Nehemia Hampel

Fournier’s Gangrene: Report of 20 Patients

Synergistic necrotizing fasciitis of the penis and scrotum was described first by Fournier and remains a rare but life-threatening disease. In Fourniers initial description the process was believed to be idiopathic. During the last 10 years we have treated 20 patients with Fourniers gangrene and a definite urologic or colorectal cause could be identified as the source of the infection in 19 (95 per cent). Despite the use of broad-spectrum antibiotics and aggressive surgical débridement the mortality rate was 45 per cent.

CURRENT INDICATIONS FOR OPEN STONE SURGERY IN THE TREATMENT OF RENAL AND URETERAL CALCULI

PURPOSE The development and advances in extracorporeal shock wave lithotripsy and endourological procedures have greatly diminished the need for open surgery in the treatment of renal and ureteral stones. We reviewed our experience with open stone surgery to determine the current indications and efficacy of this treatment modality. MATERIALS AND METHODS Hospital and office charts, operative notes and records, and pertinent radiographic studies of all patients undergoing open stone surgery from January 1991 through December 1995 at 3 university affiliated hospitals were reviewed. Patient characteristics, stone burden, indications, surgical factors and outcomes were reviewed for each patient. RESULTS Of 780 procedures performed for stone removal, 42 were open surgical procedures (5.4%) including pyelolithotomy in 15 (extended pyelolithotomy or pyelonephrolithotomy in 7), anatrophic nephrolithotomy in 14, ureterolithotomy in 7 and radial nephrolithotomy in 6. There were 24 men and 18 women ranging in age from 1 to 90 years (mean age 51.5). The most common indications for open surgery were complex stone burden (55%); failure of extracorporeal shock wave lithotripsy or endourological treatment (29%); anatomic abnormalities such as ureteropelvic junction obstruction, infundibular stenosis and/or renal caliceal diverticulum (24%); morbid obesity (10%) and co-morbid medical disease (7%). Mean estimated blood loss was 428 cc. Average hospital stay was 6.4 days. The stone-free rate after surgery was 93%. Five patients had minor postoperative complications that resolved with appropriate therapy. CONCLUSIONS While most patients with renal and ureteral stones can be treated with less invasive techniques, open stone surgery continues to represent a reasonable alternative for a small segment of the urinary stone population.

Spinal Cord Compression Secondary to Prostate Carcinoma: Treatment and Prognosis

Of 35 patients with prostate carcinoma and suspected spinal cord compression 26 (74%) had myelograms and/or magnetic resonance imaging studies demonstrating epidural spinal cord compression. In 5 of 26 patients (19%) spinal cord compression was the first indication of prostate cancer. All patients were initially treated with radiation, steroids and androgen deprivation therapy. Three patients underwent laminectomy. Of 12 patients (100%) ambulatory at presentation 12 remained ambulatory. Of 12 patients (83%) who were paraparetic at presentation 10 were ambulatory after treatment. However, 2 of these patients subsequently had recurrent compression and became paraplegic. Overall, 7 of 26 patients (27%) had recurrent compression. Of 5 patients who either presented with paraplegia or in whom paraplegia developed secondary to recurrent spinal cord compression 4 remained paraplegic despite treatment. The average survival of these 5 patients after treatment was 3.9 months versus 18 months for the group as a whole. In ambulatory or paraparetic patients radiation, androgen deprivation therapy and steroids are effective palliative therapy. However, patients who present with paraplegia or in whom paraplegia developed secondary to recurrent compression are often not palliated by this combination therapy. Prophylactic radiation of vertebral metastases discovered concurrently with compressive metastases may be valuable in preventing paraplegia.

COCAINE ASSOCIATED PRIAPISM

PURPOSE Cocaine abuse is an ongoing epidemic in the United States. Priapism associated with cocaine use has been reported only twice in the urological literature. To our knowledge we report the first series of priapism associated with cocaine use and the first case associated with the use of this drug in its solid form, known as crack. MATERIALS AND METHODS We retrospectively reviewed the presentation of 3 patients to our emergency department within the last year. Each patient presented with priapism and no identifiable predisposition other than the use of cocaine within 24 hours, as evident on positive urine toxicology. RESULTS Each patient delayed seeking treatment, which added to the complexity of therapy. Intracavernosal aspiration and irrigations failed in all 3 cases. Cavernous spongiosal shunting failed in the first 2 cases. Cases 2 and 3 were complicated by the high flow variant of priapism. Case 1 ultimately required partial penectomy for infected, gangrenous, distal penile tissue. CONCLUSIONS It appears that cocaine can be a cause of refractory priapism and treatment can be challenging. We suggest that urine toxicology screening be considered in such cases. The identification of underlying cocaine abuse is important in preventing priapism recurrence in these patients.

The accuracy of the increased prostate specific antigen level (greater than or equal to 20 ng./ml.) in predicting prostate cancer: Is biopsy always required?

PURPOSE Urologists are often referred patients who initially present with an extremely high serum prostate specific antigen (PSA) level. Despite a presumptive diagnosis of prostate cancer, many of these men undergo biopsy to obtain a tissue diagnosis before treatment with androgen ablative therapy. We examined a data base of men undergoing prostate biopsy to determine the accuracy of high PSA levels (greater than or equal to 20 ng./ml.) in predicting prostate cancer. MATERIALS AND METHODS We reviewed the records of 1,250 consecutive patients undergoing transrectal ultrasound guided prostate biopsy at 1 institution. From this data base we identified all patients with PSA greater than or equal to 20 ng./ml. at the time of prostate biopsy. The accuracy of PSA in predicting cancer was determined by calculating positive predictive values for PSA ranges and PSA cutoffs. RESULTS We identified 187 men (15%) presenting with PSA greater than or equal to 20 ng./ml. Of these 187 men 157 (84.0%) were diagnosed with prostate cancer on initial biopsy. Due to a negative initial biopsy, yet a high suspicion of cancer, 12 (6.4%) patients underwent at least 1 repeat biopsy. Of these 12 men 6 (50%) were diagnosed with cancer on repeat biopsy. Overall, 163 of the 187 men (87.2%) were diagnosed with prostate cancer by biopsy. Stratified by PSA ranges, positive predictive values were 73.6% for 20 to 29.9, 90.3% for 30 to 39.9, 93.8% for 40 to 49.9, 100% for 50 to 99.9, 95% for 100 to 199.9 and 100% for greater than or equal to 200 ng./ml. Using PSA cutoffs positive predictive values were 95.7% for PSA greater than or equal to 30, 97.6% for PSA greater than or equal to 40 and 98.5% for PSA greater than or equal to 50 ng./ml. CONCLUSIONS Serum PSA, when increased above 50 ng./ml., is 98.5% accurate in predicting the presence of prostate cancer on tissue biopsy. Nonetheless, since transrectal prostate biopsy has a low complication rate and is relatively well tolerated, we recommend continuing to biopsy most patients with high PSA levels. However, carefully selected elderly patients on chronic anticoagulation, with severe co-morbidities or presenting with spinal cord compression may not require biopsy before androgen ablative therapy since PSA is highly accurate in diagnosing prostate cancer at levels greater than 50 ng./ml.

Ureteral Injuries Complicating Vascular Surgery: Is Repair Indicated?

We have managed 8 patients who sustained an iatrogenic ureteral injury during either placement or revision of a vascular graft. Primary repair was performed in all 5 patients diagnosed at injury. Persistent extravasation necessitating nephrectomy occurred in 2 of these patients. The diagnosis was delayed in 3 patients. Two patients underwent successful ureteral reconstruction and 1 required nephrectomy. Graft complications did not occur. Ureteral repair is recommended as the preferred method to manage ureteral injuries associated with vascular reconstruction.

Giant Multilocular Prostatic Cystadenoma: A Rare Clinical Entity and Review of the Literature

Giant multilocular prostatic cystadenoma is a pathologically benign entity. To our knowledge only 3 cases have been reported in the literature, of which 2 were treated by means of pelvic exenteration. These lesions can occur in men of various ages, arise from the prostate and grow to massive proportions. Histologically the tumor is comprised of benign cysts lined with cuboidal and columnar epithelium. The lesions do not invade contiguous structures but they can be adherent to viscera in their proximity. Giant multilocular prostatic cystadenoma as demonstrated by our case is a benign entity that can be definitively treated by carefully planned complete surgical excision.

Primary lymphosarcoma of prostate

A case of primary lymphosarcoma of the prostate in a seventy-one-year-old patient is presented. He had palliative surgical treatment and radiotherapy but died seven months later of heart failure with signs of metastatic disease. Treatment of this condition should include surgery and irradiation. Only its early discovery might change the prognosis.

Percutaneous Nephrostomy and Ureteral Injury

The courses of 6 patients with various forms or ureteral injury and disruption herein illustrate the value and worth of percutaneous nephrostomy drainage and study. The nature and degree of injury are ascertained, and sepsis and obstruction are managed without formal anesthesia or surgical intervention, leading to ultimate repair in a planned and orderly fashion.

Value of 67Gallium scintigraphy in the diagnosis of localized renal and perirenal inflammation.

Eight patients with renal or perirenal abscesses were evaluated by 67gallium scintigraphy. The correlation of localized 67gallium uptake to the inflammatory lesion was proved by tissue diagnoses in 7 patients and by response to treatment and repeated studies in the remaining case. 67Gallium scanning was found to be an accurate, non-invastive technique. It should be applied early in diagnosing inflammatory lesions of the retroperitoneum and for examining fever of unknown origin.