Testicular prosthesis experience in Glasgow: a retrospective study looking at... changing trends between paediatric and adult populations

Testicular prosthesis experience in Glasgow: a retrospective study looking at... changing trends between paediatric and adult populations

1
Testicular prosthesis experience in Glasgow: a retrospective study looking at the
changing trends between paediatric and adult populations
Musaab Yassin1 , Aza Mohammed3, Gregor Walker2, David Hendry3.
1 Department of Urology, Southern General Hospital
2 Department of Paediatric Surgery, Royal Hospital for Sick Children
(Yorkhill)
3 Department of Urology, Gartnavel General Hospital
Aim of the Study: To assess the practice of testicular prosthesis insertion related to
orchidectomy in one geographical region and to identify the difference in the rates of
insertion among different age groups.
Methods: Males who underwent orchidectomy between 1989 and 2009 were
identified from data collected from Scottish Morbidity Records, ISD Scotland.
Patients were classified into six age groups. Prosthesis insertion and the relation to
original operation was analysed according to different age groups.
Main results: A total of 3366 patients underwent orchidectomy in twenty years.
Commonest indications for orchidectomy differed between age groups (UDT in 55%
of <12 yrs, trauma/torsion in 52% of 13-15yrs, UDT in 36.7% of 16-20 yrs, and
malignancy in the older patients).
The total number of patients who had a testicular prosthesis was 532 patients, of
which 410 patients (12.2%) having had a prosthesis inserted following orchidectomy.
The remaining 122 had a prosthesis inserted without prior orchidectomy. The rate of
prosthesis insertion differed among different age groups (0.6 % in < 13 years, 8.1% in
13 – 15 years, 19.7% in 16 – 20 years, 32.3% in 21 – 30 years, 23.5% in 31 – 40
years, 15.8% in 40 + years in the patients who had orchidectomy before).
In patients that opted for a prosthesis, 32% of < 16 year old males had the prosthesis
inserted at the same time as their orchidectomy operation, compared to 83% of the
16+ males. The odds ratio for having a prosthesis inserted at a later date for the under
16’s was 10.11 (5.08, 20.15, p < 0.0001).
Conclusion: There is a discrepancy in the timing of testicular prosthesis insertion in
different age groups with younger males being more likely to have a prosthesis
inserted at a later date than their orchidectomy. This may be related to patient size and
pubertal status but paediatric surgeons should be mindful of the possibility of
concurrent prosthesis insertion at the time of initial scrotal exploration.
1
2
RISING INFECTION RATE WITH CONTEMPORARY PROSTATE BIOPSY
DY GUO, S LIU, L CHAN and A LALAK
Introduction
UTI and sepsis are the commonest post-procedural complications for transrectal ultrasound
guided needle biopsy of the prostate (TRUSP). We prospectively evaluated the incidence of
infective complications and correlated with changes in our biopsy protocol over the past 15
years.
Materials and Methods
Between1995 to 2009, all TRUSP in Concord hospital (NSW, Australia) were performed or
supervised by a single urologist. A complication questionnaire was collected prospectively
following each procedure. Missing information was obtained retrospectively by searching
medical records. The data were grouped and analysed according to the number of cores and
type of prophylactic antibiotic regimens.
Results
4629 men underwent TRUSP during the studied period, 217 (4.7%) reported post-procedural
fever and 132 (2.9%) had infection requiring hospitalisation.
Sextant biopsies were routinely carried out from 1995 to 1997 and were associated with an
infection rate of 1.5% (12 of 820). Between 1998 and 2004, eight core biopsies became the
standard of practice and the infection rate was 2.8% (62 of 2240). Since 2005, a minimum of
twelve cores were routinely taken and an infection rate of 3.7% (58 of 1569) was observed.
This was statistically significant (p = 0.002).
Between 1995 and 1999, both trimethoprim and quinolones were used for prophylaxis.
Infection rate of the period was 2.2% (33 of 1510), trimethoprim was associated with a higher
infection rate (3.0% versus 1.4%, p<0.05).
Conclusion
The overall infection rate was 2.9% in our study. Higher number of cores appeared to
increase post-procedural infection. Quinolones were more superior when compared to
trimethoprim.
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3
Active surveillance for prostate cancer
Willder JM1, Qayyum T1, Clark RN2, Edwards J1, Underwood MA3
1. Institute
of Cancer, College of Medical, Veterinary and Life Sciences,
University of Glasgow, McGregor Building, Western Infirmary, Glasgow, G11 6NT, UK.
2. Department of Urology, Gartnavel General Hospital, 1053 Great Western Road, Glasgow,
G12 0YN, UK.
3. Department of Urology, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, UK.
Abstract
Introduction
Active surveillance (AS) patients are suitable for radical treatment if biochemical or
pathological progression is demonstrated.
Methods
Urology consultants in GGCHB were questioned on their management of AS patients. Follow
up of AS patients was then examined with regards to the proSTART protocol.
Results
All responding consultants stated they used PSA and repeat biopsy routinely. 32.3%
indicated which protocol they used for repeat biopsy: 50% proSTART, 10% with rising PSA,
10% “as per protocol”, 10% alternative regime.
14.8% of 115 AS patients were diagnosed by TUR (no TRUS). 47.8% had 3 monthly PSA
checked in first 2 years and 90.9% had 6 monthly PSA checked thereafter. 28.6% had repeat
biopsy at 1 year and 25% at 4 years post diagnosis.
Conclusion
For AS patients to undergo radical treatment for prostate cancer there must be clear
evidence of disease progression. AS follow up is poor, despite clinicians believing they are
offering appropriate care.
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4
Radical Treatment For Bladder Cancer In Tayside: Non-random Comparison of
Surgery Versus Radiotherapy
Tait C, Sweeney C, Byrne D, Nabi G
Department of Urology, Ninewells Hospital & Medical School, Dundee
Aim:
To assess the outcomes of radical cystectomy versus radiotherapy in patients treated
in Tayside over the past ten years.
Patients:
125 patients treated with radical cystectomy and 163 with radical radiotherapy
between 1998 and 2010 were reviewed retrospectively. Data concerning age, sex,
comorbidity, stage and grade, treatment and mortality outcomes was retrieved.
Results:
The mean age of radiotherapy patients was 72 years, and cystectomy patients 68.
Radiotherapy patients had more comorbidity, with average Charlson comorbidity
index 5.72 vs 4.73. Deceased cystectomy patients with Charlson score of 5 or less
had an average survival of 33 months compared to 17 months in radiotherapy
patients. Highest comorbidity patients survived longer when treated with
radiotherapy. Kaplan-Meier analysis for follow-up showed no significant differences
(Wilcoxon test-p Value 0. 5=605).
Conclusions:
There are no statistically significant differences in patient survival following radical
treatment between radiotherapy and cystectomy. The radical radiotherapy cohort had
higher comorbidities
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5
Is the presence or absence of tumour necrosis a significant predictor of survival in Bladder
Cancer?
Qayyum T1, McArdle PA2, Hilmy M2, Going JJ3, Orange C4, Seywright M4, Underwood MA2,
McMillan DC5, Edwards JE1
1. Institute of Cancer, College of MVLS, University of Glasgow, Western Infirmary, Glasgow
2. Department of Urology, Royal Infirmary, Glasgow
3. University Department of Pathology, Royal Infirmary, Glasgow
4. Department of Pathology, Western Infirmary, Glasgow
5. School of Medicine, College of MVLS, University of Glasgow, Royal Infirmary, Glasgow
Introduction
Currently when bladder cancer pathology is assessed, the absence or presence of tumour
necrosis is not always reported. The aim of this study was to determine whether a
quantitative assessment of necrosis would provide additional prognostic information.
Study Design
We studied the pathological features and cancer specific survival of 47 patients with bladder
cancer. A grading system depending on extent of necrosis was compared to the presence or
absence of necrosis.
Results
A simple assessment of presence or absence and quantitative assessment of necrosis was
associated with cancer specific survival (p=0.02). On multivariate analysis, using a
quantitative assessment of necrosis was retained as a significant independent factor for
cancer specific survival (HR 2.93, 95% CI 1.17-7.35, p=0.022)
Conclusion
A quantitative assessment of tumour necrosis assessment was shown to be an independent
predictor of cancer specific survival in bladder cancer.
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Circumcision under local anaesthetic; patient experience, consultant beliefs.
Mustafa Hilmy, Ian Dunn
Department of Urology, Monklands Hospital, Monkscourt Avenue, Airdrie ML6 0JS
Introduction:
Circumcision remains a general anaesthetic (GA) procedure in many centres. Local anaesthetic (LA)
circumcision has advantages in terms of cost and flexibility. We assessed patient experience of
anaesthesia for circumcision, as well as practice and attitudes among consultant urologists.
Methods:
Adult patients undergoing circumcision were invited to complete a questionnaire before discharge.
Subjective scores (scale 1-10) concerning pre-operative anxiety, pain experienced during
administration of the anaesthetic, or the procedure itself, were recorded. Patients were asked if they
would recommend the same anaesthetic. A separate questionnaire, concerning anaesthesia for
circumcision, was sent to all consultant urologists in Scotland.
Results:
42 (34 LA, 8GA) patients completed the questionnaire (under five surgeons). Fourteen (42%) in the LA
group experienced some discomfort during the anaesthetic (mean score 3.6, range 2-8). Seven of
these (and one other patient) also reported pain during the procedure (mean score 3.8, range 2-7).
All 42 patients were happy with their choice of anaesthetic and would recommend the same
anaesthetic option to a friend.
26/49 consultants completed the questionnaire. Two thirds (65%) do not routinely offer LA
circumcision. Reasons for this include a belief that patients want GA, and that LA circumcision is
associated with significant patient discomfort. More than half of this group would consider offering
more patients LA circumcision if shown evidence of equivalence in patient satisfaction.
Conclusion:
Despite reservations by consultant urologists, LA circumcision is acceptable to patients. Pre-operative
counselling should prepare the patient for minor discomfort during anaesthetic administration.
Clean intermittent self catheterization in men with
chronic urinary retention due to benign prostate
enlargement
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7
Sarfraz Ahmad, I. El-Mokadem, O. Aboumarzouk, C. Sweeney, A. Robertson,
C. Goodman, G. Nabi
Department of Urology, Ninewells Hospital and Medical School, Dundee
Background and objectives
Transurethral resection of prostate is the commonest surgical treatment offered to
men with chronic urinary retention, especially in high pressure chronic urinary
retention, albeit at no or little long-term outcome reports. The study evaluated clean
intermittent self catheterization (CISC) as an alternate option to surgical therapy.
Methods
Men presenting with chronic urinary retention (including high pressure chronic
retention) were recruited into a prospective study. The inclusion criteria were:
patient’s choice and ability to carry out CISC. The follow-up protocol carried
out in a dedicated nurse led clinic entailed satisfaction with CISC, renal
function and/or imaging of upper tract and any complications reported by
patients.
Results
59 patients were identified according to inclusion criteria. Mean follow up was
4.7 years (0.5-13 years). Based on serum creatinine at presentation,
participants were divided into two groups: group A consisted of chronic
retention with renal failure (n =11) and group B had men with chronic retention
and normal renal profile (n = 48). None of the participants had deterioration in
renal function in group B. Only one patient in group A developed worsening
of renal function. None of the participants discontinued CISC due to
dissatisfaction or complications.
Conclusions
CISC is well tolerated with low complication rate in men with chronic urinary
retention. Renal function are preserved on long-term, however patients with
high pressure retention need a close monitoring.
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Diagnostic performance and inter-observer variation of CT in
complex renal cystic masses
Ismail el-Mokadem, Matthew Budak, Sarfraz Ahmad, Omar Aboumarzouk, Christopher
Goodman, Ghulam Nabi
Ninewells Hospital, Dundee, NHS Tayside
OBJECTIVE:
To assess diagnostic accuracy and inter-observer variability of CT in the diagnosis of
complex renal cystic masses (Bosniak II and more)
MATERIALS AND METHODS:
Eighty five cystic renal masses were reported independently by two radiologists (first
radiologist observed and reported prior to multidisciplinary meeting and the second
during the meeting). The cystic masses were categorized by each reviewer according
to the Bosniak classification for complex renal cystic renal masses. Both the
individual and the pooled results for both radiologists were analyzed. Inter-observer
agreement and discordance in classifying lesions as Bosniak categories II, IIF, III or
IV were assessed.
RESULTS:
Both readers agreed on the Bosniak classification in 74%, or 63 of the 85 lesions (42
for II or IIF, 15 for III and 6 for IV). Assessment of inter-observer variability by kappa
analysis yielded scores of 0.58 (95% CI 0.44 to 0.73) for the Bosniak. 8.5% (n=7)
were upgraded from II to IIF (n=4) or from IIF to III (n=3). 11% (n=10) were
downgraded form IIF to II (n=7) or from III to IIF (n=3) by the second reader.
CONCLUSION:
In spite of a good inter-observers agreement, there is a lack of precision (low kappa
score) in categorisation of complex renal cystic masses especially Bosniak IIF cysts
and this may present as a difficulty in making recommendations for surgery versus
surveillance.
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Pictorial review of image guide suprapubic catheterisation
P Jacob, B P Rai, C Badrakumar, S Borgaonker, A Todd-Raigmore hospital,
Inverness
Aim
To review the effectiveness of imaging guided SPC insertion.
Description
Suprapubic catheter insertion is a common method of bladder
drainage in contemporary urological practice. Although generally
considered a safe procedure, the risk of bowel injury is estimated at
up to 2.5%, with a mortality of 1.8% 1. Recently published BAUS
guidelines have recommended that ultrasound may be helpful to
identify bowel loops 2.
The objectives of ultrasound guidance for SPC insertion are to
assess bladder filling, identify interposed bowel at risk from injury
and guide the needle puncture at the optimum site. Aguilera PA et al
performed real time USS guided SPC insertions in 17 patients with
AUR (acute urinary retention) with no complications 3. Evidence
from central venous catheter insertions is that ultrasound guidance
not only reduces the complication rate but improves first time
success rate and as a result reduces infection rates4.The NPSA
guidelines suggest the use of image guidance as one of the
measures for avoiding complications related to SPC insertion 5
CT guided SPC insertion is an alternative technique reserved for
patients with complex anatomy, possibly due to previous surgery.
Conclusion
Imaging guided SPC insertion has the potential to reduce the
incidence of bowel injury and other SPC related complications.
Radiologists play a key role in image guided SPC insertion,
particularly in complex cases. It could be performed as a combined
procedure with the Urologists, till they are trained adequately to be
able to perform the procedure independently. The technique
necessitates some training for most operators and will pose
training, equipment and logistical issues for medical institutions.
Logistics will vary considerably between various centres and the
above issues could be addressed on an individual basis.
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Prevalence of papillary renal cell carcinoma (pRCC) in patients
with complex cystic renal lesions (Bosniak ≥IIF): 10 years single
centre experience.
Ismail El-Mokadem, Matthew Budak, Chris Goodman, Ghulam Nabi
Department of Urology, Ninewells Hospital, Dundee
Background and objectives:
Relative hypovacularity of papillary RCC (pRCC) can be mistaken for renal cyst or on contrary
pseudo-enhancement of renal cysts can mimic pRCC. We hypothesised that incidence of
pRCC is different in patients with radiologically complex cystic renal masses as compared to
the reported incidence of 10-15%
Patients and methods
Retrospective electronic records of 434 patients who were reported as “renal cyst” or
“complex renal cyst” or “Bosniak cyst” between January 2000 and December 2010 by the
radiology department were retrieved. Simple cysts reports were excluded from further
analysis. The records of 128 patients with complex cystic renal masses (Bosniak ≥IIF) were
further analysed for further follow up imaging, requirement for surgery and incidence of
pRCC in the histopathology. The incidence rate was compared with the overall incidence of
pRCC from the same institution and the reported from the literature.
Results
Thirty three patients (25.7%, 33/128) underwent surgical excision of omplex cystic renal
lesions either for Bosniak III or IV (16/53) or for progression of Bosniak IIF (7/75) on follow
up imaging during the study period. The final histopathology showed RCC in 26 specimens,
benign cysts in 6 and 1 was reported as Transitional cell carcinoma. Of those with renal cell
carcinoma, incidence of pRCC was 34.6% (9/26). This was significantly higher than the overall
incidence of pRCC reported from the same institution and in the reported literature.
Conclusion
A higher incidence of pRCC was seen in patients with complex cystic renal masses in this
study. Our observation should help in changing the follow up radiological observation of
complex renal cysts particularly with relative hypovascularity of the pRCC.
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11
HER2 overcomes PTEN-loss induced Cellular Senescence to cause Aggressive
Prostate Cancer
I. Ahmad, R. Patel, J. Edwards, O.J. Sansom, H.Y. Leung
The Beatson Institute for Cancer Research, Garscube Estate, Switchback Road, Glasgow,
G61 1BD
Background: Prostate cancer (CaP) is the commonest cancer amongst adult men in the
western world. Given patients are often elderly and are likely to die with, rather than from
CaP, it is important to delineate key pathways which confer poor prognosis and predict
potential therapy.
Methods: We utilised a both human tissue microarrays (TMA) with cores from benign and
CaP (n=239) as well as transgenic mice driven by the prostate specific Probasin Cre.
Results: In this study we demonstrated the cooperation between PTEN loss and HER2
activation in accelerating prostate carcinogenesis, both in the human and mouse. Neither
mutation in isolation lead to changes in survival in human CaP, but on a PTEN null
background HER2 or HER3 overexpression resulted in a statistically significant reduction in
patient survival. Similarly in the mouse, presence of both mutations synergised to lead to
rapidly proliferating tumours with an aggressive phenotype, overcoming the well-documented
PTEN loss-induced cell senescence phenotype (PICS).
Treatment with a MEK inhibitor
appeared to negate the effects of activated HER2, returning the tumours to their PICS
phenotype.
Conclusion: Taken together, this suggests that stratification of CaP patients for HER2/3 and
PTEN status could identify a group of poorly performing patients that may then be responsive
to inhibition of activated MAPK signalling pathways, returning these advanced tumours to a
senescent state.
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12
Bladder cancer diagnosis using a novel dual pulse
Raman spectroscopy probe and portable system: A
feasibility study
Sarfraz Ahmad, G. P. Singh, S. Lane, T. Brown, G. Nabi
Department of Urology, Ninewells Hospital and Medical School, Dundee
Background and objectives
Accurate cystoscopic diagnosis of bladder cancer, in particular, post adjuvant
intravesical treatment remains a challenge. Raman spectroscopy, with high
chemical specificity has potential to provide fingerprint of the tissues. We
describe development of a novel probe and its application in the diagnosis of
bladder cancer in a feasibility study.
Material and methods
A prototype clinical Raman instrument including a compact diode laser,
spectrograph, CCD detector and a computer mounted on a portable cart
suitable for clinical use within an operating room was designed. A novel
optical fibre based portable near infrared (785 nm excitation) Raman
spectroscopy was used to acquire data from TURBT tissue specimen
(freshly resected bladder tumour and normal tissue of size about 2-3 mm).The
acquisition time for each spectrum was 5 s. The Raman spectra were
correlated with histopathology.
Results
20 (10 normal and 10 cancer) fresh urinary fresh bladder specimen (at
TURBT) were scanned ex-vivo prior to histopathology analyses. Raman
spectra clearly showed the biochemical difference between tumour and
normal tissue with significantly high sensitivity and specificity and were
distinctive for normal and cancer tissue in all the patients.
Conclusions
The feasibility study showed successful translation of Raman spectroscopy
technology in the diagnosis of bladder cancer. Raman spectra obtained using
novel probe are distinctive for between bladder cancer and normal mucosa.
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13
Retrospective and prospective audit of ileal conduit, continent diversion and orthotopic
neobladder at WGH, Edinburgh, to assess surgical and QOL outcomes
J Jones, D Clark, LH Stewart, A Alhasso
Western General Hospital, Edinburgh
Background
Ileal conduit remains the most common urinary diversion, but continent diversions and
orthotopic neobladder allow patients to remain continent. Here we assess the outcomes of
continent diversions at our own institution compared to the published literature and to
patients undergoing ileal conduit at our institution.
Materials & Methods
34 patients have undergone urinary diversions between 2007 and 2011 at our institution.
Patients were followed up with regards to clinical outcomes and complications/reintervention rates.
Results
12 ileal conduits, 7 orthotopic neobladders and 15 continent diversions were performed. All
patients remain within follow up. Of the ileal conduits, there were no re-interventions or
major complications. Of the orthotopic neobladders, one patient is awaiting conversion to
ileal conduit, although none have undergone further re-intervention. Of the continent
diversions, 1 patient developed pouchitis and 2 patients have required ureteric reimplantation.
Conclusions
Continent diversions are associated with higher rates of re-intervention when compared to
ileal conduits at our institution. Outcomes of continent diversions with regards to surgical
outcomes and quality of life are comparable to other published literature.
Follow up of Urological cancer patients; the results of a regional survey.
R Clark1, K Qureshi1, T Kane2
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1. Department of Urology, Gartnavel General Hospital, 1053 Great Western Road,
Glasgow, G12 0YN, UK.
2. MCN Manager, West of Scotland Cancer Network
Background: Current follow up regimes for urological cancers show significant variation
between individual clinicians. Our aim was to establish current reported follow up regimes
and compare those to existing guidelines and evidence.
Methods: We sent out an online survey to 92 clinicians in the West of Scotland (42 people
responded – 45.6%) to determine follow up practices and performed a literature review of
the evidence available to guide us.
Results: There are significant differences in the follow up regimes for prostate, renal and
bladder cancer in our region with varied practices seen across all aspects including frequency
of outpatient visits, use of imaging, length of follow up and the use of shared care with GPs
and clinical nurse specialists.
Conclusion: The evidence base proving benefit of specific follow up regimes is weak with
most recommendations based on consensus view rather than randomised studies. Regional
guidelines would act as a useful guide for clinicians to help rationalise follow up regimes and
potentially optimise use of resources.
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Teenage schistosomiasis - A real public health issue in Scotland!
O Blach, B P Rai, S Bramwell , Raigmore Hospital, Inverness
Introduction
Every year Scottish schools send students to Malawi under the patronage of the
Scotland Malawi Partnership. 22.8% of Scotland’s new cases of schistosomiasis are
from fresh water exposure at Malawi.
Case History
A 17-year-old male was referred by general practitioner with frank haematuria. As a
part of his school cultural exchange programme he recently travelled to Malawi. The
boy along with other students swam at the fresh water lakes in Malawi.
Cystoscopy showed diffuse erythematous patches with little white blobs.
Subsequent serology was positive for schistosomiasis. The school, infectious
diseases department and public health authorities were notified.
Discussion
The case highlights lack of awareness among schools to risk of schistosomiasis by
fresh water lakes exposure in Malawi. Scottish schools should adopt policies
forbidding activities involving such exposure. Public and primary health care services
should be educated about schistosomiasis risks associated with travel to
schistosomiasis endemic countries.
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The management of T1a Renal Cancer
A Hartley1, M Hair2, M Aitchison3
1: Department of Urology Ayr Hospital & University of Edinburgh, 2: University of the West of Scotland, 3:
Department of Urology Gartnavel General Hospital, Glasgow
Background:
Historical treatment for T1a renal tumours was radical nephrectomy. Recently, nephron
sparing techniques have been developed and seven different management options now
exist.
This study compares current management of T1a renal tumours in the UK, Europe and the
USA, reviews the evidence for each option and proposes two trials to compare treatment
options.
Methods:
Data was obtained from UK and American cancer registries, published literature and a
questionnaire sent to all practicing UK Urology Consultants. Two trials were designed using
appropriate statistical tests.
Results:
Radical surgery is more commonly the treatment of choice in America compared to partial
nephrectomy or ablative therapy in the UK. Active surveillance is rarely used in America but
has become popular in the UK and Europe.
Long-term follow-up data for ablative techniques and active surveillance is lacking.
Conclusion:
Lack of evidence for newer techniques could account for variation in practice. This study
proposes two trials that could provide this missing data.
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Activation of the Wnt Signalling Pathway synergises with either PI3K or MAPK
activation to lead to Urothelial Cell Carcinomas (UCC) with differing treatment
requirements
I. Ahmad, H.Y. Leung, O.J. Sansom
The Beatson Institute for Cancer Research, Glasgow, Scotland. G611BD
Background: Although deregulation of the Wnt signalling pathway has been implicated in
urothelial cell carcinoma (UCC), the functional significance is unknown.
Methods: We utilised both human tissue microarrays (TMA) with cores from benign
urothelium and UCC (n=80) as well as transgenic mice driven by the bladder-specific
Uroplakin-Cre.
Results: In our TMA we were able to establish a significant correlation between Wnt
activation and activation of either the PI3K or MAPK signalling pathways in the UCC samples.
These Wnt/PI3K and Wnt/MAPK tumours clustered to mutually exclusive groups. To test its
functional importance, we targeted expression of an activated form of β-catenin to the
urothelium of transgenic mice using Cre-Lox technology (UroIICRE+β-catenin
exon3/+
).
Expression of this activated form of β-catenin led to the formation of localised
hyperproliferative lesions by 3 months, which did not progress to malignancy. These lesions
were characterised by a marked increase of the Pten tumour suppressor protein. Thus, we
next combined the UroIICRE+β-catenin
fl/fl
exon3/+
activate either PI3K (Pten ) or MAPK (H-Ras
mice with transgenic mice engineered to
Q61L
) pathways within the murine urothelium.
We were able to elicit rapid aggressive metastatic UCC in these models. The UroIICRE+βexon3/+
catenin
Pten
(demonstrated
exon3/+
catenin
fl/fl
by
H-Ras
tumours had increased pAKT signalling and were dependent on mTOR
regression
Q61L
with
Rapamycin)
signalling,
whilst
the
UroIICRE+β-
tumours, although phenotypically similar, demonstrated dependency
on MAPK signalling (as demonstrated by regression with MEK inhibition, but not Rapamycin).
Conclusion: We demonstrate PI3K and MAPK pathway activation synergises with Wnt
signalling to drive UCC in vivo leading to tumours with differing molecular and treatment
profiles.
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The Urology One Stop Clinic
Asim Naseer Qureshi, Ian Mitchell
Department of Urology, Victoria Hospital, Kirkcaldy
Introduction
Our aim of this study was to provide effective service for patients, minimise queues,
and provide quicker diagnosis and to bring members of multidisciplinary team to one
place.
Methods
200 patients were selected in this study randomly to see case mix, diagnosis,
suspected cancer, follows up, discharge.
Discussion
Patients often wait weeks to be seen for straightforward problems. Specialists see
more and more patients in even shorter period of times leading to poor quality
consultations and potentially clinical error.
Conclusion
One stop urology clinics are tailored to patients needs. Correspondence is generated
in real time and given to GPs electronically. These clinics are maximally effective and
are efficient. One stop clinics offer the best chance of minimizing low-value followup visits or “diagnostic churn”. We propose that new referrals should only be ever
being seen in clinics where all tools necessary for diagnosis can be provided.
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The Superiority of Transperineal Template Mapping Biopsy of the
Prostate Gland over the Transrectal Saturation Approach
Sarah Housley, Stuart McCracken, Jose Dominguez-Escrig,
Krishna Narahari, Damian Greene, Sunderland Royal Hospital
(SRH)
INTRODUCTION: Recent interest in focal treatment of prostate cancer has
further highlighted the need for accurate detection of prostate cancer and in
response SRH introduced transperineal template mapping biopsy (TTMB). In
this study we aim to compare transrectal saturation and TTMB in men
attending for repeat prostate biopsy.
METHODS: The study included 100 consecutive patients who required repeat
biopsy based on rising PSA despite previous negative biopsy. The first 50
patients underwent transrectal saturation biopsies and the second 50 patients
underwent TTMB
RESULTS: Prostate cancer was detected in 46% of the 50 TTMB performed,
compared with 22% for transrectal saturation biopsy. Of the TTMB biopsies
positive for cancer, 43% (10/23) were unilateral and therefore suitable for
focal hemi-cryotherapy. TTMB had a complication rate of 12% compared with
a complication rate of 22% for the transrectal saturation biopsy group.
CONCLUSIONS: TTMB has a similar morbidity to transrectal saturation
technique. Our study demonstrates that cancer detection rate is higher in
patients who undergo TTMB. Despite the requirement for general anaesthesia
and a potential increased urinary retention rate, novel transperineal mapping
schemes allow for more accurate sampling of the entire gland.
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A study of emergency supra-pubic catheter insertion in the West of
Scotland:
Is more training needed?
A Hartley1, R Clark2, M Fraser3
1: Department of Urology, Ayr Hospital 2: Department of Urology, Gartnavel General Hospital, Glasgow 3:
Department of Urology, Southern General Hospital, Glasgow
Background:
The National Patient Saftey Agency (NPSA) commissioned guidelines for the insertion of
suprapubic catheters in 2009. These were designed to increase patient safety and reduce
the number of adverse events.
Methods:
All emergency suprapubic catheter insertions performed by Urologisits in the West of
Scotland over a six month period were documented and procedure was compared to NPSA
guidelines.
Results:
Twenty-four patients underwent an emergency suprapubic catheter insertion but absolute
adherence to NPSA guidelines was only achieved in four cases. One patient underwent a
significant complication which may have been avoided if guidelines had been followed.
Conclusion:
We highlight the need for compliance with current guidelines and have identified areas in
which further training could be useful. We propose a workshop for all core surgical trainees
on the insertion of these catheters and the associated use of ultrasound.
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Are we selecting active surveillance patients appropriately for prostate cancer?
Willder JM1, Qayyum T1, Edwards J1, Underwood MA2
1. Institute
of Cancer, College of Medical, Veterinary and Life Sciences,
University of Glasgow, McGregor Building, Western Infirmary, Glasgow, G11 6NT, UK.
2. Department of Urology, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, UK.
Abstract
Introduction
Active surveillance (AS) patients are selected according to strict criteria outlined by the
National Institute for Health and Clinical Excellence (NICE).
Methods
The allocation of patients to AS was objectively examined with regards to NICE guidelines for
low risk patients.
Results
Only 10% (n=11) of 110 patients on AS fulfilled all the selection criteria as outlined by NICE.
83.6% (n=92/110) were pathological stage T1c. Of those who had a TRUS at diagnosis 27.2%
(n=25/92) had 10 or more cores taken. 76.4% (n=84/110) were Gleason grade 3+3. 63%
(n=58/92) of patients who had a TRUS at diagnosis had cancer in <50% of the total number
of biopsy cores. 71.8% (n=79/110) had PSA <10ng/ml.
Conclusion
This review demonstrates the poor adherence to NICE guidelines in the allocation of patients
to active surveillance, thus jeopardising patients’ opportunity for curative treatment.
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Pregabalin for Chronic Prostatitis and Chronic Pelvic Pain
Syndrome
Omar M Aboumarzouk, Ismail el-Mokadem, Sarfraz Ahmad, Gulam Nabi, Paul
Halliday
Department of Urology, Ninewells Hospital and Medical School, Dundee
Introduction and Objectives:
Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a condition that is as equally
detrimental to the quality of life of patients as angina, diabetes, or Crohn's. Resent evidence
suggests that it may have a neuropathic origin and therefore medications such as pregabalin
might have a role in the controlling of symptoms.
The primary objective is to compare pregabalin to other modalities of pain relief to alleviate
patients symptoms of CP/CPPS.
The secondary objectives are to assess the safety and effectives of pregabalin to improve
various individual symptom aspects of CP/CPPS.
Methods:
Search methods
Various databases will be search for pregabalin treatment of Class III prostatitis: CP/CPPS for
study inclusion.
Selection criteria
Randomised controlled trials comparing pregabalin to a placebo or other types of analgesics
for the management of patients with CP/CPPS . Patients with known causes of
pain/discomfort with be excluded.
Data collection and analysis
Only one randomised trial was included. The trial compared pregabalin to a placebo for
patients who suffer from CP/CPPS. The results of this study was analysed and discussed.
Results:
There were a total of 324 patients included.
There were 218 patients randomised to receive pregabalin, while 106 patients received a
placebo.
Pregabalin was not superior to a placebo in improving patient overall symptoms score,
assessed by improvement in the NIH-CPSI score (P=0.07). Pregabalin was also as good as a
placebo in controlling individual domains of the NIH-CPSI score, such as pain, urinary
symptoms, and quality of life (P=0.07, 0.34, and 0.16).
Fifty-nine percent of the patients developed side effects, with neurologic symptoms
significantly higher in the pregabalin group compared to the placebo group (P=0.01) and
more pain in the placebo group (P=0.003).
Conclusion:
There is no evidence to suggest pregabalin is an effect analgesic for patients with CP/CPPS.
However further research is required on neuropathic analgesics for CP/CPPS symptom
control.
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Is Urine Cytology a relevant investigation for Urological Malignancies?
Said Mishriki, Ross Vint, Bhaskar Somani, Thomas Lam Aberdeen Royal Infirmary
Introduction and Objectives:
Most current guidelines for asymptomatic haematuria investigation recommend
mandatory urine cytology. However evidence for its continued use is weak. ValiThe
aim of this study is to gauge the value of urine cytology as routine investigation for
haematuria.
Material and Methods:
2778 patients from January 1999 to date. Urine cytology was routinely submitted at
one stop haematuria clinic.
Results:
The sensitivity and specificity of urine cytology were 45% and 88% respectively. 2 cytology
samples diagnosed cancer where all other investigations did not. The first was a primary
carcinoma in-situ of the bladder in which the cystoscopy showed inflammation and should
have been biopsied. The second was an upper tract tumour that was not diagnosed until
bilateral ureteroscopy was performed.
Conclusion:
This prospective analysis shows that omitting routine urine cytology is not detrimental in
investigating patients with haematuria and is cost effective as official NHS estimate its cost
at £92 each. Its use should be limited until after other initial investigations are clear.
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Dipstick Haematuria: Prospective Outcomes of 974 patients
SF Mishriki, B Somani, R Vint, T Lam
Aberdeen Royal Infirmary
Introduction and Objectives:
Dipstick haematuria in adults is a common finding with a prevalence of up to 20%
contributing to about 6% of urology referrals. This study assesses the incidence of urologic
malignancy, need for investigations and the outcome of dipstick haematuria.
Methods:
974 patients with dipstick haematuria attended between January 1999 and April 2007.
Results: No pathology was identified in 859 (88.2%). Malignancy was found in 47 (4.8%)
patients. The rest had benign pathology. No malignancy was identified in patients with
recurrent or persistent non-visible haematuria.
Conclusion:
The study suggests that almost 90% of patients with non-visible haematuria will not have
any underlying pathology. Benign and malignant diseases were found in 6.9% and 4.8% of
patients respectively. The study also suggests that for patients who have completed
investigations and who subsequently develop recurrent or persistent non-visible
haematuria, a repeat of the full set of urological investigations is unnecessary.
Can symptom score and prostate size predict failure of medical treatment of LUTS/BPH?
Prospective 17-year follow-up study
J Graham, BK Somani, Lam T, SF Mishriki Aberdeen Royal Infirmary
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Introduction and Objectives:
Lower urinary tract symptoms (LUTS) due to benign prostatic enlargement (BPH) can be treated with
lifestyle modification, medical treatment (MT) or surgery. Very few long-term studies report on the
predictors for failure of MT.
Methods and Materials:
178 patients with LUTS secondary to BPH between 1993 and 1994, were evaluated and prospectively
followed up. Treatment decision was based on subjective symptoms, flows and residual volumes. All
patients were initially managed medically for their symptoms. Protocol-based assessment was
performed using AUA symptom score, bother scoreQoL score and prostate size at baseline. At 17
years, MT failures (defined as requiring TURP) were compared to those on continued MT.
Results:
Fifty patients (28%) underwent TURP within the 17 year follow-up period, of which over two-thirds
(n=36) were within the first 3 years.
AUA
Bother
QoL
Long Term Medical Treatment (n=128)
Failed Medical Treatment (TURP)
(n=50)
Comparison
Baseline
12 years
p value
Baseline
12 years
p value
p value
13+/-7.5
8+/-8.24
0.01
18.5+/-6.4
4+/-4.8
<0.001
0.003
(1-34)
(0-34)
(5-31)
(0-17)
10+/-7.3
6+/-6.7
14+/-7.2
3+/-3.5
<0.001
0.002
(0-31)
(0-26)
(1-30)
(0-12)
5+/-4.2
2+/-4.1
7+/-3.5
1+/-2.9
<0.001
0.088
(0-17)
(0-14)
(2-14)
(0-10)
<0.001
<0.001
Conclusion:
Patients with worse AUA and bother scores failed MT and needed TURP. For both groups symptom
scores were improved at 12 years compared with baseline. In this study prostate size only was not a
predictor of failure.
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