Richard K. Babayan

Radical prostatectomy for adenocarcinoma of the prostate: The influence of preoperative and pathologic findings on biochemical disease-free outcome

OBJECTIVE This retrospective study evaluated the outcome for a cohort of men undergoing radical retropubic prostatectomy alone as primary treatment for clinical T1-2 prostate adenocarcinoma. METHODS Sixty-two patients treated at Boston University Medical Center between 1987 and 1992 underwent radical prostatectomy alone without adjuvant or neoadjuvant endocrine therapy. Actuarial and multivariate analyses were made of disease-free outcome according to preoperative tumor T stage, prostate-specific antigen (PSA), and biopsy grade, and according to the pathologic findings at surgery. Recurrence was defined as the persistence or recurrence of detectable serum PSA four or more weeks following surgery. RESULTS Of all patients judged clinically to have localized disease (T1-2), 52 percent proved to have pathologic T3 tumors. Of these, 81 percent had positive surgical margins. The strongest preoperative predictors of pT3 disease were the biopsy Gleason grade and the initial serum PSA value. Actuarial analysis showed the overall likelihood of remaining free from detectable PSA at four years to be 43 percent (75% for those with organ-confined disease and 27% for those who were pT3). The poorest prognosis was seen in those with seminal vesicle involvement. Biopsy Gleason grade and initial PSA were independent preoperative predictors of biochemical failure in a Cox regression analysis but clinical T stage was not. CONCLUSIONS The biopsy Gleason grade and initial PSA were identified as strong preoperative predictors of disease-free outcome. We confirmed the favorable prognosis of men with organ-confined disease, but emphasize the high likelihood of relapse in those with positive surgical margins or seminal vesicle invasion.

Transurethral ultrasound-guided laser-induced prostatectomy: National Human Cooperative study results.

Between November 1990 and March 1992, 150 patients at 10 United States institutions were treated with transurethral ultrasound-guided laser-induced prostatectomy (TULIP) for the relief of bladder outlet obstruction secondary to benign prostatic hypertrophy. The TULIP system incorporates ultrasound visualization with a 90-degree angle, side-firing laser to effect coagulation necrosis of prostate tissue. The overall preoperative prostate volume in this TULIP study was 40 cc and all types of prostatic enlargement, including median lobe obstruction, were treated. There were no intraoperative complications, with no hemorrhage or post-transurethral resection syndrome, and no blood transfusions were required. Hospital stay averaged 1.7 days and 83% of the patients went home after a 1-night stay. We evaluated 63 patients at 6 months after the TULIP procedure. Mean symptom scores decreased from 18.8 to 6.1, for a 68% improvement. The mean peak flow increased from 6.7 ml. per second preoperatively to 11.9 ml. per second, for a 78% improvement. Overall, 87% of the patients exhibited at least 50% improvement in either the symptom score or peak flow parameter, while 49% of the patients demonstrated at least a 50% improvement in both parameters.

Is a Safety Wire Necessary During Routine Flexible Ureteroscopy

BACKGROUND AND PURPOSE The use of flexible ureteroscopy (URS) for nephrolithiasis has been rapidly expanding. Initially, safety guidewires were maintained alongside the ureteroscope during stone manipulation to prevent loss of access and allow stent insertion in the event of perforation. We intend to determine the safety of flexible URS without a separate safety guidewire in a large series of patients. METHODS A retrospective chart review was performed on all cases of flexible URS with laser lithotripsy performed by a single surgeon from August 2003 to May 2008. Preoperative patient characteristics, radiographic stone sizes, operative findings, and postoperative outcomes were recorded. Patients with renal or ureteropelvic junction (UPJ) stones were isolated for a qualitative data analysis. RESULTS Flexible URS was performed on 305 kidneys in 246 consecutive patients, of which 59 cases were bilateral. Cases were subdivided into complicated and uncomplicated. Two hundred seventy cases were uncomplicated and performed without a safety guidewire. No intraoperative complications resulted from the lack of a safety guidewire, including no cases of lost access, ureteral perforation/avulsion, or need for percutaneous nephrostomy tube. Thirty-five cases were complicated, necessitating a safety guidewire. Of these, 16 had concomitant obstructing ureteral stones, 5 had encrusted ureteral stents, and 14 had difficult access because of large stone burden or aberrant anatomy. CONCLUSIONS This study demonstrates that, in a large series of patients, a safety guidewire was not necessary for routine cases of flexible URS with laser lithotripsy on renal or UPJ stones. Particular cases with complicated anatomy, difficult access, concomitant ureteral stones, simultaneous stone basketing, or bulky stone burden still necessitate use of a safety guidewire because of increased risk of adverse outcomes.

Corticosteroid use after prostate brachytherapy reduces the risk of acute urinary retention.

To evaluate the role of short‐term steroids after prostate brachytherapy to reduce oedema and thus the risk of urinary retention associated with brachytherapy, as this can require surgical intervention and may even result in incontinence.

Inguinal node metastases from testicular tumors in patients with prior orchiopexy.

Testicular tumors in patients who have had the lymphatics disrupted by prior scrotal or inguinal surgery can metastasize primarily to the ipsilateral inguinal nodes in addition to the usual retroperitoneal pattern. Whether routine inguinal node dissection along with retroperitoneal node dissection is warranted in patients with testicular tumors and prior scrotal surgery is controversial due to the small numbers of such cases reported in the literature. We report on 2 patients who had undergone previous orchiopexy and who presented with inguinal and testicular masses. Both patients underwent retroperitoneal lymph node dissection and inguinal node dissection with hemiscrotectomy and metastatic tumor was in each lymphatic area. Ipsilateral inguinal along with bilateral retroperitoneal node dissection should be considered in the primary therapy of any patient with a nonseminomatous testicular tumor who has had prior scrotal and certain inguinal procedures.

Vasectomy: What are community standards?

Vasectomy has become an increasingly popular mode of contraception in our society. It is also a procedure which places the urologist at an uncommonly high risk for litigation. To better assess the manner in which urologists within a geographical region treat their vasectomy patients, a survey was conducted of the members of the New England Section, American Urological Association. The results of that survey are presented.

Triamterene Nephrolithiasis: Renewed Attention is Warranted

Although triamterene has been known to contribute to urinary calculus formation, it has been presumed to be a rare phenomenon. Our review of stone analyses performed during the last decade by a single laboratory reveals an increasing incidence of triamterene stones. Awareness of the calculogenic potential of triamterene-containing medications should be re-emphasized.

Hematuria and the Use of Nonsteroidal Anti-Inflammatory Drugs

We reviewed 116 consecutive adults hospitalized for hematuria (92 with gross and 24 with microscopic hematuria). The cause of hematuria (that is neoplasia, stones, infection and inflammation) was recognized in approximately 79 per cent of the 116 patients (group 1), while 21 per cent (group 2) had idiopathic hematuria. Review of drug history in these 2 groups revealed that nonsteroidal anti-inflammatory drugs were used in 1 per cent of the patients in group 1 compared to 54 per cent in group 2. To confirm these findings we reviewed a control group of 60 patients without hematuria hospitalized for benign prostatic hyperplasia and followup of bladder tumors, and found a 3.3 per cent prevalence of nonsteroidal anti-inflammatory drugs. These findings implicate nonsteroidal anti-inflammatory drug use as a potential cause of idiopathic hematuria.

Primary Angiosarcoma of the Seminal Vesicle

We report on an unusual case of primary angiosarcoma of the seminal vesicle. Diagnosis was confirmed by light and electron microscopy, as well as specific immunohistochemical staining. This rare tumor is highly aggressive, and refractory to traditional surgical and adjuvant therapeutic modalities. Sarcomatous lesions of the seminal vesicle are reviewed.

Effect of Body Mass Index on Perioperative Outcomes for Laparoscopic Partial Nephrectomy

BACKGROUND AND PURPOSE Obesity is becoming an increasing problem and is associated with increased incidence of renal-cell carcinoma. We sought to assess the impact of obesity on outcomes of laparoscopic partial nephrectomy for renal masses. PATIENTS AND METHODS We retrospectively reviewed the pathologic and clinical outcomes from January 2004 through August 2010 of consecutive partial nephrectomies that were performed at a single institution. Patients were segregated according to preoperative body mass index (BMI), and outcomes were compared. RESULTS Seventy-eight nonobese (BMI<30), 24 obese (BMI 30-35), and 24 morbidly obese (BMI>35) patients were identified. Obese patients were significantly more likely to be female (66% >35 vs 32% <30). Other baseline characteristics were similar. There was a significant relationship between estimated blood loss (P=0.03) and increasing BMI when compared as a trend. No significant differences were observed in regard to operative time, transfusion rate, complications, or surgical margin status between groups. CONCLUSION Laparoscopic partial nephrectomy can be safely performed in obese patients without significant expected difference in outcomes.