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Objective: to evaluate the pharmacodynamic equivalence of 3-month and 28-day formulations of tryptoreline, a sustained-release luteininghormone (LH)-releasing hormone analogue.Subjects and methods. The patients who had a verified diagnosis of locally advanced or metastatic prostate cancer were randomized intogroups to have either one injection of a 3-month dosage form (n = 63) or 3 injections of a 28-day formulation at 28-day intervals (n = 68).The onset rate of drug-induced castration, which was defined as a percentage of the patients achieving a plasma testosterone level of ≤0.5ng/ml, was compared on day 84 (i.e. thrice every 28 days). The plasma profiles of testosterone, LH, and tryptoreline, as well as the changesin the plasma concentration of prostate-specific antigen (PCA) from the baseline values were estimated within 3 months (from the initiationof therapy to day 91).Results. In the 3-month and 28-day groups, the onset rate of drug-induced castration was 98 and 96%, respectively (at confidenceintervals (94.2% bilaterally) in [-8.1%; 9.6%]. The median time for drug-induced castration was 18.8 and 18.5 days, respective-ly (p = 0.86; log-rank test). The ratios of the mean peak plasma concentrations to AUC91 of the two formulations for testosteroneand LH were within 0.80; 1.25 equivalence interval. By day 91, the mean PSA level was decreased by 91.0 and 91.7%, respec-tively (p = 0.73).Conclusion. The use of the two formulations during 3 months is pharmacologically equal.

The aim of this study was to examine urinary tract infection (UTI) associated with conditions causing urinary tract obstruction and stasis, excluding urolithiasis and neuropathic bladder dysfunction.An electronic literature search was performed using the key words urinary tract infection (UTI), benign prostatic hyperplasia (BPH), hydronephrosis, obstruction, reflux, diverticulum, urethra, and stricture. In total, 520 abstracts were reviewed, 210 articles were studied in detail, and 36 were included as references.It is one of the axioms of Urological practice that urinary tract obstruction and stasis predispose to UTI. Experimental studies indicate that, whereas transurethral inoculates of bacteria are rapidly eliminated from the normal bladder, urethral obstruction leads to cystitis, pyelonephritis, and bacteremia. BPH is, next to urolithiasis, the most common cause of urinary tract obstruction predisposing to UTI. Urethral stricture remains a common cause of UTI in many parts of the world. Urinary stasis in diverticula of the urethra or bladder predisposes to UTI. Experimental studies have shown that, whereas the normal kidney is relatively resistant to infection by organisms injected intravenously, ureteric obstruction predisposes to pyelonephritis. It also causes renal dysfunction which impairs the excretion of antibiotics in the urine, making eradication of bacteria difficult.In patients with UTI and urinary tract obstruction, targeted antibiotic treatment according to urine culture should be complemented with urgent drainage (bladder catheterization, percutaneous nephrostomy or ureteric stenting) followed by definitive surgery to remove the cause of obstruction or stasis once infection is under control.

Cyclooxygenase-2 (COX-2) converts arachidonic acid to prostaglandins, which are important mediators of cell proliferation and inflammation. Evidence indicates that COX-2 plays a role in carcinogenesis and that it is over-expressed in prostate tumours. We investigated the role of COX-2 variants in prostate cancer in a case-control study of South African Coloured men, consisting of 151 cases and 134 controls. The genotype frequencies of four single-nucleotide polymorphisms (SNPs) in the COX-2 promoter were initially determined in 50 control subjects. One SNP, rs20417 (-899G>C), was monomorphic and excluded from further investigation. Three SNPs, rs3918304 (-1285A>G), rs20415 (-1265C>T) and rs5270 (-297C>G), were genotyped in all the case patients and control subjects. The -1285 G-allele and -1265 T-allele were associated with increased risk of prostate cancer [odds ratio (OR) = 3.53; confidence interval (CI) = 2.14-5.90; P < 0.0001 and OR = 3.01; CI = 1.82-5.02; P < 0.0001] after adjusting for age. Haplotype GTC conferred increased risk of prostate cancer in South African Coloured men (OR = 3.54 versus ACC; CI = 2.12-5.92; P < 0.0001). These findings in conjunction with findings in other populations of African descent might suggest a common causal variant for prostate cancer in COX-2, or a variant in a nearby gene.

Genetic alterations within diseased prostate tissue were analysed by genomic DNA fingerprinting using a minisatellite probe (lambda 33.6), a simple repetitive oligonucleotide probe (GTG)5, and an additional human multilocus probe (pV47-2). In prostatic adenocarcinoma, somatic mutations were detected in 77% of the samples compared with 38% of the benign prostatic hyperplasia samples. No correlation was evident with either the tissue histopathology or the grading or staging classification of the malignant tissue. Because one of the probes (pV47-2) did not demonstrate any changes in the tumour tissue, and because the probes exhibited specificity for different regions of the genome, it is possible to conclude that mutations occur widely throughout the genome, perhaps with the exception of certain domains. The results suggest that somatic mutations accompany the development of both benign and malignant pathologies of the prostate. Furthermore, benign prostatic hyperplasia should be considered as a risk indicator for processes leading to prostatic adenocarcinoma.

The polymerase chain reaction (PCR) is a technique that can be used to amplify a specific DNA genomic sequence, whereby the presence of an extremely small number of bacteria can be detected. The high sensitivity of PCR is particularly useful in paucibacillary situations such as non-pulmonary tuberculosis (TB). The aims of the present study were to establish a PCR assay for the rapid detection of Mycobacterium tuberculosis (MTb) in urine, to compare the sensitivity of PCR with routine culture technique (Bactec) and to determine the optimal type of urine specimen for PCR detection of MTb. In the first phase of the study, a total of 92 urine specimens were collected from 83 patients with suspected urinary tract TB. Two urine specimens in 2 patients were positive for TB by both PCR and Bactec, while 90 specimens from 81 patients were negative by both methods. Inhibition of PCR was present in nine urine specimens (10%). In the second phase of the study, a further seven patients were selected for intensive investigation to determine the optimal urine sampling for PCR detection of MTb. The conclusions of the study are that PCR can provide much faster confirmation of urinary TB (within 24-48 h) than Bactec urine culture (which may take several weeks). About 10% of urine specimens could not be evaluated by PCR due to the presence of inhibitory substances of unknown nature. MTb organisms were found to be excreted intermittently in the urine of infected patients, and single specimens were more likely to be false negative than a 24-h sample. The best method appeared to be the concentration of a large volume of urine, for instance 11 concentrated to 2 ml.

Analysis of 81,374 prostatectomies performed in Scotland between 1971 and 1989 showed that the annual prostatectomy rate (per 100,000 men) increased 3-fold for procedures performed by urologists, but remained static for general surgeons. In 1971, transurethral prostatectomy comprised 16% of all prostatectomies performed by general surgeons and 55% of those performed by urologists, but by 1989 it comprised 93% of prostatectomies performed by general surgeons and 96.5% of those performed by urologists. The relative increase in the annual number of prostatectomies was greatest (2.61) in the older age group (80-89 years) and smallest (1.76) in the younger age group (60-69 years). The relative increase in the age-specific prostatectomy rate was greatest (1.79) in the youngest age group (50-59 years) and smallest (1.54) in the oldest age group (80-89 years). This indicates that the increase in the annual number of prostatectomies performed in the older age groups is largely the result of an increase in the number of elderly men in the population, but this is compounded by an expansion of the indications for prostatectomy in all age groups.

A visual prostate symptom score (VPSS) compared with the international prostate symptom score (IPSS) for evaluation of lower urinary tract symptoms (LUTS) can be completed without physician assistance by a significantly larger proportion of men with limited education. We aimed to evaluate the correlation of the VPSS and IPSS with uroflowmetry parameters.Men with LUTS were requested to complete the IPSS and VPSS, consisting of pictograms to evaluate urinary frequency, nocturia, force of the stream and quality of life. The maximum (Qmax) and average urinary flow rate (Qave), voided volume (VV) and post-void residual (PVR) urine volumes were measured. Statistical analysis was performed using the Mann-Whitney and Spearman's tests.The study included 93 men (mean age 64 years, range 33 - 85), with VV150 ml in 66 (71%) and150 ml in 27 (29%) subjects. In the group with VV150 ml there were significant negative correlations between the IPSS and Qmax (r=-0.30, p=0.016), the IPSS and Qave (r=-0.29, p=0.018), the VPSS and Qmax (r=-0.38, p0.002) and the VPSS and Qave (r=-0.37, p0.003). The VPSS question on the subject's assessment of his urinary stream showed a significant negative correlation with the Qmax (r=-0.37, p=0.002) and Qave (r=-0.31, p=0.011), but the IPSS question on the subject's urinary stream did not correlate significantly with the Qmax or Qave.The VPSS is equivalent to the IPSS in terms of correlation with Qmax and Qave and can therefore be used instead of the IPSS to evaluate LUTS in men with limited education.

Recent studies have shown an increased late mortality rate due to cardiovascular causes after transurethral compared with open prostatectomy. This has been linked to the demonstration of haemodynamic changes during transurethral prostatectomy, which may cause ischaemic myocardial injury. We used transoesophageal echocardiography (currently the most sensitive modality for detecting myocardial ischaemia) to study 26 patients during prostatectomy under general anaesthesia. Evidence of myocardial ischaemia (as shown by the development of new regional wall motion abnormalities of the left ventricle) occurred in 4 of 22 patients during transurethral and in 3 of 4 patients during retropubic prostatectomy. An intra-operative fall in systolic as well as diastolic blood pressure occurred in 21 of 22 patients during the transurethral procedure and in all 4 patients during retropubic prostatectomy. The duration of anaesthesia and the operation, and the intra-operative blood loss did not differ significantly between patients with and without evidence of intra-operative myocardial ischaemia. However, the maximum intra-operative fall in systolic and diastolic blood pressure, as well as the mass of the prostatic tissue removed, were significantly greater in patients with than in those without evidence of intra-operative myocardial ischaemia, suggesting that the latter may be related to the extent of surgery and the degree of intraoperative hypotension. In this study, 7 of 26 patients (27%) showed evidence of myocardial ischaemia during prostatectomy. However, it remains difficult to explain why intra-operative myocardial ischaemia should result in an increased cardiovascular mortality rate several years after the operation.

We aimed to evaluate the presenting features and treatment outcome of prostate cancer in men aged50 years, in a region where prostate specific antigen (PSA) screening is not readily available and most men present with symptoms.We analysed the data of 1 571 men with prostatic adenocarcinoma treated between January 1997 and December 2008 at out institution, a tertiary level public secotr hospital serving a largely indigent population. Statistical analysis was performed using Student's, the Mann-Whitney and Fisher's exact tests where appropriate (p0.05 accepted as statistically significant).Of 1 571 men, 47 (3%) were aged50 years. The group aged50 years compared with that aged50 years, had a siginificantly greater proportion with poorly differentiated adenocarcinoma (53%), locally advanced (stage T3-4) tumours (56%), haematogenous metastases (75%), significantly higher serum PSA at diagnosis (mean 621, median 74 ng/ml) and shorter survival.Men aged50 years presenting with symptoms owing to prostate cancer had significantly higher risk disease, higher mean PSA, and poorer prognosis than men aged50 years. To diagnose prostate cancer at a potentially curable stage in men aged50 years, it is necessary to initiate asleine PSA testing at age 40 and 45 years, and to select high-risk men for PSA surveillance in order to diagnose potentially curable cancer in those with a life expectancy20-25 years.

La torsione del testicolo e stata inizialmente descritta da Delasiauve nel 1840 (Delasiauve 1840). Il primo caso di torsione di un testicolo completamente sceso e stato riportato da Langton nel 1881 (Williamson 1976). Nel 1893, Nash ha descritto la prima detorsione manuale del testicolo (Nash 1893). Curling (1857) ha citato un caso riportato da Rosenmerkel di Monaco, che ha detorto un criptorchidismo e lo ha fissato nello scroto con una sutura attraverso la tunica dartos (Noske et al. 1998). Defontaine ha descritto il primo caso di riparazione operatoria di una torsione intrascrotale nel 1893 (Sparks 1971). Mosby ha descritto la prima torsione sopravaginale nel 1897 (Taylor 1897).

L’associazione dell’esame clinico e dell’ecografia permette la diagnosi della maggior parte delle lesioni scrotali. Vedimomento che l’idrocele puo essere associato a una neoplasia testicolare, un’ecografia dello scroto deve essere praticata per confermare l’assenza di alterazioni del testicolo. Fig. I.8.1. Open image in new window Fig. I.8.1. Algoritmo della valutazione delle tumefazioni scrotali nell’adulto. L’ecografia scrotale e ormai disponibile e viene eseguita in numerosi centri, prima che il paziente sia esaminato in ambiente specialistico. Non ha sostituito un esame clinico accurato e il medico esperto puo spesso gestire il paziente senza ricorrere all’ecografia. Adattata con autorizzazione di Mostofi e Sesterhenn (1998)

To evaluate the safety and efficacy of vasectomy performed under local anaesthesia by junior doctors at a secondary level hospital as part of a free family planning service.Men requesting vasectomy were counselled and given written instructions to use alternative contraception until two semen analyses 3 and 4 months after vasectomy had confirmed azoospermia. Bilateral vasectomy was performed as an outpatient procedure under local anaesthesia by junior urology registrars. Statistical analysis was performed using the Mann-Whitney, Kruskal-Wallis, Fisher's exact or Spearman's rank correlation tests as appropriate.Between January 2004 and December 2005, 479 men underwent vasectomy at Karl Bremer Hospital, Western Cape, South Africa; their average age was 36.1 (range 21 - 66) years, they had a median of 2 (range 0 - 10) children, and only 19% had 4 or more children. The average operation time was 15.5 (range 5 - 53) minutes. Complications occurred in 12.9%; these were pain (7.3%), swelling (5.4%), haematoma (1.3%), sepsis (1%), difficulty locating the vas (1%), vasovagal episode (0.6%), bleeding (0.6%), wound rupture (0.4%) and dysuria (0.2%) (some men had more than one complication). Of the men 63.3% returned for one semen analysis and 17.5% for a second. The vasectomy failure rate ranged from 0.4% (sperm persisting365 days after vasectomy) to 2.3% (sperm seen180 days after vasectomy and/or in the second semen specimen). No pregnancies were reported. The complication (5.6%) and failure rates (0%) were lowest for the registrar who had performed the smallest number of vasectomies and whose average operation time was longest. Comparing the first one-third of procedures performed by each of the doctors with the last one-third, there was a significant decrease in average operating times but not in complication rates.Vasectomy can be performed safely and effectively by junior doctors as an outpatient procedure under local anaesthesia, and should be actively promoted in South Africa as a safe and effective form of male contraception.

L’association de l’examen clinique et de l’echographie permet le diagnostic de la plupart des lesions scrotales. Dans toute intervention chirurgicale portant sur le scrotum, il existe des risques de lesion des deferents ou des vaisseaux testiculaires qui pourraient affecter la fertilite les patients doivent donc en etre informes. Les hydroceles de l’enfant et de l’adulte ont des causes differentes. L’excision des kystes de l’epididyme peut ne pas resoudre la gene attribuee a ces kystes.

La torsion du testicule est une urgence frequente. Le diagnostic est clinique et le traitement consiste en une detorsion chirurgicale et une fixation bilaterale en urgence. Dans les cas douteux, il est imperatif d’avoir une tres forte suspicion, et les erreurs de prise en charge doivent se faire dans un sens plutot agressif que conservateur. Une orchidopexie homo et controlaterale doit etre effectuee avec des sutures non resorbables pour prevenir une recidive de la torsion. Les taux de sauvegarde du testicule sont correles a la duree et au degre de la torsion. L’hypofertilite apres torsion est bien connue mais n’a probablement pas d’importance clinique. La torsion du testicule reste une urgence chirurgicale en deca de 48 h de symptomatologie persistante. En presence d’une induration scrotale ligneuse, la torsion du testicule n’est plus une urgence au dela de 24 h de symptomatologie persistante. Les patients presentant un tableau clinique de torsion subaigue intermittente ou recidivante, et ceux ayant deja perdu un testicule par torsion, traumatisme ou tumeur, doivent probablement subir une orchidopexie. Les torsions d’annexes testiculaires peuvent etre traitees de facon conservatrice et n’ont pas de consequence clinique en dehors du fait qu’elles doivent etre differenciees de la torsion du testicule.

Accurate epidemiological data about the incidence and mortality of bladder cancer are unavailable for most African countries. Transitional cell carcinoma (TCC) of the bladder is probably less common in rural African regions than in industrialized countries, due to lower levels of exposure to carcinogenic chemicals. In areas with endemic schistosomiasis (bilharzia) caused by parasitic schistosomes (blood flukes), most bladder cancer cases are comprised of squamous cell carcinoma (SCC). However, with increased urbanization, industrialization, and cigarette smoking in many African countries, there is an increasing incidence of TCC relative to SCC of the bladder. SCC of the bladder presents in patients who are on average 10 to 20 years younger than those with TCC. In Egypt and other North African countries, SCC is more common in men (the male to female ratio ranges from 3:1 to 5:1), probably because boys and men performing agricultural work are more exposed to schistosomiasis-infested water. In some sub-Saharan countries, SCC of the bladder is equally common in men and women, probably due to equal schistosomiasis exposure of girls and boys, and because women obtain household water and perform most agricultural tasks. Although SCC of the bladder often presents at a locally advanced stage, the tumors are usually well differentiated, with a relatively low incidence of lymphatic and hematogenous metastases. Patients with localized SCC are ideal candidates for cystectomy and orthotopic neobladder construction, because they are relatively young and healthy, and there is no risk of urethral recurrence, unlike with TCC. Unfortunately, many patients in Africa still present with advanced and inoperable bladder cancer, and many do not have access to healthcare facilities that can provide a cure and a good quality of life by means of radical cystectomy and neobladder construction.

To determine the optimal evaluation and management of renal injuries by review of the world's English-language literature on the subject.A consensus conference convened by the World Health Organization and the Societé Internationale d'Urologie met to critically review reports of the diagnosis and treatment of renal trauma. The English-language literature about renal trauma was identified using Medline, and additional cited works not detected in the initial search obtained. Evidence-based recommendations for the diagnosis and management of renal trauma were made with reference to a five-point scale.There were many Level 3 and 4 citations, few Level 2, and one Level 1 which supported clinical practice patterns. Findings of nearly 200 reviewed citations are summarized.Published reports on renal trauma still rely heavily on expert opinion and single-institution retrospective case series. Prospective trials of the most significant issues, when possible, might improve the quality of evidence that dictates the behaviour of practitioners.

To compare the efficacy of monthly administrations of the luteinizing hormone-releasing hormone agonists triptorelin pamoate and leuprolide acetate to induce and maintain castrate levels of serum testosterone in men with advanced prostate cancer.Men with advanced prostate cancer were randomly assigned to receive triptorelin 3.75 mg or leuprolide 7.5 mg. The agent was injected intramuscularly every 28 days for nine injections. Primary endpoints were the percentages of men whose serum testosterone concentrations declined to and were maintained at or below castrate levels (/= 1.735 nmol/L or/= 500 ng/L) during 9 months (253 days) of treatment. Secondary endpoints were luteinizing hormone levels, bone pain, prostate specific antigen levels, quality of life, testosterone pharmacodynamics, survival, and safety variables.In all, 284 men received either triptorelin (140) or leuprolide (144). The percentage of men with castrate levels of serum testosterone was lower at 29 days for triptorelin than for leuprolide (91.2% vs 99.3%; point estimate - 8.0, 95% confidence interval - 16.9% to - 1.4%), but equivalent at 57 days (97.7% vs 97.1%). The mean (98.8% vs 97.3%) and cumulative (96.2% vs 91.2%) castration maintenance rates between 29 and 253 days were equivalent between the treatment groups. Secondary endpoints were equivalent between treatment groups except for the 9-month survival rate, which was significantly higher for triptorelin than for leuprolide (97.0% vs 90.5%; P = 0.033). Both treatments were well tolerated.Triptorelin reduced testosterone concentrations less rapidly, but maintained castration as effectively as leuprolide. There was no evidence that the slower onset of castration caused deleterious effects.

To assess the feasibility of detecting early-stage prostate cancer in the primary healthcare setting, and to investigate whether there is a higher incidence of prostate cancer in Black African men.The study was a collaboration with registrars in the authors' institutions and primary healthcare centres serving mainly a Black African or mixed ancestry (Coloured) population in the semi-urban Cape Town metropolitan area of South Africa. Men aged 50-70 years attending the clinics were counselled about prostate cancer and invited to have a digital rectal examination (DRE), serum prostate-specific antigen (PSA) assay and transrectal ultrasonography-guided sextant prostate biopsy if the DRE was clinically suspicious of malignancy or the serum PSA wasor = 4.0 ng/mL. An American Urological Association Symptom Index (AUA-SI) was obtained, and urine analysed using dipsticks.From May 2000 to November 2001, 660 men were assessed (mean age 59.4 years, range 30-82); 60.6% were Black African, 37.3% mixed (Coloured), 1.8% White (Caucasian) and 0.2% Asian (Indian). The mean (range) AUA-SI was 5.98 (0-35) in the whole group; the DRE was recorded as clinically suspicious of malignancy in 3.2%. The mean PSA was 20.39 (0.04-10 000) ng/mL in the whole group, but when two outliers (1865 and 10 000 ng/mL) were disregarded, it was 2.4 ng/mL. In Black patients the mean PSA was 31.8 (0.04-10 000) ng/mL, and without the outliers, 2.1 ng/mL; in Coloured patients it was 2.94 (0.05-50) ng/mL. The PSA wasor = 4.0 ng/mL in 9.6% of the whole group, in 7.8% of Black and in 13% of Coloured patients. Prostate biopsies were taken in 21 patients (3.2% of the whole group and a third of those with a PSA ofor = 4.0 ng/mL); in Black patients, biopsies were taken in 1.5% and 19.4%, respectively, and in Coloured patients in 6.1% and 46.9%, respectively. The prostate biopsy showed cancer in 43% of the whole group, in a third of Black and in 47% of Coloured patients; prostate cancer was detected in 1.4%, 0.5% and 2.8%, respectively.That prostate biopsies were obtained in only 19% of Black and in only 47% of Coloured men with a serum PSA ofor = 4.0 ng/mL is of concern. This indicates that there is a significant problem in getting men with an elevated serum PSA level to undergo a prostate biopsy in the primary healthcare setting in South Africa.

We prospectively evaluated the American Urological Association (AUA) symptom index and maximum urine flow for predicting urethral stricture recurrence in men with a previous diagnosis of urethral stricture disease.Patients were recruited at our urethral stricture clinic, where all newly diagnosed and previously treated men with urethral stricture present and are treated. The AUA symptom index was completed and uroflowmetry was done. The stricture was calibrated using Jacques catheters. If an 18Fr catheter could not be passed, a retrograde urethrogram was performed. Patients were treated with filiform dilation or direct vision internal urethrotomy. Uroflowmetry was repeated when the catheter was removed 3 days later and the AUA symptom index was repeated 1 month later.Data on 49 patients (170 consultations) between March 2000 and August 2001 were analyzed. Average patient age was 48 years. There was a significant negative correlation of urethral diameter with AUA symptom index and of AUA symptom index with maximum urine flow as well as a significant positive correlation of urethral diameter with maximum urine flow. We evaluated the usefulness of AUA symptom index and maximum urine flow at different cutoff levels for predicting urethral stricture in our study group. Using an AUA symptom index of greater than 10 or maximum urine flow of less than 15 ml. per second as cutoff values provided 93% sensitivity, 68% specificity, 78% positive predictive value, 89% negative predictive value and 82% overall accuracy. This method could have prevented further invasive studies in 34% of patients, while a clinically significant stricture would have been missed in only 4.3%.AUA symptom index combined with maximum urine flow is an accurate, time-saving and cost-effective tool for predicting recurrent stricture in patients with a known urethral stricture. It can be used to direct decision making on further invasive studies and treatment.

The purpose of this study was to evaluate the results of vesicosuspension for female stress incontinence and cystocele using fixation with pubic bone anchors in a cohort of patients operated on by a single surgeon.Using a standard questionnaire, an independent female interviewer not employed by the surgeon's practice contacted 100 consecutive patients with stress incontinence and/or cystocele who had undergone vesicosuspension using suprapubic fixation with bone anchors between October 1996 and July 1997. The patients' responses were recorded on a computerised database and analysed. All procedures were performed by a single surgeon (A.J.V.). The duration of the operation was normally 45 minutes, the patient was mobilised on day 3 postoperatively, and the catheter removed on day 7.The mean age of the 100 women was 50.4 years (range 26-84 years) and the mean follow-up was 11 months (range 1.4-19 months). Previous operations for incontinence had been performed in 44 patients. Preoperatively 56 patients had to wear protective pads, using an average of 4.4 pads per day, and 36 had to change underwear because of urine leakage. Postoperatively 14 patients had to wear protective pads, using an average of 3.5 pads per day, while 11 had to change their underwear because of urine leakage. Only 3 patients used a catheter to empty the bladder, 2 used medication for incontinence, and none had had a subsequent operation for urine leakage. Postoperatively 16 patients reported having problems with pain in the pelvis, and 6 had pain during intercourse, but there were no cases of osteitis pubis. Subjective improvement reported by the patients was 93% on average, and overall patient satisfaction with the procedure was 8.6 on a scale of 0-10. In total, 89 patients said they would be prepared to undergo the operation again, while 92 would recommend it to a friend.The use of pubic bone anchors for colposuspension is safe and reliable, with results comparable to those of other methods, and the added advantages of faster mobilisation and few short-term complications.

Early stage prostate cancer does not cause symptoms, and even metastatic disease may exist for years without causing symptoms or signs. Whereas early stage prostate cancer can be cured with radical prostatectomy or radiotherapy, the prognosis of patients with locally advanced or metastatic cancer is significantly poorer.In view of the high incidence of advanced and therefore incurable prostate cancer seen at the oncology clinic of the Department of Urology, Tygerberg Hospital, we started a prostate clinic with the aim of detecting early stage prostate cancer which is potentially curable. A secondary objective was to investigate the question whether there is a higher incidence of prostate cancer among black African men.Men aged 50-70 years were invited by means of media communications (newspaper and radio) to attend our prostate clinic for a free physical examination, including a digital rectal examination (DRE) and serum prostate specific antigen (PSA) assay. If the DRE was clinically suspicious of malignancy and/or the serum PSA was4 ng/ml, the patient was appropriately counselled and referred for transrectal ultrasound (TRUS)-guided sextant prostate biopsy.In the period June 1997-September 1999 a total of 1,056 men attended the prostate clinic. Biopsies were indicated in 160 cases, and were obtained in 114 (71.3%, i.e. 10.8% of the entire cohort). Prostate cancer was detected on first biopsy in 3.5% of the entire group of men (in 35.9% of those with a clinically abnormal DRE, in 41.3% of those with a serum PSA4 ng/ml and in 88.6% of those with an abnormal DRE and serum PSA4 ng/ml. In the 37 men with prostate cancer, the clinical tumour stage was T1-2 in 83.8% and T3-4 in 16.2%. In the group of patients with clinical stage T1-2 tumours, the treatment was watchful waiting in 62.5% of cases, radiotherapy in 20.8% and radical prostatectomy in 16.7%. Analysis of the data according to race showed that in the group of 47 black men there was a higher percentage of clinically abnormal DRE, PSA4.0 ng/ml and biopsies showing malignancy, and a higher overall prostate cancer detection rate (8.5%).Our prostate cancer detection rate of 3.5% is slightly lower than that reported in larger studies (4.7%), which may be due to the fact that prostate biopsy was performed in only 71% of those who had an indication for biopsy. In the men diagnosed with clinically localised prostate cancer, potentially curative treatment was given in only 37.5% of cases. This compares unfavourably with the historical cohort of men seen at our oncology clinic, where 53% received potentially curative treatment, and a large European study where potentially curative treatment was given in 89% of cases. Our finding that black men had a higher percentage of clinically abnormal DRE, PSA4.0 ng/ml and biopsies showing malignancy and a higher overall detection rate of prostate cancer should be interpreted with caution, since black men comprised only 4.5% of our overall study cohort.

To determine whether there is a cut-off value of serum prostate-specific antigen (PSA) which can be used confidently to make the diagnosis of prostate cancer, thereby obviating the need for biopsy.During the period October 1991 to March 1998 the Department of Chemical Pathology at Tygerberg Hospital performed a total of 6,733 serum PSA assays on 3,960 patients. The histopathological and clinical diagnoses of these patients were obtained from records in the departments of Anatomical Pathology, Urological Oncology and Radiation Oncology. The serum PSA levels were correlated with the histopathology reports, using different PSA cut-off values ranging from 5 to 500 ng/ml, to calculate the sensitivity, specificity, and positive and negative predictive values of each cut-off value of PSA in predicting the presence of prostate cancer.In total, 3,837 (57%) of the 6,733 serum PSA assays wereor = 4 ng/ml, 1,045 (15.5%) of the assays wereor = 50 ng/ml, and 798 (11.9%) wereor = 100 ng/ml. Of the total of 3,960 individual patients, 531 (13.4%) had a serum PSAor = 50 ng/ml and 423 (10.7%) had a PSAor = 100 ng/ml. A serum PSA ofor = 30 ng/ml had a positive predictive value (PPV) of 90% at a specificity of 87% and sensitivity of 78%, while a PSAor = 60 ng/ml had a PPV of 98% at a specificity of 98% and sensitivity of 65% for the presence of prostate cancer. The PPV reached 99% at a PSAor = 100 ng/ml and 100% at a PSAor = 500 ng/ml, with a specificity of 99% and 100%, but sensitivity of only 53% and 19%, respectively.A serum PSAor = 60 ng/ml has a PPV of 98% for the presence of adenocarcinoma of the prostate, and may be used as a surrogate for histological diagnosis where facilities for obtaining prostatic biopsies are not readily available, thus decreasing costs and patient morbidity.

Male patients with proven urethral strictures (total 210) were prospectively randomised to undergo either dilatation (106 patients) or internal urethrotomy (104 patients) as an outpatient procedure under local anaesthesia. The incidence of complications or failure during the performance of the procedure did not differ significantly between the two treatment groups. Complications or failure in performing urethral dilatation were significantly more common in patients who presented with retention or complications compared with symptoms only, and in those with a positive compared with negative urine cultures. Complications or failure in performing internal urethrotomy were significantly more common in patients with a positive than with a negative urine culture, and long (2 cm) rather than short (2 cm) strictures, whereas the difference approached significance for patients with multiple rather than single strictures (P = 0.06). Failure alone in the performance of internal urethrotomy was significantly more common in patients with trauma compared with urethritis as aetiology, and in those without previous stricture treatment. With a mean follow-up of 15 months the cumulative percentage of recurrent urethral strictures did not differ significantly between the two treatment groups. We conclude that urethral dilatation and optical internal urethrotomy under local anaesthesia are equally successful as initial outpatient treatment. With regard to successful performance of the procedure itself, multiple, longer (2 cm), post-traumatic, and previously untreated strictures are better managed with dilatation, whereas patients with complications or retention are better managed with internal urethrotomy. A positive urine culture is associated with a higher complication and failure rate in the performance of both procedures.

We reviewed the management of 50 patients with cancer of the penis treated between November 1983 and April 1995 at Tygerberg Hospital. The mean patient age was 54 years. The race of the patient was mixed in 40, white in 8 and black in 2 cases. Serological tests were positive for syphilis in 8/18 (44%), and for human immunodeficiency virus (HIV) in 2/11 patients (18%) who were tested. Only 1 patient had been circumcised (at puberty). Penectomy was performed in 45 patients--partial amputation in 29 cases and radical penectomy in 20 (in 4 of these after previous partial penectomy with positive margins). Complications of penectomy occurred in 9 patients (20%). The histology of the primary lesion was squamous carcinoma in 46, verrucous carcinoma in 3 and melanoma in 1 patient. Differentiation of the tumour was good in 24, moderate in 15 and poor in 8; the grade was not recorded in 3 cases. The pathological T stage was Tis in 1 patient, T1 in 5, T2 in 24, T3 in 17 and T4 in 3 cases. Inguinal lymphadenectomy was performed in 34 patients at a median interval of 72 days after penectomy. Complications after lymphadenectomy occurred in 26 of the 34 patients (76%), but a second operation was required in only 5 cases (15%). In patients without clinically palpable inguinal nodes, cancer was present in 2/8 (25%) specimens. In patients with clinically palpable inguinal nodes, metastases were present in 16/29 (55%)--in 4/16 (25%) of nodes clinically thought to be infective, and in 12/13 (92%) of nodes considered to be malignant. Lymph node metastases were present in 0/2 patients with T1, in 5/19 (26%) with T2, in 12/15 (80%) with T3 and in 3/3 (100%) with T4 tumours. At a mean follow-up of 22 months in 39 patients 62% were alive without evidence of disease, 23% were alive with carcinoma and 15% were dead. Death and recurrence or metastases were significantly more common in patients with T3-4 compared with T1-2 tumours, and in those with N1-3 compared to NO disease, but tumour grade had no significant effect on outcome. Death and recurrence or metastases were also more common in cases where the surgical margin at penectomy was involved with tumour. In conclusion, our patients presented at a relatively young age with locally advanced tumours and a high incidence of inguinal lymph node metastases. In patients with locally advanced tumours we recommend ablative surgery with bilateral inguinal lymphadenectomy 6-8 weeks after penectomy. We avoid pelvic lymph node dissection, since this does not improve the prognosis, while increasing the risk of complications, especially lower limb oedema.

Genetic alterations within diseased prostate tissue were analysed by genomic DNA fingerprinting using a minisatellite probe (lambda 33.6), a simple repetitive oligonucleotide probe (GTG)5, and an additional human multilocus probe (pV47-2). In prostatic adenocarcinoma, somatic mutations were detected in 77% of the samples compared with 38% of the benign prostatic hyperplasia samples. No correlation was evident with either the tissue histopathology or the grading or staging classification of the malignant tissue. Because one of the probes (pV47-2) did not demonstrate any changes in the tumour tissue, and because the probes exhibited specificity for different regions of the genome, it is possible to conclude that mutations occur widely throughout the genome, perhaps with the exception of certain domains. The results suggest that somatic mutations accompany the development of both benign and malignant pathologies of the prostate. Furthermore, benign prostatic hyperplasia should be considered as a risk indicator for processes leading to prostatic adenocarcinoma.

This is a review of the treatment results of 100 consecutive patients with infiltrating transitional cell carcinoma of the bladder who underwent cystectomy at Tygerberg Hospital between 1978 and 1989. Radiotherapy was given pre-operatively in 39% and postoperatively in 15%, and systemic chemotherapy was used postoperatively in 12% of the patients. Follow-up was available in 81% of patients, with a mean of 40.8 months (range 1-145 months). The estimated overall 5-year survival rate was approximately 70%, which compares favourably with the 5-year survival rate reported in other series of transitional cell bladder carcinoma treated with radical cystectomy (30-82%). There was a statistically significant decrease in overall 5-year survival in patients with more locally advanced tumours, and in patients with a higher pathological stage relative to clinical tumour stage (upstaging) than in those with a lower pathological stage relative to clinical tumour stage (downstaging). There was no statistically significant difference in overall survival between patient groups aged60 and70 years, between patients with and without pre-operative radiotherapy, between groups with different tumour grades, between those with and without carcinoma in situ, and between those with and without pelvic lymph node metastases.

We reviewed the surgical complications in 112 consecutive patients who had undergone radical cystectomy for bladder cancer at Tygerberg Hospital between 1978 and 1989. The cystectomies were performed by a total of 16 surgeons, of whom 1 (A) performed 30 and assisted at 2, 1 (B) performed 26 and assisted at 4, 2 (C + D) performed 27 and assisted at 16, and 12 (E-P) performed 29 and assisted at 46. Pre-operative radiotherapy was given in 37% of cases and intravesical chemotherapy in 25%. Major coexisting medical problems were present in 60%. The overall peri-operative mortality rate was 11%, but the rate was significantly lower (3%) in the group of patients operated on by surgeon A than in those operated on by surgeons E-P (21%). Major early postoperative complications occurred in 17% of the patients and major late complications in 25%. There were no significant differences between the different surgical groups in early and late complication rates. Peri-operative mortality and major early complications were significantly increased in patients aged over 71 years compared with those aged under 60 years. Peri-operative mortality was significantly increased in patients who had not received pre-operative radiotherapy compared with those who had done so. The presence of major coexistent medical problems did not significantly affect the rates of peri-operative mortality or major early or late surgical complications. Peri-operative mortality was lower in patients with T0-1 tumours than in those with T2-4 tumours, but the stage did not affect the incidence of major early or late surgical complications.(ABSTRACT TRUNCATED AT 250 WORDS)

We analyzed 3-dimensional (3D) computed tomographic images of the pelvicaliceal system obtained in 25 patients after opacification of the collecting system by retrograde ureteric or intravenous (IV) infusion of sodium iothalamate. 3D images were reconstructed using the data from nonoverlapping 5-mm sections taken on an Elscint 2400 scanner. Factors contributing to poor image quality were: artifacts caused by contrast in the collecting tubules, underfilling or overdistension of the pelvicaliceal system with contrast, movement of the patient and severe hydronephrosis. Satisfactory 3D images of the pelvicaliceal system can be obtained by retrograde ureteric infusion of 5% w/v sodium iothalamate at 20 cm H2O, or by IV injection of 50 ml of 70% w/v sodium iothalamate. Abdominal compression should be applied 10-15 min after the IV injection of contrast, and the computed tomographic examination should commence 20-30 min after the injection. It is imperative that the patient lie completely still and breathe normally to avoid movement of the kidneys. 3D computed tomographic imaging of the pelvicaliceal system may become a valuable adjunct to the preoperative planning and performance of percutaneous nephrolithotomy.

In order to evaluate the initial T stage and tumour grade as predictors of metastatic disease and prognosis in adenocarcinoma of the prostate, 963 patients were reviewed. Of the patients, 41% presented with metastatic disease. Stage T4 tumours were associated with a consistently poor prognosis, and 70% of such patients had demonstrable distant metastases. No patient with TOf local disease had metastases or died of prostate cancer during follow-up. The incidence of metastases was also low in stages T1 and T2. High tumour grade correlated strongly with more advanced disease. Using this information a more cost-effective approach to the staging of prostate carcinoma is proposed.

Wilms' tumor is uncommon in adults, and spontaneous retroperitoneal hemorrhage as the presenting sign of renal malignancy also is rare. A 22-year-old man with spontaneous rupture of a Wilms' tumor, who died within 5 months, is described. The factors that probably contributed to his rapid demise included preoperative tumor spilling, unfavorable histology, and the omission of radiotherapy owing to poor patient compliance. Although Wilms' tumor is known to have a poorer prognosis in adults than in children, the reason for this is not known. Due to the limited number of cases reported, the optimal treatment for adult Wilms' tumor remains to be defined. However, the recent literature indicates that radical surgery combined with maximal radiotherapy dosage and modification of the chemotherapy schedules used in children may be required to improve the prognosis for adults with Wilms' tumor.

Spontaneous (non-traumatic) intraperitoneal rupture of the bladder in a 37-year-old pregnant woman was repaired at laparotomy. Nine months later she again presented with an intraperitoneal bladder rupture during pregnancy and fatal sepsis. Histological examination of the resected bladder wall showed acute ulcerative and necrotising cystitis. All patients with apparently spontaneous bladder rupture should undergo full urological evaluation to identify possible disease which might lead to recurrent rupture.

Contracture of collagen fibres in the gubernaculum has been suggested as a mechanism responsible for fetal descent of the testis. We measured the collagen content of the gubernaculum, fetal thigh muscle and umbilical cord tissue by assaying its hydroxyproline and protein content in 194 male pig fetuses between 60 and 109 days of gestation. During the period of testicular descent (80-90 days of gestation), a decrease occurred in the hydroxyproline/wet mass and protein/wet mass of the gubernaculum, but not of fetal striated muscle or umbilical cord tissue, reflecting an increase in the water content of the gubernaculum during this period. An increase occurred in the hydroxyproline/protein concentration of the gubernaculum and fetal striated muscle, but not of umbilical cord tissue, denoting an accumulation of collagen in the gubernaculum after descent of the testis. In view of the absence of a firm distal attachment of the gubernaculum in the pig fetus, the increase in its collagen content is probably not a cause of descent by exerting traction on the testis, but merely reflects the involution of the gubernaculum noted after descent.