Thomas J. Stillwell

Cyclophosphamide-induced hemorrhagic cystitis. A review of 100 patients.

Cyclophosphamide is an alkylating agent used intravenously or orally in the treatment of both malignant and nonneoplastic diseases. A known adverse effect of such treatment is hemorrhagic cystitis. A series of 100 patients with hemorrhagic cystitis induced by cyclophosphamide was studied. Major symptoms were gross hematuria (78%) and irritative voiding symptoms (45%). Microhematuria developed in 93% of patients. Hemorrhagic cystitis developed at significantly lower doses and shorter durations of therapy in patients treated intravenously than in patients treated orally. Cystectomy was required in nine patients and bladder cancer developed in five. Urine cytologic study, urinalysis, and cystoscopy are important in the diagnosis of hemorrhagic cystitis, and these studies plus periodic excretory urography are important for surveillance. In addition, new methods of protecting against the urotoxicity are available.

Renal Lesions in Tuberous Sclerosis

The renal lesion classically associated with tuberous sclerosis is angiomyolipoma. Renal cysts are less frequent, occurring alone or in conjunction with angiomyolipomas. We reviewed the records of 274 patients with tuberous sclerosis registered at our clinic. Of 95 patients evaluated for renal lesions 51 (54 per cent) had positive findings: 45 had angiomyolipomas, 17 had renal cysts and 11 had both lesions. These lesions usually are multiple and bilateral, and are diagnosed most effectively with computerized tomography or ultrasound. Surgery (10 kidneys) was done for life-threatening hemorrhage or suspected malignant lesions.

Endometriosis of ureter

Endometriosis, a common gynecologic problem, affects up to 15 per cent of menstruating women.’ The disorder occurs more frequently in nulliparous women or women of low parity than in those of higher parity. Its incidence appears to be increasing with the current trend toward smaller families.2,3 Urinary tract involvement occurs in 1.2 per cent of cases, the bladder, ureter, and kidney being affected in a ratio of 40:5:1.4.5 More than 100 cases of ureteral obstruction secondary to endometriosis have been recorded; however, this number probably is an underestimation because of the silent way in which obstructive uropathy can occur.6 A striking nephrectomy rate-as high as 43 per cent-has been reported;7 thus, compulsive surveillance of premenopausal women with endometriosis is mandatory. We present a case of endometriosis of the ureter that produced severe hydroureteronephrosis necessitating nephroureterectomy. The current literature is reviewed, and treatment recommendations are proposed.

The Clinical Spectrum of Granulomatous Prostatitis: A Report of 200 Cases

Granulomatous prostatitis, reviewed in 200 tissue-diagnosed cases, occurred in 0.8 per cent of the benign inflammatory prostatic specimens. Often the disease followed a recent urinary tract infection (71 per cent) and was suspicious clinically for prostatic cancer (59 per cent). The diagnosis usually was made by needle biopsy or at transurethral prostatectomy (94 per cent). Most cases of granulomatous prostatitis were classified as nonspecific. The recently identified entity of post-transurethral resection granulomatous prostatitis was found in 49 patients. A proposed new category of granulomatous prostatitis that is secondary to systemic granulomatous diseases was documented in 6 patients. Most cases of granulomatous prostatitis resolved spontaneously and required no specific therapy.

Prostatic Involvement in Wegener’s Granulomatosis

Wegeners granulomatosis involving the prostate gland is unusual. We report 3 cases of this condition in which typical necrotizing granulomas with vasculitis were seen histologically. These lesions may cause gross hematuria or obstructive voiding, including urinary retention. Management includes prostatectomy when the symptoms are severe but an initial trial of aggressive medical therapy may be successful. Treatment requires a knowledge of the natural history of Wegeners granulomatosis and its usual response to medical therapy.

Incidental Adenocarcinoma After Open Prostatic Adenectomy

Adenocarcinoma of the prostate occasionally is discovered incidentally in the enucleated gland at open prostatic adenectomy for benign disease. Among 468 men who underwent open prostatic adenectomy, unsuspected adenocarcinoma of the prostate was found on pathological examination in 28 (6.0 per cent). The tumors were stage A1 in 14 patients and stage A2 in 14. Careful tissue review resulted in reassigning 5 cases from stage A1 to stage A2. At a mean followup of 10.6 years disease progression had occurred in 4 patients with stage A2 disease. When stage A adenocarcinoma is discovered after open prostatectomy we recommend careful review of the surgical specimen for accurate staging, and adjuvant therapy for all patients with stage A2 disease an for younger patients (less than 65 years old) with stage A1 disease who have favorable life expectancies.

Amyloidosis of the Urethra

Primary, localized amyloidosis of the urethra is rare. The patient usually presents with hematuria and the appearance of urethral carcinoma. However, the disease is benign and it is treated effectively with local removal. We report our experience with 5 cases.

Neodymium:YAG Laser Treatment of Cystitis Glandularis

We report a case of severe cystitis glandularis of the entire bladder, which caused a large retrovesical mass and bilateral hydronephrosis. Treatment included whole bladder neodymium:YAG laser therapy, a technique not previously reported for this extent of disease. The etiology, diagnosis, treatment and malignant potential of cystitis glandularis are discussed.

Bladder carcinoma presenting with rectal obstruction

Two patients with bladder carcinoma that caused annular constriction of the rectum are described. A mechanism of local invasion by genitourinary malignancies (bladder and prostate) involves penetration of the rectovesical fascia of Denonvillier and circumferential rectal spread. Treatment of complete or partial obstructing lesions includes surgery, radiotherapy, or chemotherapy (or combination), as well as several new techniques, notably laser destruction and transrectal tumor resection.

Adenomatous polyp in defunctionalized colonic segment used as a urinary bladder

For transitional cell carcinoma of the urinary bladder, an eighty-two-year-old man underwent cystoprostatectomy. His urine was diverted to a defunctionalized right colonic segment used to replace his bladder. Four months after the surgery, gross hematuria appeared; endoscopy disclosed an adenomatous polyp in the substitute bladder. We review the incidence and origin of neoplasia in colonic segments used for urinary diversion.