British Journal of Urology

Summary— A randomised controlled trial was undertaken to determine the effects of midnight removal of urinary catheters on patients' voiding patterns and subsequent discharge from hospital. Patients whose urinary catheters were removed at midnight showed a greater volume of initial void than those whose catheters were removed at the usual time of 0600. Removal of urinary catheters routinely at midnight permits earlier assessment of patients' voiding, which may allow for earlier discharge from hospital.

Summary— Thirteen patients with interstitial cystitis (detrusor mastocytosis) and 12 other patients with painful bladder disease without mastocytosis collected 24-h urine specimens that were analysed for the major metabolite of histamine, 1,4-methyl-imidazole-acetic-acid (1,4-MIAA), by reversed phase ion-pair high performance liquid chromatography. The median urinary excretion of 1,4-MIAA was 3.34 mg/24 h (range 1.47–4.66) in the patients with detrusor mastocytosis and 1.75 mg/24 h (range 0.18–4.30) in the other patients with a painful bladder (P<0.01). It was concluded from this study that patients with a painful bladder and detrusor mastocytosis had a significantly elevated urinary excretion of 1,4-MIAA compared with other painful bladder patients without mastocytosis, whose urinary excretion of 1,4-MIAA was within the normal range (0.72–2.34 mg/24 h). We suggest that the urinary excretion of 1,4-MIAA might be useful in the diagnosis of interstitial cystitis.

To evaluate the potential benefits of reducing the glycine concentration from 1.5% to 1.0% in the irrigating fluid used during transurethral resection of the prostate (TURP) when 1% ethanol is used as the tracer of absorption. The effect of 1% ethanol on the tendency for blood to haemolyse was tested in vitro and the optical condition of the irrigating fluids were studied during 10 TURPs. The breath ethanol level was monitored during 423 operations where these fluids were used in a randomized double-blind study. The incidence of 13 symptoms was recorded in the 77 patients who absorbed irrigating fluid. Ethanol slightly lowered the tendency for blood to haemolyse. Reducing the glycine concentration did not alter the optical conditions during TURP. The incidence of symptoms increased significantly as more glycine solution was absorbed, arterial hypotension and nausea being the most usual. Bradycardia, prickling skin sensations and feelings of uneasiness were less common when 1.0% glycine was used, but the choice of irrigating fluid had no effect on the total incidence of symptoms. We found no clear advantage in lowering the glycine concentration of the irrigating fluid used during TURP.

The urological irrigating fluid 1.5% glycine is routinely warmed in specifically designed warming drawers prior to use. This study shows that the use of microwave energy to achieve body temperature in 2-litre bags of glycine solution is biochemically safe and that the sterility of the solution is maintained. There is a linear relationship between the temperature of the solution and time in the microwave oven, so allowing a simple formula to predict the correct heating time given variable ambient starting temperatures.

Profuse, short-lived haematuria occurring as an occasional event in a number of long-distance runners has been found to originate from lesions in the bladder. These lesions are either ecchymosis or frank contusions which have a typical distribution. They are sited on the inter-ureteric bar, the posterior half of the rim of the internal meatus and on the posterior bladder wall in which position there is "mirroring" of the trigonal lesions. The possible mode of injury is discussed.

A retrospective study of 1000 live renal transplants was performed in order to assess the factors associated with hypertension in renal transplant recipients. The prevalence of hypertension prior to transplantation was 48%. The need for antihypertensive drugs decreased in 43%, increased in 31% and remained the same in 26%. The presence of hypertension before transplantation, rejection episodes, transplant renal artery stenosis and native kidney disease were the main factors associated with post-transplant hypertension. An algorithm for the management of post-transplant hypertension is suggested.

For 4 yr a system of stone analysis based on the quantitation of 5, and subsequently 6, of the most frequent parameters was in operation in the author's laboratory. By this system, 1,022 stones were investigated. From the results a study was made of the differences in the chemical aspect of stone formation between: male and female patients; patients of the same sex from various ethnic groups (as overseas male patients were far more numerous, females were excluded from this study); adults and children; patients suffering from various conditions of which repeated stone formation is a distinguishing clinical feature, i.e., hyperparathyroidism, sponge kidney and idiopathic hypercalciuria; staghorn calculi as oppoed to those of more regular or indeterminate shape; stones above and below 100 mg in weight. A correspondence was apparent between stone composition and the sex of the stone former. This is probably due to the greater risk in women of urinary infection, giving rise to the type of calculus which forms in an alkaline medium, typically magnesium ammonium phosphate or carbonate apatite in composition and staghorn in shape. Children of both sexes tended also to form these types of stone. Environmental factors were less easy to evaluate, but it was found that Afro Asian and Eastern European males formed more uric acid, more oxalate and fewer apatite calculi than Western males. It was also shown that small stones contain significantly more oxalate than larger stones. In the 3 diagnostic states in which the stone chemistry was scrutinized, idiopathic hypercalciuria presented a very low proportion of triple phosphate or apatite carbonate calculi. There was some evidence, at present inconclusive, that hyperparathyroidism favors the production of apatite stones. Repeated stone formation appeared to follow a predetermined fashion. Providing that urinary infection did not occur between stones or during stone formation, successive stones from the same patients tended to be similar in chemical composition.

Over a period of 5 consecutive years, 1039 renal units were treated by percutaneous nephrolithotripsy for stone disease of the kidney. The success rate was 93.7%. Residual stones remained in 4.2% of patients and in 2.1% we failed to remove the stones. The complication rate was 17.8%. Complications were treated conservatively in most cases but nephrectomy was required on one occasion to control severe bleeding. The average hospital stay was 6.9 days. Follow-up of 339 renal units (333 patients), for a minimum of 60 months, revealed minor late sequelae such as pelviureteric junction obstruction in 1 patient (0.3%) and post-catheterisation strictures of the anterior urethra in 4 (1.2%). Stone recurrence was observed in 9.1% of patients. Percutaneous nephrolithotripsy is an effective, safe treatment for renal stones with minimal late sequelae and is still required even in the era of extracorporeal shock wave lithotripsy.

Summary— A review was carried out on 1000 cases of percutaneous nephrolithotomy (PCNL), Group 1 (500), 1981–1985, being compared with Group 2 (500), 1985–1988. Previous renal surgery had been performed in 17.4% of patients in Group 1 and 36% in Group 2. There were 17.2% complicated patients in Group 1 and 51% in Group 2. The stone burden included 30.2% multiple, partial staghorn and staghorn calculi in Group 1 and 47.2% in Group 2. The use of in situ stone disintegration increased from 22.2% in Group 1 to 73.4% in Group 2 and nephrostomy drainage was necessary in 29.6% compared with 75%. Post-operative complications increased from 13.6 to 24%. Stone-free rates decreased from 92 to 51%, but the addition of other methods of treatment and the inclusion of patients with stone fragments of 2 mm or less increased these figures to 98% in Group 1 and 83% in Group 2. More complicated patients with complex stones are now being referred for PCNL. These patients require multiple treatments, including extracorporeal shock wave lithotripsy (ESWL) and percutaneous surgery, in combination with other endoscopic and radiological procedures.

A series of 1000 patients with calculi of the ureter at various levels were treated by ureteroscopy and lithotripsy over a period of 27 months. The overall success rate was 88.8%. Stones in the upper third of the ureter were removed in 15 of 39 patients. Calculi in the middle third were successfully removed in 52 of 102 patients. A success rate of 95.5% was achieved for calculi of the lower ureter. Per-operative complications included 10 ureteric perforations, 4 of which were treated surgically and 6 conservatively. Urography, performed in 520 patients 3 months post-operatively, showed 12 ureteric strictures; 9 of these were treated by insertion of a self-retaining pig-tail catheter and 3 required an operation. Ureterolithotripsy appears to be the method of choice in the management of ureteric calculi.

Since March 1985, over 1000 patients have been treated on the lithotripter at St Thomas' Hospital. Since it is the only machine in the country offering treatment to National Health Service patients at no cost to the referring Health Authority, there has been a heavy demand for treatment and 97% of referrals have been accepted. Analysis of the first 1000 patients shows extracorporeal shockwave lithotripsy (ESWL) to be a safe procedure with a low morbidity rate and no mortality. The number of patients who were stone-free 3 months after treatment was low (44.1%) compared with the numbers reported in other series. The most likely reasons for this are the poor follow-up rate (48.9%), the stringent criteria for the diagnosis of "stone-free" and a possible skewed referral and follow-up pattern.

Sedoanalgesia is a technique developed to provide safe and satisfactory operating conditions for a wide range of patients independent of age and overall level of fitness (although its use in children remains to be established). It is suitable for both endoscopic and open procedures, day-cases and in-patients. When used in day-case surgery it significantly improves overall efficiency. It is recognised that day-case surgery is an important and cost-effective element in surgical care. With increasing restraints being imposed upon hospital finances, patient beds and staffing levels, any strategies designed to improve efficiency in this sphere of surgical activity are to be welcomed. That 93% of patients prefer sedoanalgesia to conventional general anaesthesia attests to its high degree of acceptability. The technique of sedoanalgesia, its applications and potential impact for urology are detailed.

A retrospective survey of 1025 consecutive men referred to a male fertility clinic was carried out: 180 (18%) produced a pregnancy while attending the clinic. There was an overall inverse relationship between age and the production of pregnancy, although the majority of pregnancies were in the partners of men aged 25 to 39 at referral. The proportion of pregnancies rose from 4% for men presenting with azoospermia to 27% for those with initial sperm counts of 11 to 20 million/ml. The relationship between production of pregnancy and sperm density was inconsistent for men with sperm densities above 20 million/ml. There was no significant difference in the sperm motility at referral between those who did or did not produce a pregnancy. Success was highest for men whose duration of infertility at referral was between 2 and 3 years. The importance of these findings to the investigation of infertile men is discussed.

The mineral composition of 103 stones from Iran was determined by a polarisation microscope and infrared spectroscopy. The commonest components were whewellite (81.5%), weddellite (40.7%), apatite (69%) and ammonium acid urate (24.4%). Ectopic cossification in the nuclei was found in three renal calculi (2.9%). Twenty-five stones were from children, where one of the most frequent patterns was formed by both ammonium acid urate and calcium oxalate. This suggests that a high proportion of the children from Iran with urolithiasis have nutritional disorders.

SUMMARY1. Retropubic combined vesical capsule prostatectomy with routine Y–V closure is a safe and simple surgical procedure applicable to all age groups and any type of lesion obstructing the vesical neck. Its advantages are as follows:–Minimal morbidity.Low mortality–2 per cent.Short post–operative hospitalisation–eight days.Absence of late vesical neck stenosis post–operatively.Excellent control of bleeding during surgery.Quick and permanent conversion of patient to normal pain–free micturition with sterile urine.Requires no special instruments.Allows early ambulation.Permits relatively early removal of urethral catheter–three to five days. Can be done in obese patients.2. Post–operative voiding cystograms and panendoscopy one year following surgery have revealed no late contracture of the vesical neck and minimal regrowth of the residual prostatic tissue. We feel that this is an interim report and final conclusions will be obtained in a five–year period on a larger series of patients.3. This operation, although not recommended for cases where open cystostomy has been performed, offers the urologist an added weapon to deal effectively with a common problem.

The inflatable hydraulic penile prosthesis has been implanted in 103 patients with both organic and psychogenic impotence. The 4 failures in this series resulted from infection. Mechanical problems occurred in 27 patients, but with additional implant experience, these have been significantly induced. All mechanical complications are correctable through secondary and tertiary surgical procedures. Ninety-eight of 99 patients with a normally functioning prosthetic device had satisfactory intercourse without significant difficulty. The inflatable penile prosthesis has improved to be a highly satisfactory method of treating male impotence.

To review the efficacy of the combination of the anti-androgen nilutamide (Anandron) plus orchidectomy in patients with stage D prostate cancer who had received no previous treatment. The results of seven randomized double-blind trials were analysed. In these studies patients were followed up until progression of disease or withdrawal for other reasons. Bone pain, urinary symptoms, performance status, levels of prostatic acid phosphatase (PAP) and alkaline phosphatase (AP) were evaluated before treatment and after 1, 3, 6, 12 and 18 months of treatment. Bone scans and X-rays were taken every 6 months. The best objective response, the time of progression and the time of death were recorded. The changes from baseline in symptoms and levels of tumour markers at month six and the percentages of objective regressions in the two treatment groups were compared using the Cochran-Mantel-Haenszel test stratified by study. Peto's method was used for the analysis of time to progression and of survival. Of the 1191 patients enrolled in all the original trials, 1056 were eligible. In the group of patients treated with nilutamide 50% had complete or partial regression of disease compared with 33% of those who were given a placebo (P < 0.001); bone pain and levels of PAP and AP were improved or returned to normal significantly more frequently (P < 0.01); the odds of disease progression were significantly reduced (odds ratio 0.84, P = 0.05); the odds of death from cancer and from other causes were reduced but the difference was not statistically significant. The combination of nilutamide and orchidectomy has a beneficial effect on pain of metastatic origin, levels of tumour markers, the objective response of disease and the time to disease progression. This treatment combination might also improve survival.

To describe the technique and report our experience of laparoscopic nephrectomy. Between August 1992 and December 1993, 106 patients underwent laparoscopic nephrectomy at the Mansoura Urology and Nephrology Center. Of the 106 patients, laparoscopic nephrectomy was performed successfully in 97 cases. Conversion to an open procedure was necessary in the remaining nine patients. For a selected group of patients, laparoscopic nephrectomy is a feasible and safe technique. The length of hospital stay and convalescence is short and return to work is rapid.

Following the development of suitable equipment for the endoscopic application of an Nd-YAG laser in this department, the laser has been used routinely in the management of bladder cancer since 1978. To evaluate side effects and efficiency, 252 consecutive laser treatments were evaluated with a minimum follow-up of 12 months. Side effects were few (0.3% perforation) and patients tolerated the treatment very well. The general recurrence rate of T1 tumours varied from 33% for primary carcinomas to 54% for recurrent tumours, but the incidence of local recurrence was only 7%. The long-term results of laser treatment showed a decrease in the local recurrence rate when compared with the results of conservative electocautery resection, but there was no significant influence on the total recurrence rate.

The notes of 134 consecutive patients undergoing bladder neck incision (BNI) were analysed retrospectively. Details of pre-operative symptoms and the short-term results of the operation were studied, as well as the need for reoperation. Long-term results of the operation were not available in 100 patients and a questionnaire was sent to them asking for details of their present symptoms. This produced results on the long-term follow-up of 107 patients with a mean follow-up of 31 months (range 18-48); 86% of patients showed an improvement in symptoms in the short term whilst 68% maintained a subjective improvement in symptoms in the long term. Further surgery was required in 18 patients (13%). Possible reasons for this are discussed.

To evaluate the outcome of implantation of the AMS 800 artificial urinary sphincter in children with neurogenic bladder. The records of 107 children (74 boys and 33 girls) treated for neurogenic urinary incontinence by implantation of the AMS 800 artificial sphincter between 1983 and 1993 were reviewed retrospectively. The underlying cause of incontinence in 92 patients was spina bifida, the mean age at implantation was 13.7 years and 30 patients had undergone previous bladder neck surgery. Implantation was carried out in combination with another surgical procedure in 24.3% of patients. The mean follow-up was 61 months (minimum 12). The mean operational life of the sphincter was 56 months. No deaths occurred but removal of the artificial sphincter was necessary in 20 patients (19%). Surgical revision was not required in 44 patients (41%) but at least one revision was performed in 63 and more than one in 42. There were 21 mechanical failures, 40 surgical complications and 39 cases involving changes in the dynamics of bladder function. Of the 87 children (81%) in whom the device is still in place, 72 are completely continent (83%), 10 are slightly wet, and five are incontinent. The overall success rate was 77%. The results emphasize that for successful implantation of an artificial urinary sphincter in children, the pre-operative bladder capacity must be sufficient and previous surgery should not have been performed on the bladder neck, the site of choice for implantation in children. Sphincterotomy is not always necessary in paediatric patients. Children and parents should be informed of the high complication rate and the need for long-term follow-up.

To determine: (i) the proportion of vesicoureteric reflux (VUR) associated with congenital renal damage and whether it can be severe enough to cause renal impairment from birth: (ii) to evaluate the distribution of males and females affected; and (iii) to describe the course of congenital damage in the first years of life. A total of 108 children (76 male and 32 female, M:F 2.3:1), whose VUR was diagnosed before any infection, were followed from birth for a mean (range) of 4.3 (1-10) years. Renal damage was defined by serum creatinine concentration, creatinine clearance and renal imaging (ultrasonography and renal scintigraphy) performed within the first month of life and periodically thereafter. Of the 108 children, 58 had bilateral and 50 unilateral reflux (total number of refluxing units, 166). High-grade VUR (grade > or = 4) was found in 96 (58%) refluxing renal units (RRUs). Males had a prevalence of bilateral severe (> or = grade 4) reflux (M:F 5.2:1), while in those wit unilateral VUR, the M:F ration was 1.5:1. At birth, mild to moderate damage was present in 56 (36%) RRUs and only associated with VUR of grade > or = 3. Bilateral reflux of grade > or = 4 was associated with congenital moderate/severe renal failure in nine neonates (seven males). In infants with grade > or = 4 VUR who underwent surgical correction, VUR resolved in 92% of cases. In infants with VUR of grade > or = 4 followed medically, the reflux spontaneously resolved in 42% and ameliorated in 16% after 18 months. Serial renal scans during the follow-up showed no progression of renal damage. VUR diagnosed at birth on prenatal ultrasonography is associated with congenital damage, with males affected more often than females. The damage involves both kidneys in a consistent proportion and is an important cause of chronic renal impairment from birth. It does not progress in the first years of life if infections are prevented. It is suggested that males with this condition may constitute a major group at risk of developing chronic renal failure in later life.

To determine the effect of vitamin D3 analogue (EB-1089) on the growth and proliferation of a prostate cancer cell line (PC-3). PC-3 cells (10(4) cells per well) were plated into 24-well tissue culture plates. After 24 h, the culture medium was replaced with one containing the vitamin D3 analogue EB-1089; a control treatment using only replacement medium was conducted in parallel. Cell proliferation was measured by the incorporation of 3H-thymidine 7 and 12 days after the addition of the vitamin D3 analogue. Cells were precipitated with 5% trichloroacetic acid and the radioactivity determined using a scintillation counter. Each experiment was performed at least five times. There was a significant dose-dependent inhibition of cell growth after 7 and 12 days of treatment with EB-1089, varying from 40 to 70% of the 3H-thymidine incorporation by controls, respectively. The maximum inhibition occurred with 0.1 micromol/L EB-1089 on day 7 and day 12 (both P < 0.01). Longer incubation times appeared to have a greater effect when higher concentrations of EB-1089 were used. These in vitro studies have shown that the vitamin D3 analogue EB-1089 can significantly reduce the growth rate of the prostate cancer cell line PC-3. This would support the hypothesis that deficiency of vitamin D increases the risk of prostate cancer and further in vivo testing of vitamin D is warranted for its potential role in active therapy.

Summary— The evolution of a collagen/vicryl composite membrane designed as a prosthetic material for use in urinary tract surgery is described. The early experiments in which collagen film alone was used to repair experimental ureterotomies are reviewed together with our first experiments with the collagen/vicryl prosthesis in the repair of partial nephrectomies and of full thickness defects created in the urinary bladder of experimental rabbits. These early results led to the preparation of a composite using a more highly purified collagen and employing a method of sterilisation (gamma irradiation) which would be acceptable for regular use in medical products. The results of a further series of partial nephrectomy and full thickness bladder repairs show that irradiation does not compromise the efficacy of the collagen/vicryl composite in vivo.

Summary— We report a case of bladder cancer developing in a patient after renal transplantation in whom it was possible to demonstrate DNA evidence for infection of the tumour with HPV Type 11. The significance of the observation is discussed in relation to the hypothesis that immunosurveillance can control the development of malignancy.

To investigate whether positron emission tomography (PET) with L-methyl-11C-methionine as a tracer could be used for diagnostic purposes and for evaluation of therapy in patients with varying stages of urinary bladder cancer treated with chemotherapy. PET was employed in 44 separate examinations involving 29 patients (24 men and five women with a median age of 68 years [mean 66, range 47-78]) with localized or metastatic transitional cell carcinoma of the urinary bladder. In four patients PET examinations were performed prior to the commencement of chemotherapy, and after one course and after three courses. The diagnostic accuracy of PET was poor. The technique did not monitor the therapeutic effect of neoadjuvant chemotherapy, producing results that correlated with therapy outcome. PET identified those patients who responded less successfully to therapy. PET with L-methyl-11C-methionine demonstrates alterations in tumour metabolism long before visible changes appear on computed tomography or magnetic resonance imaging. Further work is required to develop more specific tracers.

An improved design of the recently developed urethral plug was evaluated for the treatment of women with genuine urinary stress incontinence. The plug consists of an oval meatal plate, a soft stalk and 1 or 2 spheres along the stalk with fixed distances between the meatal plate and the spheres. Inside the stalk is a removable semi-rigid guide pin to ease insertion. Forty women were randomly allocated to treatment with either the 2-sphere or the 1 -sphere plug during period 1 (2 weeks). In period 2 (2 weeks) the patients used the other plug. They then continued with what they judged to be the better plug in period 3 (2 months). Eighteen patients (45%) completed period 3 with the “preference” plug and 17 were subjectively and objectively continent or improved. Fourteen of these women preferred the 2-sphere device. The plugs were equally effective in patients with mild or severe incontinence. To accommodate variations in urethral length and to avoid the loss of plugs, the devices are available in different lengths. Six women developed urinary tract infections and 2 of these had a plug in the bladder. The urethral plug is an effective treatment in a group of women with stress incontinence. Removal by hand is advisable in order to avoid retention of plugs in the bladder.

To review the records of patients with suspected urinary tract trauma to determine whether eliminating imaging studies would have missed any significant injuries. The records of 1103 consecutive patients who underwent radiographic evaluation of the urinary tract because of suspected renal trauma were evaluated retrospectively. A comprehensive review was made of the group of patients who were normotensive and had only microscopic haematuria. Abnormal intravenous pyelograms (IVP) were found in 10% of patients with normotension and microscopic haematuria. In patients with injuries due to penetrating trauma, five of 16 with an abnormal IVP required operative intervention, while in patients with injuries due to blunt trauma, only one of 60 had a significant renal injury. None of the 605 patients with a blunt injury, microscopic haematuria, no history of hypotension, and no significant associated injuries required operative intervention solely for the renal injury. Radiographic evaluation of the urinary tract is recommended for all patients with penetrating trauma and any degree of haematuria, but only for patients with blunt trauma if associated with gross haematuria, microscopic haematuria and hypotension, or microscopic haematuria and significant associated injuries.

One thousand one hundred and seventeen patients with genitourinary tuberculosis who were treated over a period of 34 years have been reviewed. During this time various regimens of treatment were used and have been evaluated. Emphasis is placed on the results of the group on short-course chemotherapy which has been in use since 1970 and is now standard practice. This group has been carefully studied, as the chemotherapeutic combinations are important to developing countries. The clinical response, sterilisation of urine, urinary reversion, drug toxicity and the place of surgery in relation to modern chemotherapy have been discussed and assessed. They show that the results of short-course chemotherapy are satisfactory and confirm that there is no need to extend chemotherapy beyond 4 months, except in unusual circumstances.

A consecutive series of 1120 patients with ureteric stones is presented. Conservative and surgical treatment is discussed and the results of ureteric catheterisation, dilatation, transurethral manipulation and extraction, ureteric meatotomy and ureterolithotomy are presented.

A retrospective review of 114 cases of squamous cell carcinoma of bladder presenting in Glasgow between 1964 and 1978 is described with emphasis on treatment and survival. Ninety-seven patients (92.4%) were found to have invasive tumours (T2-T4) at diagnosis. Metastatic disease was confirmed in only 10 patients (8.8%). Only 23.8% of patients were alive one year after diagnosis, the overall 5-year survival rate being 1.9%. The 5-year survival rates for patients with T2 and T3 disease following radical radiotherapy were 16.7 and 4.8% respectively. No conclusions concerning the role of total cystectomy could be drawn from this series because of the small number of patients undergoing the operation, but a review of the literature suggests this may be the treatment of choice.

The gonadal effects produced by injection of cadmium in the rats are well known. The effects of direct injection into the prostate are less well understood. The present experiments indicated the retention of cadmium by the various lobes of the rat prostate following direct injection of radioactive cadmium into the organ. The cells of the prostate are capable of retaining cadmium in measurable amounts up to at least 6 weeks following the injection. The subcellular fractions were measured with respect to cadmium activity and these are indicated. In addition measurements were made in organs which are known to be affected by cadmium, that is, the kidney and the testicle. The affinity of the kidney for cadmium is confirmed. The areas of the prostate gland with a high zinc content appear to retain less cadmium than areas of the gland which are known to have a low zinc content. This suggests a possible zinc protective mechanism.

One hundred and sixteen patients with detrusor instability, detrusor hyper-reflexia or bladder hypersensitivity who had failed to respond to standard conservative methods of management were treated by transvesical infiltration of the pelvic plexuses with phenol. A satisfactory response was obtained in detrusor hyper-reflexia (82%), in detrusor instability in patients over 55 years of age (69%) and in idiopathic bladder hypersensitivity (68%). The response rate was much less satisfactory in detrusor instability in patients less than 55 years of age (14%) and when there was a definable cause for bladder hypersensitivity (0%).

A series of 135 kidneys with pelviureteric obstruction in 117 children is reviewed (a 16% incidence of bilateral obstruction). The majority (89%) of pyeloplasties or other reconstructive procedures were performed via an anterior transperitoneal approach which afforded excellent surgical exposure with a low (4%) incidence of related post-operative complications. Extra-renal drainage alone was preferred to nephrostomy in the majority of patients. Children presenting with bilateral hydronephrosis were managed by a single, simultaneous bilateral procedure rather than by 2 operations. The total nephrectomy rate of 5% compares favourably with the results reported by authors who favour an extraperitoneal approach and routine nephrostomy drainage.

To determine if the chemokine monocyte chemo-attractant protein-1 (MCP-1) is produced locally in patients with bladder cancer and to analyse a possible correlation between tumour stage, grade and metastatic spread, and the urinary and systemic levels of MCP-1. PATIENTS SUBJECTS AND METHODS: Urine and serum samples were obtained from 60 patients with bladder cancer and 20 control subjects. Tumour stage, grade, metastasis and nodal status were assessed. MCP-1 levels in serum and urine were determined using a sandwich enzyme-linked immunosorbent assay. Two transitional cell cancer cell lines (grade I and grade III) were analysed for MCP-1 production under normal and nutritive-stress cell culture. The correlation of urinary MCP-1 levels with tumour stage, grade and distant metastasis was highly significant. Patients with stage T2-T4 bladder cancer had three to fourfold higher mean MCP-1 concentrations (pg/mL) in their urine than those with T1 stage tumours or than the controls (controls 260; T1 359; T2 967; T3 917; T4 1829; P < 0.005). A tumour grade of > GI and the existence of distant metastasis (M1) also correlated significantly with higher urinary MCP-1 levels (GI 373; GII 661; GIII 1111; M0 644; M1 1379; P < 0.05). No differences in circulating serum MCP-1 level were detected between controls and patients. The low-grade (GI) RT4 bladder cancer cell line produced only traces of MCP-1, which did not change under nutritional stress; in contrast, the highly malignant T24 bladder cancer cell line (GIII) spontaneously secreted large amounts of MCP-1 (approximately 7000 pg/mL) which increased under nutritive stress to 13,000 pg/mL. MCP-1, as a potent monocyte chemo-attractant to tumour sites, is probably produced by bladder cancer cells; MCP-1 levels in the vicinity of the tumour (i.e. urine) correlate significantly with TNM stage and grade. As has already been shown in other neoplasms, the resulting monocyte/macrophage infiltrate possibly facilitates tumour neovascularization and tissue invasion. Therefore, MCP-1 levels in the urine of patients with bladder cancer may be a prognostic marker for the natural course of the disease, and modulation of this chemokine might be a future therapeutic approach for adjuvant treatment of bladder cancer.

Diurnal profiles of circulating gonadotrophins and testosterone have been measured in patients with prostatic carcinoma on long-term treatment with the LHRH agonist analogue ICI 118630, which was administered either by subcutaneous daily injection or monthly injection of the depot preparation. These have been compared with profiles in patients who had undergone orchiectomy. Daily injection of the analogue induced a significant rise in the level of LH but this was not associated with a significant rise in circulating testosterone. There was no diurnal variation of LH or testosterone concentration in patients receiving the depot preparation and this did not differ in patients who were "mid-cycle" compared with those who were "end-cycle". The depot preparation did, however, induce significantly lower circulating levels of testosterone than did daily injection of the analogue and the levels were comparable with those achieved after orchiectomy.

The clinical and endocrine response to a depot preparation of the LH-RH analogue ICI 118630 (Zoladex) was assessed in 55 untreated patients with advanced prostatic cancer. Whereas gonadal androgen suppression was achieved in all patients, subjective and objective clinical response occurred in only 69%, indicated by a relief of bone pain, a decrease in the size of the primary tumour and lymph node metastases and improvement in bone scan appearances. A third of these patients, however, subsequently showed progression of their disease. Serious side effects were not encountered in this study. The depot formulation is a simple, safe and convenient method of administering Zoladex and offers an alternative treatment for metastatic prostatic cancer.

Summary— One hundred and nine patients undergoing 119 transplants have been followed up from 8 months to 9 years. Urological complications occurred in 16 transplants, an incidence of 13.4%. Ureteroneocystostomy was performed primarily in all cases; in 98 by the conventional Politano-Leadbetter technique with 9 (9.2%) urological complications and in 32 by an extravesical technique with 7 (21.8%) urological complications. One patient died as a result of ureteric obstruction, without operation. In 3 patients with lower ureteric obstruction, transurethral ureteric meatotomy was successful in 2 cases and resulted in no change in renal function in the third. Two patients with urinary fistulae were managed successfully by continuous drainage with indwelling urethral catheters. The remaining 10 patients required 12 open surgical procedures for relief of ureteric obstruction, with improvement in function in 7 patients.

The pulsed dye laser has proved to be an effective and safe method of treating ureteric stones; 120 patients have been treated. Ureteroscopic lasertripsy (107 cases) had an overall success rate of 84%. The failures were due to mobile stones inadvertently flushed back into the kidney (14%) and 2% of patients required open ureterolithotomy after failure of two ureteroscopic procedures. "Blind" lasertripsy (13 cases) was safe but not as efficient, the success rate being only 23%.