorescence-controlled laser therapy in a retrospective comparison with laser therapy under conventional conditions with a corresponding extent of human papillomavirus lesions.

CONCLUSIONS

Nd:YAG laser therapy enables a specific topical clearance of human papillomavirus lesions at different locations in the urethra. 5-Aminolevulinic acid-induced fluorescence diagnostics enhances the effectiveness of Nd:YAG laser therapy of human papillomavirus lesions. Urethral instrumentation of any kind leads to viral contamination of the proximal urethra.

Temporal trends in orchidopexy, Great Britain, 1992-1998

Concern has been expressed in recent years about worsening male reproductive health, possibly mediated by increasing exposures to environmental endocrine-disrupting agents. Trends suggested large increases in cryptorchidism in Britain and the United States between the 1950s and 1980s, although published data on recent trends have been scarce. We examined numbers of orchidopexy procedures, as a marker for cryptorchidism, using routine hospital admission data for England, Wales, and Scotland for fiscal years 1992-1993 through 1998-1999. Annual trends in orchidopexy rates were analyzed by age, in-patient admission versus day case, and geographical region. Orchidopexy rates were also obtained from the General Practice Research Database (GPRD) for England to cross-validate the hospital admissions data. Orchidopexy rates for boys 0-14 years old fell by 33% (from 23.5 to 15.8 per 10,000 population) between 1992 and 1998, with the steepest decline (50%) in 5-9-year-olds. The decreasing trend for 0-14-year-olds was evident in every region in England, in Wales, and in Scotland. Rates remained stable for men 15 or more years old, at 0.7 per 10,000. There was a marked shift from in-patient to day-case procedures. Rates from the GPRD showed a similar downward trend to the hospital data. Our findings could represent either an underlying decrease in the frequency of undescended testis or a fairly dramatic improvement in the diagnosis of cryptorchidism--resulting in fewer orchidopexies performed for retractile testis--in Great Britain during the 1990s, or both. Either way, our findings do not support the postulate of a recent worsening of male reproductive health of the scale suggested by some recent commentators on the endocrine disruptor hypothesis.

Management of prepubertal varicoceles-results of a questionnaire study among pediatric urologists and urologists with infertility training

OBJECTIVES

Varicoceles are a common condition affecting male fertility seen by urologists. However, prepubertal varicoceles are much less common and their management is controversial. We designed a questionnaire to assess the practice patterns among urologists (pediatric urologists/urologists with infertility training) with regard to prepubertal varicocele management.

METHODS

A 15-point questionnaire pertaining to management issues of prepubertal varicoceles was sent to 150 pediatric urologists and 150 urologists with infertility training. Two clinical scenarios referring to treatment algorithms of prepubertal varicoceles were included.

RESULTS

Of the 300 questionnaires mailed, 174 urologists (58%) responded. Seventy-five of the respondents were urologists with an interest in infertility, and 99 were pediatric urologists. Of the 174 respondents, 86.2% treated prepubertal varicoceles and 13.8% referred patients to interventional radiologists for embolization. The ratio of varicocelectomy to expectant management was about equal between urologists with infertility training and pediatric urologists (46% versus 54%). A difference in testicular size was the most common indication for varicocelectomy (80.5%), followed by pain (51.1%) and potential fertility problems (24.7%). About one third of all urologists would perform varicocelectomy on patients of any age and seven (4%) would not operate before puberty. In 136 responses (78.2%), follow-up information was not available. Among the 35 respondents with follow-up information (21.8%), 21 reported infertility occurring after varicocelectomy and 16 after expectant management. If varicocelectomy was performed, most urologists (47.2%) used magnification loupes, 29.3% used microscopes, and 29% used no magnification. The preferred approach was inguinal (Ivanissevich) in 35.6% followed by subinguinal in 30%; 21% performed retroperitoneal varicocelectomy (Palomo) and 9.8% used a laparoscopic approach. Of the 300 complications reported, postoperative hydroceles were the most common (40.4%), followed by recurrence (20.8%) and hematomas (17.4%).

CONCLUSIONS

The management of prepubertal varicoceles is controversial among different urologic subspecialties (pediatric urology/infertility). Differences include indications, timing, and techniques used for varicocelectomy. Accurate follow-up information for children with prepubertal varicoceles is rare. A prospective randomized study comparing varicocelectomy versus expectant management of prepubertal varicoceles is needed to assess the outcomes and define uniform treatment criteria.

[Surgical procedures of the urinary tract and male genital organs. Rates of surgical intervention: variability and its relationship with distance and income]

OBJECTIVE

To valorate the existence of the variability, in surgical rates on urinary tract and masculine genital organs, between the population of Health Centres (HC) adscribed to the Hospital of Ciudad Real. It so, quantify the influence of the distance (from Health Center to Hospital) or the income have in the variability of these rates.

MATERIAL AND METHOD

Surgical activity of the period 1996-98. It has been analyzed for every procedure: residence, sex, age and type (coded by CIE 9th MC). The surgical rates, standardized for age and sex, (TFQ) for every HC has been compared whit the mean (t alpha/2 n-1 alpha = 0.99) of the distribution of rates by HC. The relation between the TFQ and distance or income has been analyzed by lineal regression and ANOVA test for one variable, using the Newman Keuls test to assess the difference of the rates between the HC at different distance or income. It has been considered as significative every p < 0.05.

RESULTS

The population studied has a TFQ significatively different (p < 0.01). significant relationship exists between the TFQ and the distance. There were no relations between the TFQ for HC and the income.

CONCLUSIONS

42% of the variance (variability) of the distribution of TFQ for HC is due to the distance.

Hydrocelectomy: a proxy for hydrocele prevalence in coastal Kenya

To assess the value of hydrocelectomy as an indicator of the prevalence of lymphatic filariasis, the frequency of hydrocelectomy was investigated in five hospitals in an area of coastal Kenya where filariasis is endemic. Two of the hospitals studied (Kinango and Msambweni) were in Kwale district, two (Kilifi and Malindi) in Kilifi district and one (the Coast Provincial General Hospital) in Mombasa. Surgical operations performed between January 1991 and August 1993 were tallied from the main theatre registers. Additionally, admission files for hydrocelectomy patients were examined prospectively between September 1993 and February 1994, to obtain age profiles. Hydrocelectomies accounted for 27.6%, 16.6%, 13.6%, 4.3% and 2.0% of the major operations (totalling 6339) recorded in Kinango, Msambweni, Kilifi, Malindi and Coast Provincial General Hospital, respectively. The proportion of operations involving hydrolectomy was significantly higher in the two hospitals in Kwale district, in the southern part of the study area, than in the two hospitals in Kilifi district, in the northern part (23.4%, with 95% confidence intervals of 20.9%-25.9%, v. 10.3%, with 95% confidence intervals of 8.7%-11.9%; P < 0.001). The generally high frequencies of hydrocelectomy in the study area are evidence of the heavy social and economic burden imposed by hydrocele-attributable morbidity and its management. The age distribution pattern of the hydrocelectomy patients paralleled that of the individuals with hydrocele in the surrounding area.

CAG repeat within the androgen receptor gene and incidence of surgery for benign prostatic hyperplasia in U.S. physicians

BACKGROUND

CAG repeat length in exon 1 of the androgen receptor (AR) gene correlates inversely with transcriptional transactivation activity of the AR. Men with shorter AR CAG repeat lengths are at higher risk of prostate cancer. Because benign prostatic hyperplasia (BPH) is an androgen-dependent condition, we examined the hypothesis that a shorter AR gene CAG repeat length increases the risk of developing of BPH.

METHODS

Among 14,916 men of the Physicians' Health Study who had provided a blood sample in 1982, we measured AR gene CAG repeat lengths for 310 men who had surgery for BPH up to 7.5 years of follow-up and 1,041 controls.

RESULTS

Risk of surgery for BPH increased linearly with decreasing AR CAG repeat length (P (trend) = 0.03). Relative to men with a CAG repeat length > or = 25, men with a repeat length < or = 19 had an odds ratio of BPH surgery of 1.76 (95% confidence interval, 1.16-2.65).

CONCLUSIONS

Variability in the AR gene CAG repeat influences the development of symptomatic BPH.