Muta M. Issa

Routine Transition Zone and Seminal Vesicle Biopsies in All Patients Undergoing Transrectal Ultrasound Guided Prostate Biopsies are Not Indicated

PURPOSEnTransrectal ultrasound guided biopsies of the transition zone and seminal vesicles have been useful in select patients. More widespread use of these additional biopsies has been proposed. The efficacy of routine transition zone and seminal vesicle biopsies was examined.nnnMATERIALS AND METHODSnFrom January 1988 to October 1994, 736 transrectal ultrasound guided systematic sextant biopsies were performed. From October 1994 to July 1995, 161 consecutive patients underwent transrectal ultrasound with systematic sextant, transition zone and seminal vesicle biopsies.nnnRESULTSnOf the 736 patients undergoing only sextant biopsies 309 (42.0%) had cancer and 24 (3.3%) required repeat biopsy, compared to 55 (34.2%) and 4 (2.5%) of 161 undergoing combined sextant, transition zone and seminal vesicle biopsies. Prostate cancer was found only in the systematic sextant biopsies in 43 of the former 55 patients (78.2%), and in the transition zone and systematic sextant biopsies in 11 (20.0%). One patient (1.8% of patients with cancer or 0.6% of all 161 patients) had cancer in only the anterior biopsies and 6 (10.9 and 3.7%, respectively) had cancer involving the seminal vesicles.nnnCONCLUSIONSnRoutine transition zone and seminal vesicle biopsies in all patients undergoing transrectal ultrasound guided systematic sextant biopsies are not warranted.

Large, Organ Confined, Impalpable Transition Zone Prostate Cancer: Association with Metastatic Levels of Prostate Specific Antigen

We present 3 of 25 patients with massive, occult transition zone cancers 7 to 86 cc in volume. Despite serum prostate specific antigen (PSA) levels of 150 to 456 ng./ml. (Yang polyclonal assay), all 3 were organ confined at radical prostatectomy and have undetectable serum PSA levels by an ultrasensitive assay at 300 to 650 days postoperatively. This clinical syndrome includes a highly elevated PSA level, benign prostatic hyperplasia on digital rectal examination, a nondiagnostic transrectal ultrasound and frequently negative transrectal or perineal needle biopsies. Clinical recognition of this syndrome plus systematic biopsies of the transition zone are the keys to diagnosis and potential cure of these patients. These cases may explain the 10% rate of men who present with metastatic prostate cancer and a normal rectal examination, much of the discrepancy between focal cancer on biopsy and large cancers in radical prostatectomy specimens, and why some men have an extraordinarily high serum PSA level and organ-confined cancer at prostatectomy.

Intravesical Migration of Intrauterine Device

Intrauterine devices have been plagued by many early and late complications, including uterine perforation and migration into adjacent structures. To our knowledge only 18 cases have been reported in the literature of migration of an intrauterine device into the bladder. We report on a 38-year-old woman in whom an intrauterine device eroded from the uterus 3 years after placement. The device remained asymptomatic in the pelvis for an additional 13 years before the patient presented with urinary symptoms. The literature is reviewed.

Transurethral Needle Ablation of the Prostate: Report of Initial United States Clinical Trial

PURPOSEnWe studied the efficacy and safety of transurethral needle ablation of the prostate for treatment of symptomatic benign prostatic hyperplasia (BPH).nnnMATERIALS AND METHODSnA total of 12 patients with symptomatic BPH underwent transurethral needle ablation of the prostate. Voiding outcomes, including American Urological Association symptom scores, bother scores, bother scores, quality of life scores, peak urinary flow rates, residual urine volumes and urodynamic pressure flows, were measured with time, and immediate and short-term (6 months) complications were assessed.nnnRESULTSnTransurethral needle ablation of the prostate was performed with local intraurethral lidocaine anesthesia in 11 patients and general anesthesia in 1. At 6 months there was a 61.7% improvement in American Urological Association symptom score (25.6 to 9.8, p = 0.0001), 61.1% improvement in bother score (18.8 to 7.3, p = 0.0002), 70.0% improvement in quality of life score (13.7 to 4.1, p = 0.0001), 73.0% increase in peak flow rate (7.8 to 13.5 cc per second, p < 0.0001) and 54.9% decrease in the post-void residual (111 to 50 cc, p = 0.0457). Prostate volumes, maximum detrusor pressures and detrusor opening pressures decreased significantly. There were no intraoperative complications. Postoperatively, all 12 patients had mild dysuria for 1 to 7 days, 5 had transient urinary retention for 1 to 4 days, 3 had hematuria for 1 to 2 days and 1 had retrograde ejaculation. CONCLUSIONS. This initial United States trial confirms previous experience, and shows that transurethral needle ablation of the prostate appears to be a simple, safe and efficacious procedure for treatment of symptomatic BPH. In addition, it can be performed in the majority of patients using topical urethral anesthesia.

Youssef’s Syndrome: Preservation of Uterine Function with Subsequent Successful Pregnancy following Surgical Repair

We report a 30-year-old female with vesicouterine fistula (Youssefs syndrome). Surgical therapy included transabdominal repair of bladder and uterus with interposition of greater omentum. Uterine function was preserved with subsequent successful pregnancy and delivery of a healthy baby boy by elective Cesarean section at 36 weeks gestation. The details of the case are discussed and the literature is reviewed regarding fertility and pregnancy after surgical repair.

Analgesia during extracorporeal shock wave lithotripsy using the medstone STS lithotriptor: A randomized prospective study

OBJECTIVESnTo investigate and compare the effectiveness of three analgesic protocols for pain management during extracorporeal shock wave lithotripsy (ESWL) in a prospective, randomized clinical trial.nnnMETHODSnSeventy-four patients were randomized into three groups before ESWL; group A (n = 23) received 10 mg morphine sulfate (MS), group B (n = 25) 60 mg ketorolac tromethamine (KT), and group C (n = 26) topical 2.5% lidocaine/prilocaine gel (Emla). Each method of pain management during ESWL was assessed using a standard 10-point linear pain scale and by the requirement for supplemental analgesia during treatment. Supplemental analgesia was administered intravenously using a patient-controlled analgesic pump. The results were compared between the three groups, as were such parameters as body habitus, stone burden, stone location, number of shock waves, and the presence of ureteral stents.nnnRESULTSnPain severity averaged 4.6 points on the pain scale for the three groups combined. Pain tended to be more severe in group C (5.4) than in group A (4.3) or group B (4.1); however, the differences were not statistically significant (P>0.05). The amount of supplemental analgesia was similar in all three groups. Stone burden, stone location, and number of shock waves did not influence the severity of pain or analgesic requirement during ESWL. The analgesic requirement was significantly less in patients with ureteral stents (n = 32) than in patients without (n = 42), averaging 10 mg versus 24 mg MS, respectively (P = 0.01). KT was not associated with adverse events such as bleeding. MS was more likely to cause oversedation and nausea or vomiting, necessitating naloxone and antiemetic therapy, respectively.nnnCONCLUSIONSnThe use of KT was safe and effective for premedication before ESWL; patients receiving KT before ESWL reported lower pain scores and required less supplemental analgesia requirement than those who received MS or Emla; however, the differences were not statistically significant. Patients receiving Emla recorded the highest pain scores. Patients with ureteral stents had lower pain scores and required less supplemental analgesia.

INSIGHT INTO MECHANISM OF NEODYMIUM: YTTRIUM-ALUMINUM-GARNET LASER PROSTATECTOMY UTILIZING THE HIGH-POWER CONTACT-FREE BEAM TECHNIQUE*

OBJECTIVESnThe objective of this study was to define the actual mechanism of neodymium: yttrium-aluminum-garnet (Nd:YAG) laser prostatectomy achieved with the previously described contact-free beam technique using the Ultraline delivery system at high-power settings.nnnMETHODSnTransurethral Nd:YAG laser application was performed with the Ultraline side-firing laser fiber in canine and human prostates. Total or radical prostatectomy was performed after laser treatment to examine and measure laser tissue effects produced using the contact-free beam technique.nnnRESULTSnMinimal actual tissue evaporation or vaporization was noted in either the canine or human prostate using this technique. The extent of tissue vaporization achieved was probably insufficient to produce clinically significant voiding outcomes acutely or chronically. However, this technique, using the Nd:YAG laser, produced excellent tissue coagulation and necrosis, similar to other laser delivery systems and reports dealing with laser coagulation prostatectomy.nnnCONCLUSIONSnThe primary mechanism accounting for therapeutic efficacy of the contact-free beam technique for Nd:YAG laser prostatectomy utilizing the Ultraline delivery system at high-power settings appears to be tissue coagulation with subsequent necrosis and slough, rather than tissue vaporization. This is consistent with the known tissue effects of the Nd:YAG laser wavelength in other systems.

Familial occurrence of thyroglossal duct cyst

Persistence and dilation of the embryologic thyroglossal tract gives rise to the condition of thyroglossal duct cyst. Although these cysts have an embryologic origin, there is rarely a history of inheritance. A search of the literature shows only two family reports, which includes a total of nine patients. We report on a third family with thyroglossal duct cyst in two members. The patients were female siblings aged 2 and 6 years, both of whom underwent successful surgical excision of their thyroglossal duct cysts by modified Sistrunks technique.

The Effect of Bacteriuria on Bladder and Renal Pelvic Pressures in the Rat

We investigated the effect of urinary tract infection on bladder and renal pelvic urodynamics in a rat model to examine the role of pressure during infection. Either an antibiotic solution (control group) or Escherichia coli with type 1 pili (infected group) was instilled into the bladder. After 2 to 6 days simultaneous continuous bladder and renal pelvic pressures were measured during urinary flows from less than 2 to greater than 20 ml./kg. per hour while the bladder filled and emptied. Bladder pressures from 50 to 100% of maximum capacity and maximum voiding pressures were significantly higher in the infected group than the control group (36.7 +/- 6.79 cm. water versus 25.5 +/- 5.21 cm. water, respectively, p less than 0.0001). Renal pelvic pressures were significantly higher in the infected group during bladder filling at all urinary flows examined and actually exceeded bladder pressure for the highest flows. We conclude that elevated renal pelvic pressures may contribute to renal changes observed during urinary tract infection.

A unique perineal herniation of large bladder diverticulum: successful surgical repair through posterior sagittal approach

We report a case of symptomatic perineal herniation of a massive posterior bladder diverticulum following abdominoperineal resection in a 75-year-old man with Crohns disease and renal failure. Presentation, evaluation, and management issues are discussed.