W. Scott McDougal

Treatment of Carcinoma of the Penis: The Case for Primary Lymphadenectomy

There were 65 patients with squamous cell carcinoma of the penis followed for a minimum of 5 years. Patients with stage I disease uniformly survived with local treatment only. Of the patients with stages II and III carcinoma of the penis 88 and 66 per cent, respectively, were free of disease if lymphadenectomy was performed shortly following treatment of the primary lesion, compared to only 38 and 0 per cent, respectively, if the primary lesion was treated locally and no lymphadenectomy was performed. These data support the concept that lymphadenectomy should be an integral part of the primary treatment in patients with stages II and III penile cancer.

National Institutes of Health state-of-the-science conference statement: prevention of fecal and urinary incontinence in adults.

The ramifications of fecal incontinence and urinary incontinence extend well beyond their physical manifestations. To promote work that will reduce suffering and costs attributable to fecal and uri...

Carcinoma of Penis: Improved Survival by Early Regional Lymphadenectomy Based on Histological Grade and Depth of Invasion of Primary Lesion

PURPOSE This study was performed to validate a new staging system and support the concept of early regional lymphadenectomy based on this system. MATERIALS AND METHODS A total of 76 cases from 4 teaching hospitals was reviewed. RESULTS Of 24 patients with well or moderately differentiated noninvasive primary tumors 1 had regional metastases compared to 43 of 52 patients with poorly differentiated or invasive tumors. CONCLUSIONS By classifying disease according to the depth of invasion and degree of differentiation of the primary lesions a high degree of accuracy could be obtained in predicting the likelihood of positive groin nodes. Removing groin nodes that are microscopically positive improves the survival rate over that of delayed lymphadenectomy.

Long-Term Oncologic Outcomes After Radiofrequency Ablation for T1 Renal Cell Carcinoma

BACKGROUND Radiofrequency ablation (RFA) of renal cell carcinoma (RCC) is used to obtain local control of small renal masses. However, available long-term oncologic outcomes for RFA of RCC are limited by small numbers, short follow-up, and lack of pathologic diagnoses. OBJECTIVE To assess the oncologic effectiveness of RFA for the treatment of biopsy-proven RCC. DESIGN, SETTING, AND PARTICIPANTS Exclusion criteria included prior RCC or metastatic RCC, familial syndromes, or T2 RCC. We retrospectively reviewed long-term oncologic outcomes for 185 patients with sporadic T1 RCC. Median follow-up was 6.43 yr (interquartile range [IQR]: 5.3-7.7). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The chi-square test and Wilcoxon rank-sum tests were used to compare proportions and medians, respectively. Disease-specific survival and overall survival (OS) were calculated using Kaplan-Meier analysis, then stratified by tumor stage, and comparisons were made using log-rank analysis. The 5-yr disease-free survival (DFS) and OS rates are reported. A p value <0.05 was considered statistically significant. RESULTS AND LIMITATIONS Median tumor size was 3 cm (IQR: 2.1-3.9 cm). Tumor stage was T1a: 143 (77.3%) or T1b: 42 (22.7%). Twenty-four patients (13%) were retreated for residual disease. There were 12 local recurrences (6.5%), 6 recurrences in T1a disease (4.2%) and 6 in T1b disease (14.3%) (p=0.0196). Median time to recurrence was 2.5 yr. Local salvage RFA was performed in six patients, of whom five remain disease free at 3.8-yr median follow-up. Tumor stage was the only significant predictor of DFS on multivariate analysis. At last follow-up, 164 patients (88.6%) were disease free (T1a: n=132 [92.3%]; T1b: n=32 [76.2%]; p=0.0038). OS was similar regardless of stage (p=0.06). Five patients developed metachronous renal tumors (2.7%). Four patients developed extrarenal metastases (2.2%), three of whom died of metastatic RCC (1.6%). CONCLUSIONS In poor surgical candidates, RFA results in durable local control and low risk of recurrence in T1a RCC. Higher stage correlates with a decreased disease-free survival. Long-term surveillance is necessary following RFA. Patient selection based on tumor characteristics, comorbid disease, and life expectancy is of paramount importance.

Evaluation of NMP22 in the detection of transitional cell carcinoma of the bladder

PURPOSE Urinary nuclear matrix protein (NMP22) was evaluated for detection of new and recurrent bladder tumors in patients with a history of transitional cell carcinoma. Our objective was to determine sensitivity and specificity of this marker for tumors of various stages and grades, as well as its use as an adjunct to or substitute for urinary cytology. MATERIALS AND METHODS A total of 231 patients with a history of transitional cell carcinoma provided 288 voided urine samples before cystoscopic examination at 1 of 3 institutions (53 patients were reevaluated at least once). Urine samples were assayed for NMP22 using the NMP22 Test Kit. Select patients underwent biopsy with appropriate additional therapy. Voided urinary cytology was obtained in 200 cases. End points for determination of the absence and presence of tumor were negative cystoscopy and positive biopsy, respectively. A receiver operating characteristics curve was constructed to determine the optimal NMP22 threshold for detection of transitional cell carcinoma. For positive biopsies NMP22 values were also correlated with tumor stage and grade. Comparison to cytology was limited to patients with complete data. RESULTS There were 208 negative cystoscopies (158 with cytology) and 66 positive cystoscopies with biopsy (42 with cytology). Of the cases 14 were eliminated from statistical analysis due to incomplete data. Receiver operating characteristics curve interpretation determined that 6.4 units per ml. was an optimal reference value for detection of transitional cell carcinoma in this patient group. Sensitivity and specificity for all pathological groupings was 68 and 80%, respectively. When compared to cytology the sensitivities of NMP22 and cytology were 67 versus 31 or 40% (depending on the definition of positive cytology). CONCLUSIONS NMP22 values represented significant improvement over urinary cytology for detection of transitional cell carcinoma. The sensitivity of NMP22 for detection of transitional cell carcinoma in bladder cancer patients was as much as twice that of cytology when a reference value of 6.4 units per ml. was used. NMP22 analysis was less costly than cytology and operator independent. While NMP22 has previously been shown to be a strong predictor of recurrence after tumor resection, it is an effective and sensitive screening test for detecting tumors in patients with transitional cell carcinoma.

Metabolic Characterization of Human Prostate Cancer with Tissue Magnetic Resonance Spectroscopy

Diagnostic advancements for prostate cancer have so greatly increased early detections that hope abounds for improved patient outcomes. However, histopathology, which guides treatment, often subcategorizes aggressiveness insufficiently among moderately differentiated Gleason score (6 and 7) tumors (>70% of new cases). Here, we test the diagnostic capability of prostate metabolite profiles measured with intact tissue magnetic resonance spectroscopy and the sensitivity of local prostate metabolites in predicting prostate cancer status. Prostate tissue samples (n = 199) obtained from 82 prostate cancer patients after prostatectomy were analyzed with high-resolution magic angle spinning proton magnetic resonance spectroscopy, and afterwards with quantitative pathology. Metabolite profiles obtained from principal component analysis of magnetic resonance spectroscopy were correlated with pathologic quantitative findings by using linear regression analysis and evaluated against patient pathologic statuses by using ANOVA. Paired t tests show that tissue metabolite profiles can differentiate malignant from benign samples obtained from the same patient (P < 0.005) and correlate with patient serum prostate-specific antigen levels (P < 0.006). Furthermore, metabolite profiles obtained from histologically benign tissue samples of Gleason score 6 and 7 prostates can delineate a subset of less aggressive tumors (P < 0.008) and predict tumor perineural invasion within the subset (P < 0.03). These results indicate that magnetic resonance spectroscopy metabolite profiles of biopsy tissues may help direct treatment plans by assessing prostate cancer pathologic stage and aggressiveness, which at present can be histopathologically determined only after prostatectomy.

Spontaneous Rupture of the Kidney with Perirenal Hematoma

Spontaneous rupture of the kidney involves either the collecting system or parenchyma, the latter being associated with a subcapsular or perirenal hematoma. A review was made of 78 cases of spontaneous parenchymal rupture with perirenal hematoma, including 4 of our own. One of these cases is the first description of spontaneous rupture of the kidney secondary to renal vein thrombosis. The patients are usually in the fourth decade of life and present with an acute onset of flank pain, a tender mass and commonly symptoms and signs of shock. Hematuria is often present and generally urography reveals a mass, distorted collecting system and/or non-visualization of the kidney. Tumors are the most common cause followed by vascular diseases, infection, nephritis and blood dyscrasias. Nephrectomy when possible should be performed expeditiously since conservative therapy is uniformly unsuccessful.

Long-Term Metabolic Effects of Urinary Diversion: A Comparison of Myelomeningocele Patients Managed by Clean Intermittent Catheterization and Urinary Diversion

We previously reported that chronic urinary diversion through intestinal segments may have adverse effects on bone and mineral metabolism. This study examined the long-term health of patients managed by urinary diversion (94% by ileal conduit) for neuropathic bladders secondary to myelomeningocele defects and compared them to a control population of myelomeningocele patients managed by intermittent catheterization. Of the patients 93 were studied by personal interview, chart review, morphometric analysis, serum studies and dual-photon bone density determination. Average followup was 23 +/- 6 years in the urinary diversion group and 17 +/- 5 years in the intermittent catheterization group. Fractures occurred in 40% of the patients in both groups. Patients with a urinary diversion had an increased need for surgery to correct spinal curvature (57% versus 40%) and a significantly increased incidence of complications resulting from orthopedic procedures (17% versus 3%, p less than or equal to 0.05). There was also an adverse effect on renal function. The urinary diversion group had an increased incidence of radiographic renal deterioration (57% versus 8%, p less than 0.001), nephrolithiasis (43% versus 2%, p less than 0.001), pyelonephritis (60% versus 21%, p less than 0.001) and intermittent metabolic acidosis (20% versus 5%, p = 0.05). Surgery was required in 37% for stomal complications and in 17% for ureterointestinal stricture. Linear growth was adversely affected by urinary diversion. Patients with urinary diversion had decreased lengths for all morphometric parameters and a greater percentage of them were at or below the 10th percentile standards. Serum electrolytes, liver function studies, vitamin D3 and parahormone showed no differences in the 2 groups. No patient had a significant metabolic acidosis at the time of study. Bone densities were significantly diminished in both groups and not significantly different. This study strongly suggests that urinary diversion through intestinal segments is associated with adverse effects on bone health.

Immediate management of prostatomembranous urethral disruptions

We present 33 patients with complete prostatomembranous urethral disruptions: 20 were managed by immediate realignment, while 13 were managed by initial cystotomy and delayed urethroplasty. Techniques for immediate realignment are described. Immediate realignment of complete prostatomembranous disruptions resulted in an overall potency rate of 80% compared to only 50% in patients who underwent delayed repair. In addition, there was an increased need for a secondary operation when the repair was delayed. Continence rates were excellent and similar in both groups. Immediate urethral realignment as described results in impotence and incontinence rates that are comparable to or better than delayed repair techniques without the need for multiple surgical procedures.

Synergistic gangrene of the scrotum and penis secondary to colorectal disease.

We recently encountered 5 patients with synergistic gangrene of the genitalia secondary to colorectal disease. This number of cases suggests that there may be an increasing incidence of this entity that has been reported only several times in the past. Pseudomonas was one of the organisms cultured in all cases. Because of the high mortality rate we advocate aggressive therapy, consisting of early and repeated radical débridement into normal tissues and appropriate management of the colorectal source of contamination. Our experience indicates that the lower gastrointestinal tract should be considered as a possible cause of infection in all cases of synergistic gangrene of the scrotum and penis.