William Bihrle

Dramatic rise in prostate-specific antigen after androgen replacement in a hypogonadal man with occult adenocarcinoma of the prostate

We present the case of a hypogonadal patient in whom a 20-fold increase in prostate-specific antigen and a palpable prostatic nodule developed 6 months into the administration of intramuscular testosterone.

Corticosteroid-Associated Fatal Mycobacterial Sepsis Occurring 3 Years after Instillation of Intravesical Bacillus Calmette-Guerin

A case is reported of systemic Mycobacterium bovis infection that occurred 3 years after uneventful instillation of intravesical bacillus Calmette-Guerin (BCG) and after several months of oral prednisone therapy. The literature on delayed BCG infection and the systemic persistence of BCG after intravesical instillation is reviewed. We propose that rarely a reservoir of dormant M. bovis may become established after intravesical therapy. Reactivation infection may later develop in a manner that parallels the natural history of secondary tuberculosis.

Oral bropirimine immunotherapy of bladder carcinoma in situ after prior intravesical bacille Calmette-Guérin

OBJECTIVESnBropirimine is an oral immunomodulator that has demonstrated anticancer activity in transitional cell carcinoma in situ (CIS) in both the bladder and upper urinary tract. Activity also has been documented in patients after prior therapy with bacille Calmette-Guérin (BCG). To more accurately estimate bropirimines efficacy in BCG-resistant bladder CIS, a Phase II trial was performed. A separate analysis was performed in additional patients intolerant of BCG toxicity.nnnMETHODSnPatients received bropirimine 3.0 g/day by mouth for 3 consecutive days, weekly, for up to 1 year. Bladder biopsies and cytologic examination were performed quarterly. Complete response (CR) required negative biopsy and cytology results.nnnRESULTSnTwenty-one of 86 patients entered were not evaluable. CR was seen in 21 (32%; 95th percentile confidence interval [CI], 21% to 44%) of 65 evaluable patients, including 14 (30%, CI 17% to 43%) of 47 BCG-resistant, and 7 (39%, CI 16% to 61%) of 18 BCG-intolerant patients. Overall, by intent-to-treat analysis, CR was thus seen in 21 (24%) of 86 subjects. Most BCG-resistant patients were failures to BCG without relapse, and had received 12 to 36 (median 12) BCG treatments; intolerant patients had received 4 to 11 treatments (median 6). Response duration ranged from 65 to 810 days, with median not yet reached (but greater than 12 months). Thirteen (15%) of 86 stopped bropirimine due to toxicity. Progression to invasive or metastatic disease during or immediately after therapy was documented in only 4 patients (6%), all nonresponders.nnnCONCLUSIONSnBropirimine may be an alternative to cystectomy for some patients with bladder CIS who have failed or have not tolerated BCG. Further evaluation to improve responses and durability is warranted.

Surgical repair of vesicovaginal fistulas

Despite the many controversies surrounding the proper surgical repair of vesicovaginal fistulas, the current methods available allow surgeons to select the procedure best suited for each specific problem. Because each fistula is unique, surgeons will often be required to individually vary their approach and technique. Regardless of whether a transabdominal or transvaginal approach is selected, the concepts of using healthy tissue in tension-free closures and reinforcing the closures in high-risk situations will ensure success nearly all of the time. A urinary diversion should be considered in the rare situation where the fistula has failed even the most technically sound repair.

Complications of retropublic bladder neck suspension

Seven women who underwent the Stamey endoscopic bladder neck suspension performed by different urologists at a variety of institutions were evaluated at the Lahey Clinic Medical Center. Two to 36 months after operation, each woman sought medical attention because of complaints of pain in the lower abdomen, pelvis, or groin with or without urinary frequency and urgency. Endoscopic examination revealed an acute mucosal inflammatory reaction, perforating sutures or Dacron pledgets, and formation of calculi around a suture. In each patient, sutures or pledgets were removed endoscopically with resolution of presenting complaints.

Primary skeletal metastasis of a nonseminomatous germ cell tumor

Bony metastasis is common in patients with germ cell tumor of the testicle; however, it is usually seen late in the disease process and is associated with lymph node or other visceral involvement. We present a case of isolated bony metastasis in a patient with a nonseminomatous germ cell tumor of the testis and normal retroperitoneal lymph nodes as determined by surgical resection.

TUBERCULOSIS OF THE PENIS AFTER INTRAVESICAL BACILLUS CALMETTE-GUERIN TREATMENT

Infectious complications associated with intravesical bacillus Calmette-Guerin (BCG) are rare. We report on a patient with culture proved, BCG related penile infection with Mycobacterium bovis following intravesical therapy for superficial transitional cell carcinoma of the bladder. To our knowledge only 4 reports of BCG related penile or urethral infection have been previously published in the literature.

RENAL CELL CARCINOMA PRESENTING AS VAGINAL BLEEDING

Abstract A case is presented of a patient who manifested vaginal bleeding due to metastatic renal cell carcinoma. Although the lungs are the primary focus of metastatic renal cell carcinoma, nearly any organ system can be a site for metastases giving bizarre symptoms. The mechanism of dissemination of tumor emboli is discussed.

Ureteroscopic removal of retainedureteral double-J stents

At the Lahey Clinic Medical Center, Double-J stents are placed primarily for management of patients with calculi. They are used before extracorporeal shock-wave lithotripsy (ESWL) of large renal calculi or bilateral ESWL treatments and after ureteroscopic instrumentation or removal of calculi. They are also used for palliative urinary diversion for patients with ureteral obstruction secondary to pelvic cancer. Fluoroscopy with C-arm guidance is the standard radiologic technique employed for manipulation of all calculi and insertion of stents. Results have been good with the use of these stents, but in 3 patients the rigid ureteroscope was required to remove a retained Double-J stent.

CLINICAL UROLOGY: Case ReportsChromophobe Renal Cell Carcinoma In A Patient With The Birt-Hogg-dube Syndrome

A 42-year-old pregnant white female was treated for spontaneous pneumothorax at 6 weeks of gestation. During hospitalization signs and symptoms of an acute urinary tract infection with left flank pain developed. A 20 cm. left renal mass was found on abdominal ultrasonography, which prompted a urological consultation. In an effort to limit radiation exposure in the first trimester of pregnancy local tumor staging was completed with magnetic resonance imaging. The scan revealed a large lower pole lesion without obvious perirenal, vascular or lymphatic extension (fig. 1, A). Left radical nephrectomy was performed through a supracostal 12th rib incision at the beginning of the second trimester. Histopathological examination demonstrated an eosinophilic variant of chromophobe renal cell carcinoma with oncocytic features and no capsular penetration (fig. 1, B). Postoperative course was uneventful and the patient delivered a healthy baby girl at term. During a departmental discussion held in the interim, the association of spontaneous pneumothoraces and renal tumors in the Birt-Hogg-Dube syndrome was raised. This syndrome is associated with characteristic cutaneous features and has been described in the dermatological literature but to our knowledge it has been mentioned only once in a urological article regarding hereditary renal tumors.1–3 At the time of our patient’s followup examination she was noted to have facial eruptions consisting of small skin-colored, dome-shaped papules over the malar area and nose, which are characteristic of this syndrome (fig. 2). Skin biopsy showed characteristic perifollicular fibrosis. The patient has been constitutionally well since nephrectomy and has recently been invited to the National Institutes of Health along with her family to undergo further study of this syndrome. Accepted for publication May 24, 2002. * Financial interest and/or other relationship with Ilex Pharmaceuticals and PhotoCure. FIG. 1. A, T2-weighted axial magnetic resonance imaging demonstrates 20 cm. heterogeneous mass arising from left kidney and displacing it across midline. B, chromophobe renal cell carcinoma (solid nests of cell in organoid pattern at center) with eosinophilic variance (left). H & E, reduced from 100.