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Introduction. Transrectal biopsy in suspected adenocarcinoma of the prostate (ACP) may cause significant morbidity and even mortality. A strong association between serum prostate-specific antigen (PSA) and tumour burden exists. If biopsy can be avoided in advanced disease, much morbidity and cost may be saved.Objective. To evaluate the reliability of using PSA and clinical features to establish a non-histological diagnosis of ACP.Methods. Androgen deprivation therapy (ADT) was used in 825 (56.2%) of 1 467 men with ACP. The diagnosis of ACP was made histologically in 607 patients (73.6%) and clinically alone in 218 (26.4%), based on a serum PSA level of >60 ng/ml, and/or clinical evidence of a T3 - T4 tumour on digital rectal examination, and/or imaging evidence of metastases. We compared two randomly selected groups treated with bilateral orchidectomy (BO) based on a clinical-only (n=90) v. histological (n=96) diagnosis of ACP.Results. There was no significant difference between the groups with regard to mean follow-up (26.1 v. 26.8 months), documented PSA relapse (70% v. 67.7%), and patients alive at last follow-up (91.1% v. 95.8%). ZAR1 068 200 (US$1 = ZAR8) was saved by treating men with advanced ACP on the basis of a clinical (non-histological) diagnosis only, and a total of ZAR24 321 000 was saved by using BO instead of luteinising hormone-releasing hormone agonists as ADT.Conclusion. A reliable clinical (non-histological) diagnosis of advanced ACP can be made based on serum PSA and clinical features. This avoids the discomfort and potentially serious complications of biopsy and saves cost.

Background: Changing from an open to a laparoscopic live renal donor programme poses challenges and may affect donor and graft outcomes., Objectives: To evaluate donor safety and graft outcomes for the first 50 retroperitoneoscopic live donor nephrectomies performed at Tygerberg Hospital, Cape Town, South Africa., Methods: The procedures were performed by a single surgeon from 8 April 2008 to 3 April 2012. Operative and anatomical data were prospectively collected. A flank approach with lateral and posterior placements was used. Vascular control was achieved with Hem-o-lok clips in the majority of cases., Results: The mean age of the donors was 31.5 years (range 18 - 50), 28 (56.0%) were male, and the left kidney was harvested in 28 (56.0%) of cases. The mean operating time was 149.8 minutes (range 75 - 250), mean warm ischaemic time (WIT) 181.3 seconds (107 - 630), mean blood loss 139.7 ml (5 - 700) and mean hospital stay 3.2 days (2 - 5). Mean WIT was significantly longer for right-sided than left-sided nephrectomy (213 v. 162 seconds). In two right-sided cases the renal vein was too short and vena profunda femoris was used to create length. No donor received a blood transfusion. Comparing the last 25 with the first 25 cases showed a significant decrease in mean WIT (158 v. 204 seconds) and operating time (128 v. 172 minutes). No major complications occurred., Conclusion: Our initial 50 retroperitoneoscopic live donor nephrectomies were performed without major complications. Donor safety was maintained during the early learning curve of the transition to minimal-access donor nephrectomy.

Objective: To evaluate the correlation between the visual prostate symptom score (VPSS) and the international prostate symptom score (IPSS) and uroflowmetry parameters in men with urethral stricture disease. The VPSS offers a nonverbal, pictographic assessment of lower urinary tract symptoms., Methods: A total of 100 men followed up with a diagnosis of urethral stricture were evaluated from March 2011 to November 2012 with IPSS, VPSS, uroflowmetry, urethral calibration, and urethrography. Follow-up every 3 months for 3-18 months was available in 78 men for a total of 289 visits. Procedures performed were urethral dilation in 105, internal urethrotomy in 54, and urethroplasty in 8 patients. Statistical analysis was performed with Spearman's rank correlation, Fisher's exact, and Student t tests., Results: The time taken to complete the VPSS vs IPSS was significantly shorter (118 vs 215 seconds at the first and 80 vs 156 seconds at follow-up visits; P <.001). There were significant correlations between the VPSS and IPSS (r = 0.845; P <.001), maximum urinary flow rate (Qmax; r = 0.681; P <.001) and urethral diameter (r = -0.552; P <.001). A combination of VPSS >8 and Qmax <15 mL/s had positive and negative predictive values of 87% and 89%, respectively, for the presence of urethral stricture., Conclusion: The VPSS correlates significantly with the IPSS, Qmax, and urethral diameter in men with urethral stricture disease and takes significantly less time to complete. A combination of VPSS >8 and Qmax <15 mL/s can be used to avoid further invasive evaluation during follow-up in men with urethral strictures., (Copyright © 2014 Elsevier Inc. All rights reserved.)

The use of highly active antiretroviral therapy (HAART) in HIV-infected people has led to a dramatic decrease in the incidence of opportunistic infections and virus-related malignancies such as non-Hodgkin lymphoma and Kaposi sarcoma, but not cervical or anal cancer. Advanced-stage cervical cancer is associated with a high incidence of urological complications such as hydronephrosis, renal failure, and vesicovaginal fistula. Adult male circumcison can significantly reduce the risk of male HIV acquisition. Although HAART does not completely eradicate HIV, compliance with medication increases life expectancy. HIV infection or treatment can result in renal failure, which can be managed with dialysis and transplantation (as for HIV-negative patients). Although treatment for erectile dysfunction--including phosphodiesterase 5 inhibitors, intracavernosal injection therapy, and penile prosthesis--can increase the risk of HIV transmission, treatment decisions for men with erectile dysfunction should not be determined by HIV status. The challenges faced when administering chemotherapy to HIV-infected patients with cancer include late presentation, immunodeficiency, drug interactions, and adverse effects associated with compounded medications. Nonetheless, HIV-infected patients should receive the same cancer treatment as HIV-negative patients. The urologist is increasingly likely to encounter HIV-positive patients who present with the same urological problems as the general population, because HAART confers a prolonged life expectancy. Performing surgery in an HIV-infected individual raises safety issues for both the patient (if severely immunocompromised) and the surgeon, but the risk of HIV transmission from patients on fully suppressive HAART is small.

Prostate cancer (CaP) is the leading cancer among men of African descent in the USA, Caribbean, and Sub-Saharan Africa (SSA). The estimated number of CaP deaths in SSA during 2008 was more than five times that among African Americans and is expected to double in Africa by 2030. We summarize publicly available CaP data and collected data from the men of African descent and Carcinoma of the Prostate (MADCaP) Consortium and the African Caribbean Cancer Consortium (AC3) to evaluate CaP incidence and mortality in men of African descent worldwide. CaP incidence and mortality are highest in men of African descent in the USA and the Caribbean. Tumor stage and grade were highest in SSA. We report a higher proportion of T1 stage prostate tumors in countries with greater percent gross domestic product spent on health care and physicians per 100,000 persons. We also observed that regions with a higher proportion of advanced tumors reported lower mortality rates. This finding suggests that CaP is underdiagnosed and/or underreported in SSA men. Nonetheless, CaP incidence and mortality represent a significant public health problem in men of African descent around the world.

Objective: To determine the prevalence of prostatitis on histopathological evaluation of prostatic tissue in men without urinary retention., Design, Setting and Subjects: The clinical data and histopathology reports of men seen from January 1999 through March 2009 at our institution were analysed using Student's t-test, the Mann-Whitney test and Fisher's exact test where appropriate. Values were expressed as means, medians and ranges (p<0.05 accepted as statistically significant)., Outcome Measures: Data collected included patient age, duration of lower urinary tract symptoms and hospitalisation, findings on digital rectal examination, prostate volume, haemoglobin concentration, serum creatinine and prostate-specific antigen (PSA) levels, and histological findings., Results: Prostatic tissue of 385 men without urinary retention at presentation was obtained via biopsy (48.3% of cases), transurethral prostatectomy (62.9%), retropubic prostatectomy (6.8%) or radical prostatectomy (28.3%). On histological examination, benign prostatic hyperplasia (BPH) was found to be present in 213 patients (55.3%) and adenocarcinoma of the prostate (ACP) in 172 (44.7%). Histological prostatitis was present in 130 patients (61.0%) with BPH and 51 (29.7%) with ACP (p<0.001). A previous study of 405 men presenting with urinary retention at our institution showed histological prostatitis in 98/204 (48.0%) with BPH and in 51/201 (25.4%) with ACP. The group of men with BPH alone had a significantly lower mean serum PSA at presentation (4.5 ng/ml, range 0.3 - 20.8 ng/ml) compared with the group with BPH and prostatitis (11.2 ng/ml, range 0.2 - 145 ng/ml, p=0.011). The mean PSA level at presentation did not differ significantly between the group with ACP only (40.9 ng/ml, range 0 - 255 ng/ml) and the group with ACP plus prostatitis (1 672 ng/ml, range 0.3 - 38 169 ng/ml, p=0.076)., Conclusions: Among men presenting without urinary retention, histological prostatitis was significantly more prevalent in those with BPH than in those with ACP (61% v. 30%), similar to the previous study of men presenting with retention at our institution, in which histological prostatitis was significantly more prevalent in BPH than in ACP (48% v. 25%). This finding suggests that histological prostatitis is not significantly associated with the causation of ACP or urinary retention. Serum PSA at presentation was significantly higher in the group with BPH plus prostatitis compared with BPH alone, but not in the group with ACP plus prostatitis compared with ACP alone.

Objective: To investigate the possible reasons for repeated urethral dilatation or optical internal urethrotomy rather than urethroplasty in the treatment of male urethral strictures., Patients and Methods: Men referred to the stricture clinic of our institution during the period April 2007 - March 2008 were reviewed and the operative urological procedures performed in the same period were analysed. Statistical analysis was performed using Student's t-test and Fisher's exact test (p<0.05 statistically significant)., Results: The mean age of the 125 men was 49.9 years (range 12.8 - 93.4 years). Previous stricture treatment had been given 1 - 2, 3 - 4 and 5 - 6 times in 52%, 32% and 12% of patients, respectively (4% had not undergone treatment). In these groups, previous treatment was dilatation in 70%, 76% and 72%, urethrotomy in 26%, 15% and 28%, and urethroplasty in 4%, 9% and 0, respectively. The group with 5 - 6 compared with 1 - 2 previous treatments was significantly older (mean age 60.2 v. 46.6 years) and had a significantly greater proportion with underlying co-morbidities (80% v. 52%). The group that had undergone urethroplasty compared with 5 - 6 repeated dilatations or urethrotomies was significantly younger (mean age 48.2 v. 60.2 years) with a lower prevalence of co-morbidities (47% v. 80%). During the study period urethroplasty was performed in 16 (2%) of 821 inpatients, whereas 55 men were seen who had undergone ≥3 previous procedures, indicating that urethroplasty was performed in less than one-third of cases in which it would have been the optimal treatment. Owing to limited theatre time, procedures indicated for malignancy, urolithiasis, renal failure and congenital anomalies were performed more often than urethroplasty., Conclusions: Factors that possibly influenced the decision to perform repeated urethrotomy or dilatation instead of urethroplasty were limited theatre time, increased patient age and the presence of underlying co-morbidities.

There is a considerable discrepancy between the number of identified occupational-related bladder cancer cases and the estimated numbers particularly in emerging nations or less developed countries where suitable approaches are less or even not known. Thus, within a project of the World Health Organisation Collaborating Centres in Occupational Health, a questionnaire of the Dortmund group, applied in different studies, was translated into more than 30 languages (Afrikaans, Arabic, Bengali, Chinese, Czech, Dutch, English, Finnish, French, Georgian, German, Greek, Hindi, Hungarian, Indonesian, Italian, Japanese, Kannada, Kazakh, Kirghiz, Korean, Latvian, Malay, Persian (Farsi), Polish, Portuguese, Portuguese/Brazilian, Romanian, Russian, Serbo-Croatian, Slovak, Spanish, Spanish/Mexican, Tamil, Telugu, Thai, Turkish, Urdu, Vietnamese). The bipartite questionnaire asks for relevant medical information in the physician's part and for the occupational history since leaving school in the patient's part. Furthermore, this questionnaire is asking for intensity and frequency of certain occupational and non-occupational risk factors. The literature regarding occupations like painter, hairdresser or miner and exposures like carcinogenic aromatic amines, azo dyes, or combustion products is highlighted. The questionnaire is available on www.ifado.de/BladderCancerDoc.

Objective: To compare the clinical features of patients having urinary retention and benign prostatic hyperplasia (BPH) with those having adenocarcinoma of the prostate (ACP) and to evaluate the significance of histological prostatitis., Patients and Methods: The clinical data and histopathology reports of patients with retention admitted to Tygerberg Hospital between September 1998 and June 2007 were evaluated. Statistical analysis was performed with Student's t-test, Mann-Whitney test and Fisher's exact test where appropriate and P < 0.05 was considered to indicate statistical significance., Results: Prostatic histology was available in 405 patients, 204 with BPH and 201 with ACP. Comparing those with BPH and those with ACP showed statistically significant differences in mean age (69.5 vs 71.9 years), serum prostate-specific antigen (PSA) level (18.6 vs 899.5 ng/mL) and histological prostatitis (48 vs 25%) but not duration of catheterization, prostate volume or urinary tract infection (UTI). Comparing those with BPH only and those with BPH plus prostatitis showed significant differences in mean age (71.9 vs 67.1 year) and PSA level (14.6 vs 22.8 ng/mL) but not prostate volume, UTI or duration of catheterization. Comparing those with ACP only and those with ACP plus prostatitis showed significant differences in stage T4 cancer (68.1 vs 35.4%) and PSA level (1123.4 vs 232.4 ng/mL) but not age, prostate volume, UTI or duration of catheterization., Conclusions: Histological prostatitis was almost twice as common in patients with urinary retention associated with underlying BPH than in patients with ACP, but there was no significant difference in the duration of catheterization, prostatic volume or presence of UTI, suggesting that histological prostatitis more often contributes to the development of retention in patients with underlying BPH than in those with ACP. In patients with BPH, histological prostatitis was associated with urinary retention at a significantly younger age and with higher serum PSA levels. In patients with ACP, histological prostatitis was associated with urinary retention at an earlier stage of cancer., (© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.)

Objective: 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., Methods: 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., Results: The study included 93 men (mean age 64 years, range 33 - 85), with VV >150 ml in 66 (71%) and <150 ml in 27 (29%) subjects. In the group with VV >150 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, p<0.002) and the VPSS and Qave (r=-0.37, p<0.003). 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., Conclusions: 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.

Purpose: 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., Methods: 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., Results: 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., Conclusions: 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.

Objective: We aimed to evaluate the presenting features and treatment outcome of prostate cancer in men aged <50 years, in a region where prostate specific antigen (PSA) screening is not readily available and most men present with symptoms., Methods: 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 (p<0.05 accepted as statistically significant)., Results: Of 1 571 men, 47 (3%) were aged < 50 years. The group aged <50 years compared with that aged >50 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., Conclusion: Men aged <50 years presenting with symptoms owing to prostate cancer had significantly higher risk disease, higher mean PSA, and poorer prognosis than men aged >50 years. To diagnose prostate cancer at a potentially curable stage in men aged <50 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 expectancy >20-25 years.

Objective: To evaluate the correlation between the International Prostate Symptom Score (IPSS) and a new Visual Prostate Symptom Score (VPSS) using pictures rather than words to assess lower urinary tract symptoms (LUTS)., Methods: Four IPSS questions related to frequency, nocturia, weak stream, and quality of life (QoL) were represented by pictograms in the VPSS. Men with LUTS were given the IPSS and VPSS to complete. Peak (Qmax.) and average (Qave.) urinary flow rates were measured. Statistical analysis was performed using Student's t, Fisher's exact, and Spearman's correlation tests., Results: The educational level of the 96 men (mean age 64, range 33-85 years) evaluated August 2009 to August 2010 was school grade 8-12 (62%), grade 1-7 (28%), university education (6%), and no schooling (4%). The IPSS was completed without assistance by 51 of 96 men (53%) and the VPSS by 79 of 96 men (82%) (P<.001). Comparing education grade<7 vs grade>10 groups, the IPSS required assistance in 27 of 31 men (87%) vs 9 of 38 men (24%) (P<.001), and the VPSS required assistance in 10 of 31 men (32%) vs 3 of 38 men (8%) (P=.014). There were statistically significant correlations between total VPSS, Qmax. and Qave., total VPSS and IPSS, and individual VPSS parameters (frequency, nocturia, weak stream and QoL) vs their IPSS counterparts., Conclusions: The VPSS correlates significantly with the IPSS, Qmax. and Qave., and can be completed without assistance by a greater proportion of men with limited education, indicating that it may be more useful than the IPSS in patients who are illiterate or have limited education., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: • To compare prostate cancer detection rates using the Vienna nomogram versus an 8-core prostate biopsy protocol. To compare the complication rates of transrectal prostate biopsy in the two groups., Patients and Methods: • In a prospective randomized trial, men with a serum PSA ≥ 2.5 ng/ml were stratified according to serum PSA (I = PSA 2.5-10; II = PSA 10.1-30; III = PSA 30.1-50 ng/mL) and were then randomized to group A (number of cores determined according to the Vienna nomogram) or group B (8-core prostate biopsy). • Statistical analysis was performed using Student's t-test for parametric data, Mann-Whitney test for nonparametric data and Fisher's exact test for contingency tables. A two-tailed p-value <0.05 was accepted as statistically significant., Results: • In the period July 2006 to July 2009, 303 patients were randomized to group A (n = 152) or group B (n = 151). There were no significant differences in serum PSA, prostate volume, PSA density or post-biopsy complications between the groups. • The cancer detection rate was lower in group A than in group B for the whole study cohort (35.5% vs 38.4%), for those with PSA < 10 ng/ml (28.1% vs 33%) and for those with prostate volume >50 ml (22% vs 25.8%). These differences were not statistically significant (NSS)., Conclusion: • These findings suggest that there is no significant advantage in using the Vienna nomogram to determine the number of prostate biopsy cores to be taken, compared to an 8-core biopsy protocol., (© 2010 THE AUTHORS. BJU INTERNATIONAL © 2010 BJU INTERNATIONAL.)

Objectives: We aimed to compare the presenting features and management of prostate cancer among different racial groups., Patients and Methods: We studied all patients diagnosed with prostate cancer at the Urological Oncology Clinic, Tygerberg Hospital, from January 1995 to December 2005. Most presented symptomatically as PSA screening is not readily available in the referral area of the hospital. Race was self-defined as white, coloured or black. Statistical analysis was performed using Student's t-test or Fisher's exact test, where appropriate. A two-tailed p-value <0.05 was accepted as statistically significant., Results: There were 901 patients: 291 (32.3%) white, 539 (59.8%) coloured and 71 (7.9%) black. Mean age at presentation was significantly higher in the white than the coloured and black groups (69.7, 67.9 and 68.9 years, respectively). Grade 1 adenocarcinoma was most common in the white (37%) and coloured groups (38%), and grade 2 was most common in the black group (39%). There was a significantly lower percentage of patients with T3-4 disease at diagnosis in the white group (47%) than the coloured (61%) and black (62%) groups. Mean serum PSA at diagnosis was significantly higher in the black than the coloured and white groups (766.1,673.3 and 196.1 ng/ml, respectively). Potentially curative therapy (radical prostatectomy or radiotherapy) was chosen by 31% of white, 23% of coloured and only 12% of black patients. The mean duration of follow-up was significantly shorter in the black than in the white or coloured groups (24.0, 31.5 and 35.0 months, respectively)., Conclusions: Black men presented with higher grade and stage disease and higher serum PSA, received potentially curative treatment less often, and had a shorter follow-up (probably owing to shorter survival) than the white and coloured groups. Greater prostate cancer awareness and education among patients and physicians and more widespread use of PSA screening of presymptomatic men at risk of prostate cancer is needed.

Background. In South Africa white men have the highest incidence of prostate cancer (PCa), coloured (mixed ancestry) men have an intermediate incidence, and low incidences are reported for black and Asian men. It has been suggested that ethnic differences in incidence and mortality of PCa are related to genetic variations in genes that regulate androgen metabolism. We investigated the role of genetic variants in the androgen metabolism genes and the probability of developing PCa in South African coloured and white men. Methods. Genotype and allele counts and frequencies of single nucleotide polymorphisms (SNPs) in CYP3A5, CYP3A4 and CYP3A43 were assessed in coloured men (160 case individuals, 146 control individuals) and white men (121 case individuals, 141 control individuals). Results. A genetic association indicating an increased probability of developing PCa was observed with the G allele of the SNP rs2740574 in CYP3A4 in coloured men, the A allele of rs776746 (CYP3A5) and the G allele of rs2740574 (CYP3A4) in white men, and the G allele of rs2740574 and the C allele of rs501275 (CYP3A43) in the combined ethnic groups analysis. In addition, we identified allele combinations (termed haplotypes) with significantly higher frequencies in the PCa case individuals than in the control individuals. Conclusions. The findings support the role of variants in genes that regulate androgen metabolism and the probability of developing PCa. The study paves the way to identify other genetic associations in South African men, and to establish genetic profiles that could be used to determine disease progression and prognosis.

Purpose: To design a simple, cost-effective system for gaining rapid and accurate calyceal access during percutaneous nephrolithotomy (PCNL)., Materials and Methods: The design consists of a low-cost, light-weight, portable mechanical gantry with a needle guiding device. Using C-arm fluoroscopy, two images of the contrast-filled renal collecting system are obtained: at 0-degrees (perpendicular to the kidney) and 20-degrees. These images are relayed to a laptop computer containing the software and graphic user interface for selecting the targeted calyx. The software provides numerical settings for the 3 axes of the gantry, which are used to position the needle guiding device. The needle is advanced through the guide to the depth calculated by the software, thus puncturing the targeted calyx. Testing of the system was performed on 2 target types: 1) radiolucent plastic tubes the approximate size of a renal calyx (5 or 10 mm in diameter, 30 mm in length); and 2) foam-occluded, contrast-filled porcine kidneys., Results: Tests using target type 1 with 10 mm diameter (n=14) and 5 mm diameter (n=7) tubes resulted in a 100% targeting success rate, with a mean procedure duration of 10 minutes. Tests using target type 2 (n=2) were both successful, with accurate puncturing of the selected renal calyx, and a mean procedure duration of 15 minutes., Conclusions: The mechanical gantry system described in this paper is low-cost, portable, light-weight, and simple to set up and operate. C-arm fluoroscopy is limited to two images, thus reducing radiation exposure significantly. Testing of the system showed an extremely high degree of accuracy in gaining precise access to a targeted renal calyx.

Although inflammation is emerging as a candidate prostate cancer risk factor, the T-helper cytokine-rich [interleukins (IL)-5, 13 and 4] chromosomal region at 5q31.1 has been implicated in prostate cancer pathogenesis. In particular, IL-4 has been associated with prostate cancer progression, whereas the IL-4 -589C>T (rs2243250) promoter variant has been associated with differential gene expression. We genotyped rs2243250 and 11 tag single-nucleotide polymorphisms (SNPs) spanning 200 kb across the 5q31.1 region on 825 cases and 732 controls from the Risk Factors for Prostate Cancer Study. The minor alleles of rs2243250 and an IL-4 tagSNP rs2227284 were associated with a small increase in prostate cancer risk. Per allele odds ratios (ORs) are 1.32 [95% confidence interval (CI) 1.08-1.61, P = 0.006] and 1.26 (95% CI 1.07-1.48, P = 0.005), respectively. Although these associations were not replicated in an analysis of the Melbourne Collaborative Cohort Study, including 810 cases and 1733 controls, no clinicopathological characteristic was implicated for this divergence. Correlating rs2243250 genotypes to IL-4 gene transcript levels and circulating IL-4 plasma levels, we observe in contrast to previous reports, a non-significant trend toward the minor T-allele decreasing the likelihood of IL-4 activity. From our observed association between a low IL-4 producing promoter T-allele and prostate cancer risk, our study suggests an antitumor role for IL-4 in prostate cancer. Although we saw no association for IL-5 or IL-13 gene variants and prostate cancer risk, our findings call for further evaluation of IL-4 as a contributor to prostate cancer susceptibility.

Donor nephrectomy with laparo-endoscopic single site (LESS) surgery has been reported via the transperitoneal approach. We describe a novel technique of retroperitoneal donor nephrectomy using a single surgical incision in the groin, below the abdominal skin crease or "bikini line". The LESS groin incision offers superior cosmesis, while the retroperitoneal approach has distinct advantages, such as the ability to identify the renal vessels early. The new procedure has been performed in two obese patients (body mass index 32 and 33 kg/m2, respectively). The operative times were 4 and 5 hours, warm ischemic times 135 and 315 seconds, blood loss 100 and 250 mL, and hospitalization 3 and 2 days, respectively. Retroperitoneal LESS donor nephrectomy through a single, inconspicuous groin incision is feasible and safe. Further evaluation of the technique in a larger patient cohort is indicated.

A comprehensive literature study was conducted to evaluate the levels of evidence (LEs) in publications on the diagnosis and staging of penile cancer. Recommendations from the available evidence were formulated and discussed by the full panel of the International Consultation on Penile Cancer in November 2008. The final grades of recommendation (GRs) were assigned according to the LE of the relevant publications. The following consensus recommendations were accepted. Fine needle aspiration cytology should be performed in all patients (with ultrasound guidance in those with nonpalpable nodes). If the findings are positive, therapeutic, rather than diagnostic, inguinal lymph node dissection (ILND) can be performed (GR B). Antibiotic treatment for 3-6 weeks before ILND in patients with palpable inguinal nodes is not recommended (GR B). Abdominopelvic computed tomography (CT) and magnetic resonance imaging (MRI) are not useful in patients with nonpalpable nodes. However, they can be used in those with large, palpable inguinal nodes (GR B). The statistical probability of inguinal micrometastases can be estimated using risk group stratification or a risk calculation nomogram (GR B). Surveillance is recommended if the nomogram probability of positive nodes is <0.1 (10%). Surveillance is also recommended if the primary lesion is grade 1, pTis, pTa (verrucous carcinoma), or pT1, with no lymphovascular invasion, and clinically nonpalpable inguinal nodes, but only provided the patient is willing to comply with regular follow-up (GR B). In the presence of factors that impede reliable surveillance (obesity, previous inguinal surgery, or radiotherapy) prophylactic ILND might be a preferable option (GR C). In the intermediate-risk group (nomogram probability .1-.5 [10%-50%] or primary tumor grade 1-2, T1-T2, cN0, no lymphovascular invasion), surveillance is acceptable, provided the patient is informed of the risks and is willing and able to comply. If not, sentinel node biopsy (SNB) or limited (modified) ILND should be performed (GR B). In the high-risk group (nomogram probability >.5 [50%] or primary tumor grade 2-3 or T2-T4 or cN1-N2, or with lymphovascular invasion), bilateral ILND should be performed (GR B). ILND can be performed at the same time as penectomy, instead of 2-6 weeks later (GR C). SNB based on the anatomic position can be performed, provided the patient is willing to accept the potential false-negative rate of /=2 nodes on one side, contralateral limited ILND with frozen section analysis can be performed, with complete ILND if the frozen section analysis findings are positive (GR B). If clinically suspicious inguinal metastases develop during surveillance, complete ILND should be performed on that side only (GR B), and SNB or limited ILND with frozen section analysis on the contralateral side can be considered (GR C). Endoscopic ILND requires additional study to determine the complication and long-term survival rates (GR C). Pelvic lymph node dissection is recommended if >/=2 proven inguinal metastases, grade 3 tumor in the lymph nodes, extranodal extension (ENE), or large (2-4 cm) inguinal nodes are present, or if the femoral (Cloquet's) node is involved (GR C). Performing ILND before pelvic lymph node dissection is preferable, because pelvic lymph node dissection can be avoided in patients with minimal inguinal metastases, thus avoiding the greater risk of chronic lymphedema (GR B). In patients with numerous or large inguinal metastases, CT or MRI should be performed. If grossly enlarged iliac nodes are present, neoadjuvant chemotherapy should be given and the response assessed before proceeding with pelvic lymph node dissection (GR C). Antibiotic treatment should be started before surgery to minimize the risk of wound infection (GR C). Perioperative low-dose heparin to prevent thromboembolic complications can be used, although it might increase lymph leakage (GR C). The skin incision for ILND should be parallel to the inguinal ligament, and sufficient subcutaneous tissue should be preserved to minimize the risk of skin flap necrosis (GR B). Sartorius muscle transposition to cover the femoral vessels can be used in radical ILND (GR C). Closed suction drainage can be used after ILND to prevent fluid accumulation and wound breakdown (GR B). Early mobilization after ILND is recommended, unless a myocutaneous flap has been used (GR B). Elastic stockings or sequential compression devices are advisable to minimize the risk of lymphedema and thromboembolism (GR C). Radiotherapy to the inguinal areas is not recommended in patients without cytologically or histologically proven metastases nor in those with micrometastases, but it can be considered for bulky metastases as neoadjuvant therapy to surgery (GR B). Adjuvant radiotherapy after complete ILND can be considered in patients with multiple or large inguinal metastases or ENE (GR C). Adjuvant chemotherapy after complete ILND can be used instead of radiotherapy in patients with >/=2 inguinal metastases, large nodes, ENE, or pelvic metastases (GR C). Follow-up should be individualized according to the histopathologic features and the management chosen for the primary tumor and inguinal nodes (GR B)., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

A comprehensive literature study was conducted to evaluate the levels of evidence (LEs) in publications on the diagnosis and staging of penile cancer. Recommendations from the available evidence were formulated and discussed by the full panel of the International Consultation on Penile Cancer in November 2008. The final grades of recommendation (GRs) were assigned according to the LEs of the relevant publications. The following consensus recommendations were accepted: physical examination of the primary penile lesion is mandatory, evaluating the morphologic and physical characteristics of the lesion (GR A). Evaluation of the primary lesion with ultrasonography is of limited value for local tumor staging (GR C); however, evaluation of the primary tumor with magnetic resonance (MRI) imaging during artificial erection induced by intracavernosal injection of prostaglandin might be more useful (GR B). Histologic or cytologic diagnosis of the primary lesion is mandatory (GR A). For accurate histologic grading and staging, a resected specimen is preferable to a biopsy specimen alone (GR B). Penile cancer should be staged according to the TNM system; however, the 1987/2002 TNM staging system requires revision using data from larger patient cohorts to validate the recently proposed modifications (GR B). The histopathology report should provide information on all prognostic parameters, including the tumor size, histologic type, grade, growth pattern, depth of invasion, tumor thickness, resection margins, and lymphovascular and perineural invasion (GR B). Physical examination of the inguinal and pelvic areas to assess the lymph nodes is mandatory (GR B). Ultrasound-guided fine needle aspiration cytology is indicated for both palpable and nonpalpable inguinal nodes. If the findings confirm lymph node metastasis (LNM), complete inguinal lymph node dissection is indicated (GR B). In patients with nonpalpable inguinal nodes, if the ultrasound-guided fine needle aspiration cytology findings are negative for tumor, dynamic sentinel node biopsy can be performed if the equipment and technical expertise are available (GR C). In patients at high risk of inguinal LNM according to the available guidelines and nomograms, surgical staging can be performed by complete, bilateral inguinal lymph node dissection, which might also be curative (GR B). In patients at intermediate risk of LNM, sentinel node biopsy or modified (limited) inguinal lymph node dissection might be performed (GR B). In patients with nonpalpable inguinal nodes, imaging with computed tomography (CT) or MRI is not indicated, because they are not useful in detecting small-volume LNM. Also, it is very unlikely that large-volume LNM (detectable by CT/MRI) would be present in the pelvic nodes (GR B). In patients with confirmed inguinal LNM, CT of the pelvis is indicated to detect iliac LNMs (GR B). Abdominal CT and chest radiography are advisable if the pelvic CT findings are positive (GR B)., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to evaluate the efficacy of TachoSil (Nycomed UK, Oxford, Buckinghamshire, UK), a hemostatic sponge, to seal major collecting system injuries (in addition to providing an adjunct to hemostasis) after partial nephrectomy in a porcine chronic survival model., Materials and Methods: Laparoscopic upper-pole partial nephrectomies were performed in 10 farm pigs (>40 kg). After hilar clamping, an energyless incision was made at a point halfway between the hilum and the upper pole of the kidney and the collecting system was opened widely. TachoSil was applied to cover the defect; 15 to 20 minutes after the application of TachoSil, the hilar clamp was removed, hemostasis confirmed, and the pig survived. Assessment was made for hematoma and urinoma. Four weeks postoperatively, the pigs were euthanized. Ex-vivo retrograde studies were performed to assess collecting system leak. Weight, blood pressure, estimated blood loss, the weight of the partial and completion nephrectomy specimen, presence/absence of urinary leak on retrograde study, histopathologic findings, and complications were recorded., Results: All pigs survived. Mean warm ischemia time was 18 minutes, mean blood loss was 90 mL, and mean resected weight was 13.7 g. There was no evidence of leak on retrograde study. Histologically, nonspecific changes were noted in all specimens, which included dystrophic calcification, scarring, and areas of fibrosis at the partial nephrectomy surgical margin., Conclusion: TachoSil seals the collecting system after partial nephrectomy on a porcine chronic survival model, in addition to providing an adjunct to hemostasis. More studies, including human trials, are warranted to evaluate this observation further.

Acute radiation cystitis occurs during or soon after radiation treatment. It is usually self-limiting, and is generally managed conservatively. Late radiation cystitis, on the other hand, can develop from 6 months to 20 years after radiation therapy. The main presenting symptom is hematuria, which may vary from mild to severe, life-threatening hemorrhage. Initial management includes intravenous fluid replacement, blood transfusion if indicated and transurethral catheterization with bladder washout and irrigation. Oral or parenteral agents that can be used to control hematuria include conjugated estrogens, pentosan polysulfate or WF10. Cystoscopy with laser fulguration or electrocoagulation of bleeding points is sometimes effective. Injection of botulinum toxin A in the bladder wall may relieve irritative bladder symptoms. Intravesical instillation of aluminum, placental extract, prostaglandins or formalin can also be effective. More-aggressive treatment options include selective embolization or ligation of the internal iliac arteries. Surgical options include urinary diversion by percutaneous nephrostomy or intestinal conduit, with or without cystectomy. Hyperbaric oxygen therapy (HBOT) involves the administration of 100% oxygen at higher than atmospheric pressure. The reported success rate of HBOT for radiation cystitis varies from 60% to 92%. An important multicenter, double-blind, randomized, sham-controlled trial to evaluate the effectiveness of HBOT for refractory radiation cystitis is currently being conducted.

Objectives: To compare the characteristics of confirmed vs suspected cases of urogenital tuberculosis (UGTB) in a geographic region with an extremely high prevalence of pulmonary tuberculosis. UGTB is notoriously difficult to diagnose., Methods: A retrospective clinical record review was performed of 68 patients treated from March 1998 to July 2007. Group 1 (n = 45) had UGTB confirmed by microbiologic or histologic examination. Group 2 (n = 23) had a high suspicion of UGTB because of the clinical features, but no microbiologic or histologic confirmation. The data were collected and statistically analyzed using Student's t test for parametric data and Fisher's exact test for contingency tables (P < .05 was accepted as statistically significant)., Results: The clinical characteristics were not significantly different statistically, except for flank pain (14% vs 43%), renal cavitation (14% vs 44%), urolithiasis (0% vs 25%), and ureteral stricture formation (7% vs 39%) in groups 1 and 2, respectively. Anti-TB medication was given to 7 patients (30%) in group 2 despite the lack of a confirmed diagnosis. The outcome in terms of complications and renal function loss was not significantly different between the 2 groups., Conclusions: Flank pain, renal cavitation, urolithiasis, and ureteral stricture formation were significantly more common in the group with suspected UGTB than in those with confirmed UGTB. However, other clinical characteristics did not differ significantly between the 2 groups. In patients with clinical features highly suspicious of UGTB, it appears reasonable to institute anti-TB treatment, despite the lack of a confirmed diagnosis.

Objective: 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., Method: 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., Results: 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 persisting > 365 days after vasectomy) to 2.3% (sperm seen > 180 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., Conclusions: 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.

Penile cancer normally spreads in a predictable manner to the regional lymph nodes: first inguinal and then the pelvic nodes. We report a case where the patient presented synchronously with secondary skin metastases and primary high grade penile squamous carcinoma. In addition the patient also had pulmonary metastases, loco regional spread to the groin nodes, liver metastases and tumour erosion of a right sided rib. The skin metastases appeared nodular, were firm in consistency and appeared intradermal. Skin metastases have been described for a number of solid malignancies - the clinician must have an index of suspicion to relate a less obvious primary lesion with secondary skin lesions. The patient died before chemotherapy could be administered.