Daniel P. Dalton

Radiographic Assessment of the Vesicourethral Anastomosis Directing Early Decatheterization Following Nerve-Sparing Radical Retropubic Prostatectomy

Early decatheterization directed by postoperative gravity cystography in 55 consecutive radical prostatectomy patients is described. The catheter-free status was 22 per cent by postoperative day 8, 62 per cent by postoperative day 11 and 80 per cent by postoperative day 14. Cystograms performed beginning on postoperative day 7 identified 3 groups of patients and dictated their management: 1) no extravasation resulting in immediate catheter removal (36 patients), 2) moderate extravasation requiring repeat cystography leading to decatheterization by postoperative day 15 (9 patients) and 3) severe extravasation necessitating prolonged catheter drainage (8 patients). A decatheterization protocol is presented.

The Incidence of Prostate Cancer Progression with Undetectable Serum Prostate Specific Antigen in a Series of 394 Radical Prostatectomies

PURPOSE Serum prostate specific antigen (PSA) has been reported to be a sensitive indicator of recurrent carcinoma after radical prostatectomy but it is not absolute. Disease progression with undetectable PSA levels has been described but the incidence of this phenomenon is unknown. MATERIALS AND METHODS We retrospectively analyzed the records of 394 consecutive men who underwent radical prostatectomy between 1980 and 1991 to characterize the incidence of recurrent carcinoma despite undetectable serum PSA levels. RESULTS Of the 394 men 133 had documented evidence of disease recurrence, 3 (2.3%) despite undetectable serum PSA levels (2 had local and systemic evidence of disease progression). Histological dedifferentiation characterized these recurrences. CONCLUSIONS Although a post-prostatectomy detectable serum PSA level precedes clinical evidence of disease progression by years, rare patients (2.3% in our series) in whom recurrent disease is characterized by marked histological dedifferentiation will remain negative for PSA.

Simultaneous diversion of the urinary and fecal streams utilizing a single abdominal stoma: the double-barreled wet colostomy.

A new technique to achieve simultaneous diversion of the urinary and fecal streams using a single abdominal stoma is described. The procedure consists of the construction of a diverting loop colostomy with division of the colon approximately 10 to 15 cm. distal to the stoma. The segment of colon distal to the stoma, the urine limb, acts as a urinary conduit. To date 3 patients have undergone the procedure with followup of 3, 13 and 18 months. Neither upper tract infection nor upper tract deterioration has occurred. The potential role of this procedure to treat a difficult group of patients is discussed.

The Natural History of Simple Renal Cysts: A Preliminary Study

We examined the natural history of simple renal cysts in 59 patients followed periodically with renal ultrasonography. Using the parameters of cyst diameter and number we grouped the patients according to the differing natural history of the cystic lesions. The results indicate that simple cysts tend to progress in number rather than size. Furthermore, 3 patients had independent solid or complex lesions. The only patient explored had an adenocarcinoma of the kidney. Periodic reevaluation of patients with an ultrasonic diagnosis of simple renal cyst warrants serious consideration.

The Clinical and Pathological Manifestations of Renal Tumors in Von Hippel-Lindau Disease

The protean nature of renal lesions in von Hippel-Lindau disease has made surgical management difficult. To develop a sensible surgical approach the pathological and clinical manifestations of renal involvement in von Hippel-Lindau disease patients were defined. A total of 87 lesions in 9 kidneys from 6 patients with von Hippel-Lindau disease was examined for size, presence of renal cell carcinoma, cystic or solid qualities and local invasion. There was no correlation between the size of the lesion and renal cell carcinoma. All 44 benign lesions were cystic, while 35% (15 of 43) of malignant lesions were cystic and 65% (28 of 43) were solid. All 9 locally invasive tumors were solid. The distribution of lesions in our patients was compared to the findings in 138 cases we collected from the literature. The 3 patterns of clinical presentation recognized were solitary, multiple and diffuse. We recommended that all lesions, cystic or solid, be excised at the time of nephron sparing surgery, with a wider margin for solid lesions, and that nephron sparing surgery should be reserved for patients with cystic and small solid lesions, with radical nephrectomy being preferred for patients with diffuse disease.

Multilocular Prostatic Cystadenoma Presenting as a Large Complex Pelvic Cystic Mass

Symptomatic prostatic cysts are not common. We report a case of a large complex cystic pelvic mass encountered in a Jordanian man that proved to be a huge midline prostatic cyst with seminal vesicle contained within the wall. This finding represents a variation of the newly proposed diagnosis, multilocular prostatic cystadenoma.

Accidental ureteral ligation during an inguinal hernia repair of patient with crossed fused renal ectopia

Because most of the presenting symptoms of ureteral herniation and crossed renal ectopia are nonspecific, it is important to be aware of their presence and association to avoid iatrogenic injuries to the kidneys and/or the ureters. We present the imaging findings of a patient with ureteral ligation whose ureteral herniation and crossed renal ectopia were identified after undergoing hernia repair.

Simultaneous abdominal aortic aneurysm repair and nephrectomy for neoplasm

BACKGROUND Abdominal aortic aneurysm and renal neoplasm are occasionally discovered concurrently. Simultaneous operative therapy may be an effective alternate management strategy to a staged procedure. PATIENTS AND METHODS The medical records of 10 consecutive patients undergoing abdominal aortic aneurysm repair and nephrectomy for renal neoplasm were reviewed. Data collected included mode of presentation, preoperative evaluation, renal pathology, and in-hospital morbidity and mortality. Long-term follow-up was obtained through office records and telephone contact. RESULTS In 7 patients, the renal mass was identified during evaluation of abdominal aortic aneurysm. The aneurysm was identified during evaluation of hematuria in 2 patients. One patient was discovered to have both conditions simultaneously. All patients underwent successful aneurysm repair and nephrectomy. Pathology revealed 6 renal cell carcinomas, 2 complex cysts, 1 hemangiopericytoma, and 1 oncocytoma. Four patients have died in the follow-up period: 1 of metastatic cancer and 3 of unrelated causes. There have been no cases of graft infection. CONCLUSION Simultaneous abdominal aortic aneurysm repair and nephrectomy for neoplasm is an appropriate management strategy for selected patients.

Pathologic outcomes during the learning curve for robotic-assisted laparoscopic radical prostatectomy

OBJECTIVE We report our initial experience with 62 patients undergoing robotic-assisted laparoscopic prostatectomy (RALP), focusing on the primary parameter of positive surgical margins. The authors demonstrate that excellent oncologic outcomes can be attained with a less steep learning curve than previously hypothesized. MATERIALS AND METHODS The first 62 patients undergoing RALP by a single physician (DPD) at our institution between November 2005 and August 2007 were retrospectively assessed. Surgical pathology records were reviewed for Gleason score, pathologic tumor stage, nodal status, location of prostate cancer within the specimen, extracapsular extension, surgical margin status, presence of perineural invasion, tumor volume, and weight of the surgical specimen. Margin status was determined using surgical specimens only, and not intraoperative frozen sections. All cases in this series were completed using the four-arm da Vinci Robotic System (Intuitive Surgical, Sunnyvale, California). RESULTS Sixty-one patients had prostate cancer on their final surgical pathology specimens. Pathologic stage T2 and stage T3 patients were 88.7% and 9.7% of all cases, respectively. The pathologic Gleason score was 7 or greater in 62.3%. Our overall positive surgical margin rate was 3.3%. Patients with pathologic T2 and T3 disease had a positive surgical margin rate of 1.8% and 16.7%, respectively. CONCLUSIONS Our study suggests that RALP can have equal if not better pathologic outcomes compared to open radical prostatectomy even during the initial series of cases. We argue that the learning curve for RALP is shorter than previously thought with respect to oncologic outcomes, and concerns asserting that lack of tactile feedback leads to poor oncologic outcomes are unfounded.

Solitary fibrous tumor of the prostate a report of 2 cases and review of the literature.

We report 2 cases of solitary fibrous tumor of the prostate. Histologically, both tumors demonstrated a multipatterned architecture with varying degrees of collagenization and hemangiopericytoma-like foci, and both were composed of CD34-immunopositive spindled cells that insinuated themselves between strips of collagen. The tumor in case 1 was well circumscribed and showed minimal mitotic activity or pleomorphism, whereas the tumor in case 2 was more cellular, less collagenous, had a more diffuse growth pattern, and exhibited cytologic atypia and high mitotic activity. Prostatic solitary fibrous tumor must be distinguished from other spindle cell tumors reported to occur in the prostate. To our knowledge, these cases represent only the fifth and sixth reported cases of prostatic solitary fibrous tumor.