Jordan Brown

Anastomotic Strictures Following Radical Prostatectomy: Risk Factors and Management

Stricture of the anastomosis between the bladder neck and membranous urethra after radical prostatectomy can cause significant voiding dysfunction. Of 156 patients undergoing radical prostatectomy for localized prostatic carcinoma 18 had anastomotic stricture for an over-all incidence of 11.5%. The risk factors for anastomotic stricture and the treatment outcome in these patients were analyzed. Excessive intraoperative blood loss, extravasation of urine at the anastomotic site and a prior transurethral prostatic operation significantly contributed to the development of stricture. More than half of the patients did not respond to simple dilation alone. Cold knife incision of the stricture by itself was effective in only 62% of the patients. The remaining patients required periodic dilation to maintain an adequate urine flow. Incision of the stricture with electrocautery resulted in urinary incontinence in all patients.

Extended Pelvic Lymphadenectomy for Prostatic Cancer

Thirty patients with clinically localized prostatic carcinoma underwent extended pelvic lymph-adenectomy, including the presacral and presciatic (lateral sacral) areas. The first echelon of pelvic nodes to be involved by metastases was the external iliac, obturator, presacral and presciatic. The deep presacral-presciatic nodes were involved almost as often as the more superficial external iliac-obturator group. Metastases limited only to the deep pelvic nodes were found in 14 per cent of the cases.

Partial Nephrectomy for Renal Cell Carcinoma: Indications, Results and Implications

Of 52 patients who underwent partial nephrectomy for tumor 44 were found to have renal cell carcinoma. The indications for this parenchyma-sparing procedure were categorized according to the initial status of the contralateral kidney and included bilateral tumors or tumor in a solitary kidney in 16 patients (mandatory indications), unilateral carcinoma with compromise of the contralateral kidney by a benign disease process in 9 (relative indications) and small peripheral tumor with a normal contralateral kidney in 19 (elective indications). There were 4 recurrences that accounted for 3 deaths, all in patients with mandatory indications. All patients who underwent partial nephrectomy for relative or elective indications were without definite evidence of recurrent disease at last followup (over-all mean 36 months). Our results suggest that conservative surgery can often provide effective and advantageous therapy for renal cancer and we encourage further consideration of the role of partial nephrectomy as an alternative to radical nephrectomy in selected patients with small peripheral tumors and normal contralateral kidneys.

Followup Interval Prostate Biopsy 3 Years After Diagnosis of High Grade Prostatic Intraepithelial Neoplasia is Associated With High Likelihood of Prostate Cancer, Independent of Change in Prostate Specific Antigen Levels

PURPOSE Repeat biopsy has been advocated following the diagnosis of high grade prostatic intraepithelial neoplasia to exclude coexisting prostate cancer. We further define the natural history of high grade prostatic intraepithelial neoplasia by determining the incidence of prostate cancer 3 years following diagnosis. MATERIALS AND METHODS A total of 31 men underwent followup interval biopsy 3 years after high grade prostatic intraepithelial neoplasia diagnosis in 1996 to 1997, regardless of change in serum prostate specific antigen (PSA) or digital rectal examination findings. A single pathologist reviewed all biopsy specimens. All men had a minimum of 12 biopsy cores taken at the time of diagnosis. RESULTS A 3-year followup interval biopsy eight (25.8%) men had prostate cancer, 11 (35.5%) had high grade prostatic intraepithelial neoplasia only and 12 (38.7%) had no disease. Mean serum PSA at diagnosis and before the followup biopsy was 6.88 and 9.69 ng./dl., respectively (p = 0.008). Of the men 48% had less than a 1.0 unit increase in serum PSA. Upon univariate regression analysis change in serum PSA was not associated with the detection of prostate cancer (p >0.10). All 4 patients who subsequently underwent radical prostatectomy had organ confined disease. CONCLUSIONS In a high proportion of men with high grade prostatic intraepithelial neoplasia prostate cancer will develop in a 3-year interval. Our findings support the concept that high grade prostatic intraepithelial neoplasia is a precursor to prostate cancer and that repeat biopsy at a delayed interval is recommended regardless of changes in PSA.

Varicocelectomy in the Subfertile Male: a Ten-Year Experience with 295 Cases *

During a 10-year period 295 varicocelectomies were performed in subfertile males. Results of follow-up studies indicate the following: (1) Semen quality improved in a meaningful manner in 58% of men following varicocelectomy. The improvement, except at times for motility, was often only modest. The semen improved in 46% of men with a preoperative average count of less than 10 million/ml and in 70% whose count was 10 million/ml or more. (2) The stress pattern of sperm morphology was seen prior to surgery in 93% of the men. (3) The pregnancy rate for the entire series was about 41%. Men with a preoperative count of 10 million/ml or more achieved a 48% conception rate and those with a count of less than 10 million/ml succeeded 35% of the time. Only 7% of the pregnancies occurred without a concomitant improvement in the semen quality. (4) Men with moderate- and large-sized left varicoceles fared better than those with small-sized varicoceles. (5) Varicocelectomy, when varicocele and poor semen quality coexist, is a justified procedure in the treatment of the infertile couple.

The role of internal spermatic vein plasma catecholamine determinations in subfertile men with varicoceles.

Catecholamine concentrations were determined in left spermatic vein blood of 18 patients with varicocele. These values were compared with concentrations of catecholamines in the right femoral vein. Of 18 patients studied, 6 had moderate to marked elevations of spermatic vein catecholamine concentrations. Norepinephrine was the fractioned component that was elevated. In an average 1-year follow-up the group with elevated catecholamine levels had a much better semen improvement percentage and pregnancy rate than the other group. Chronic exposure of testicular vasculature to norepinephrine may account for the spermatogenic dysfunction encountered in varicocele patients. Once this exposure is interrupted, there may be reversibility of function and the fertility prognosis may improve. The presence of other adrenal or renal metabolites detrimental to spermatogenesis must be considered.

Radiotherapeutic prophylaxis of estrogen-induced gynecomastia: A study of late sequela

Radiation therapy is an effective means of preventing the development of hormone-induced gynecomastia in men with cancer of the prostate. The efficacy and morbidity of this type of radiation was studied in a retrospective analysis of 87 patients referred for treatment from 1972 to 1982. Patients receiving DES as treatment for prostate carcinoma were treated with irradiation to the breast tissue. Patients were treated with 4 MV, 60Co superficial X rays. Doses range from 1200 to 1500 cGy in 3 fractions. The majority of patients had satisfactory results in terms of prevention of gynecomastia and mammalgia. There were few acute reactions noted and no evidence of long term sequela.

The effect of orally administered androgens on sperm motility.

The administration of oral androgens increased sperm motility to normal in 30 (52%) of 58 men whose impaired motility was the only defect in their semen quality. Their ejaculate volume, sperm count, and morphology were not benefited. Suppression was infrequently seen and appeared to be transient. Pregnancies were documented in 15 (26%) of the 58 couples studies. However, communication regarding this matter was made with only 39 of the 58 couples. The benefical effect from a single course of androgen is likely to persist. However, if a pregnancy does not ensue, semen analysis should be repeated to determine if additional medication is necessary. Pretreatment serum testosterone determinations were not helpful in determining those men who would most likely benefit from therapy. No appreciable benefit was noted in the semen quality of the 35 subfertile men identically treated who, in addition to poor sperm motility, had other defects in their semen.

Carcinoid tumor of kidney.

A case of carcinoid tumor of the kidney is reported. Pathologic findings of the tumor, clinical manifestation, and treatment are discussed.

Neurogenic bladder in normal pressure hydrocephalus

Five patients wíth normál pressure hydrocephalus who had urinary incontinence were found to have neurogenic bladders by cystometry. The bladder disturbance in this disorder whould be considered the result of a specific defect of brain function and not just and artifact of gait disturbance or of dementia.