Christopher L. Coogan

Genital Fournier's gangrene: Experience with 38 patients

OBJECTIVES Fourniers gangrene (FG) is an extensive fulminant infection of the genitals, perineum, or the abdominal wall. We report our experience with the management of this difficult infectious disease. METHODS Thirty-eight patients were admitted with the diagnosis of FG between May 1993 and May 1995. All patients were treated with broad-spectrum triple antimicrobial therapy, broad debridement, exhaustive cleaning, and application of unprocessed honey dressings. Patients then underwent split-thickness skin grafts or delayed closure as needed. RESULTS Patient ages ranged between 33 and 86 years (mean, 54) with a mean hospital stay of 17 days (range, 1 to 45). Sixty-six percent of the patients were diabetic, 16% had previous orchiepididymitis, and 5% had scrotal and urethral trauma. All the patients underwent surgical debridement and application of unprocessed honey to the wound. Cystostomy was performed in 60% of the patients and 21% underwent orchiectomy of the affected side. Free skin grafts were applied to 6 patients (16%) and the remaining wounds, once clean, were approximated. One patient died as a result of severe metabolic acidosis and sepsis. CONCLUSIONS The management of this infectious entity should be aggressive. Patients with FG need extensive debridement and cystostomy or colostomy when necessary. Broad-spectrum triple antimicrobial regimen and aggressive debridement are mandatory. Topical application of unprocessed honey is beneficial to the healing process. A minority of patients require split-thickness skin grafts on denuded areas.

Nerve sparing post-chemotherapy retroperitoneal lymph node dissection for advanced testicular cancer.

PURPOSE Nerve sparing techniques are used routinely during retroperitoneal lymph node dissection in patients with low stage testis cancer in an attempt to preserve postoperative ejaculation. Preservation of ejaculation without an increased retroperitoneal recurrence rate in such patients prompted us to reevaluate the role of nerve sparing techniques in select patients undergoing post-chemotherapy retroperitoneal lymph node dissection. MATERIALS AND METHODS Of 472 patients who underwent post-chemotherapy retroperitoneal lymph node dissection between March 1988 and January 1995, 93 (19.7%) underwent a nerve sparing procedure. Two patients died of disseminated cancer within 6 months after post-chemotherapy retroperitoneal lymph node dissection. In 10 patients the ejaculatory status could not be established from the clinical notes and the patient was lost to followup. The remaining 81 patients form the basis of this report. Disease status, complications and ejaculatory status were evaluated. Mean followup was 35.5 months. RESULTS Of the patients 76.5% reported normal ejaculation after post-chemotherapy retroperitoneal lymph node dissection. Testis cancer recurred after nerve sparing surgery in 6 patients but no tumor was retroperitoneal. Ten pregnancies have been reported to date with uneventful term deliveries in 7. CONCLUSIONS Select patients are candidates for nerve sparing post-chemotherapy retroperitoneal lymph node dissection. Although indications for nerve sparing techniques in the post-chemotherapy population have expanded, the local recurrence rate has not increased. Nerve sparing post-chemotherapy retroperitoneal lymph node dissection can preserve the inherent fertility potential of the patient without increasing retroperitoneal relapse rates.

Bilateral testicular tumors: Management and outcome in 21 patients

The authors examined the clinical course of patients with bilateral testicular tumors to determine whether the outcome after treatment was different from patients with unilateral tumors.

Penile Vascular Assessment Using Color Duplex Sonography in Men with Peyronie's Disease

PURPOSE We assessed penile vasculature in men with Peyronies disease using color duplex ultrasound. MATERIALS AND METHODS A total of 99 men with Peyronies disease underwent duplex ultrasound with 60 mg. intracavernous papaverine to gain an understanding of penile vasculature and its correlation to erectile rigidity. Patients were stratified into groups according to duplex ultrasound vascular parameters and the presence or absence of impotence (that is rigidity adequate for intromission). RESULTS Of 97 men 31 (32%) complained of impotence, 8 of 99 (8%) had evidence of corporeal veno-occlusive dysfunction on duplex ultrasound (defined as end diastolic flow velocity greater than 4.5 cm. per second) and 43% had a history of vascular risk factors that may have contributed to erectile insufficiency. Impotent patients had decreased peak systolic flow velocity, increased end diastolic flow velocity and higher a percent of vascular risk factors (p= 0.0006, 0.027 and 0.0004, respectively) compared to potent patients. CONCLUSIONS Duplex ultrasound provides a dynamic noninvasive functional assessment of penile vasculature in Peyronies disease. Although corporeal veno-occlusive dysfunction has been considered the primary vascular etiology of erectile dysfunction associated with Peyronies disease, arterial insufficiency is a major contributor, which is best detected before definitive therapy.

Percutaneous Cryoablation of the Prostate: Preliminary Results After 95 Procedures

PURPOSE We examined the role of percutaneous cryoablation of the prostate in the treatment of prostate cancer. MATERIALS AND METHODS We performed 95 percutaneous cryoablations of the prostate on 87 patients with prostate cancer. Of the patients 6 had positive lymph nodes preoperatively, radiation failed in 9 and 9 began postoperative hormonal therapy because of treatment failure. Mean patient age, prostate specific antigen (PSA) level (ng./ml.) and Gleason score were 65.4, 12.60 and 6.03, respectively. Median followup was 12 months (mean 9.3, range 1 to 24). In 49 of the 87 patients (56%) the lymph nodes were evaluated before cryoablation based on the treatment protocol. RESULTS Median PSA level at 12 months was 0.55 ng./ml. (mean 1.73) with a 17% positive biopsy rate at 3 months. When the positive lymph node, radiation failure and postoperative hormonal therapy groups were removed from analysis, the median PSA level was 0.80 ng./ml. (mean 1.86) with a 5% positive biopsy rate. Of the patients in the radiation failure group 37% had a positive biopsy at 3 months. Cases were classified according to stage, grade and PSA level, and the biopsy results were presented. The complications of percutaneous cryoablation of the prostate were reviewed. CONCLUSIONS The low percentage of positive biopsies is encouraging but the significance of the persistent PSA levels remains uncertain.

Postchemotherapy Retroperitoneal Lymph Node Dissection is Effective Therapy in Selected Patients With Elevated Tumor Markers After Primary Chemotherapy Alone

OBJECTIVES Elevated tumor markers after primary chemotherapy for metastatic testis cancer are usually an indication of persistent cancer. Subsequent treatment has usually been salvage chemotherapy. This article examines the possibility that selected patients can achieve long-term disease-free survival with surgery alone. METHODS Using a computerized data base of 627 postinduction chemotherapy retroperitoneal lymph node dissections (PC-RPLND), 23 patients with elevated tumor markers who have undergone PC-RPLND after induction chemotherapy alone were identified. Of the 23 patients, 15 were considered candidates for salvage chemotherapy, but instead underwent salvage surgery. Case histories were reviewed to establish selection criteria for PC-RPLND. RESULTS Eight patients originally presented as clinical Stage C, 6 as clinical Stage B-3, and 1 as clinical Stage B-2. All patients initially received cisplatin combination chemotherapy. Twelve patients had an elevated alpha-fetoprotein level and 3 patients had an elevated beta human chorionic gonadotropin level prior to PC-RPLND. Seven patients had rising markers at the time of PC-RPLND. Seven patients had teratoma only in their resected specimen and all have no evidence of disease (NED) at a median of 35 months. Two patients had necrosis only in their RPLND specimen and both are NED at 10 and 42 months. Six patients had cancer in their resected specimen and 2 are NED, 1 is alive with disease, and 3 are dead of disease. Five of the 6 patients with cancer in their resected specimen were the only patients who received postoperative chemotherapy. CONCLUSIONS Some patients with modest elevations of tumor markers after induction chemotherapy may only have teratoma or necrosis in the postchemotherapy resected specimen. These patients (n = 9) remain continuously NED. Patients who undergo salvage surgery and have cancer in the resected specimen do less well, but selected patients can be cured with this modality and thus avoid the morbidity of salvage chemotherapy.

Increasing the number of biopsy cores improves the concordance of biopsy Gleason score to prostatectomy Gleason score.

To evaluate taking more biopsy cores for predicting the radical prostatectomy (RP) Gleason score compared with the biopsy Gleason score, as although random sextant biopsies are the standard for a tissue diagnosis of prostate cancer, and taking more biopsies increases the detection rate, it is uncertain whether taking more cores improves the prediction of the RP Gleason score.

Urethral catheter removal prior to hospital discharge following radical prostatectomy.

OBJECTIVES To investigate the feasibility of early catheter removal following radical prostatectomy. METHODS Fifty-eight consecutive patients underwent radical prostatectomy, with intent of early catheter removal. Catheter removal was based on postoperative cystograms performed on postoperative day (POD) 3 or 4. Charts were retrospectively reviewed and patients were contacted by phone and specifically questioned regarding continence and bladder control. RESULTS Fifty-one patients (87.9%) had a cystogram performed on POD 3 or 4. In 43 patients (74.1%), the catheter was successfully removed prior to hospital discharge. Eight patients experienced either early or late complications (excluding incontinence); these included 3 patients with a superficial wound infection, 2 patients with hematuria requiring reinsertion of a urethral catheter, 1 patient with a spontaneous pneumothorax, 1 patient who developed a deep vein thrombosis and lymphocele, and 1 patient with a bladder neck contracture. Urinary continence was reported as excellent to good in 86% of the patients at a mean follow-up of 17.4 months. Three patients (5%) underwent placement of an artificial urinary sphincter. CONCLUSIONS Catheter removal prior to hospital discharge after radical prostatectomy is feasible without any increase in morbidity.

Renal Medullary Carcinoma in Patients with Sickle Cell Trait

Renal medullary carcinoma has recently been described as an aggressive neoplasm affecting young African Americans with sickle cell disease or sickle cell trait. We report the presentation, treatment, and outcome in 3 patients with renal medullary carcinoma along with a description of the unsuccessful treatment attempts. A brief discussion and review of the literature is included.

Schwannoma of a seminal vesicle.

We present the first reported case of a schwannoma of the seminal vesicle that occurred in a 48-year-old man who presented with right lower quadrant abdominal pain. Computed tomography scan and magnetic resonance imaging revealed a mass in the patients right seminal vesicle. The patient was also found to have a rising prostate-specific antigen level and underwent a transrectal ultrasound-guided biopsy of the prostate and seminal vesicles, which revealed prostate cancer and schwannoma of the seminal vesicle, respectively. Radical prostatectomy with en bloc removal of the seminal vesicle mass was performed and the patient has been free of disease 24 months postoperatively.