Stephen H. Weinstein

Preliminary Observations on the Results of Combined 125Iodine Seed Implantation and External Irradiation for Carcinoma of the Prostate

Fifty-seven patients with localized carcinoma of the prostate were treated with pelvic lymphadenectomy and a reduced 125iodine implant dosage, supplemented by a moderate dose of external beam radiotherapy to the whole pelvis delivered 4 to 6 weeks later. The incidence of pelvic nodal metastases was 28 per cent and the operative morbidity was 15 per cent. Late radiation sequelae developed in 18 patients, including 15 patients with radiation proctitis (29 per cent), among whom 2 (4.6 per cent) suffered rectal ulceration and required diverting colostomy. Followup has been 2 years or longer (median 33 months) in 26 patients, of whom 22 (85 per cent) are free of disease. Three patients are living with osseous metastases or local disease and there has been 1 death of prostatic carcinoma, for an absolute 2-year survival rate of 95 per cent. Of the 7 patients with poorly differentiated tumor and of the 8 patients with positive pelvic lymph nodes 5 and 6, respectively, remain free of disease after a minimum 2-year followup. Potency has been lost in 20 per cent and reduced significantly in 30 per cent of the patients followed 18 months or longer. Prostatic biopsies on 28 asymptomatic patients 12 to 30 months after completion of therapy showed no tumor in 21 (75 per cent).

Carcinoma of the Prostate Treated by Pelvic Node Dissection, Iodine-125 Seed Implant and External Irradiation" A Study of Rectal Complications

The University of Missouri-Columbia protocol for localised cancer of the prostate calls for pelvic node dissection, 10000 cGy at the periphery of the prostate from 125I and 4000 cGy in 20 fractions to the whole pelvis using supervoltage X-ray therapy. Rectal complications were studied in 104 patients; acute and chronic reactions were defined. During external irradiation 54% did not develop diarrhoea, 43% had mild diarrhoea and 3% had severe diarrhoea. In the chronic stage 77% did not have diarrhoea, 12% had delayed, non-distressing rectal bleeding which did not need specific treatment or needed only simple treatment, 7% had prolonged distressing proctitis and 4% had rectal ulceration or recto-urethral fistula necessitating colostomy. Each of the four patients who had colostomy had an additional aetiological factor (arterial disease, pelvic inflammation, additional radiation, pelvic malignancy or second operation). None of the patients entered in the combined brachytherapy and teletherapy programme, and in whom 0.5 cm space was maintained between the closest seed and the rectal mucosa, developed prolonged proctitis.

Nonpalpable occult testis tumor.

We present a case study of a patient with seminoma who had normal testicles on palpation. Testicular ultrasound is the technique of choice to locate occult nonpalpable testis lesions. We recommend its use in the search for the source of any retroperitoneal mass of undetermined origin.

Percutaneous Decompression: Treatment for Respiratory Distress Secondary to Multicystic Dysplastic Kidney

Multicystic dysplastic kidney is a common renal anomaly in the newborn. Long-term problems, such as pain, infection, hypertension and neoplasm, although infrequent, have been reported. Acute, life-threatening complications resulting from the size of the affected kidney are rare and emergency nephrectomy has been the only reported effective therapy. We present a case of ultrasound-guided percutaneous cyst decompression used as definitive treatment of respiratory failure associated with multicystic dysplastic kidney.

Carcinoma of the prostate irradiated by combined I125 and external, irradiation. Analysis of failure and significance of positive biopsy one year or more after therapy

Sixty-three patients with cancer of the prostate T2 or T3 were evaluated. The protocol of treatment called for pelvic lymphadenectomy, 10,000 rad from I125 implant and 4000 rad in 20 fractions using a Cobalt60 machine. They were followed for 1 to 5 years with a plan to rebiopsy the prostate 1 to 2 years after therapy. Six of 59 evaluable patients (10%) showed progressive disease. Distinctive prognostic features in the failure group were younger age, larger prostate, more advanced stage, poorer differentiation, more possibility of positive pelvic lymph nodes, and if the nodes were positive, the involvement of more than two pelvic lymph nodes. On the other hand, the patients with controlled disease with or without positive prostatic biopsy on follow-up showed identical features regarding age, size of prostate, stage, differentiation, involvement of pelvic lymph nodes, and if the nodes were positive, only one or two nodes involved. Positive biopsy 1 to 2 years after radical irradiation in otherwise controlled disease is considered of no prognostic value.

Late results of combined Iodine-125and external beam radiotherapy in carcinoma of prostate

A total of 96 patients were treated for localized carcinoma of the prostate using combined Iodine-125 (125I) implantation and external beam radiotherapy. The implant was tailored to deliver 10,000 rad to the periphery of the prostate. A significant incidence of serious late rectal complications was observed. Positive pelvic nodes were found in 28 percent of the patients. Disease-free survival at seven years was 76 percent for those with negative nodes and 46 percent for patients with positive nodes.

Renal Transplantation in the End Stage Renal Disease of Drug Abuse

Abstract Intravenous drug abuse may produce end stage renal disease. In a small group of formerly addicted Federal prisoners on dialysis cadaveric renal transplantation has provided an effective alternative to chronic dialysis. This finding may relate to some abrogation of the immune system in such patients.

Use of preoperative embolization prior to Transplant nephrectomy

ABSTRACT Introduction After a failed transplant, management of a non-functional graft with pain or recurrent infections can be challenging. Transplant nephrectomy (TN) can be a morbid procedure with the potential for significant blood loss. Embolization of the renal artery alone has been proposed as a method of reducing complications from an in vivo failed kidney transplant. While this does yield less morbidity, it may not address an infected graft or refractory hematuria or rejection. We elected to begin preoperative embolization to assess if this would help decrease the blood loss and transfusion rate associated with TN. Materials and Methods We performed a retrospective analysis of all patients who underwent non-emergent TN at our institution. Patients who had functioning grafts that later failed were included in analysis. TN was performed for recurrent infections, pain or hematuria. We evaluated for blood loss (EBL) during TN, transfusion rate and length of hospital stay. Results A total of 16 patients were identified. Nine had preoperative embolization or no blood flow to the graft prior to TN. The remaining 7 did not have preoperative embolization. The shortest time from transplant to TN was 8 months and the longest 18 years with an average of 6.3 years. Average EBL for the embolized patients (ETN) was 143.9cc compared to 621.4cc in the non-embolized (NETN) group (p=0.041). Average number of units of blood transfused was 0.44 in the ETN with only 3/9 patients requiring transfusion. The NETN patients had average of 1.29 units transfused with 5/7 requiring transfusion. The length of stay was longer for the ETN (5.4 days) compared to 3.9 in the NETN. No intraoperative complications were seen in either group and only one patient had a postoperative ileus in the NETN. Conclusion Embolization prior to TN significantly decreases the EBL but does not significantly decrease transfusion rate. However, patients do require a significantly longer hospitalization with embolization due to the time needed for embolization. Larger studies are needed to determine if embolization before transplant nephrectomy reduces the transfusion rates and overall complications.

Adult urology: Prospective evaluation of neomycin serum concentrations after direct corpora cavernosa irrigation during penile prosthesis placement

OBJECTIVES To determine if toxic serum levels of neomycin are generated after direct corpora cavernosa irrigation during penile prosthesis placement. METHODS We have used an infection prophylaxis technique that involves directly irrigating the corpora cavernosa tissue (through the corporotomy) with 0.5% neomycin solution. Serum neomycin concentrations were measured at 1 hour and 4 hours after irrigation in 13 patients undergoing penile prosthesis placement. A subset of patients who had preimplant and postimplant serum creatinine concentrations was evaluated for changes in renal function. RESULTS The mean 1-hour postirrigation serum neomycin level was 1.2 micrograms/mL and the mean 4-hour postirrigation level was 1.2 micrograms/mL. These serum neomycin concentrations are lower than those thought to be necessary to produce nephrotoxicity or ototoxicity. Renal function was not significantly affected by the neomycin irrigation. CONCLUSIONS Although aminoglycosides are ototoxic and neomycin has the highest nephrotoxic potential of the aminoglycosides, we conclude that direct irrigation of the corpora cavernosa with 0.5% neomycin solution does not produce significant systemic exposure to result in nephrotoxicity or ototoxicity. One-time prophylactic neomycin irrigation remains an effective, safe, and economic adjunct to penile prosthesis placement.

Case report: Incidental metastatic prostate cancer with undetectable PSA in pelvic lymphadenectomy

We report a patient that had a prior radical prostatectomy and negative PSA levels for two years and subsequently developed bladder cancer requiring radical cystectomy with mixed lymph nodes on final pathology. The nodes were found to be positive for both metastatic urothelial cell carcinoma and metastatic prostatic adenocarcinoma based on immunohistochemical staining. Treatment for metastatic bladder cancer was pursued after radical cystectomy recovery.