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Many cross-sectional and follow-up studies of large numbers of patients with hypertension have demonstrated an increased prevalence and mortality from renal cancer. We report the details of three patients with renal cell carcinoma from a series of 254 consecutive patients with malignant phase hypertension, an excess over the expected number reported from several large published series with non-malignant hypertension. In view of this excess we investigated the prevalence of hypertension in a series of 192 consecutive patients who presented with a diagnosis of renal cell carcinoma, in comparison with a local unselected population screening survey. Hypertension was found in 43% of the renal carcinoma patients and 20% of the local population, also a clear excess. The mechanism of the association between renal cancer and malignant and non-malignant hypertension is unclear.

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OBJECTIVE: To investigate the frequency of microsatellite instability, a marker for genetic instability, in incidental and advanced prostate cancers, and to determine the role and prognostic importance of genetic instability in prostate carcinogenesis. PATIENTS AND METHODS: Microsatellite analysis was performed on 72 prostate cancers, of which 26 were incidentally discovered at transurethral prostatectomy (TURP) for benign disease. They were staged and graded 1-3 according to glandular differentiation. Fresh prostatic tissue was obtained at TURP performed for bladder outlet obstruction, from 43 patients (median age 73 years, range 55-88), with tissue from the remaining 29 (median age 75, range 53-83) patients obtained from pathology archives, having been originally collected at TURP between 1969 and 1986. RESULTS: Instability was detected in 14 (19%) cancers overall, in eight (31%) of 26 incidental tumours and in six (13%) of 46 clinically apparent tumours. These differences were not statistically different (2P=0.1). The time to progression and survival were similar between men with tumours showing instability and those with no instability. CONCLUSION: These data suggest that genetic instability is an early event in prostate carcinogenesis, but does not appear to influence prognosis.

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OBJECTIVE: To evaluate the efficacy and safety in a dose-ranging study of tamsulosin (once-daily) as a modified-release formulation compared with placebo in patients with lower urinary tract symptoms (LUTS) associated with benign prostatic obstruction (BPO), and to establish the optimum dosage for phase III clinical studies. PATIENTS AND METHODS: Of 169 patients with LUTS associated with BPO enrolled in a 3 week placebo run-in period, 126 were subsequently randomized to receive placebo (28), or 0.2 mg (35), 0.4 mg (30), or 0.6 mg (33) of tamsulosin once daily for 4 weeks. Free-flow and pressure-flow measurements, and modified Boyarsky symptom scores were used to determine efficacy. Safety was evaluated by monitoring adverse events and vital signs (including 8 h after the first dose), and by laboratory determinations. RESULTS: Tamsulosin 0.4 mg and 0.6 mg produced significantly greater improvements in maximum urinary flow rate (Qmax) (2.2 mL/s, 22.6%, and 1.8 mL/s, 20.2%, respectively) than did placebo (-0.1 mL/s, -0.9%). The results from the pressure-flow studies confirmed the results for Qmax in the free flow studies, with optimum and significant effects for tamsulosin 0.4 mg. This also applied for detrusor pressure at maximum flow, which decreased by 26.6 cmH2O (-28.2%) on 0.4 mg tamsulosin whereas it increased by 4.9 cm H2O (5.7%) on placebo. The greatest reductions in total symptom score were obtained with tamsulosin 0.4 mg and 0.6 mg (4.1, -28.7%, and 4.4 points, -28.2%, respectively) compared with reductions of 3.4 (-20.1%) in the tamsulosin (0.2 mg) and 2.9 points (-17.7%) in the placebo groups. The difference in effects on total symptom score between treatment groups was not statistically significant, which can be attributed to the small sample size. Tamsulosin was well tolerated; at least one adverse event was reported by 29%, 23%, 27% and 36% of patients in the placebo and tamsulosin 0.2 mg, 0.4 mg and 0.6 mg groups, respectively. There were no apparent tamsulosin dose-dependent changes in vital signs from baseline to the end of 4 weeks of randomized treatment. Tamsulosin caused no statistically significantly greater changes in blood pressure than placebo during the initial 8 h after the first dose. There were no clinically significant changes in laboratory variables. CONCLUSION: Tamsulosin is well tolerated and effective in improving urinary flow and relieving LUTS associated with BPO. Optimal effects are achieved with tamsulosin 0.4 mg administered once daily.

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PURPOSE: To investigate the frequency and prognostic significance of genetic alterations in incidentally diagnosed, transitional zone prostate cancer. MATERIALS AND METHODS: Twenty-six incidentally diagnosed, transitional zone cancers were examined by the PCR for genetic alterations on chromosomes 8p and 13q and by immunohistochemistry for alterations of the expression of the cell-cycle regulatory proteins RB1 and p53 and of the cell adhesion molecules E-cadherin and alpha-catenin. RESULTS: All of the tumors had at least one molecular abnormality (median 2.0 range 1 to 4). Allelic loss on 8p occurred in 37% and on 13q in 50% of informative tumors. Abnormal expression of pRb was found in 67%, of p53 in 33%, of E-cadherin in 36% and of alpha-catenin in 43%. In addition microsatellite instability was found in 23% of tumors. Only loss of expression of alpha-catenin was found to have prognostic importance. CONCLUSIONS: Genetic alterations were common, but, apart from alpha-catenin, did not appear to be related to tumor progression. The lack of prognostic significance is likely to be due to the multifocal nature of prostate cancer, but may also relate to qualitative differences between transitional zone and peripheral zone prostate cancers.

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The radiological appearances of 11 cystic renal cell carcinomas (RCC) presenting over a 13-year-period are reviewed and correlated with their clinicopathological features. The tumours occurred in seven males and four females with a mean age of 59.1 years (range 27-87 years). Their ultrasound features were categorized according to Bosniak [5]. There were six category 3 or 4 cysts (indeterminate or malignant); three category 2 cysts and two category 1 cysts. Computed tomography scans (CT) demonstrated malignant features in all seven patients scanned. Cyst aspiration, intravenous urograms and arteriograms were generally unhelpful. Histological growth patterns of nine tumours were determined and all were staged by Robson's classification: eight were Stage 1, one was Stage 3 and two were Stage 4. Three of four deaths were related to tumour bulk, and the fourth patient died from an unrelated cause. All seven survivors had Stage 1 disease. No correlation existed between different histological subtypes and tumour aggression. Overall, the behaviour of cystic RCCs was similar to those of solid RCCs apart from the high percentage (72.2%) of Stage 1 disease. We conclude that any deviation from a simple cyst on ultrasound should be assessed by CT and/or surgery. Indeterminate lesions on CT including multilocular lesions should be surgically explored.

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OBJECTIVE: To compare the analgesic efficacy of a single 30 mg intramuscular dose of ketorolac with that of intramuscular pethidine 100 mg, in a double-blind, parallel-group investigation of patients presenting with pain suggestive of renal colic. PATIENTS AND METHODS: Seventy-six patients (17 women, 15 men; mean age 45.2 years, range 20-80) were allocated by means of a pre-determined randomization schedule to receive ketorolac and 78 patients (20 women, 58 men; mean age 42.1, years range 18-70) to receive pethidine. Data from eight patients in the ketorolac group and six in the pethidine group were excluded from the efficacy analyses because of protocol violations. The severity of each patient's pain was assessed on a four-point verbal rating scale (VRS) and a 10 cm visual analogue scale at pre-dose and at 15 min intervals for the first hour post dosing. The time to first administration of rescue analgesic, up to 24 h following dosing with the study medication, was recorded. Adverse events were elicited by general questioning. RESULTS: Eighty-eight per cent of patients in each treatment group had improved according to the VRS of pain severity 1 h after dosing; the summed pain intensity differences up to 1 h were statistically significantly different in favour of ketorolac (P < 0.05). Fifty-six per cent of patients who were receiving ketorolac required rescue analgesia during the study period compared with 74% receiving pethidine. The incidences of adverse events were lower in the ketorolac group (28%) than the pethidine group (51%). CONCLUSION: Ketorolac can be considered a viable alternative to pethidine for the treatment of renal colic.

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An open randomised Phase III trial was conducted of the depot GnRH analogue goserelin (Zoladex) versus stilboestrol (3 mg/day) in patients with advanced or metastatic prostate cancer. The study included 250 patients and the median follow-up was 43 months. In the Zoladex arm the time to first response was achieved earlier and more patients reported an improvement in symptoms. There was no statistically significant difference between the Zoladex and the stilboestrol arms with regard to survival and time to treatment failure. A major reason for treatment failure was the preponderance of adverse events in patients receiving stilboestrol. It is suggested that stilboestrol should no longer be used for prostate cancer when equally effective alternative treatments are available.

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Staghorn calculi may cause several complications, particularly important being the development of pyonephrosis due to long-standing infection. We describe four patients who presented with either a marked systemic illness or a loin mass due to pyonephrosis. In each patient, the plain abdominal radiograph showed a fragmented staghorn calculus, which is suggested as a radiological sign of pyonephrosis and indicative of the need for surgical attention.

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We report our experience in setting up a urological laser unit. An operating theatre was upgraded to include the required safety features and a neodymium-YAG laser was installed. A preliminary study using cadaver bladders was performed to establish the technique of cystoscopic laser application. We treated 55 bladder tumours in 12 patients by laser coagulation, with total destruction of 54 tumours and no serious complications; 6 patients developed recurrent tumours. Twenty-one patients underwent surgery with the contact laser scalpel. The instrument proved slow but effective, with excellent haemostasis and almost painless wounds. Healing was delayed in 2 cases but there were no wound infections. All wounds healed with good cosmetic scars. The neodymium-YAG laser is an effective means of destroying superficial non-invasive bladder tumours endoscopically and can also be used in conjunction with a laser scalpel for open surgery.

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Zoladex is a potent decapeptide analogue of luteinising hormone releasing hormone (LHRH). The drug is formulated as a 3.6 mg depot dispersed in a matrix of d,l-lactide-glycolide copolymer, which is totally biodegradable. This formula releases drug continuously for at least 28 days and reliably suppresses serum testosterone into the castrate range. The effect of the depot was studied in 29 patients with locally advanced or metastatic carcinoma of the prostate. Average age at entry was 71 years (range 52-87) and follow-up was from 13.5 to 34.5 months (median 23). Endocrine studies showed that medical castration was maintained in all cases. Three patients experienced bone pain in the first month of treatment and two others had temporary nephrostomies for worsening ureteric obstruction. Subjective improvement was seen in 23/28 cases (82%). There were no complete responses, but partial response was seen in 24/28 (85.7%) using our own criteria, 24/28 (85.7%) using the criteria recommended by the British Prostate Group (BPG) and 15/28 (53.6%) using NPCP criteria. Stable disease was seen in 3/28 patients (10.7%) by our own or BPG criteria, and in 12/28 patients (42.9%) according to NPCP criteria. Progression of disease was measurable in 21 patients (72.4%) whatever criteria were applied; 11/29 (37.9%) have died, giving a median survival of 10 months (range 2.4-26). Following these encouraging results, a multicentre randomised comparative study with stilboestrol 3 mg daily is being undertaken.

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Partial ureteric duplication may cause delayed drainage of urine from the upper tracts because of ureteroureteric "see-saw" reflux. This can be eliminated by the procedure of ureteropyelostomy, in which the partially duplicated ureter is converted into a bifid renal pelvis. This operation leaves a short anastomotic suture line and has a low complication rate. We report seven patients who have undergone ureteropyelostomy for symptomatic ureteroureteric reflux. All remain symptom-free after follow-up for a minimum of 1 year.

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We report 2 cases of hypertension with segmental renal hypoplasia (Ask-Upmark kidney) and other anomalies in the absence of vesicoureteral reflux. These cases support the view that the Ask-Upmark kidney is a defect of renal development rather than acquired as a consequence of vesicoureteral reflux. In 1 patient the abnormal renal vein renin ratio suggested that the renin-angiotensin system may have had a part in the pathogenesis of the hypertension.

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