William L. Furlow

Management of High Grade Transitional Cell Cancer of the Upper Urinary Tract

A total of 175 patients was operated on for grade 2, 3 or 4 transitional cell epithelioma of the upper urinary tract. Followup was between 5 and 26 years. The operations involved total nephroureterectomy, simple nephrectomy and local resection. Patient survival correlated well with tumor stage and, particularly, with tumor grade, and, consistently, was inferior to that of an age and sex-matched control group. The correlation of survival and ipsilateral tumor recurrence with the type of operation suggests that patients with grade 2 tumors may benefit from total nephroureterectomy. The incidence of ipsilateral tumor recurrence (28 per cent) was high in this group. The radical procedure seems to be of no benefit to patients with grade 3 or 4 tumors. The incidence of subsequent bladder tumor was 30 per cent in patients with grades 2 and 3 tumors. The latent period ranged from 2 months to 10 years (average 23 months); 82 per cent of the tumors occurred within 3 years of treatment of the upper tract tumor.

Primary Grade 1 Transitional Cell Carcinoma of the Renal Pelvis and Ureter

During a 22-year period 224 patients were seen for treatment of transitional cell carcinoma of the renal pelvis or ureter. Of these patients 49 (22 per cent) had grade 1 lesions. Followup ranged from 5 to 25 years. The most common symptom was hematuria. In only 54 per cent of the 49 patients was a filling defect noted on excretory urography. Forty-seven patients (96 per cent) had stage I disease. Treatment included total nephroureterectomy, nephrectomy or segmental resection. In 11 patients (23 per cent) evidence of bladder tumor developed 8 months to 12 years (average 4 years) after the diagnosis of tumor of the upper urinary tract and 73 per cent of these recurrences were noted within the first 3 years. In 1 patient a tumor developed in the opposite upper urinary tract. In only 1 of 15 patients who had had partial ureterectomy or local excision tumor developed in the ipsilateral ureter. Patient survival time was identical to that in an age-matched control group. We conclude that the most significant findings are the subsequent high incidence (23 per cent) of bladder tumor and the comparable survival in these pateints and in an age-matched control group. Furthermore, these results suggest that operations preserving the renal parenchyma, that is segmental resection, should be used more frequently.

Radical retropubic prostatectomy and pelvic lymphadenectomy for high-stage cancer of the prostate

A series of 340 patients with adenocarcinoma of the prostate treated by bilateral pelvic lymphadenectomy and radical retropubic prostatectomy was reviewed to determine the factors that influence survival and time to progression of disease. Follow‐up ranged from 1–12½ years. Factors evaluated were grade, stage, and bulk of tumor; influence of seminal vesical involvement and number of pelvic nodes involved; age of patient; and year of surgery. Tumor grade was the only factor related significantly to patient survival. However, grade, stage, and bulk of tumor were all significantly associated with interval between surgery and disease progression. Furthermore, in Stage C disease, seminal vesical involvement (C+) was an adverse factor for disease progression, particularly among patients with low‐grade tumor. This is in contrast to the finding that, among patients with Stage D1 disease, those with seminal vesical involvement experienced more favorable survival times and times to progression of disease when compared with patients without seminal vesical involvement. Overall, patient survival compared favorably with an age‐matched control group for all stages, A through D1. Patients with few pelvic nodes involved had a survival experience nearly comparable with that of an age‐matched control group. This suggests that pelvic lymphadenectomy might have a therapeutic value and that patients with pelvic nodal disease only, without evidence for metastatic disease, should not be denied radical surgery. The influence of concomitant hormonal manipulation or radiotherapy (or both) on patient survival and disease progression is not conclusively answered in this report.

Relationship Between Grade and Stage of adenocarcinoma of the Prostate and Regional Pelvic Lymph Node Metastases

The relationship of grade and local tumor extent to pelvic nodal involvement was assessed surgically in 469 patients who underwent pelvic lymphadenectomy and radical retropubic prostatectomy for adenocarcinoma of the prostate. Grade and local stage alone and combined score were associated in a linear fashion with nodal involvement. Gleason sum and Mayo grade alone were not predictive of nodal metastases. Some patients with a Gleason score of 4 had positive nodes and some with a score of 8 to 10 had negative nodes. Mayo sum (grade plus stage) consistently was related to negative nodal involvement.

Peyronie’s Disease: A Study of its Natural History and Treatment with Orthovoltage Radiotherapy

Followup data on 90 of 177 patients with Peyronies disease seen from Janurary 1, 1950 to April 1, 1970 revealed that the ultimate outcome of the disease when not treated was no different from that following orthovoltage radiotherapy. The real benefit derived from orthovoltage radiotherapy appears to be that it hastens symptomatic improvement by 3 to 7 months. In 21 per cent of the patients there was an associated inflammatory joint or tendon disease, an association not previously reported.

Inflatable penile prosthesis: follow-up study of patient-partner satisfaction.

The surgical success rates using implantable penile prostheses are well documented, although follow-up on their functional success is required. In this study of 175 patients with an inflatable penile prosthesis, patients and their partners were evaluated as to patient-partner satisfaction, levels of satisfaction, causes of dissatisfaction, frequency of intercouse, and over-all acceptance of the device by patient and partner. The initial satisfaction rates of 79 per cent were significantly improved to 89 per cent after management of specific unrecognized complications. The high levels of satisfaction found in this study continue to support our guidelines for device selection and implantation.

Inflatable penile prosthesis: Mayo Clinic experience with 175 patients.

Sex prosthetics have become an established alternative of therapy for both the organically and the psychogenically impotent male patient. Functional success with the implantation of the inflatable penile prosthesis can be anticipated in 90 to 95 per cent of the patients. Both mechanical and pathologic complications occur, but with relatively low frequency. There have been no reported operative or postoperative deaths associated with the implantation of more than 6,000 devices. The availability of penile prostheses to impotent patients should be limited only by the patients ability to meet the rigid criteria for selection of patients. When these criteria are fulfilled and the patients expectations are in harmony with the known results that can be provided by implantation, uniformly successful results can be expected.

The Model as 800 Artificial Urinary Sphincter: Mayo Clinic Experience

The model AS 800 artificial urinary sphincter was implanted in 100 male and 9 female patients between 7 and 89 years old. Postoperative followup was 1 to 32 months. The indication for implantation was total urinary incontinence in 86 patients (78.9 per cent), stress incontinence in 22 (21.2 per cent) and urgency incontinence in 1 (0.9 per cent). Of the patients 97 (89 per cent) underwent implantation for the first time, 7 (6.4 per cent) had a previous artificial urinary sphincter model replaced by the AS 800 device and 5 (4.6 per cent) underwent reimplantation of a previous model. The cuff was placed around the bladder neck in all 9 female patients, whereas in the male patients the cuff was implanted around the bladder neck in 20 and around the bulbous urethra in 80. Thirty-one patients (28.4 per cent), 29 of whom were continent at night, were practicing nocturnal deactivation of the device. Complete post-activation continence was achieved in 91 patients (83.5 per cent), some leakage occurred in 10 (9.2 per cent) and 8 (7.3 per cent) remained incontinent. A total of 23 patients required 1 or more revisions, the most common indications for the first revision being loss of cuff compression (9), tubing kink (3), cuff erosion (3) and infection (2). At the time of this report 89 patients (81.7 per cent) were continent, 9 (8.3 per cent) still had some leakage, 3 (2.8 per cent) were incontinent, 5 (4.6 per cent) were awaiting reimplantation and 3 (2.8 per cent) had died of unrelated causes.

Implantation of a New Semiautomatic Artificial Genitourinary Sphincter: Experience With Primary Activation and Deactivation in 47 Patients

AS 742 is a new semiautomatic artificial genitourinary sphincter that has been used at the clinic for the last 21/2 years in the management of urinary incontinence. Compared to the previous model the simplified design provides for much easier implantation, more reliable function related to cuff pressures and to cuff configuration, and more flexibility in the selection of the site for cuff placement. In addition, this new device has enabled the development and use of a new concept of primary and secondary activation. A total of 47 patients (41 male and 6 female subjects) has undergone implantation of the AS 742. Of the 42 patients who had primary activation 34 experienced continence without further surgical revision. The remaining 5 patients who primarily had deactivated devices subsequently had the devices activated and the patients are dry. Of the 8 patients with initial failures 2 had infection and 6 had primary cuff erosion of the urethra. In 4 of the 8 patients the cuff was replaced, and the device was deactivated and then activated after 3 to 4 months. All 4 of these patients are continent. Followup for these patients has ranged from 6 to 30 months. Over-all, 43 of the 47 patients are continent.

Salvage of the eroded inflatable penile prosthesis: a new concept.

Most surgeons consider erosion of any component of an inflatable penile prosthesis as an indication for total device removal. However, it has been our contention that in selected cases conservative management can be used and the device can be salvaged. In 32 patients with erosion of various device components we performed conservative salvage techniques, consisting of immediate component replacement, repositioning of the eroded component or removal of only the eroded component in conjunction with closed drainage and antibiotic irrigation. Early success with device salvage resulted in the development of a rigid protocol for patient selection and management. Salvage techniques were successful in 16 of 22 cases of scrotal pump erosion and in all 8 cases of reservoir erosion. In 2 cases of cylinder erosion salvage attempts failed.