Biomedical subjects
Publications and source records attributed to Damien M Bolton.
The key diagnosis and treating of vesicovaginal fistulae is accurate imaging. We illustrate the latest use of enhanced computed tomography for such cases.
INTRODUCTION: The growth of human tumours under the renal capsule in animal models has been performed in the past. However, the use of modern surgical equipment has not always been translated into the laboratory. We report on a novel method for human renal tumour transplants using an automated biopsy gun to obtain tumour tissue and an epidural needle with introducer to easily deploy the grafts under the renal capsule. METHODS: Nude mice had human xenografted tumours grown subcutaneously after implantation of cells from culture. Tumours were then biopsied using a 16-gauge automated biopsy gun. Digital calipers were used to measure a 2-mm segment of the biopsy core that was cut and placed inside a hollow needle (epidural needle). The needle was placed under the renal capsule and the trocar introduced to deploy the graft beneath the capsule with minimal trauma. Further groups had tumour harvested similarly by automated biopsy gun but had the implants placed subcutaneously for comparison. RESULTS: Tumour grafts were established in 90% of grafted kidneys in this renal subcapsular model (229.68 +/- 118.32 mm(3); mean +/- 95% CI) which compared favourably to the subcutaneous model (163.81 +/- 43.3 mm(3)). Grafts were confirmed by direct observation and histology. CONCLUSION: Modern surgical equipment may be utilised to allow tumour transplantation to be precise, with an identifiable and reproducible tumour volume deployed. Surgical researchers and laboratory-based scientists need to embrace new techniques and utilise them to improve models. This model may be adapted to many situations in oncologic research involving xenografting.
Primary sclerosing lipogranuloma is an unusual benign condition of the genitalia typically presenting as a painless mass affecting the penis and scrotum. Its importance lies in differentiating it from malignancy to avoid extensive surgery. It is normally treated with total or partial excision. This is the first reported case where oral corticosteroids have been used to treat this condition whereby a six-week course resulted in the mass disappearing. In conclusion, if sclerosing lipogranuloma is suspected biopsy should be undertaken to exclude sarcoma. We believe surgery should be reserved for recurrent or refractory cases when steroids have failed as first-line treatment.
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OBJECTIVE: To investigate if women with recurrent urinary tract infection (UTI) warrant cystoscopy to exclude an abnormality of the lower urinary tract. This is particularly relevant given that non-invasive imaging has often been performed to exclude abnormality. Our further aims were to correlate imaging and risk factors with cystoscopic findings to determine their predictive value in finding pathology. PATIENTS AND METHODS: A database of women undergoing cystoscopy with recurrent UTI has been maintained at our institution for 10 years. We retrospectively examined this and patient records for patient demographics, and investigative and operative data. RESULTS: A total of 118 patients (mean 55 years) having recurrent UTI (mean 4.7 infections/year) were available. There were nine patients (8%) with significant abnormalities at cystoscopy: urethral stricture (six), bladder calculus (one), bladder diverticulum (one) and colovesical fistula (one). The negative predictive value (NPV) of imaging was 99% and significant (P < 0.01). Women with no risk factors for UTI had a NPV of 93% for normal cystoscopy (P > 0.05). The positive predictive value was low for imaging and risk factors in predicting cystoscopy findings. CONCLUSIONS: In our study, 8% of women had significant abnormalities detected during cystoscopy with most over 50 years. Women without risk factors for recurrent UTI and with normal imaging could have a cystoscopy omitted. Younger women are less likely to have pathology and this must be factored into decisions to perform cystoscopy.
OBJECTIVES: To ascertain the frequency of in-hospital deaths after urological surgery in a compulsory reporting setting, and to identify the contributing and potentially reversible factors involved in patients who had had transurethral resection of the prostate (TURP). METHODS: We reviewed all hospital deaths reported to the State Coroner from Coronial Services Victoria (CSV), Australia, in 2000-2002 to identify those instances associated with urological surgery. These cases were then analysed using methods developed by CSV. Resources available included medical records, police reports, government data on operative procedures and autopsy results. RESULTS: There were 20 in-hospital deaths after urological surgery identified for the 3-year period; most related to pre-existing comorbidities, predominantly ischaemic heart disease. Two episodes of hospital-acquired infection, two instances of technical complication of surgery contributing to death, and one pulmonary embolus were identified. Numerically the largest group of deaths after surgery was patients having TURP, and these deaths represented 0.05% (nine of 17 044) of all TURPs in this period. Most in this group (eight) had an acute myocardial infarction. CONCLUSION: Death after urological surgery appears to be uncommon; assessing patients for coronary artery disease before urological surgery, particularly TURP, closer cardiovascular monitoring after surgery, and rapid transfer to a coronary care unit if required, may further reduce mortality.
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OBJECTIVE: To evaluate the accuracy of fine-needle aspiration (FNA) cytology of palpable inguinal lymphadenopathy before definitive management of the primary tumour, in predicting inguinal lymph node (LN) metastasis in men with primary squamous cell carcinoma (SCC) of the penis. PATIENTS AND METHODS: Sixteen men with primary SCC of the penis and palpable inguinal lymphadenopathy (unilateral or bilateral) were treated by primary resection and bilateral inguinal LN dissection. FNA cytology was analysed for 25 palpable inguinal LNs at the time of penile biopsy. The sensitivity, specificity and accuracy of FNA cytology was compared with the histological findings from surgical LN clearance. RESULTS: The 25 FNAs were without complication and without evidence of implantation of metastasis in the needle tracts; 14 FNA samples were positive for metastasis, 10 were negative, and one was inconclusive. From the histological assessment of the surgical inguinal LN specimens, FNA cytology had a sensitivity of 93%, and specificity of 91% in predicting metastatic disease. CONCLUSION: FNA cytology of palpable inguinal lymphadenopathy before surgery for the primary tumour has a high sensitivity and specificity for metastatic penile cancer. This procedure permits early inguinal lymphadenectomy where appropriate without need for prolonged initial antibiotic treatment.
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A simple technique using a fenestrated urethral catheter to assist in drainage of pericatheter urethral exudates from the anastomosis of the urethra to the bladder neck in radical prostatectomy is described. It is applicable to open and laparoscopic techniques of radical prostatectomy.
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OBJECTIVE: To compare the findings of multidetector computed tomography (CT) with surgical pathology and magnetic resonance imaging (MRI), to determine the accuracy of delineating the superior extent of inferior vena cava (IVC) thrombotic involvement in renal cell cancer (RCC). PATIENTS AND METHODS: A prospective database was examined of 11 patients (median age 65 years, range 45-77) being assessed for suspected IVC extension of RCC tumour thrombus with both multidetector CT and MRI. All had pathology confirming RCC, and eight of those undergoing surgery had pathological confirmation of tumour thrombus extent. All images were analysed originally, then re-analysed by two independent radiologists, an experienced urologist and a urological trainee unaware of the original reports and other imaging results, with a final determination on tumour thrombus level by consensus. RESULTS: The multidetector CT results were completely accurate when compared with surgical specimens and were in agreement with MRI on all but one occasion, where MRI determined the renal vein to be clear when it was involved on CT and at surgery, giving MRI an accuracy of seven of eight samples. CONCLUSIONS: Whilst there were few patients and further studies are needed, multidetector CT was comparable with MRI in determining tumour thrombus level. More importantly, in the eight patients with surgical pathological confirmation, multidetector CT was accurate in all. Ultimately, it may replace MRI as the 'gold standard' for imaging to delineate the upper limit of tumour thrombosis in RCC.
OBJECTIVE: To present our experience of percutaneous nephrolithotomy (PCNL) for treating urolithiasis in patients with spinal cord injury (SCI) using a single-stage dilator for percutaneous access. PATIENTS AND METHODS: A prospective database of patients with SCI having PCNL using the single-stage dilator was assessed, analysing patient data, stone-free rates, morbidity and the follow-up outcome. RESULTS: In all, 26 patients had 54 PCNLs on 32 kidneys; 20 had unilateral and six bilateral stone disease; there were many staghorn calculi (24/54). Major complications occurred in three of 54 PCNLs (6%). The complete stone-clearance rate was 87% for PCNL alone, rising to 29 of 32 kidneys (91%) or 24 of 26 patients (92%) with adjuvant procedures. A further three kidneys required no further treatment and were monitored, having residual fragments of < or = 2 mm. CONCLUSIONS: PCNL has a high success rate and acceptable complication rate compared to extracorporeal shock-wave lithotripsy, and remains a valid first-line treatment option for kidney stones in patients with SCI.
OBJECTIVE: To assess renal tumours for hypoxic regions using 18F-fluoromisonidazole (18F-FMISO) positron emission tomography (PET), a recognized noninvasive method for detecting hypoxia in tumours, as renal cell carcinoma (RCC) can be potentially cured with nephrectomy but recurrence develops in most patients, who then respond poorly to treatments such as chemotherapy, and hypoxia is known to confer resistance to radiotherapy and chemotherapy in many solid tumours. PATIENTS AND METHODS: In all, 17 patients had 18F-FMISO PET scans before nephrectomy for presumed RCC. Specimens were examined histologically, and immunohistochemistry was used to compare the microvessel density (MVD) as an indicator of angiogenesis in the tumour and normal parenchyma, in 15 patients. Tumour oxygenation was measured invasively in three patients using a polarographic oxygen sensor probe. RESULTS: Of the 15 patients with histological results, 11 had RCC and four had other tumours. Although there was a trend there was no statistically significant (P = 0.14) difference in the maximum standardized uptake value (SUV(max)) when comparing the region of the kidney involved with RCC; the mean (95% confidence interval) SUV(max) in the tumours was 1.3 (0.15), whilst that in the normal contralateral kidney was 1.1 (0.22). The MVD was greater in RCC, at 13.7 (3.1) mean vessels per high-power field than in normal tissue, at 6.9 (1.9). Hypoxia as measured polarographically was detected in three RCCs (median pO2 9.6 mmHg) compared to normal parenchyma at 37.6 mmHg. CONCLUSIONS: Although 18F-FMISO scans showed significant uptake in other solid tumours, there was only mild 18F-FMISO uptake in the present RCCs. The invasive measurements indicated that there was hypoxia in RCC, but the median pO2 did not fall below 9.5 mmHg. Further direct studies of renal tumour oxygenation combined with therapies directed towards hypoxia may allow a better understanding of the relationship between 18F-FMISO results and the biological significance of hypoxia in RCC.
OBJECTIVE: To assess the attitudes of final-year medical students to digital rectal examination (DRE) and their experience of performing DRE during clinical training. DESIGN: Questionnaire-based survey. SETTING AND PARTICIPANTS: All students in the final year of medical school at the University of Melbourne in 2003. OUTCOME MEASURES: Agreement with statements about attitude to DRE; number of DREs performed and abnormalities palpated; and ratings of frequency of supervision and perceived barriers to performing DRE. RESULTS: 222 of 256 students (87%) responded. Almost all (97%) believed that DRE is an essential requirement for a medical practitioner, and 94% that they should have the skill before graduating, while 92% said they had been taught how to perform it. The median number of DREs performed was two, with 17% of students performing none. Sixty-three per cent had palpated a prostate, 24% a prostate cancer, 19% a rectal tumour, and 11% faecal constipation. Half the students (52%) felt they could give a reasonable or confident opinion based on their DRE findings. The most often cited reason for not performing DREs was the lack of a doctor to act as a supervisor. CONCLUSIONS: A concerted effort is needed from academics, supervising doctors and students to improve medical students' proficiency in performing DRE and confidence about their findings.
OBJECTIVE: To conduct a systematic review of studies on clinically relevant digital mobile phone electromagnetic interference with medical equipment. DATA SOURCES: MEDLINE and SUMSEARCH were searched for the period 1966-2004. The Cochrane Library and Database of Abstracts of Reviews of Effects were also searched for systematic reviews. STUDY SELECTION: Studies were eligible if published in a peer-reviewed journal in English, and if they included testing of digital mobile phones for clinically relevant interference with medical equipment used to monitor or treat patients, but not implantable medical devices. DATA SYNTHESIS: As there was considerable heterogeneity in medical equipment studied and the conduct of testing, results were summarised rather than subjected to meta-analysis. RESULTS: Clinically relevant electromagnetic interference (EMI) secondary to mobile phones potentially endangering patients occurred in 45 of 479 devices tested at 900 MHz and 14 of 457 devices tested at 1800 MHz. However, in the largest studies, the prevalence of clinically relevant EMI was low. Most clinically relevant EMI occurred when mobile phones were used within 1 m of medical equipment. CONCLUSIONS: Although testing was not standardised between studies and equipment tested was not identical, it is of concern that at least 4% of devices tested in any study were susceptible to clinically relevant EMI. All studies recommend some type of restriction of mobile phone use in hospitals, with use greater than 1 m from equipment and restrictions in clinical areas being the most common.
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