John W. Weigel

Analysis and management of chronic testicular pain

A total of 45 patients was seen in consultation between May 1980 and April 1989 for chronic unilateral or bilateral orchialgia, defined as intermittent or constant testicular pain 3 months or longer in duration that significantly interferes with the daily activities of the patient so as to prompt him to seek medical attention. We analyzed 34 patients available for followup in terms of socioeconomic parameters, etiology and duration of pain, associated urological symptomatology, specific treatment and results of therapy. Of the patients 31 underwent surgical treatment after failing medical management (24 orchiectomies, 10 epididymectomies, 5 orchiopexies and 1 hydrocelectomy). Of 10 patients who underwent epididymectomy 9 underwent subsequent orchiectomy as definitive treatment. Of 15 patients who underwent inguinal orchiectomy 11 (73%) reported complete relief of pain, while 4 had partial relief. Of the 9 patients who underwent scrotal orchiectomy 5 (55%) reported complete relief of pain, 3 had partial relief and 1 denied improvement. On the basis of these results we recommend inguinal orchiectomy as the procedure of choice for the management of chronic testicular pain when conservative measures are unsuccessful.

Long-term complications related to the modified Indiana pouch.

OBJECTIVESnTo describe a single-institution, single-surgeon experience with 125 modified Indiana pouches performed during a period of 14 years and their long-term complications. The modified Indiana pouch is a widely accepted and often used form of continent urinary diversion. Few studies have established the long-term complication rates associated with the procedure.nnnMETHODSnA retrospective chart review of 129 modified Indiana pouches constructed from March 1985 to August 1998 was performed, and the long-term complications and reoperation rates were tabulated.nnnRESULTSnComplete information was obtained for 125 of the 129 charts, with a mean follow-up of 41.1 months (range 3 to 127). Complications occurred in 112 patients (89.6%; several patients had more than one complication), with a mean onset of 20.4 months (range 1 to 125) postoperatively. Seventy-three complications (58.4%) were due to the efferent limb, of which incontinence (defined as any leakage) was the most common (35 [28.0%]), followed by stomal stenosis in 19 (15.2%) and difficult catheterization in 12 (9.6%). Of the 26 pouch-related problems (21.8%) that occurred, the most common were stones in 13 (10.4%), perioperative leaks in 5 (4.0%), and perforations in 4 (3.2%). Ureteral anastomotic strictures were seen in 9 (7.2%). Other complications included gallstones in 32 (25.6%), kidney stones in 8 (6.4%), and small bowel obstruction in 6 (4.8%). Reoperation was performed in 65 patients (52.0%; several patients with more than one reoperation). Twenty-six (20.8%) of the patients required an open operation, and 39 (31.2%) received minimally invasive (percutaneous, endoscopic, extracorporeal shock wave lithotripsy) procedures. Sixty percent of the reoperations were minimally invasive. Reoperation was due to stomal stenosis in 18 (14.4%), pouch stones in 13 (10.4%), ureteral strictures in 9 (7.2%), and parastomal hernias in 6 (4.8%). Small bowel obstruction required reoperation in 5 patients (4.0%).nnnCONCLUSIONSnIn our experience, long-term complications of the modified Indiana pouch were mostly related to the efferent limb, and reoperations were usually due to stomal stenosis. Our data suggest that with longer follow-up, the complication and reoperation rates of the modified Indiana pouch appear to be higher than previously reported.

Muscarinic cholinergic receptors promote growth of human prostate cancer cells

Recent evidence suggests that muscarinic receptors induce mitogenesis in cells capable of undergoing cell proliferation. Human prostate gland is innervated by the autonomic nervous system and muscarinic receptors have been localized in the prostate gland.

Comparison of computed tomography and ultrasound in abdominal staging of renal cancer

The relative accuracy of computed tomography (CT) and ultrasound in abdominal staging of renal cancer was determined in 22 patients. CT is capable of detecting tumor invasion of perinephric fat and adjacent muscles, which cannot usually be shown by ultrasound. While both CT and ultrasound demonstrate venous and retroperitoneal tumor extension, CT is more reliable since bowel gas not infrequently obscures the retroperitoneum on ultrasonic scanning. However, ultrasound will often provide valuable information; and whenever a solid renal mass is detected by echography using prone scans, abdominal scans should be obtained for staging pruposes.

Correlation of Ultrasound Guided and Digitally Directed Transrectal Biopsies of Palpable Prostatic Abnormalities

The authors evaluated 51 patients with palpable prostatic abnormalities detected during digital rectal examination. These findings consisted of a nodule or an area of induration. Each palpable abnormality was confined to 1 prostatic lobe and there was no suggestion of extracapsular extension of neoplasm or systemic metastatic disease. All patients underwent 7.0 MHz. sagittal ultrasound guided transrectal biopsy followed by digitally directed transrectal biopsy. Biopsies were obtained only from the area of interest. The procedure was performed in the outpatient clinic without use of sedation or anesthesia. Digitally directed biopsies were positive for adenocarcinoma in 9 lesions. Ultrasound guided biopsies detected adenocarcinoma in 23 lesions, including all those detected by the blind digitally directed technique. This study demonstrates greater diagnostic accuracy using 7.0 MHz. ultrasound guided techniques and its routine use is warranted in the evaluation of palpable prostatic abnormalities.

Papaverine-Induced Priapism: 2 Case Reports

Intracorporeal papaverine injection therapy for impotence has been reported recently as a therapeutic option with low morbidity. We report 2 cases of papaverine-induced priapism that required surgical intervention.

Renal cell carcinoma--angioinfarction.

In our experience the mortality rate in 46 patients who underwent angioinfarction for renal cell carcinoma was 4 per cent. Fever, ileus and leukocytosis were noted in 86 to 90 per cent of our patients. The use of absolute ethanol as a medium for renal infarction was associated with a significant incidence of damage to other organs. A 30 per cent decrease in tumor volume following angioinfarction using absorbable gelatin sponge and Gianturco coils was noted in 75 per cent of the patients. There was no evidence of metastatic tumor reduction and we could not document any significant decrease in operative time or blood loss. It would appear that there is some increased survival rate in patients with metastasis who are given adjuvant immune ribonucleic acid therapy. However, the numbers in our series are not significant to draw any definite conclusion. It is apparent that patients treated with infarction, delayed nephrectomy and medroxyprogesterone acetate did not have any significant survival over those treated with palliative nephrectomy or chemotherapy. The macrophage maturation assay may be useful during clinical followup.

Primary Neoplasms of the Ureter

The role of tobacco as a carcinogenic agent should be considered in ureteral carcinoma. In our study 77 per cent of the patients had a history of smoking, with an average of 50 packs a year consumption. Various studies have shown that the prognosis for ureteral carcinoma is related primarily to the grade and stage of the disease at the time of treatment. Therefore, it is imperative that the clinician maintain a high index of suspicion. This index of suspicion should be heightened in any patient with lower tract urothelial tumors. In addition to endoscopic followup excretory urography should be done on an annual basis, with retrograde studies when necessary. Ureteral brush biopsies or tissue obtained with the Dormia basket may be diagnostic. A Dormia stone basket was used in 3 patients in our study and sufficient tissue for diagnosis was obtained in each case. No complications were encountered. The results obtained in treating a primary leiomyosarcoma of the ureter are noteworthy in that complete remission of pulmonary metastases was obtained after the patient received a course of doxorubicin hydrochloride and dimethyl-triazeno imidazole carboxamide.

Adenocarcinoma of the Prostate Discovered in 2 Young Patients Following Total Prostatovesiculectomy for Refractory Prostatitis

Adenocarcinoma of the prostate gland is the most common cancer in men in the United States but it occurs rarely in men younger than 40 years. Incidental prostate cancer has been shown to exist in a significant number of patients older than 50 years, found either at autopsy or after cystoprostatectomy for a pathological condition of the bladder. We report 2 cases of unsuspected adenocarcinoma of the prostate gland discovered after total prostatovesiculectomy for refractory prostatitis in men 25 and 36 years old, respectively.

Conversion of percutaneous ureteral stent to indwelling pigtail stent over guidewire.

A ureteral stent placed percutaneously through a nephrostomy can be readily exchanged endoscopically for a ureteral indwelling pigtail stent over a percutaneous guide wire. Percutaneous antegrade stent placement can sometimes be accomplished when retrograde placement cannot. We report 10 successful conversions to indwelling stent in 11 cases. In 1 case the percutaneous guide wire could not be retrieved endoscopically because of a bleeding tumor in the bladder. No serious difficulties or complications were encountered. The percutaneous approach offers an alternative method of providing internal urinary diversion if retrograde ureteral indwelling stent placement has failed.