Identification of a novel nuclear speckle-type protein, SPOP

A careful evaluation of local tumoral extension is mandatory in patient selected for radical surgery for prostate cancer. Nevertheless, prostatic imaging, achieved with transrectal ultrasonography (TRUS) and CT scan, is often unable to stage accurately the disease. The Authors report a retrospective analysis of 43 patients treated with radical retropublic prostatectomy: their findings support the idea that both TRUS and CT scan are unable to define the extent of the tumor, reaching respectively accuracies of 38 and 46%. From these data they conclude that CT can be excluded from the preoperatory workup of prostate cancer, except in selected patients, at high risk of nodal metastasis on the basis of PSA. TRUS is the mainstay of prostate cancer diagnosis and staging because it guides transrectal biopsies, but any conclusion made exclusively on the base of its imaging seems not reliable.     

Quality of life of patients with renal cell carcinoma or prostate cancer after radical surgery

OBJECTIVES: To study the impact of radical tumour surgery in prostate and renal cell cancer patients on quality of life (QOL). METHODS: In 38 male patients suffering from organ-confined prostate or renal cell cancer, a prospective study was performed. For the evaluation of QOL, we used the EMPK (Erfassung multipler psychischer Konstrukte). Urologic symptoms were evaluated with a specially designed symptom score. The test instrument was filled out the day before surgery and one year after operation. RESULTS: The EMPK was able to detect and describe significant changes in certain aspects of QOL in renal cell cancer and prostate cancer patients. Moreover, there seems to be a difference between the two groups. A direct relation between QOL and the different quality and quantity of operation-related symptoms, however, could not be proven. CONCLUSIONS: In this pilot study, radical surgical therapy did not significantly change QOL in prostate cancer patients, but seemed to have a positive influence on the QOL of renal cell cancer patients.     

A prospective randomized trial for treating stages B2 and C prostate cancer: radical surgery or irradiation with neoadjuvant endocrine therapy

A randomized clinical trial of neoadjuvant endocrine therapy followed by either surgery or irradiation and a resumption of endocrine therapy for stages B2 and C prostate cancer has been in progress since 1989. A hundred patients entered the trial between 1989 and 1993, and 95 cases were evaluated. Forty-six patients received surgery and 49 were treated with irradiation. Neoadjuvant endocrine therapy for two months resulted in prostate shrinkage and prostate specific antigen lowering. Except for two patients, one dying of a progression of disease and the other of another concurrent cancer, all are alive with an average follow-up term of 25 (range 3-53) months. The good prognostic results obtained from both treatment groups at present seem to be due in part to the neoadjuvant endocrine therapy; but in order to reach a final conclusion further comparisons need to be made.     

Clinical and cost impact of second-opinion pathology. Review of prostate biopsies prior to radical prostatectomy

Despite numerous studies evaluating second-opinion surgical programs, we are unaware of work evaluating the cost effectiveness of a second opinion for pathology prior to surgery. One of six pathologists reviewed the pathology of the outside needle biopsies of 535 consecutive men referred to Johns Hopkins Hospital for radical prostatectomy over a 12-month period (from October 1993 until October 1994) before the men underwent surgery. Of the 535 needle biopsies initially diagnosed on the outside as adenocarcinoma of the prostate, seven (1.3%) were reclassified as benign upon pathology review at Johns Hopkins Hospital. The most common lesion misinterpreted as adenocarcinoma was adenosis or less pronounced examples of adenosis consisting of foci of crowded glands (five cases). Foci of atrophy in the remaining two cases were misdiagnosed as adenocarcinoma of the prostate. Upon subsequent clinical work up, six of seven men were considered not to have adenocarcinoma, and their surgery was cancelled. The cost for reviewing all 535 preoperative needle biopsies was $44,883, which included the cost of immunohistochemical studies for high-molecular-weight cytokeratin and repeat biopsies and ultrasounds in men whose diagnoses were reversed. The total cost of the radical prostatectomies had the six men undergone surgery was estimated at $85,686, including hospitalization, anesthesia, radical prostatectomy pathology, and surgery. This cost savings did not include other costs resulting from lost wages, morbidity, or potential litigation. Second-opinion pathological evaluation of prostate biopsy before radical prostatectomy is cost effective and has a major impact on clinical treatment for a subset of patients.     

Failure of pain relief after surgery. Attitudes of ward staff and patients to postoperative analgesia

Three surveys of postoperative patients and surgical ward staff were conducted in an 840-bed university hospital to ascertain the severity of pain after surgery and the reasons why patients in pain do not receive more of the analgesia prescribed for them. In the first survey, 206 inpatients were questioned within 24 h following operation, and 25.2% of patients experienced moderate pain whilst 9.2% experienced severe pain but received only 36% of their prescribed analgesics. In the second survey, 176 staff reported that the commonest reasons why patients in pain did not receive analgesics were that they did not request analgesia, were too sleepy or refused the dose. In the final survey, of 200 inpatients questioned, 88% had experienced pain since operation, 97% had been offered analgesics, 14% refused a dose. Twenty-nine percent were moderately or very concerned about injections. The beliefs of both ward staff and patients could have contributed to this failure of pain relief.     

Lithiasis of the prostatic loge

Lithiasis may develop in the prostate loge following prostate surgery. Calculus formation in the prostate can be ascribed basically to foreign bodies, residual adenomatous spheroids and clots or fragments of sphacelous mucosa in the presence of a stenotic area after surgery and/or infection. The diagnosis is based on the physical examination and particularly on the radiological findings. Treatment is by open surgery or endoscopic or extracorporeal lithotripsy.     

The ocular blood flow tonograph: a new instrument for the measurement of intraocular pressure in rabbits

OBJECTIVES: To determine the intraprostatic pathologic changes following accurately measured doses of transurethral microwave thermal energy in patients with benign prostatic hyperplasia. METHODS: Eight patients scheduled for prostate surgery were treated for approximately 1 hour without anesthesia using a newly designed microwave treatment catheter that allows a close impedance match to prostate tissue and concentrates thermal energy preferentially in the anterior and lateral prostate gland. Interstitial, urethral, and rectal temperatures were continuously measured using a novel stereotactic thermal mapping technique. Serial sections of prostate tissue harvested during subsequent surgery were evaluated pathologically with prostate mapping. RESULTS: Microwave treatment resulted in marked and continuous intraprostate temperature elevation, while urethral and rectal temperatures remained low. Peak intraprostate temperatures in individual patients reached as high as 80 degrees C. Mean temperature reached a maximum of 54 degrees C at a radial distance of approximately 0.5 cm from the urethra and remained 45 degrees C or higher up to a distance of 1.6 cm. The predominant pathologic findings were uniform hemorrhagic necrosis and tissue devitalization without significant inflammation. The mean distance from the urethra to the viable-necrotic tissue border was 1.6 +/- 0.2 cm (range, 0.5 to 2.5). At this border, no more than 1 mm in thickness, temperature averaged 45.7 +/- 0.6 degrees C, and there was a suggestion that pure stromal nodules were more resistant to thermal injury. CONCLUSIONS: Microwave treatment can destroy obstructive prostate tissue while maintaining innocuous urethral and rectal temperatures. Temperatures of 45 degrees C or higher for approximately 1 hour cause uniform thermoablation of prostate tissue.     

Autonomic neuropathy: clinical and instrumental findings

A good staging system should be able to accurately reflect the natural history of a malignant disease, to express the extent of the disease at the time of diagnosis, and stratify patients in prognostically distinctive groups. The staging system for prostate cancer, as it is today, fails to fulfill these requirements. Approximately one third of the patients who undergo surgery for complete excision of prostate cancer in fact do not have a localize disease. The incidence of tumor at the inked margin may reach 30% for T1 stage and up to 60% for clinical T2b prostate cancer according to comparison with pathologic examination of resected specimen. Several concepts have been recently proposed as a means of improving the accuracy of the available staging system. In this paper, we review current aspects of clinical and pathological staging of prostate cancer, and the importance of these new concepts on the early stages of prostate cancer.     

Multivariate analysis of prognostic factors in 75 patients with soft tissue sarcoma

Traditionally, patients who received minor gynecology surgery remained in the hospital for a few days, during which time post-operative care was given by nurses. However, since patients are now often discharged the same day, the responsibility for this care has been transferred to the patients and their families. Because the nursing staff of the Gynecology Day Surgery Unit at the Royal Victoria Hospital believes there is a need for patient-monitoring after discharge and CLSCs do not offer services for this generally healthy clientele, they developed, with the head nurse and the assistant head nurse, a post-operative telephone follow-up program. This idea stemmed from the general need to adapt care as a result of the increase in day surgery. In addition to extending care beyond the hospital walls and improving its quality, this program has increased the job satisfaction of the nurses involved.     

Prevention of respiratory complications after abdominal surgery: a randomised clinical trial

OBJECTIVE: To evaluate the prevention of respiratory complications after abdominal surgery by a comparison of a global policy of incentive spirometry with a regimen consisting of deep breathing exercises for low risk patients and incentive spirometry plus physiotherapy for high risk patients. DESIGN: Stratified randomised trial. SETTING: General surgical service of an urban teaching hospital. PATIENTS: 456 patients undergoing abdominal surgery. Patients less than 60 years of age with an American Society of Anesthesia classification of 1 were considered to be at low risk. OUTCOME MEASURES: Respiratory complications were defined as clinical features consistent with collapse or consolidation, a temperature above 38 degrees C, plus either confirmatory chest radiology or positive results on sputum microbiology. We also recorded the time that staff devoted to prophylactic respiratory therapy. RESULTS: There was good baseline equivalence between the groups. The incidence of respiratory complications was 15% (35/231) for patients in the incentive spirometry group and 12% (28/225) for patients in the mixed therapy group (P = 0.40; 95% confidence interval -3.6% to 9.0%). It required similar amounts of staff time to provide incentive spirometry and deep breathing exercises for low risk patients. The inclusion of physiotherapy for high risk patients, however, resulted in the utilisation of an extra 30 minutes of staff time per patient. CONCLUSIONS: When the use of resources is taken into account, the most efficient regimen of prophylaxis against respiratory complications after abdominal surgery is deep breathing exercises for low risk patients and incentive spirometry for high risk patients.     

A case of cow''s milk allergy in the neonatal period--evidence for intrauterine sensitization?

Cleft lip and palate surgery team activities in Cambodia were launched in 1989 by a Japanese non-governmental organization. The objectives of the project were to provide appropriate surgical treatment and safe general anaesthesia for local patients, and also to teach general anaesthesia and surgery to local medical staff. A surgery team was sent on four occasions between 1991 and 1993 and a total of 130 patients received surgical treatment and general anaesthesia. Anaesthesia techniques employed included total intravenous anaesthesia in 70 patients and intravenous anaesthesia and low dose halothane in 60 patients. There were no major complications, such as airway obstruction or apnoea in the postoperative period. Total intravenous anaesthesia is an appropriate technique for patients in developing countries. The teaching of anaesthesia should be emphasized during the surgery team activities.     

Cancer of the prostate. 3: Men's healthcare needs

This article, the third in a three-part series, addresses the complex issues surrounding screening for prostate cancer. The purpose of screening in health care is discussed and the advantages and disadvantages of the various screening tests for the early detection of prostate cancer are outlined. The use of one specific technique to screen men for prostate cancer is questioned. It is suggested that several techniques should be used to assess risk in detail. Employing only one technique, for example prostate specific antigen, may result in men undergoing unnecessary surgery or inappropriate treatment. Nurses have a professional duty to ensure that they are aware of the advantages and disadvantages with respect to screening men for cancer of the prostate. Patients' must be in possession of the facts before they make important decisions about their health. In order to reduce harm the nurse can become the patient's advocate and act in such a way as to safeguard and promote the patient's interests.     

Comparison of the efficacy and bioequivalence of two oral formulations of tiludronate in the treatment of Paget''s disease of bone

BACKGROUND: There has been a resurgence of interest in cryosurgical ablation of the prostate for the treatment of carcinoma. This is due to recent advances in cryosurgical technology, which have resulted in relatively lower morbidity. The objective of this study was to evaluate the effectiveness of ultrasound-guided cryosurgical ablation of prostate carcinoma. METHODS: Eighty-three patients who had biopsy-proven prostate carcinoma underwent cryosurgical ablation of their entire prostate gland. The initial group of 12 patients had their procedures performed under ultrasound guidance only. The other 71 patients had cryosurgery performed with temperature monitoring in combination with ultrasound guidance. Twelve patients who had positive biopsies underwent a second cryosurgical procedure. All patients had prostate specific antigen (PSA) levels measured at 3, 6, 12, 18, 24, and 30 months after cryosurgery. Ultrasound-guided sextant biopsies were performed at 3-6, 12-18, and 24 months. RESULTS: The median PSA dropped by 95%, from a preoperative value of 4.3 ng/mL to 0.2 ng/mL 30 months after cryosurgery. The authors experienced a high failure rate (positive biopsies) of 83% for the initial group of 12 patients who did not have temperature monitoring during the cryosurgical procedure. This was in contrast to a success rate of 90% (negative biopsies) for the next 71 patients, who did have temperature monitoring (P < 0.05, chi-square test). Twelve patients underwent a second cryosurgery, and the success rate for this group was 91% (11 of 12 patients). The combined success rate for both the first cryosurgery and the second was 94% (62 of 77 patients). Complications included urethral sloughing, urinary incontinence, impotence, bladder neck contracture, and bladder contracture. The majority of patients recovered rapidly from their cryosurgical procedures and were able to resume normal activities 3-4 weeks afterward. CONCLUSIONS: These preliminary results demonstrate that cryosurgical ablation of the prostate is a viable treatment option for prostate carcinoma. In the authors' experience, ultrasound alone may not be adequate for monitoring the entire cryosurgical procedure. The authors found that temperature monitoring shortened their learning curve, enabled them to freeze prostate tissue more aggressively, and may have contributed to their overall success.     

Treatment of prostate cancer in patients aged 75 or older

In view of the increasing incidence and mortality rate of prostate cancer in Japan, the management of elderly patients with prostate cancer is an important issue now. We therefore analyzed the clinicopathological features and long-term outcomes of 182 patients with prostate cancer, aged 75 or older, in order to establish the treatment strategy for this age group of patients. There were more patients with advanced disease (stage C-D) than those with localized disease (stage A2-B), and the patients with moderate to poorly differentiated tumors were more numerous than those with well-differentiated tumors. The overall survival curve of the patients with localized prostate cancer was in line with the age-matched expected survival curve, while that with advanced prostate cancer was far below the expected survival curve. These results demonstrated that advanced prostate cancer in elderly patients is as harmful as in younger patients, indicating the necessity for early detection and treatment of prostate cancer among the younger generation. On the other hand, localized prostate cancer in elderly patients should be treated less invasively to maintain their quality of life.     

Spirituality and the treatment of the dually diagnosed: an investigation of patient and staff attitudes

Spirituality is a neglected area of study and research in the treatment of addictions. The role of spirituality in the treatment of the dually diagnosed has received particularly scant attention. One hundred and one patients on an in-patient dual-diagnosis unit, as well as the 31 members of the nursing staff who treat them were surveyed. Patients and staff were questioned about their spiritual beliefs and what was the role of spirituality in the patients' recovery from addiction. Staff were questioned about their own spirituality and what they think the patients' level of spirituality is. In addition the staff were asked what they think the patients' view of spiritually is. Results indicate that the patients and staff are equally spiritually oriented. The patients view spirituality as essential to their recovery and value spiritual programming in their treatment more than some concrete items. The nursing staff underestimated both the patients' level of spirituality and this importance placed on spiritual issues. The authors suggest that more attention should be given by staff to spirituality in the treatment of this population.     

Increase in endogenous thrombopoietin in healthy donors after automated plateletpheresis

Inguinoscrotal bladder hernias are uncommon clinical facts more predominant in males aged between 50 and 70. This entity has no specific clinical character and diagnosis usually happens in the course of surgical repair of inguinal hernia. In about 3%-10% cases, it appears associated to inguinal hernia. Discussion of two case-reports of patients with giant inguinoscrotal bladder hernia; one patient with synchronous association to bladder transitional carcinoma. The literature on the clinical, diagnostic and therapeutic aspects is revised. The high index of suspicion for making a pre-operative diagnosis, specially in aged patients with inguinal hernia and expanded prostate signs and symptoms is highlighted. Emphasis is placed on the need for surgical hernia repair prior to prostate and/or bladder transurethral surgery.     

The case management model of patient care delivery

Case management is a model of care delivery that integrates patient and provider satisfaction and consideration of cost factors and provides a method of managing individuals' holistic health concerns. Using the case management approach, nurses can optimize client self-care, decrease fragmentation of care, provide quality care across a continuum, enhance clients' quality of life, decrease length of hospitalization, increase client and staff satisfaction, and promote cost-effective use of scarce resources. Case management offers nurses an opportunity to demonstrate their roles in multidisciplinary health care teams. Case management is relevant in ambulatory surgery settings and in the perioperative care of complex surgical patients.     

Treatment of clinically localized prostatic cancer--endocrine therapy

We assessed the actuarial survival of 28 patients with localized prostate cancer who were treated with endocrine therapy in comparison with that of 19 patients who had radical prostatectomy between 1972 and 1995. There were no significant differences among the cause-specific curves and clinical disease-free survival of patients treated with endocrine therapy and radical prostatectomy but the all-cause survival curves favored the surgery group. The results of endocrine therapy alone were unsatisfactory for the patients with high grade tumors. In conclusion, the patients with localized prostate cancer at high risk of death from other complications are reasonable candidates for endocrine therapy.     

Urinary symptoms, potency, and quality of life in patients with localized prostate cancer followed up with deferred treatment

OBJECTIVES: To evaluate urinary symptoms, potency, and quality of life in a group of patients with prostate cancer followed up with deferred treatment. METHODS: A self-administered questionnaire was mailed to patients with localized prostate cancer who were followed up with deferred treatment. Data regarding clinical stage, pathologic grade, and treatment after diagnosis were obtained from patient files. RESULTS: A total of 71 consecutive patients (age 79 years or less) were included. Of the 52 patients (73%) who responded, 31% had undergone transurethral resection of the prostate, 8% underwent radiation therapy, and 44% underwent hormonal deprivation during the follow-up period. With respect to incontinence, 21% were using pads and 37% leaked urine daily; in 21% of the patients, urine dripping or leaking was a substantial problem. Before the diagnosis of their prostate cancer, 81% stated they were able to have an erection. At the time of the questionnaire, 77% stated that their ability to have erections was reduced and only 29% had had an erection after the prostate cancer was diagnosed. For 12%, impotence was a problem. With respect to quality of life, 52% of the patients rated their health as excellent or good and 61% would be happy to spend the rest of their life feeling the way they did at the time of the questionnaire. Eighty-five percent were satisfied with the treatment policy for their prostate cancer, and 96% would choose deferred treatment again if faced with the decision. CONCLUSIONS: By use of a self-administered questionnaire, a high frequency of incontinence and impotence was found in a group of patients with prostate cancer followed up with deferred treatment. Despite these problems, more than half of the patients rated their health as good and would undergo expectant management again if faced with the decision.     

Ambulatory surgery. Patients and patient education

This article reviews the concept of day surgery and shows how the treatment can be organized pre-, per- and post-operatively. It can be established in a hospital-integrated unit, a unit separate from the hospital, but connected with it, or a satellite ambulatory facility. Because the patient spends only a short time in hospital it is necessary to have structured preparations before admission, for the benefit of both patient and staff. It should be easy to identify patients suitable for day surgery from the waiting lists, and preparations should be directed at treatment by day surgery right from the start. Rules must be worked out for selecting patients, as well as guidelines for information to patients. It is also necessary to plan the operation programme, and to agree how nurses and doctors should take care of the patient during the different steps of treatment.