Ann R Coll Surg Engl 2009; 91: 565-569 565Over the last century, there has been an evolution of methods for lower urinary tract reconstruction following cystectomy, from being simple means of diverting urine to techniques allowing normal voiding pattern through the intact native urethra. Various methods for continent urinary diversion have been developed to provide such realistic options from simply diverting urine through a conduit to orthotopic reconstruction. [1][2][3][4][5] These innovations in urinary diversions should allow patients to lead a near-normal lifestyle, eliminating the need for a urostomy. However, orthotopic bladder substitution (OBS) is not offered to a majority of patients undergoing cystectomy as the benefits of OBS over ileal conduit diversion (ICD) on quality-of-life parameters remain indeterminate.Health-related quality of life (HRQoL) is a multifaceted and subjective concept taking into consideration the patient's physical and emotional status, general health, social interaction and mental health. Comparison of QoL parameters in patients who have had cystectomy has been difficult with variable results. [6][7][8][9] This could be explained by the use of different questionnaires comparing a multitude of techniques. We compared HRQoL between patients who underwent OBS or ICD following cystectomy using a bladder cancer specific functional index questionnaire. Patients and MethodsOver a 6.5 year period, 57 consecutive patients who underwent Evolution of pathological guidelines has empowered centres to offer orthotopic substitution (OBS) to patients undergoing radical cystectomy. We compared health-related quality of life (HRQoL) between patients who underwent OBS or ileal conduit urinary diversion (ICD) following radical cystectomy. PATIENTS AND METHODS A total of 57 patients who underwent cystectomy were assessed pre-operatively using Karnofsky performance scale (KPS). Of these, 52 patients (28 OBS and 24 ICD) who responded to a postal questionnaire consisting of SF-36 and a functional index questionnaire were included. RESULTS Median age of patients was 70 years. Pre-operative KPS scores were similar. All eight HRQoL scales were favourable in both groups. OBS patients had significantly better physical functioning. In the cohort, 42% of men with OBS and 25% of diversions could maintain an erection to varying degrees. Of the OBS patients, 85% were continent with two patients reporting reduced QoL with pad usage. Of ICD patients, 63% felt less complete and 42% were embarrassed due to the stoma, with 58% apprehensive of stomal leakage. Of OBS patients, 96% had significant relationships and a more active life-style. CONCLUSIONS In a similar age-group population, there was no significant difference in most QoL indices but body image issues persist in ICD patients. OBS patients had significantly better physical function, continuing to have a more active lifestyle. They attained urethral voiding with good continence. A detailed discussion of long-term functional outcome would engender a realistic ...

OBJECTIVES To evaluate the use of topical glyceryl trinitrate (GTN) ointment as an adjunct to periprostatic nerve block in reducing pain associated with transrectal ultrasonography (TRUS)‐guided prostatic biopsy. PATIENTS AND METHODS In all, 148 consecutive patients (mean age 67.0 years) having their first TRUS‐guided biopsy were randomized to receive either 0.2% GTN ointment or placebo 10 min before biopsy. All patients had a biopsy preceded by an injection with 10 mL of 1% lidocaine local anaesthesia. A 10‐point visual analogue score was used to record ‘Overall discomfort due to the presence of the probe’, the biopsy itself and pain after the procedure. RESULTS There was no significant difference in age, PSA level and prostate volume between the groups. There was a significantly lower mean pain score due to probe insertion in the GTN than placebo group (1.94 vs 3.24, P < 0.01); pain perception was lower for the whole procedure in the GTN group, and was most pronounced in men aged <60 years (2.13 vs 4.61, P < 0.005). CONCLUSIONS Topical GTN ointment is safe and effective in reducing the discomfort associated with TRUS‐guided biopsy of the prostate, in particular the insertion of the ultrasound probe. It might be of maximum benefit in the younger patient and those having a repeat biopsy who previously failed to tolerate the procedure well.

Malakoplakia is a rare, granulomatous condition most commonly found in the genitourinary tract. It can present in a myriad of ways depending on the organ involved, thus presenting a huge diagnostic challenge. We present 4 patients with genitourinary malakoplakia, who manifested with recurrent urinary tract infection (UTI) and hematuria in all except one, who presented with hydronephrosis secondary to a large pelvic mass. We discuss the need for a high index of suspicion and careful scrutiny of histology to order to avoid misdiagnosis as simple long term antibiotics are an effective treatment in all but those with large pelvic masses.

OBJECTIVE To assess the cancer detection rate per individual core biopsy in a 12‐core protocol and develop an optimal biopsy regimen for detecting early prostate cancer. PATIENTS AND METHODS The study included 445 new patients who had a 12‐core transrectal ultrasonography (TRUS)‐guided prostatic biopsy over a 40‐month period. The 12‐ core biopsy protocol included parasagittal sextant and six peripheral biopsies. The cancer detection rate per individual core was evaluated to give an optimal biopsy protocol. RESULTS Prostate cancer was detected in 142 patients (31.9%). Parasagittal sextant biopsy would have failed to detect 40 (28.2%) of the cancers. Among the various possible biopsy protocols, the optimum 10‐core biopsy strategy excluding the parasagittal mid‐zone biopsies from the 12‐core protocol achieved a cancer detection rate of 98.6%. CONCLUSION The cancer detection rate increased from 71.8% for parasagittal sextant biopsies to 88.7% by adding peripheral basal biopsies (8‐biopsy protocol); 98.6% of cancers in the series would have been detected with a 10‐biopsy strategy omitting the parasagittal mid‐zone biopsies. Thus we recommend a 10‐core protocol incorporating six peripheral biopsies in patients with elevated age‐ specific prostate‐specific antigen levels (2.6–10.0 ng/mL) for maximising cancer detection.

OBJECTIVE To prospectively compare the efficacy of bi‐basal vs bi‐apical periprostatic nerve block (PPNB) during 12‐core prostate biopsy guided by transrectal ultrasonography (TRUS), and to evaluate the pain experienced on inserting the probe compared to the biopsy procedure, as PPNB with lignocaine local anaesthesia has been used for over a decade for minimizing pain during prostatic biopsy. PATIENTS AND METHODS In all, 143 men who were to have a TRUS‐guided prostate biopsy were systematically randomized to two groups, to receive PPNB at the apex or base. A 10‐cm visual analogue score was used to record the pain experienced during probe insertion, the biopsy and just before to leaving the department . RESULTS The mean pain score on biopsy in the apical group was similar to that of the basal group (apex 1.9, base 1.6, P = 0.36). Probe introduction produced a significantly higher pain score (probe 2.2, biopsy 1.7, P < 0.001) than at the biopsy. CONCLUSIONS Patients who experienced greater pain with the introduction of the probe also reported more pain with the biopsy procedure. The site of local anaesthetic before prostatic biopsy showed no significant difference in pain scores. Older men tolerated the procedure better. Analgesia after PPNB at near either the apex or base appears equal, regardless of the site of injection. We suggest that topical perianal anaesthetic agents could significantly reduce not only pain perception, but also improve tolerance.

The combination of lidocaine PPNB with DS provides additional pain relief during and after prostatic TRUS biopsy.

study. They had a DRE by either of two experienced consultant urologists. The results of the DRE and core biopsy histology were compared with the histology and the radical prostatectomy specimen in a subset (82 men) of the study population.

The provided evidence for evaluation of patients with urolithiasis aims at defining patients at high risk for recurrent/complicated stone disease. Based on this approach, evidence-based dietary and medical management regimes are suggested.