James M. Holland

Cancer of the kidney—natural history and staging

The natural history of renal cell carcinoma is kaleidoscopic. Growth may be indolent, intermittent, or rapid. The tumor may remain encapsulated for years. Ultimately it may invade intrarenal veins and lymphatics, thence to vena cava, aortic nodes, thoracic duct, and beyond. Spread to contiguous organs gives entry to portal and vertebral venous systems. Unusual metastases are common. Gross hematuria, loin pain, and mass occur together in only 10‐15% and portend advanced neoplasm. Microscopic hematuria is found in about two‐thirds. Non‐specific signs and symptoms such as fatigue, weight loss, gastrointestinal symptoms, fever, and anemia are misleading. Fascinating clues such as hypercalcemia, erythrocytosis, hepatopathy, polyneuritis, acute left varicocele, etc., may alert the wary clinician. Rare but titillating spontaneous regression of hypernephroma metastases, usually pulmonary and in older males, have occurred whether or not nephrectomy is done. About 60 cases have been reported. Understanding this apparent tumor‐specific immunologic response may bring earlier diagnosis and control of metastases. Selection of best treatment requires surveying metastatic sites. Accurate staging at operation and at the time of recurrence is imperative to help determine cause and correction of treatment failures.

Molecular Detection of Prostate Epithelial Cells from the Surgical Field and Peripheral Circulation during Radical Prostatectomy

PURPOSE Prostate cancer progression despite organ confined pathological assessment has been reported in a variable number of men after radical retropubic prostatectomy. To study this phenomenon, we used the prostate specific antigen (PSA) reverse transcriptase-polymerase chain reaction assay. MATERIALS AND METHODS We prospectively assayed the peripheral venous blood before, during and after surgical manipulation as well as the intraoperative field blood for PSA reverse transcriptase-polymerase chain reaction-positive cells in 22 men undergoing radical retropubic prostatectomy. RESULTS PSA reverse transcriptase-polymerase chain reaction-positive cells were identified in 20 of the 22 operative field samples (91%) and 4 of 16 (25%) had evidence of intraoperative hematogenous dissemination (p = 0.046). No significant association was identified among Gleason score, pathological stage and the PSA reverse transcriptase-polymerase chain reaction result. CONCLUSIONS Our results suggest that tumor cell spillage and less frequently hematogenous dissemination may be associated with operative manipulation of the prostate during radical retropubic prostatectomy and may potentially represent mechanisms of failure after radical retropubic prostatectomy.

Conservative Management of Twisted Testicular Appendages

We planned non-operative treatment of a twisted intrascrotal appendage in 23 consecutive patients, ranging in age from 6 to 45 years, in whom the diagnosis could be made confidently. Only 3 patients have required subsequent removal of the infarcted appendage because of persistent or recurrent pain. The remaining patients became free of pain within a week. Prompt surgical exploration to exclude torsion of the spermatic cord remains necessary if scrotal swelling obscures the diagnosis. At operation for the latter indication 5 additional boys were found to have a twisted appendix testis during the study interval.

Priapism in boys. Management with cavernosaphenous shunt.

Two children with priapism are presented; one case was secondary to trauma and the other was idiopathic in nature. Both boys were effectively treated by bilateral corporosaphenous shunts. The mechanism of normal erection and the pathophysiology of priapism are discussed.

Prostatic aspiration biopsy: an assessment of accuracy based on long-term observations.

We present the results of transrectal thin needle aspiration biopsy of the prostate in 133 patients. Test specificity was 94 per cent and sensitivity also appeared to be high initially. However, with repeated rectal examinations and biopsies during an 11-year period a number of additional false negatives became apparent, which resulted in an apparent test sensitivity of 82 per cent, lower than most previously published reports. Our data suggest that aspiration biopsy has specificity and sensitivity similar to core biopsy, it is important to re-test patients who have a palpable abnormality and an initially benign biopsy, and aspiration biopsy simplicity allows for a low threshold of suspicion of subtle abnormalities and for repeating biopsies after negative findings.

Radiation Therapy for Carcinoma of the Prostate: 5-Year Followup

Our original series of patients with prostatic carcinoma treated with irradiation as the initial modality has been updated. The over-all 5-year survival rate for patients with stage III carcinoma of the prostate was 55 per cent--26 per cent were alive with residual disease and have had post-irradiation hormone manipulation, while 29 per cent were alive without metastases at 5 years.

Three-phase cystoscopic inspection of vesicoureteral valve

Abstract Attempts to visualize cystoscopically what happens to the ureterovesical valve mechanism before and during detrusor contractions, much as one does on voiding cystograms, are described. In some patients, especially those demonstrating reflux, the valve changes are remarkable as the bladder contracts.

Matrix obstruction of solitary kidney during pregnancy

Abstract A matrix calculus obstructed the ureter of a solitary kidney during pregnancy. Anuria and azotemia were reversed by extracting the calculus. The matrix was an amorphous mass of glycoprotein and mucopolysaccharide; there were only microscopic nests of calcium. Only electron micrographs demonstrated a tendency of the crystals and matrix to display lamellae. This unusual architecture suggests matrix calculi can grow without organized lamellae.

Vesicoureteral Reflux—Who Needs Ureteroneocystostomy?

Today the urologist treating a patient having recurrent urinary tract infections performs voiding cystourethrography almost as routinely as excretory pyelography (IVP) and cystoscopy. The high yield of vesicoureteral reflux, paraureteral diverticula, and bladder outlet obstruction has stimulated much creative work searching for cause and best treatment of these congential disorders.