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Objective: To reinvestigate whether South Asian men in the UK are at lower risk of being diagnosed with prostate cancer in a UK-based retrospective cohort study and to examine possible reasons that may explain this., Patients and Methods: The catchment areas were predefined in four areas of southern England, and age- and race-specific populations for those areas taken from census data. Cases were ascertained through review of multiple hospital sources, while race, other demographic factors, and medical history were determined using questionnaires sent to the men, hospital records review and death certificates. The South Asian group included men of Indian, Bangladeshi and Pakistani origin., Results: There was modest evidence of lower prostate cancer rates in South Asian men compared with their White neighbours (age-adjusted rate ratio 0.81; 95% confidence interval 0.65-1.00). This difference did not reflect less use of prostate-specific antigen (PSA) testing or differences in clinical features at presentation., Conclusion: This study provides evidence of a lower incidence of prostate cancer amongst South Asian men living in England, in comparison with their White counterparts. If anything, South Asian men presented with clinical features of earlier disease suggesting that the reduced risk is unlikely to be an artefact of poorer access to health care.

The rapid advances made by ultrasound in recent years have increasingly taken 3-D ultrasound (3DUS) and 4-D ultrasound (4DUS) from the research setting to the patient's bedside. There are still unexplored areas like renal percutaneous intervention, where 4DUS has yet to be proven an effective tool. Ultrasound-only guidance in renal percutaneous access is used in selected well-dilated pelvi-calyceal systems (PCS), and fluoroscopy is often utilized as an adjunct. Our aim was to compare 2-D and 4-D guidance for punctures, with fluoroscopy as control, using an in vitro ultrasound phantom. Agar and latex were the tissue-mimicking materials used for the construction of the phantom. The latex targets were designed to simulate multidirection-facing minimally dilated renal calyces. Two interventional fellows punctured the "calyces" using first 2DUS and then 4DUS guidance, making use of a different set of targets each time. The time to puncture, time to introduction of wire, quality of puncture (judged on fluoroscopy) and global rating of both modalities were documented. There was no significant difference between the times to puncture using 2DUS (1.8 min) and 4DUS (2 min). Nor was there a significant difference in the quality of puncture. 4DUS had a higher median difficulty rating. The multiplanar reformatted (MPR) longitudinal and transverse images were found to be the most useful for needle guidance. Cross hairs in all MPR images were not just useful in aligning the images on target but also as surrogate targets. The phantom was found to be robust, with only one instance of air introduction after 30 punctures. We have found that 4DUS is at least as good as 2DUS in terms of quality of punctures in vitro. The technology still has some way to go as frame rates, transducer size and resolution improve.

Objectives: Three-dimensional (3D) reconstruction of the pelvicaliceal system (PCS) can be helpful for percutaneous renal procedures. 3D reconstruction of the PCS using ultrasound (US) has not been studied. We determined the feasibility and accuracy of 3DUS reconstruction of the PCS in an in vitro model., Methods: Ten pig kidneys were scanned in vitro using freehand 3DUS (Logiq 9, GE medical systems). Multi-planar reformatted (MPR) and volume rendered (VR) reconstructions of the PCS were processed on a workstation. Using resin casts of the PCS as the reference standard, MPR reconstructions were compared for maximal polar and antero-posterior (AP) PCS length, lower pole infundibular (LPInf) diameter and number of calices. VR movies were compared for number of calices. Three blinded reviewers matched VR movies to casts and given an "anatomical representation" score using a five-point scale., Results: There were no significant differences in maximal AP length, LPInf diameter or number of calices between MPR reconstructions and casts. Maximal polar length between MPR reconstructions and casts were different (t = 6.44, P = 0.0001). VR movie reconstructions underestimated the number of calices visualised (t = 3.23, P = 0.01). A total of 22 out of 30 (73%) 3D VR videos were accurately matched to their casts. The 3D VR median score for anatomical representation was 3 (fair representation)., Conclusions: Three-dimensional ultrasound reconstruction of the porcine PCS is quantitatively comparable to corresponding casts of the PCS. 3D VR movies of the PCS were a fair representation of the PCS anatomy. 3DUS is a potential tool in the planning and execution of percutaneous renal procedures.

Purpose: Catheter associated urinary tract infection is the most common type of hospital acquired infection. An understanding of catheter associated urinary tract infection pathogenesis is needed to improve the control and treatment of these infections. We investigated the relationship among catheter material, bacteria and bladder epithelial cell reaction., Materials and Methods: Urinary catheter sections and a clinical isolate of Escherichia coli were added to human bladder carcinoma epithelial cells in vitro in combination or independently. The catheters were rotated for 30 seconds over the cells, followed by incubation. The cytokines interleukin-6 and 8 were measured by enzyme-linked immunosorbent assay as indicators of inflammation and cell membrane disruption was assessed using a lactate dehydrogenase assay., Results: The levels of lactate dehydrogenase release and cytokine production depended on the number of bacteria added. Bacteria grown for 3 days caused greater secretion of cytokines than bacteria grown overnight. Silicone catheter material alone caused immediate damage to cells with increased lactate dehydrogenase in the supernatant but little interleukin-6 or 8 production. Silicone catheters caused significantly less cytokine secretion from bladder cells than latex catheters. Conversely bacteria caused little immediate damage to cells but stimulated cytokine production after 12 hours., Conclusions: Disruption of bladder epithelial cell membranes in vitro occurred immediately as a result of physical abrasion caused by catheters but delayed inflammation occurred in response to bacterial infection.

Objective: To examine the microbial colonization of urinary catheters that have been used by patients, to model catheter colonization in vitro and thus provide information about the way bacteria gain access to the bladder during catheterization., Materials and Methods: Microbial growth patterns from patients' indwelling catheters and from catheters used in an in vitro model of the catheterized urinary tract were compared. Catheters were cut into short segments, microorganisms from the inside and outside of each segment of the catheters were removed by sonication, and viable bacteria counted. DNA was extracted from selected patient catheter isolates and the DNA fragment of 16S ribosomal RNA was amplified by polymerase chain reaction and confirmed by DNA sequencing. The DNA sequences from the isolates obtained from different catheter sections and from urine in the same patient were compared., Results: After 1 day of catheterization there was significant bacterial growth on the outside of all the segments of patient catheters; there was significant growth on the inside of all segments by 4 days. Higher viable counts and a wider spectrum of genera were found on the outside than on the inside of these catheters. The same strains of bacteria, as determined by >or=98% similarity of the 16S ribosomal DNA sequence, were found on the outside and inside of catheters and in the urine. In the in vitro model, when the distal urethra was inoculated before inserting the catheter, the viable counts after incubation were variable along the outside of the catheter and the inside counts were uniformly high. By contrast, there was a different pattern after inoculating the inside of the distal end of the catheter, leading to an ascending biofilm on the inside. A smaller inoculum delayed but did not prevent infection in the model., Conclusion: The present results are consistent with the hypothesis that contamination of the tip of the catheter while it is being inserted is a possible means by which bacteria gain access to the bladder.

Purpose: There is increasing concern about the risks of radiation exposure with the advent of new, more complex imaging modalities. For example, computed tomography (CT), with its obvious advantages, is being more commonly used in the investigation of acute flank pain. The likely radiation exposure a patient can expect during a single complete urinary stone episode was studied., Patients and Methods: The hospital records of 60 consecutive unselected patients who had become or were rendered stone-free were studied. The effective radiation doses in milliSieverts (mSV) associated with diagnostic imaging modalities such as intravenous urogram studies and CT scans were calculated for St. George's Hospital. By combining these with the published effective doses for interventional examinations, the total effective dose over an entire stone episode was derived., Results: There were a total of 60 patients with 68 stones (15 renal, 9 in the upper, 12 in the middle, and 32 in the lower ureter), with a median stone burden of 4 mm. Thirty-two patients had procedures performed, including extracorporeal shockwave lithotripsy SWL. Total effective doses ranged from 1.18 to 37.66 mSv (median 5.3 mSv; 95% CI of the median 4.13, 7.61). Renal and proximal ureteral stones resulted in the highest radiation exposures., Conclusion: In this study the median radiation dose per stone episode was calculated at 5.3 mSv, with higher doses in those with renal stones and those who required CT scans and other interventions. Monitoring and reduction of radiation exposure is advised for all patients presenting with urolithiasis.

We describe the use of polyester resin casting of the pelvi-calyceal (PC) system as a method of evaluating the accuracy of new three-dimensional imaging technology such as ultrasound and computerised tomography. Thirty-eight kidneys from large white pigs were used for the study. We describe the process of preparation of the kidney and polyester resin for injection into the PC systems. The setting process of the resin is an exothermic reaction with an associated change in consistency. The PC systems of the kidneys were injected with resin in a controlled manner and casts obtained by maceration of the kidneys. Some of these kidneys had been distended previously with 11% glycerol and three-dimensional ultrasound reconstructions of their PC systems were compared to resin casts to assess accuracy of the reconstructions. Thirty-eight casts were created out of which 13 were poor. The quality of the casts improved with practice and pelvi-calyceal morphology could be faithfully recreated. Controlled perfusion and watching for signs such as a "turgid feel" of the kidney help avoid pelvi-calyceal disruption. Anatomically accurate casts of the kidney PC system can be created using polyester resin with the technique described. These casts can be a useful research and training tool with urological and radiological applications.

Objectives: It is known that African American men have a greater risk of prostate cancer than white men. We investigated whether this was true for first-generation black Caribbean and black African men in the United Kingdom., Methods: A clinical cohort study design recruiting all cases of prostate cancer diagnosed over a 5-yr period and residing in defined areas of London and Bristol. We calculated the age-standardised incidence rates and relative risk for all black men, and black Caribbean and black African men versus white men., Results: Black men had higher age-adjusted rates of prostate cancer (166 per 100,000, 95% confidence interval [95%CI], 151-180 per 100,000) than white men (56.4 per 100,000, 95%CI, 53.3-59.5 per 100,000). The relative risks for all black, black Caribbean, and black African men were 3.09 (95%CI, 2.79-3.43; p<0.0001), 3.19 (95%CI, 2.85-3.56; p<0.0001) and 2.87 (95%CI, 2.34-3.53; p<0.0001), respectively. There was no strong evidence that the rates for black Caribbean differed from black African men. The higher risk in black men compared with white men was more apparent in younger age groups (p value for interaction<0.001)., Conclusions: Black men in the United Kingdom have substantially greater risk of developing prostate cancer compared with white men, although this risk is lower than that of black men in the United States. The similar rates in black Caribbean and black African men suggest a common genetic aetiology, although migration may be associated with an increased risk attributable to a gene-environment interaction.

Sensitivity analysis is commonly used to characterize the effects of parameter perturbations on model output. One use for the approach is the optimization of an experimental design enabling estimation of model parameters with improved accuracy. The primary objective of this study is to conduct a sensitivity analysis of selected target-mediated pharmacokinetic models, ascertain the effect of parameter variations on model predictions, and identify influential model parameters. One linear model (Model 1, control) and 2 target-mediated models (Models 2 and 3) were evaluated over a range of dose levels. Simulations were conducted with model parameters being perturbed at the higher and lower ends from literature mean values. Profiles of free plasma drug concentrations and their partial derivatives with respect to each parameter vs time were analyzed. Perturbations resulted in altered outputs, the extent of which reflected parameter influence. The model outputs were highly sensitive to perturbations of linear disposition parameters in all 3 models. The equilibrium dissociation constant (K(D)) was less influential in Model 2 but was influential in the terminal phase in Model 3, highlighting the role of K(D) in this region. An equation for Model 3 in support of the result for K(D) was derived. Changes in the initial receptor concentration [R(tot) (0)] paralleled the observed effects of initial plasma volume (V(c)) perturbations, with increased influence at higher values. Model 3 was also sensitive to the rates of receptor degradation and internalization. These results suggest that informed sampling may be essential to accurately estimate influential parameters of target-mediated models.

The use of adhesive plastic drapes is common throughout laparoscopic and percutaneous surgery. We report a case in which a significant portion of the plastic drape was translocated into the renal pelvis during tract dilation for percutaneous nephrolithotomy. The complication was recognized only on endoscopy and the plastic successfully removed. The potential for morbidity in other patients in the future remains, and we recommend operators be aware of this unusual, but entirely preventable, complication. We highlight some measures to help avoid and check for this complication before the end of the procedure.

Objectives: To examine the association between coping style and emotional adjustment following traumatic brain injury., Participants: Thirty three individuals who had sustained a traumatic brain injury (mean duration of posttraumatic amnesia = 32 days) between 1(1/2) months and almost 7 years previously., Measures: Coping Scale for Adults, Hospital Anxiety and Depression Scale, Rosenberg Self-Esteem Scale, State-Trait Anger Expression Inventory, and the Sickness Impact Profile., Results: Approximately 50% of the sample reported clinically significant levels of anxiety and depression. Coping characterized by avoidance, worry, wishful thinking, self-blame, and using drugs and alcohol was associated with higher levels of anxiety, depression, and psychosocial dysfunction and lower levels of self-esteem. Coping characterized by actively working on the problem and using humor and enjoyable activities to manage stress was associated with higher self-esteem. Lower premorbid intelligence (measured via the National Adult Reading Test) and greater self-awareness (measured via the Self-Awareness of Deficits Interview) were associated with an increased rate of maladaptive coping., Conclusions: The strong association between the style of coping used to manage stress and emotional adjustment suggests the possibility that emotional adjustment might be improved by the facilitation of more adaptive coping styles. It is also possible that improving emotional adjustment may increase adaptive coping. The development and evaluation of interventions aimed at facilitating adaptive coping and decreasing emotional distress represent important and potentially fruitful contributions to enhancing long-term outcome following brain injury.

Primary Objective: To examine the impact of a cognitive behaviour therapy (CBT) based intervention programme, termed the Coping Skills Group (CSG), on coping strategy use and emotional adjustment., Research Design: Thirty-one individuals with TBI participated and a wait-list control design was used., Methods and Procedures: The CSG ran twice a week, for 5 weeks and focused on developing adaptive coping skills for the management of emotional and adjustment issues., Main Outcomes and Results: Following the CSG, the majority of participants subjectively reported that they had a better understanding of emotional issues and an improved ability to implement strategies to manage these issues. Adaptive coping, as measured on the Coping Scale for Adults, increased significantly immediately following intervention. However, no significant changes in anxiety, depression, self-esteem and psychosocial function were observed on the measures used., Conclusions: The results suggest that it may be possible to modify coping strategy use following brain injury, through CBT.

Primary Objective: To investigate the variables associated with positive psychological outcome following a group intervention for 33 individuals with traumatic brain injury., Research Design: Evaluation study which used multiple regression analysis to examine the variables associated with change in psychological adjustment following a 10-session cognitive behaviour therapy-based group., Methods and Procedures: The predictor variables were age at injury, time since injury, injury severity, self-awareness, pre-morbid intellectual function, memory function, executive function and level of depression and anxiety prior to intervention., Main Outcomes and Results: The predictor variables contributed a significant proportion of the variance in percentage change in depression. The major finding was that better outcomes following intervention were associated with greater self-awareness of injury-related deficits., Conclusions: The present study identified a number of variables that were associated with improvement in depression following psychological intervention and may assist future treatment resources to be directed most effectively.

Purpose of Review: Transurethral resection of the prostate remains the gold standard treatment for benign prostatic obstruction. Owing to the significant morbidity traditionally associated with the procedure, a large number of expensive, high-energy alternative treatments have been developed, which have enjoyed varying degrees of success. At the same time, transurethral resection of the prostate has evolved into a safer operation whilst maintaining its excellent efficacy. This review aims to outline the major advances that have occurred recently in transurethral resection of the prostate., Recent Findings: Optimizing each stage of transurethral resection of the prostate can result in reduced morbidity. Preoperative treatment with oral antiandrogens and 5-reductase inhibitors appears to reduce intraoperative bleeding, appropriate prophylactic antibiotic regimens reduce postoperative infection rates, improved instrumentation and diathermy delivery can reduce intraoperative bleeding and hence reduce postoperative irrigation requirements, and alcohol monitoring of irrigant absorption can eliminate transurethral resection syndrome. Careful patient selection, meticulous surgical technique combined with an aggressive postoperative irrigation and catheter removal policy can result in transurethral resection of the prostate being performed safely on a day-case basis., Summary: Whilst our attention has been distracted by the many alternative treatments brought to the market over the past decade or so, transurethral resection of the prostate has been undergoing a quiet evolution. With fine tuning of all aspects of the patient journey we can now offer a procedure with excellent long-term efficacy combined with reduced morbidity and inpatient stay.

Percutaneous management of calculi within horseshoe kidneys can be difficult because of the abnormal renal anatomy. We report our use of 16-slice CT scans to obtain three-dimensional (3D) volume-rendered (VR) movies of the pelvicaliceal system and stone for planning percutaneous renal stone surgery. The movie is formatted onto a disc, which can be played on a personal computer without additional software. This technique allows user-friendly 3D planning in the operating theatre. Unlike conventional two-dimensional images, the 3D VR movie provides a global appreciation for planning.

A regional audit report on the management of uncomplicated urinary tract infections (UTIs) in genitourinary (GU) medicine clinics in the UK in South Thames (South London, Kent, Surrey and Sussex). The majority of centres use trimethoprim as first-line treatment for uncomplicated UTIs. The incidence of trimethoprim resistance was 22.6%. The group has therefore recommended that cephalexin should be the first choice antibiotic for suspected UTIs within GU medicine.

Outcome of percutaneous nephrostomy creation during pregnancy was retrospectively studied. Catheter insertion was successful in all cases (N = 8; 3% of all nephrostomies over a 5-year period), with one major complication (sepsis) and three minor complications. Catheters remained in situ for a mean of 9.4 days until the stone passed (n = 1) or was removed on ureteroscopy (n = 2) or a ureteral stent was inserted (n = 5). Maternal outcome was normal in all cases, but there were two premature deliveries. Nephrostomy during pregnancy has acceptable technical and clinical results, but the possibility of an increased risk of septic complications (12.5% in this series) necessitates further study.

Purpose of Review: We have witnessed an explosion of interest in surgical alternatives to transurethral resection of the prostate over the past decade. These have predominantly involved the delivery of heat to the prostate to cause either coagulation or vaporization. The latest generation laser technique involves the delivery of the potassium titanyl phosphate wavelength at high powers to cause large volumes of prostatic vaporization. This short review assesses the limited present evidence base supporting its use and asks the question of whether it will relegate transurethral resection of the prostate to an operation of historical interest only., Recent Findings: The 80 W delivery system clearly results in impressive tissue vaporization with minimal bleeding. There is a learning curve to the procedure with operative times varying between 30 and 120 min. The postoperative recovery appears rapid and generally uncomplicated with early catheter removals. The short-term results suggest equivalent efficacy to transurethral resection of the prostate with improved safety; the lack of phase III trials, however, means that the durability of the procedure cannot be assessed at this early stage., Summary: Like many of the surgical alternatives to transurethral resection of the prostate this procedure shows early promise and represents the latest evolutionary development in the laser prostatectomy story. Only randomized comparisons with transurethral resection will tell us if it is a worthy challenger or simply a young pretender to the throne.

Study Objectives: The intent of the study was to explore the nature and function of the cardiovascular activation response that occurs at an arousal from sleep., Design: Four experiments were conducted. The first compared the pattern of physiologic response to orienting and startle stimuli and arousal from sleep. The second and third measured the amplitude of the cardiovascular arousal response as a function of the trait of fearfulness and the threat value of the arousing stimulus, respectively. The final experiment assessed the effect of arousal duration., Setting: The experiments were conducted in the sleep laboratory of the Department of Psychology, University of Melbourne., Participants: A total of 42 (24 women and 18 men) healthy individuals between the ages of 18 and 24 participated in the experiments., Interventions: The experiments manipulated the stimuli to which participants were exposed (orienting and startle stimuli and arousal from sleep), the threat value of stimuli used to arouse participants from sleep, and individual differences in fearfulness., Measurements and Results: The major dependent variables were heart rate, blood pressure, and a measure of peripheral vasoconstriction (digital pulse volume). In addition, in the first study, the galvanic skin response and orbicularis oculi electromyographic activity were measured. Experiment 1 showed that the pattern of physiologic response at an arousal from sleep differed, with a substantially larger cardiovascular component, from responses to orienting and startle stimuli. Experiments 2a and 2b indicated that the magnitude of the cardiovascular response at an arousal was unrelated to either individual differences in fearfulness or differences in the threat value of arousing stimuli. The final experiment showed that the cardiovascular response at an arousal was not a return to waking levels of activity but, rather, was a transient activation response., Conclusions: The study supported the view that the cardiovascular activation response at an arousal from sleep is a transient, reflex-like response that is different from the response that occurs during normal wakefulness.

The majority of renal and ureteric stones are now managed by minimally invasive techniques, for example nephrostomy, ureteral stents, extracorporeal shockwave lithotripsy or percutaneous nephrolithotomy. A multi-disciplinary approach is necessary, and this review examines the status of modern stone therapy and the contribution of the radiology department.

The modern management of urolithiasis requires a multi-disciplinary approach. Imaging plays a central role in both diagnosis and planning therapy of renal and ureteric calculi. This article reviews the current status of diagnosis and management of stone disease, and the contribution of radiological imaging in accurately triaging a given case to the most appropriate therapy.

Objective: To determine the long-term objective and subjective outcome of patients with benign prostatic enlargement (BPE) treated by endoscopic laser ablation of the prostate (ELAP), as part of a multicentre randomized controlled trial of ELAP against TURP., Patients and Methods: Initially, 151 patients with BPE were randomized to undergo either ELAP or TURP, starting in March 1992. ELAP was performed using the Urolasetrade mark fibre (Bard, Covington, GA, USA) in conjunction with a Nd:YAG laser source. All patients who had originally participated in the study were approached 5 years later to obtain a urological history, American Urological Association (AUA) symptom score and two measurements of urinary flow rate, with an ultrasonographic assessment of the postvoid residual urine volume (PVR)., Results: The mean duration of follow-up was 61 months; 109 patients were traced, comprising 69 who were alive and well, and had undergone no further bladder outlet surgery, 26 who had required revision surgery, 12 who were dead or terminally ill and three who had dementia. Both ELAP and TURP produced sustained improvements in mean AUA score, maximum flow rate and PVR, with respective values at 5 years of 6.3, 17.8 mL/s and 76 mL, and 6.5, 20.0 mL/s and 55 mL. Eighteen of 47 ELAP patients (38%) and eight of 51 (16%) TURP patients underwent revision surgery within the follow-up., Conclusion: ELAP and TURP produced similar subjective and objective outcomes at 5 years. The re-operation rate after ELAP was more than double that after TURP and suggests that ELAP should not be used routinely in the management of men with BPE.

Background and Objective: Research interests in laser prostatectomy continue to evaluate a variety of wavelengths and treatment parameters in an effort to optimize treatment. Recently, a semiconductor diode laser with a wavelength of 805 nm has become available for clinical use; however, free-beam noncontact applications were limited by the low power output (25 W). In this study in the canine prostate, the possible potentiating effects of intravenously administered indocyanine green (ICG) were evaluated with the 805 nm diode laser., Study Design/materials and Methods: A total of 16 fixed position, free-beam lasings were performed at 25 W for 60 sec in four dogs with eight lasings before and eight lasings after ICG administration. Endoscopic observations and measurements of lesion volumes were used to evaluate the laser-tissue interactions., Results: Prior to ICG administration, we observed that side fire irradiation produced primarily small coagulative lesions. Following ICG administration, however, immediate and more noticeable tissue vaporization occurred, although total lesion size was not increased. Pathologic review demonstrated less coagulation and hyperemia, but a larger vaporized cavity in the ICG treated tissue., Conclusion: These findings suggest intravenous ICG alters laser-tissue interaction with the 805 nm diode laser in the canine prostate. The use of the 805 nm diode laser with enhancing chromophores deserves further investigation.

Degenerate PCR primers were designed from the N-terminal amino acid sequence of a glutamyl aminopeptidase (PepA) from Lactococcus lactis. These primers were used to screen a lambda library for clones containing the gene (pepA) encoding PepA. The DNA sequence of a 2.1 kb fragment containing pepA was determined. The sequence revealed the presence of one complete and two incomplete open reading frames (ORFs). The complete ORF encodes a putative protein of 353 amino acids with a predicted N-terminal sequence identical to that determined for purified PepA. The pepA gene was subcloned on an Escherichia coli plasmid vector and production of active PepA was confirmed by means of a zymogram. Mutants of L. lactis in which the pepA gene was inactivated grew to normal cell densities in milk but exhibited a reduced growth rate during the exponential phase. Thus whilst PepA is required for optimal growth it is not essential.

Objectives: To assess the safety and efficacy of endoscopic laser ablation of the prostate (ELAP), performed with the Urolase fiber and the neodymium:yttrium-aluminum-garnet laser, compared to transurethral resection of the prostate (TURP) in patients with bladder outflow obstruction secondary to benign prostatic hyperplasia (BPH)., Methods: In this multicenter, prospective, randomized study, a total of 151 patients were treated (ELAP, 76; TURP, 75) of whom 137 completed 1 year follow-up (ELAP, 67; TURP, 70). Safety parameters included measurement of preoperative and 24-hour postoperative sodium, hematocrit, and hemoglobin values and careful monitoring of adverse events. Efficacy was assessed with the American Urological Association symptom score (6), urinary flow rates, and residual urinary volume measurements., Results: There was 1 death in each group during the study period unrelated to the treatment procedure. There was a clinically significant improvement in all efficacy parameters in both groups. Between group comparisons favored TURP in maximum flow rate, residual urinary volume, and symptom score. ELAP had a better safety profile than TURP in the defined safety parameters of drop in hemoglobin and hematocrit values. In 16% of patients, a blood transfusion was required after TURP compared with no transfusions in the ELAP group. Urinary tract infections and dysuria were more frequent in the ELAP group., Conclusions: ELAP performed with the Urolase fiber is a useful alternative therapy to TURP in patients presenting with bladder outflow obstruction secondary to BPH.

Objective: To compare the diagnostic yield of ultrasonically guided and digitally guided systematic biopsies of the prostate., Patients and Methods: Fifty two patients with suspected but unproven carcinoma of the prostate underwent simultaneous transrectal ultrasonography (TRUS)-guided and digitally guided systematic biopsies of the prostate. A mean of 12 cores was obtained from each patient. On average more cores were obtained with TRUS guidance (mean 6.7) than with digital guidance (mean 5.3)., Results: Cancer was detected in 19 patients and the diagnosis was made by both techniques in 16. Two patients had tumour detected only with TRUS guidance and one only with digital guidance. No complications occurred., Conclusion: This study indicates that there is no significant difference between TRUS guidance and digital guidance to direct systematic biopsies of the prostate. The use of routine TRUS in screening programmes is now in doubt.

Objective: To assess how elderly and medically unfit patients cope with day case surgery in a urological unit using sedoanalgesia., Patients and Methods: One hundred patients (mean age 78 years, range 59-97) either over the age of 75 years, or with an American Society of Anesthesiologists (ASA) status of 3 or 4 (58 patients) were studied before and after surgery to assess their medical condition, home circumstances and how they coped with their first day after the operation., Results: Ninety patients found the procedure good or acceptable and 86 thought having their operation and going home on the same day was a good idea., Conclusion: Elderly and medically unfit patients can be treated safely with no serious complications using sedoanalgesia in a well organized Day Unit equipped with full monitoring facilities.

A number of endoscopic laser strategies have been employed in the treatment of symptomatic benign prostatic hyperplasia at our hospital. The post-operative results in 102 patients are presented. Sidefiring fibres were coupled with the Nd:YAG laser to produce a deep coagulative necrosis within the prostatic adenoma. This approach was associated with a short operative time and a delay of up to three months before treatment effect. Contact laser techniques (with both the 1064 nm and 805 nm lasers) were used to vaporize prostatic tissue in an attempt to produce a defect similar to that following TURP. This provided an immediate treatment effect with early removal of catheters. The operative time, however, was long and this limited the procedure to glands of less than 40 ccs. The hybrid approach (combining laser prostatotomies with coagulation) provided an immediate relief of obstruction with an additional delayed effect as the coagulated cavity matured. All approaches were associated with minimal haemorrhage and limited morbidity with encouraging improvements in both symptom scores and uroflowmetry. The various advantages and disadvantages of each endoscopic laser strategy are discussed.

A global analysis of surgical bed dynamics in a District General Hospital over a typical 18 working day period is presented. All surgical specialties are represented. A total of 2,484 bed days were studied. Bed occupancy was 92 per cent. Seven per cent of bed capacity was occupied by acute medical patients. The operation cancellation rate was 7 per cent. Fifteen per cent of beds were closed for financial reasons. The study of admission and the stay and discharge policies of different specialties indicated that potential cost improvements could be made by the introduction of more day surgery, day of surgery admission, efficient discharge, ring fencing of beds and improved hospital data collection. While these recommendations are financially desirable, their impact on patients and staff remains to be seen.

Recently great interest has been generated in alternatives to transurethral resection for benign prostatic hyperplasia. Lasers are currently being assessed, but marketing has for the moment outstripped basic science. A cystoscopic approach was used delivering Nd:YAG or KTP laser energy via forward and sidefiring fibers and contact tip devices in 51 patients. The sidefiring device is intended to coagulate a volume of prostate that subsequently sloughs, leaving a cavity. Treatment of the apical and middle lobe tissue using this technique was unsatisfactory. A further disadvantage was the interval between treatment and improvement in urine flow, which was approximately 6 weeks. The use of temporary prostatic stents has helped to overcome this delay in treatment effect. Encouraging early results have been achieved using forward-firing fibers to treat apical and middle lobe tissue. The use of contact tip devices to perform bloodless prostatotomies in combination with sidefire or bare fiber has also proved useful. Laser prostatectomy is an exciting field with considerable potential but remains in the developmental stage.

The specific antagonist flumazenil has been shown to reverse the central actions of benzodiazepines. Its use, in day-case procedures performed under benzodiazepine sedation, offers the potential for enhanced patient recovery. However, concern has been expressed over the possibility of resedation given the short elimination half-life of flumazenil. A randomised, double-blind, placebo controlled trial was therefore designed to assess patient recovery profiles after flumazenil. A total of 44 adults were entered into the trial. Recovery was assessed by means of a battery of psychomotor tests performed pre- and postoperatively. Psychomotor function in patients receiving flumazenil returned to, or near to, baseline levels within 15 min of administration--an improvement maintained throughout the 6 h test period. Patients receiving placebo did not recover fully until the 2 h test point--significant differences between the two groups existing at 15 min and 1 h. In this study, flumazenil effectively reversed midazolam-induced sedation without evidence of resedation. The implications for day-case surgery are discussed.