Clinical Practice in Urology – serie

Such an important subject as urinary diversion is unlikely to remain unchanged and unchallenged for long. The problem is to determine when is an appropriate time to examine current clinical practice of this major urological procedure. Historically, urinary diversion began with attempts to resolve the distressing problems associated with ectopia vesicae; later, urinary diversion was extended to help those patients with neurological problems of bladder function and with malignant diseases of the lower urinary tract. A significant landmark in the development and use of these procedures came with the introduction of a uretero-ileostomy (ileal conduit) by Bricker. With this diversion, faecal and urinary streams were separated and the incidence of metabolic and infective problems dramatically reduced. The procedure was received with great enthusiasm and indeed the pendulum soon swung so far in its favour that some urologists would scarcely admit to carrying out an occasional ureterosigmoidostomy. The impact of change in a surgical technique can be slow to determine especially when, numerically, it is an uncommon procedure and when the follow-up is hoped to match normal life expectancy. Thus the impact of ileal conduits has taken some years to evaluate and only during the past decade have the data been sufficient to show the advantages and disadvantages. This book is a landmark in the literature on this subject. The editor has selected eminent contributors who have described the main clinical groups where urinary diversion is an important aspect of management.

Chemotherapy for malignant disease has brought about many rapid and often spectacular improvements in the survival rate of some groups of patients. Yet enthusiasm for these successes has, in part, been offset by the problems in evaluating responses to treatment and by the disappointment of failing to check the progress of still so many other tumours. These reactions will be no surprise to the medical historian but perhaps the expectations from scientific progress nowadays sometimes demand more than can reasonably be expected. Another expectation is that any review of chemotherapy is com­ pletely up to date, even prophetic. Such is the expansion of the subject that new drugs and trial results are continually being reported but it is this very mass of information that creates its own problems and makes many clinicians despair of finding a balanced judgement on all of this information. This was the challenge accepted by Professor Spiers. He then gathered together a group of colleagues who are amongst the acknowledged leaders in the field of chemotherapy for urological tumours, all of whom have made important contributions to this subject. However, each chapter is not merely a record of the author's experience but encompasses an assessment of past and present practice as well as perspectives in diagnosis and management. Almost all chapters include reference to published work up to and including 1981.

The interface between the urologist and other disciplines in medicine continues to increase as the character of urology continues to change. Urologists have, for example, developed strong links with microbiol­ ogists over mutual problems of infection in the urinary tract, urolog­ ists have been involved in the development of modern management of renal disease and especially renal failure, indeed even before the subject of nephrology had been defined. Similarly the links between endocrinology and infertility and more recently links between imaging and urology have led to the mutual benefit of these subjects and certainly to better patient care. The Pharmacology of the urinary tract has proved to be a difficult area of study. Slowly but progressively it has become evident that this is an area of great potential for urologists. Our patients have a range of problems where non-surgical management would be ideal but finding the right drug for the right condition has remained an elusive task. Many of the earlier trials showed an impressive placebo­ response rate and emphasised the need for well planned controlled clinical trials. The place of such trials in the evaluation of new treatments for urinary symptoms is now unchallenged and uncon­ trolled data are of little value. This book represents a skillful combination of background infor­ mation and its clinical application. The review of the pharmacokine­ tics of the various groups of drugs provides a very useful background to both the use of current drugs and also the prospects for the future.

Cancer of the bladder has a bad reputation: the combination of urinary problems and malignancy gives just cause for continuing concern. Not only is this common cancer a burden to the patient but, because of the need for regular follow-up, it creates a large workload on the urological services. It might be imagined that the bladder would give early warning signals of disease, and indeed it may do so; yet it can also be hesitant to reveal its severity. Thus there are many problems that create challenges in the diagnosis and management. Prevention is still the first goal of an oncologist, with early detection of early disease being the next best option. Early bladder cancer is amenable to several therapeutic approaches, but we have still to determine the best approach. The management of more advanced invasive bladder cancer all too often leads to disappointment, and we remain uncertain as to the optimum approach-surgery, radiotherapy, chemotherapy or some combination of these. Although none of these problems may be fully answered either now or in the near future, many people are working towards their solution, and the rate of progress needs to be documented from time to time. This volume aims to set the standard for the present state of our knowledge on bladder cancer. The editors, Professor Ernst Zingg and Mr'. Michael Wallace, have gathered together the best opinions on a wide range of topics relating to bladder cancer.

Any book with the words percutaneous and interventional is immediately identified as one that brings to its readers a distillation of a number of new and exciting techniques. Percutaneous is not exactly a new word but it has come to take on an entirely new meaning in recent years. Interventional is a recent acquisition to medical language indicating an entirely new approach to many aspects of medical management. Exactly when is the right time to make a distillation of new thoughts and expertise requires something of the art of a master brewer. First the ingredients must be prepared, the recipe must be just right, there must be excellent quality control as well as the master brewer's touch to produce the product when the time is right. Dr. Lang has assembled just the right ingredients in the form of a very impressive team of experts in these new fields of uroradiology and urological management. Ventures into percutaneous urology may date back 30 years but the main growth in the range of procedures and the development of the technology has occurred only in the last 10 years. Relieving upper tract obstruction seemed a natural sequel to renal biopsy but the imagination to develop an effective treatment for stones was an impressive extension of the concept of minimally invasive surgery.

Carcinoma of the prostate increasingly dominates the attention of urologists for both scientific and clinical reasons. The search for an explanation and the prediction of the variable behaviour of the malignant prostatic cell continues unabated. The search for more precise tumour staging and more effective treatment is equally vigorous. Editors Andrew Bruce and John Trachtenberg have assembled acknowledged leaders in prostate cancer to present those areas of direct interest to the clinician. There are a number of other topics that might have been considered but most of these, such as experimental tumour models or biochemical factors affecting cell growth, still lack immediate application for the clinician. Carcinoma of the prostate continues to have its highest incidence in the western world, and the difference in comparison with the incidence in the Far East appears to be real and not masked by diagnostic or other factors. A number of other epidemiological aspects need careful analysis: Is the incidence increasing? Is the survival improving? Is the prognosis worse in the younger patient? Epidemiological data are easily misused and misinterpreted so that a precise analysis of the known facts makes an important opening chapter to this book.

A further volume in the successful 'Clinical Practice inUrology' series Urological Protheses, Appliances andCatheters, provides for the first time practical informationon all those aspects of urology which depend on manufacturesarticles that are inserted in or attached to patients.

Any discussion of the present success in management of urological cancers evokes a mixed response. Oncologists and urologists can enjoy the success with chemotherapy for testicular cancers but cannot forget the dismal results with any form of treatment, other than surgery, for renal carcinoma. But these are the less frequent urolegi­ cal tumours: what are the attitudes to the more common prostate and bladder cancers. Intensive study, many clinical trials and much debate lead us to the conclusion that we understand them better, we can tailor the treatment more appropriately to the individual patient but there remains some uncertainty as to the overall success that we have achieved. There have been no striking changes in the 5-year survival data. Clinicians tend to see their success in terms of their special interest. Radiotherapists point to their success in stage-reduction but what are we to do with the many patients whose tumour is unaltered by radiotherapy. Urological surgeons, and especially those who are still influenced by the shadow of Halsted, point to their success in excising the cancer but apart from that highly selected group, what are we to do for the very large number of patients for whom surgery is inappro­ priate. Bystanders can only watch and listen to the arguments for and against these views.

The aim of this series is to bring the reader up-to-date data and opinions on the practice of urological surgery. The ten titles published since 1982 have all been concerned with adult urology, with reference to paediatric problems included in some relevant chapters. The addition of this title on paediatric urology is especially welcome because it brings together the important components of the sub-specialty. This book has developed from one of the first of the annual courses in urological sub-specialties provided for trainees in the UK as part of their higher surgical training. But that audience is not the only one at which this book is aimed. In his Preface, Robert Whitaker emphasises the changes over the past ten to fifteen years: this means that any urologist over the age of 45 is already out of date in much of his or her knowledge of paediatric urology - unless there has been a genuine attempt at continuing medical education. Attendance and discussions at meetings and reading of current literature are useful methods of updating our knowledge. However, this book provides a much-needed link with the paediatric urology course and is a splendid reference source for all urologists. Robert Whitaker has gathered together four eminent co-authors to present their material on the main issues in paediatric urology. In keeping with the aims of this series, the data are up to date, the perspectives are contemporary and in every way this is an excellent addition to Clinical Practice in Urology.

In keeping with the aims of other books in this Series the Editors have concentrated on the practical aspects of management -in this case of the urinary tract in patients with spinal cord injury.