Henry A. Wise

Significance of Impaired Penile Tumescence and Associated Polysomnographic Abnormalities in the Impotent Patient

Of 15 consecutive patients with secondary impotence 7 (46 per cent) had varied degrees of abnormal nocturnal penile tumescence and 1 or more of the following sleep-associated events: frequent apnea and hypoventilation, myoclonus and a slow but remarkably stable heart rate even during episodes of respiratory impairment. All nocturnal penile tumescence measurements, except circumference change at the glans, were significantly lower than in patients with psychogenic impotence or normal subjects. These findings, not described previously, suggest probable central nervous system etiology of organic impotence in some patients. Skilled nocturnal penile tumescence assessment in conjunction with a comprehensive polysomnographic study is an essential diagnostic procedure in the evaluation of the impotent patient.

Active specific immunotherapy of stage iv renal carcinoma with aggregated tumor antigen adjuvant

Active‐specific immunotherapy of human malignancy with a vaccine consisting of admixtures of modified tumor antigens and an adjuvant such as tuberculin has not been fully explored, despite preliminary reports of clinical success and conceptual support from animal studies. Three years ago, we designed a prospective study using aggregated soluble tumor antigens admixed with tuberculin or phytohemagglutinin as an adjuvant (TAA) in order to treat patients with Stage IV renal carcinoma. Autologous tumor vaccines were used initially in 24 patients with operatively accessible tumor, although most patients eventually were switched to allogeneic preparations. Scarifications with Bacillus‐Calmette Guerin were used in order to ensure maximum reactivity to tuberculin and patients received no other therapy while in the study. Two patients achieved complete remission and 2, partial remission. The overall survival rate for the 30 patients entered is equivalent to reported survival rates for patients with extensive disease treated with aggressive surgery with or without chemotherapy. We believe these results offer strong preliminary evidence of efficacy of this particular type of therapy in an advanced human malignancy.

Carcinoma in a Colon Conduit Urinary Diversion

In recent years urinary diversion by means of the colon conduit has gained popularity because of the failure to exhibit reflux and the lower incidence of stomal stenosis. However, colon conduit diversion may be associated with adenocarcinoma, as is ureterosigmoidostomy. We report the first occurrence of adenocarcinoma in a colon conduit and, perhaps more important, in a colon conduit in which there had never been a fecal stream.

Computed tomography of primary transitional cell carcinoma of upper urinary tracts

Preoperative computed tomography (CT) was utilized to evaluate 20 patients with primary transitional cell carcinoma of the upper urinary tracts. Of the 20 patients, 18 (90%) had CT visualization of the tumor as either a discrete mass or local ureteral and/or renal pelvic wall thickening; 2 (10%) had false-negative examinations. Seven of the 20 patients (35%) had CT evidence of tumor extension demonstrated by frank tumor invasion beyond the urothelium or by perirenal pelvic and/or periureteral fat streaks. Of the 4 patients with fat streaks, 2 (50%) had superficial tumors (T(A)T2), 1 had a T1 (25%) tumor, and 1 had a T3 (25%) tumor. All 3 patients with CT findings of direct extension of tumor through the wall of the ureter or renal pelvis had T3 tumors. Among the 13 with localized noninvasive tumor on CT, 5 (38%) had superficial tumors (TA, TIS, T1), 5 (38%) had T2 tumors, and 3 (21%) had T3 tumors. Of the 5 patients with enlarged regional lymph nodes (greater than or equal to 1.5 cm) on CT, 2 had tumor confirmed histologically, 2 had subsequent negative CT-guided biopsies, and 1 had a negative lymphadenectomy. Distant metastasis was discovered in 1 patient. The data suggest that when CT demonstrates direct tumor extension through the renal pelvic or ureteral wall, it is a sensitive indicator of high-stage disease. However, in the absence of this finding, CT is of limited value in staging patients with primary transitional cell carcinoma of the pyeloureteral system.

Successful Management of Small Cell Carcinoma of the Bladder with Cisplatin and Etoposide

A 63-year-old white man with metastatic small cell carcinoma of the bladder attained a complete remission with a combination of etoposide and cisplatin chemotherapy, which has lasted for more than 2 years.

Flow Cytometric Analysis of Primary and Metastatic Bladder Cancer

A total of 22 patients with high grade P2-4N+ transitional cell carcinoma of the bladder underwent flow cytometric analysis of nuclei obtained from paraffin embedded specimens from the primary (bladder) and metastatic (lymph node) sites. Tumor heterogeneity was defined as polyclonal aneuploidy of the primary tumor (not identified in the population studied) or as a difference in the deoxyribonucleic acid index of the primary and metastatic sites of 0.20 or more (8 patients). With these criteria 8 patients (36%) had heterogeneous tumors and 14 (64%) had homogeneous tumors. The median survival of 14 patients with aneuploid and 8 with diploid primary tumors was 17.5 and 8.0 months, respectively (p equals 0.08, Lee-Desu test). When patient survival was compared to the ploidy of the metastatic site, or in patients with diploid primary and metastatic lesions versus deoxyribonucleic acid aneuploidy at either the primary and/or metastatic site, the aneuploid tumors had a longer survival but this difference was not significant (p equals 0.13 and 0.23, respectively). Our study demonstrates the value of flow cytometry to identify primary metastatic tumor heterogeneity. It also suggests that the presence of metastasis may be a more important factor to define the biological potential of transitional cell carcinoma than is deoxyribonucleic acid ploidy.

Phase II trial of interferon-beta-serine in metastatic renal cell carcinoma

Interferon-beta-serine (IFN-beta-ser) is a muteine, recombinant IFN that is tolerated at a dose fivefold to 10-fold higher than IFN-alfa and interacts with the same cell membrane receptor as IFN-alfa. We hypothesized that at high doses IFN-beta-ser might induce a higher response rate than IFN-alfa in metastatic renal cell carcinoma. We undertook a phase II trial of IFN-beta-ser in patients with metastatic renal cell carcinoma. Patients were treated three times each week by a 2-hour intravenous infusion. Doses were escalated weekly (.25 to 5.5 mg, 1 mg = 180,000,000 U) until the maximum-tolerated treatment dose (MTTD) was determined. The MTTD is defined as one dose level less than that which caused grade 3 toxicity and was subsequently administered three times weekly for at least 4 weeks. Twenty-nine patients were entered, and 25 were assessable for response and toxicity. The performance status was 0-1 in all patients and only one patient received previous chemotherapy. The MTTD dose was 2.5 mg (range, 0.5 to 5.5 mg per treatment), although in 10 patients, doses were later deescalated because of cumulative toxicity. Initial dose-limiting toxicity and cumulative toxicity were fatigue, malaise, and fever in most patients. Hepatic transaminitis, neutropenia, and elevation of serum creatinine were also observed but were not dose-limiting. There was one complete response (CR) and four partial responses (PRs). All responses but one occurred in pulmonary metastases. The median time to response was 26 days (range, 17 to 102 days). These data demonstrate that IFN-beta-ser given in high doses exhibits significant antitumor activity in renal cell carcinoma; however, the objective response rate is 20%. This is no higher than previous IFN studies; therefore, we reject the hypothesis than IFN-beta-ser at high doses may induce a greater response rate than IFN-alfa. However, we did observe more responses than were seen in a similar trial undertaken with lower dose IFN-beta serine in renal cell carcinoma.

Results in children managed by cutaneous ureterostomy.

A review of 59 children with severe hydronephrosis managed by cutaneous ureterostomy reveals that the procedure is safe, quick, and effective in draining the kidney. Although chronic bacteriuria is common, pyelonephritis is rare. The major drawback of this technique for temporary urinary diversion in children is that the subsequent urinary reconstruction is formidable and more difficult than primary repair. The complications of urinary diversion using this technique are low, however, and it may remain the safest form of diversion available for long-term use in children with dilated ureters.

Clinical and Urodynamic Features of a New Intestinal Urinary Sphincter for Continent Urinary Diversion

We describe a new sphincter mechanism and its clinical application in 11 patients requiring continent diversion. The sphincter, composed of 2 short segments of ileum, is urodynamically responsive and actually increases its resistance to leakage when reservoir pressure or volume increases. Because of this dynamic continence control and its ease of construction, it appears to be a useful addition to the reconstructive urological armamentarium.

An Unusual Presentation of Intrinsic Ureteral Obstruction Secondary to Carcinoma of the Prostate: A Case Report

We report on a patient with a known diagnosis of adenocarcinoma of the prostate who had acute renal failure. An excretory urogram showed bilateral ureteral obstruction and retrograde ureteral catheterization was attempted. Because the retrograde catheters could not be passed into the bladder percutaneous nephrostomies were placed immediately. Dissection of the right ureter showed complete intrinsic occlusion by a multinodular tumor, with no evidence of secondary extension at the ureterovesical junction on the right side or circumferential spread along the involved ureter.