Laurence F. Greene

Prostatic adenocarcinoma of ductal origin.

Clinical and histopathologic features of prostatic ductal adenocarcinomas have been incompletely described. A review of 4,286 cases of prostatic adenocarcinoma (1950 through 1970) at the Mayo Clinic showed 55 cases in which lesions were of a distinctive ductal type. Eight of the 55 lesions originated from periurethral primary prostatic ducts and had exuberant papillary folds. Cystoscopic examination revealed a polypoid and villous or an infiltrative urethral component. The 5‐year survival rate (42.8%) was similar to that for the usual acinic adenocarcinomas. Carcinomas originating from secondary ducts had a multi‐centric origin and papillary, comedo‐like, and cribriform‐papillary histopathologic features. The overall 5‐year survival rate was 24.2%. Palliative hormone therapy appeared to be less effective in prolonging life in these patients as compared to patients with acinic carcinomas. Bone metastases were osteoblastic, and serum acid phosphatase activities were elevated if metastases were present.

Prostatosis, prostatitis or pelvic floor tension myalgia?

Patients with symptoms suggestive of prostatitis or prostatosis who do not have pathogenic bacteria in the prostatic secretions may, in fact, not have prostatic problems. The possibility of pelvic floor tension myalgia should be considered in these patients.

Arteriovenous fistula of the kidney; new observations and report of three cases.

Only 5 reports of cases of renal arteriovenous fistula appeared before or in 1953. Subsequently, 7 isolated reports brought the total to 12, and the 3 that we are reporting make 15. In reviewing the subject, the classification, incidence, causation, clinical features, diagnostic procedures, and pathophysiologic features were considered. Good evidence supports the thesis that in cases of congenital arteriovenous fistula an eroding renal arterial aneurysm is etiologic. Outstanding clinical features were hypertension (to group 4) and myocardial insufficiency; these contrast markedly with features of the usual peripheral arteriovenous fistula. Dramatic relief of heart failure and lowered reserve followed corrective operation in every case in which these features were recorded; relief of hypertension followed corrective operation in 11 of 12 cases in which this feature was mentioned. A loud, diffuse, continuous bruit invariably was present. Preoperative and postoperative catheterization and indicator-dilution studies, angiograms and aortograms are diagnostic measures emphasized in our 3 cases. Arterialization of blood in the vena cava, greatly increased cardiac output, and markedly shortened recirculation times of the dye were found. Excretory urograms were abnormal in 11 of the 12 cases in which they were made. The mechanism producing hypertension appears related to loss of pressure, decrease in flow, and loss of pulsatile character in the renal artery distal to the fistula, giving a Goldblatt-kidney type of end result. A vicious cycle of increasing hypertension followed by increasing flow through the shunt makes heart failure inevitable. Since 10 of the 15 cases were reported in the last 4 years, indicating that the lesion is commoner than previously supposed, we advise auscultation over the renal regions in patients with cardiac enlargement or failure of unknown causation, unexplained deformities in urograms, and renal tumors.

Functional Characteristics of the Separate Kidneys in Hypertensive Man

1. 1. Functional studies of the separate kidneys were undertaken in 165 hypertensive patients who had previously undergone excretory urography. Of these, 150 had isotope renography and 147 had renal arteriography. Complications consisted of acute or recurrent pyelonephritis in 4 patients; all responded promptly to appropriate chemotherapy. 2. 2. In 17 hypertensive patients with dominantly unilateral atrophie pyelonephritis, mean values revealed markedly diminished urine volume (54%), clearances of inulin and paraaminohippuric acid (PAH) (65 and 62%), and reabsorption of filtered sodium (1.5%) and water (1.6%) for the diseased kidney. Concentrations of sodium, PAH, and inulin and osmolality of the urine from the diseased side were usually slightly to moderately diminished. In two patients data on urine volume and sodium concentration met criteria for a positive Howard test. 3. 3. Patients with apparent essential hypertension had only minor differences between the kidneys in all parameters studied. The range of differences in those with essential hypertension and aberrant arteries was somewhat greater; however, mean differences were minimal except for greater clearances of inulin and PAH which correlated well with greater renal mass. 4. 4. Of 102 patients with stenosing lesions of the renal arteries, 53 had unilateral and 49 had bilateral obstruction. In patients with unilateral severe renal artery stenosis urine volume and sodium concentration were diminished along with usually diminished clearances of inulin and PAH on the involved side (mean values − 79, − 53, − 47 and − 47%, respectively). Urine osmolality was usually increased as were concentrations of inulin and PAH, the latter two usually by more than 100 per cent. The percentage reabsorption of filtered sodium and water was markedly increased on the involved side (mean values 3.1 and 2.6%, respectively). Patients with unilateral severe renal artery stenosis and aberrant renal arteries differed only in that the mean value for sodium concentration in the urine was only slightly diminished on the involved side (6%). Patients with unilateral renal artery stenosis and partial renal infarction usually could not hyperconcentrate urine on the involved side. Urine volume, sodium concentrations, and osmolality were diminished; however, inulin and PAH concentrations were slightly but consistently increased. When stenosis was severe on one side and mild on the other, functional characteristics were similar to those observed with unilateral stenosis, except for more variable sodium concentrations and osmolality. When stenosis was bilateral and equally severe, significant differences in functional characteristics were seldom observed. Patients with mild or moderate stenosis (less than 50% narrowing of the renal artery) seldom had more than slight differences in functional characteristics. 5. 5. With arteriographically demonstrated renal artery stenosis, (a) increased reabsorption of filtered sodium and water by 1 per cent or more on the involved side, a positive Howard test, and increased osmolality characterized functionally significant lesions and were not seen in essential hypertension; (b) differences in inulin and PAH concentrations largely reflected differences in water reabsorption; and (c) when sodium concentrations were greater on the involved side (negative Howard test), a high incidence of either a branch artery lesion, multiple arteries to the involved kidney, bilateral main artery stenosis, or partial renal infarction was observed.

Primary Carcinoma in Situ of the Ureter and Renal Pelvis

Primary carcinoma in situ of the ureter or renal pelvis is rare. We describe 3 patients, each of whom had a different mode of presentation. When malignant cells in the urine from the upper urinary tract are associated with urographic evidence of an appropriate lesion, aggressive surgical therapy is indicated. In the absence of such a urographic abnormality patients with positive cytologic examinations should be followed closely because the exfoliated cells usually are from poorly differentiated neoplasms.

Non-specific granulomatous prostatitis.

Between 1963 and 1972, 86 patients with non-specific granulomatous prostatitis were seen. Symptomatology was suggestive of a lower urinary tract infection in the majority of the cases. The most important feature on prostatic examination was the likelihood of confusion with prostatic carcinoma. Management by whatever means yielded uniformly good results. The natural history of this disease seems to be that of gradual resolution.

Transurethral Prostatic Resection in Patients with Prosthetic Cardiac Valves

Twenty-one patients with prosthetic cardiac valves successfully underwent transurethral prostatic resection at the Mayo Clinic. Temperature elevation in 4 patients was the only postoperative complication; in particular, neither congestive heart failure nor thromboembolic complications developed and there were no operative deaths. Preoperative evaluation and clinical management of potential complications are based on the recognition of the complications that are peculiar to these patients. Particularly important is the proper use of antibiotics and anticoagulants and avoidance of overloading the circulation with fluid from open prostatic venous sinuses.

Clinical evaluation of hypertensive patients

Abstract Four cases of hypertension secondary to lesions of the renal arteries are presented with comments on the history, results of physical and laboratory examinations and surgical findings. Points emphasized are as follows: 1. 1. Hypertension of renal or renal arterial origin should be suspected in the presence of: (A) acute hypertension in young patients with angiospastic ocular changes; (B) rapidly progressive symptomatic hypertension of recent onset; (C) abrupt acceleration of chronic essential hypertension; (D) a history suggestive of a recent renal vascular accident; (E) a continuous bruit over the superolateral area of the abdomen and (F) a disparity in the size and function of the kidneys on excretory urography. 2. 2. In our experience the isotope renogram has served as an excellent screening procedure for the evaluation of renal function in hypertensive patients. 3. 3. Renal arteriography is a highly desirable procedure which aids in the more complete evaluation of hypertensive patients in whom abnormalities suggestive of renal arterial disease are found on physical or urographic examination or in the isotope renograms. This is especially true when surgical intervention is planned. The vagaries of translumbar aorticorenal arteriography are legion. Retrograde aortographic technics for renal arteriography are technically more satisfactory in our experience. 4. 4. Evaluation of function of each kidney alone may on occasions prove not only of diagnostic help, but more importantly, it may provide evidence of the adequacy of function of the individual kidneys, and thus may prove decisive regarding the feasibility of surgical intervention.

Postpartum onset of urinary incontinence associated with ureteral ectopia

The onset of urinary incontinence in adult women in association with extrasphincteric ureteral ectopia is rare. Herein we report 2 cases of this unusual occurrence. The incontinence in both patients began after significant obstetric trauma. Ureteral ectopia should be included in the differential diagnosis of incontinence beginning in the immediate postpartum period.

Bolus nephrotomography in diagnosis of lesions of kidney

Bolus nephrotomography was employed in the study of 100 patients with renal adenocarcinoma and 100 patients with renal cyst. A retrospective review of the vascular and nephrographic phases of this study was made. A diagnosis of renal adenocarcinoma could be made with confidence by bolus nephrotomography in 82 per cent of cases with the remaining cases indeterminate and requiring further investigation; the vascular phase was of greater diagnostic value than the nephrographic phase. A diagnosis of renal cyst could be made with confidence by bolus nephrotomography in 85 per cent of cases with the remaining cases indeterminate and requiring further investigation; the nephrographic phase was of greater diagnostic value than the vascular phase.