Radical cystectomy with or without adjuvant polychemotherapy for non-organ-confined transitional cell carcinoma of the urinary bladder: prognostic impact of lymph node involvement.

OBJECTIVES: To analyze the effectiveness of adjuvant polychemotherapy after radical cystectomy for non-organ-confined transitional cell bladder cancer (Stages pT3b, pT4a, and/or pN1 or pN2). METHODS: Of 166 consecutive patients undergoing cystectomy at two institutions from 1987 to 1993, 80 received adjuvant polychemotherapy with methotrexate, vinblastine, and cisplatin plus doxorubicin (MVAC) or epirubicin (MVEC), whereas 86 had cystectomy only. The patients were evaluated for relapse-free survival and length of progression-free interval on the basis of follow-up data obtained in 1995 and 1996. RESULTS: Kaplan-Meier analysis revealed a significantly higher progression-free rate for patients after adjuvant chemotherapy (P = 0.0002, log-rank test). With and without adjuvant chemotherapy, prognosis declined in a stepwise manner, depending on the extent of lymph node involvement. Nevertheless, the superior prognosis of the chemotherapy group could be demonstrated at each lymph node stage. Of the 166 patients, 49 had initially entered a prospective trial comparing adjuvant with no adjuvant treatment. That study was discontinued in December 1990 after an interim analysis revealed a significant prognostic advantage in favor of the 26 patients randomized to receive chemotherapy compared with the 23 control patients. Current follow-up data continue to demonstrate a significant improvement in progression-free survival in favor of patients randomized to receive adjuvant chemotherapy (P = 0.0040). The follow-up period of patients living free of disease ranges from 58 to 96 months. CONCLUSIONS: Adjuvant chemotherapy with MVAC/MVEC leads to significant prolongation of relapse-free survival and improvement of the definitive cure rate after radical cystectomy for locally advanced transitional cell carcinoma of the urinary bladder.

Epithelioid leiomyoma of the prostate.

We report a case of an unusual mesenchymal tumor of the prostate. Rectal-digital palpation and transrectal ultrasound showed a circumscribed and inhomogeneous tumor within the right prostatic lobe. Surgical treatment consisted of transurethral resection of the right prostatic lobe. On the basis of morphology and immunohistochemical detection of desmin and smooth-muscle-type actin, the diagnosis of an epithelioid leiomyoma was made. This is the first report of this entity in the prostate. A definite prediction of the biological potential is currently not yet possible.

Transurethral prostatectomy: a long-term follow-up study of 166 patients over 80 years of age.

OBJECTIVES AND METHODS: In a retrospective analysis, the medical records of 166 patients over 80 years of age (80-99 years, mean age 82 years) who underwent transurethral prostatectomy (TURP) for clinically benign prostatic hyperplasia (BPH) were reviewed in order to evaluate the morbidity and mortality rates in this special group of patients. The mean follow-up was 60 months (6-85 months). RESULTS: According to the American Society of Anesthesiologists operative risk classification, 147 (88.5%) patients were found to be of groups ASA III and IV. All patients had at least one serious associated medical disease. Early complications occurred in 25.9% (n = 43) of patients. Late significant urology complications were noted in 13.2% (n = 22) of patients. Reoperation was carried out in 4.2% (n = 7) of cases. Two patients died within 30 days after the operation (1.2%). During the period of follow-up 43 patients died. Comparing the survival curve (according to the Kaplan-Meier analysis) of our group with the expected survival rate of the age-matched overall population, no statistical difference could be observed. CONCLUSION: Being aware of the limits of a retrospective study, we believe that TURP as a treatment for BPH in patients over the age of 80 years has a satisfactory outcome with an acceptable morbidity and mortality rate.

[Continent urinary diversion and pregnancy]. / Kontinente Harnableitung und Schwangerschaft.

We report on our experience with 7 pregnancies in 6 women who previously underwent reconstruction of the urinary tract with a continent urinary diversion using an ileo caecal segment (Mainz-Pouch I), ureterosigmoidostomy or bladder augmentation. Urinary tract infection and upper tract dilatation were the only complications during pregnancy which required bilateral nephrostomies in one case. All other sequelae were handled conservatively. The continence mechanisms were not compromised during pregnancy or delivery. Deliveries were vaginal in two cases and by Caesarean section in five. All seven newborn were healthy. Pregnancy is not contraindicated after any type of urinary diversion including continent reservoirs. Close urological and gynaecological observation of these women throughout pregnancy is mandatory. The mode of delivery is in the majority of cases guided by obstetric indications. If Caesarean section is necessary, the obstetrician should be familiar with the intraabdominal situation.

Analysis of meatal location in 500 men: wide variation questions need for meatal advancement in all pediatric anterior hypospadias cases.

The high incidence (70%) of anterior hypospadias, mostly without penile curvature, in our pediatric hypospadias patients led us to study the meatal location in normal men to investigate if meatal advancement in all patients with anterior hypospadias can be justified when the wide variation of meatal locations in normal men is considered. The location of the external meatus was analyzed in 500 men (mean age 57 years) with classification of the meatal position in relation to the tip of the glans and corona. Quality of erections and sexual intercourse, presence or absence of penile curvature, urinary stream and ability to void in a standing position were assessed in an interview. Of the 500 men only 275 (55%) were normal with the meatus in the distal third of the glans, while 65 (13%) had anterior hypospadias (glanular in 49, coronal in 15 and subcoronal in 1). In 160 men (32%) the urethral meatus was located in the mid third of the glans. Analyzing coronal and subcoronal hypospadias further, all but 6 patients were not aware of any penile anomaly, all but 1 homosexual patient have fathered children and only 1 had penile curvature (subcoronal hypospadias). However, all patients participated in sexual intercourse without problems and were able to void in a standing position with a single stream. In our study of 500 "normal" men the meatal location varied widely with only 55% of all meatus at the tip of the glans and significant hypospadias in patients without complaints about cosmetic or functional aspects. We believe that these observations might question the need for meatal advancement in cases of anterior hypospadias without associated penile curvature.

Antegrade scrotal sclerotherapy for the treatment of varicocele in childhood and adolescence.

OBJECTIVE: To test the efficacy of antegrade scrotal sclerotherapy (ASS) for the treatment of varicocele in teenagers. PATIENTS AND METHODS: The study included 38 patients (mean age 14.9 years, range 12-18) with left-sided varicocele. Three patients had a grade 1 varicocele, 22 were grade 2 and 13 were grade 3. ASS was performed under local anaesthesia on an out-patient basis. RESULTS: ASS was accepted by all patients except one. There were no peri-operative problems and only one patient developed post-operative epididymitis. During 9 to 15 months of follow-up (mean 11 months), only two patients developed persistence of a lower grade of varicocele. CONCLUSION: This study illustrates that ASS is a safe and successful out-patient procedure for the treatment of varicocele in teenagers.

Maximum androgen deprivation prior to radical retropubic prostatectomy in patients with stage T3 adenocarcinoma of the prostate.

Eighty-two patients with stage T3 carcinoma of the prostate were treated for 3 months prior to radical retropubic prostatectomy with a luteinizing-hormone-releasing hormone analogue and an antiandrogen. Based on digital rectal examination (DRE), reduction of prostate and tumor size was noted in all cases. Ultrasound demonstrated a decrease in prostatic volume between 0 and 62.5% (median 32%). Prostate-specific antigen levels (PSA, Hybritech) decreased substantially (mean PSA of 29.5 ng/ml before to a mean PSA of 1.3 ng/ml after hormonal treatment). Pathologically, only 15 patients (18.3%) had organ-confined disease (stage pT2), 44 (53.7%) had stage pT3 tumors and 22 (26.8%) had positive lymph nodes. In 1 surgical specimen (1.2%), no residual tumor was identified. In 5 patients with nodal metastasis and 13 patients with seminal vesicle invasion, PSA levels after pretreatment were below 0.5 ng/ml. Compared to the preoperative needle biopsy, a decrease in the histological grade was found in only 7 tumors, while an increase was noted in 26. DRE, ultrasound and PSA suggest a downstaging of stage T3 prostate cancer after 3 months of maximum androgen deprivation. This cannot be confirmed pathologically. Prospective studies with this treatment regimen should concentrate on a possible benefit concerning local and distant cancer control and survival.

Adjuvant polychemotherapy of nonorgan-confined bladder cancer after radical cystectomy revisited: long-term results of a controlled prospective study and further clinical experience.

A total of 83 patients with nonorgan-confined bladder cancer with or without lymph node metastases (tumor stages pT3b, pT4a and/or pN1, pN2) was evaluated in November 1993 for relapse-free and overall survival. All patients underwent radical cystectomy between 1987 and 1991, 38 underwent adjuvant polychemotherapy with methotrexate, vinblastine and cisplatin plus doxorubicin (M-VAC) or epirubicin (M-VEC). Of the 83 patients 49 had entered a prospective randomized trial comparing adjuvant to no adjuvant treatment. The protocol was activated in May 1987. Patient recruitment was concluded in December 1990 because an interim analysis of the 49 randomized patients revealed a significant prognostic advantage in favor of the 26 patients randomized to the chemotherapy group compared to 23 in the control group (p = 0.0015, log-rank test for relapse-free survival curves). Preliminary data were published in 1992. Of the 26 patients randomized for adjuvant chemotherapy 18 were treated with M-VAC or M-VEC, 7 refused chemotherapy before or during cycle 1 and 1 received chemotherapy without cisplatin because of impaired renal function. The update of patient followup obtained in November 1993 continues to demonstrate a significant improvement in progression-free survival in favor of patients randomized for adjuvant chemotherapy (p = 0.0005). Followup of patients living free of disease ranged from 38 to 78 months. In a second analysis of actual treatment, the total collective of 83 patients treated from 1987 to 1991 was reviewed: 38 who had actually undergone adjuvant M-VAC/M-VEC (18 during the prospective trial and 20 in 1991 as the routinely recommended therapy) were compared with 45 without adjuvant M-VAC/M-VEC (7 refused to participate in the adjuvant trial, 8 randomized for but did not undergo adjuvant M-VAC/M-VEC, 23 belonged to the control group of the trial, and 7 underwent cystectomy in 1991 and remained without adjuvant treatment). This analysis again revealed a significant prognostic advantage in favor of the patients treated with adjuvant M-VAC/M-VEC. We conclude that adjuvant chemotherapy with M-VAC/M-VEC leads to a significant prolongation of relapse-free survival and to an improvement of the definitive cure rates after radical cystectomy for locally advanced transitional cell carcinoma of the bladder.

Hormone therapy prior to radical prostatectomy in patients with clinical stage C prostate cancer.

Seventy patients with clinical stage C carcinoma of the prostate were treated for 3 months with the gonadotropin-releasing hormone analog, goserelin acetate (Zoladex; Zeneca Pharmaceuticals, Macclesfield, UK) plus an antiandrogen (flutamide). Based on digital rectal examination (DRE), reductions of the size of the prostate and the tumor were noted in 91.4% of patients. Ultrasound demonstrated a decrease in prostatic volume between 0% and 62.5% (median 31%). Prostate-specific antigen (PSA) levels (Hybritech) decreased substantially (mean PSA of 31.3 ng/ml before, to a mean PSA of 1.4 ng/ml after hormonal treatment). A total of 64 patients subsequently underwent radical retropubic prostatectomy. Pathologically, only 9 patients (14.1%) had organ-confined disease (stage B), 34 (53.1%) had stage C tumors, and 21 (32.8%) had positive lymph nodes (stage D1). In 5 patients with nodal metastasis and 7 patients with seminal vesicle invasion, PSA levels after pretreatment were below 0.5 ng/ml. Maximal androgen blockade for a period of 3 months in clinical stage C prostate cancer induces a notable reduction in prostate size ("downsizing"). A "downstaging" effect, as suggested by DRE, ultrasound, and PSA, was not observed. Prospective studies with this treatment regimen should concentrate on a possible benefit concerning local and distant cancer control and survival.

[Malignant pheochromocytoma of the urinary bladder. Case report and review of the literature]. / Malignes Phäochromozytom der Harnblase. Fallbericht und Literaturübersicht.

Iatrogenic ureteral lesion is a severe complication in gynecological surgery. We present a case in which the obstruction led to fornix rupture, urine extravasation and urinary ascites. The problematic diagnostic pathway is emphasized.

[Nuclear medicine diagnosis and therapy in urology. Diagnosis of bone metastases]. / Nuklearmedizinische Diagnostik und Therapie in der Urologie. Diagnostik von Knochenmetastasen.

Bone scintigraphy with 99mtechnetium-labelled polyphosphonates is the most sensitive test for early detection of skeletal metastases. Bone metastases are a major factor in prognosis and have a considerable influence on the therapy selected. In patients with prostate cancer, we recommend routine bone scintigraphy in the initial staging. Follow-up bone scans are indicated whenever a patient develops pain, an elevated level of acid phosphatase, or a rise in prostate specific antigen (PSA). Routine bone scans are not necessary for the initial staging of patients with renal cell carcinomas, bladder carcinomas and testicular tumours. Scans should be routinely performed, however, in patients with bone pain or elevated alkaline phosphatase or when radiological findings are inconclusive. Bone scanning is necessary in patients with neuroblastoma, both for the initial diagnosis and during follow-up in all cases with known skeletal involvement. In addition, bone scintigraphy should be performed in cases of recurrent or suspected malignant phaeochromocytoma as a complement to scintigraphy with iodine-123- or iodine-131-MIBG, respectively. Even though skeletal scintigraphy is a very sensitive test, it lacks specificity. This can be compensated, however, by careful interpretation of the scan in the light of the patient's history and the clinical findings. As a positive side-effect, bone scanning--especially in the form of multiphase scintigraphy--may detect renal abnormalities, concurrent diseases or complications in the upper or lower urinary tract. If scintigraphic findings are doubtful, plain film radiographs are required or, in selected cases, bone biopsy must be performed.

Pathologic parameters and flow cytometric ploidy analysis in predicting recurrence in carcinoma of the prostate.

Recurrence of prostate cancer following radical prostatectomy is determined by the extent of local disease. Tumor volume and grade have improved our ability to predict extraprostatic extension, but tumors of intermediate volume and grade vary in their biologic behavior. To assess the prognostic significance of DNA ploidy, we performed flow cytometry in 85 patients with prostate cancer volumes > 4 cm3. Post-radical prostatectomy serum prostate-specific antigen was used to prove recurrence of cancer. Mean follow-up was 35 months (median 31 months). 26 patients (30%) had diploid histograms, 55 (65%) non-diploid histograms. In 4 cases (5%) the histograms were uninterpretable. Tumor volume and percent of Gleason grades 4 or 5 separated the recurrent from nonrecurrent groups in a highly significant manner (p < 0.001). When tested alone, ploidy had no ability to predict recurrence (p = 0.26). However, in a subset of patients with 4-8 cm3 of cancer with < 30% Gleason grade 4 or 5 tumor, ploidy conferred significant additional prognostic information (p < 0.005).

The predictive significance of substaging stage A prostate cancer (A1 versus A2) for volume and grade of total cancer in the prostate.

Morphometric analysis was performed on 44 radical prostatectomy specimens for clinical stages A1 and A2 carcinoma of the prostate. The majority of stage A cancers (86%) were located in the transition zone of the prostate, while only 14% arose in the peripheral zone. The subclassification into stages A1 and A2 based on the percentage of cancer in the transurethral resection chips did not reliably distinguish those cancers of high volume (transurethral resection plus residual). All 6 cases with Gleason grade 4 elements in the transurethral resection chips had relatively high volume cancer. In 32 of the 44 cases (73%) unsuspected cancers unrelated to the tumor detected at transurethral resection were found in the radical prostatectomy specimen. Of these cancers 87% were nontransition zone tumors. Eight unsuspected cancers were larger than the stage A cancer but only 2 of them were larger than 1 cc. Post-resection serum prostate specific antigen (PSA) levels were elevated with increasing total residual cancer volume in the radical specimen. In 19 of 20 cases with a PSA of greater than 2.5 ng./ml. the total residual cancer volume was more than 0.9 cc, while in 7 of 8 with a PSA of less than 1 ng./ml. total residual tumor volume was lower than 0.4 cc.

Morphologic analysis of surgical margins with positive findings in prostatectomy for adenocarcinoma of the prostate.

Apical invasion and positive apical margins were assessed in 165 consecutive radical prostatectomies. Apical invasion, defined as cancer in the distal 8 mm of the prostate, was evident in more than 80% of the cases, and apical margins occurred in 16% of the specimens with apical Clinical judgement was not effective in predicting apical cancer. Frequency of apical margins increased in proportion to greater cancer volume, from 9.8% in cancers smaller than 4 cc to 30.7% in cancers larger than 12 cc. However, most positive margins in the group with cancers smaller than 4 cc were caused by inadvertent incision into the prostate during the operation, whereas the vast majority of apical margins in cancers larger than 4 cc were caused by capsule penetration of the tumor. Although margins associated with capsule penetration occurred characteristically in the posterior (rectal) portion of the apex, margins caused by incision into the prostate were distributed over the entire apical surface of the gland. Positive margins at the urethral stump were quite uncommon (occurring in four cases). These findings suggest that modifications of surgical technique might reduce the frequency of this complication.

[Incidental prostate cancer: volume, location and degree of differentiation of the tumor in the radical prostatectomy specimen and value of subclassification to stage A1 and A2]. / Das inzidentelle Prostatakarzinom: Volumen, Lokalisation und Differenzierungsgrad des Tumors im radikalen Prostatektomiepräparat und Stellenwert der Subklassifikation in ein Stadium A1 und A2.

Morphometric analysis was performed on 22 radical prostatectomy specimens of clinical stage A1 and 22 specimens of stage A2 prostate cancers. Of 44 stage A cancers (86%), 38 arose in the transition zone of the prostate, while only 6 were peripheral zone tumors. The subclassification into stages A1 and A2 based on the percentage of cancer in the transurethral resection specimen was not able reliably to separate patients with high-volume stage A cancer from those with low-volume stage A cancer. The same was true when the patients were subclassified according to the criteria of the TNM system (TNM 1987). However, all cases (n = 6) with Gleason grade 4 elements in the TUR chips had relatively high-volume residual TUR cancer (greater than or equal to 1.7 cm3) in the radical specimen. Unsuspected cancers unrelated to the incidental prostate cancer were found in 73% of the specimens. The vast majority (87%) were peripheral zone cancers. Eight unsuspected cancers were larger than the Stage A cancer, but only 2 of the 8 were larger than 1 cm3. Our data suggest that the subclassification of stage A into stages A1 and A2 or the subclassification according to the TNM criteria (TNM 1987) does not reliably separate patients who are at risk of cancer progression. Further diagnostic procedures are necessary in these patients. Post-TUR serum PSA levels (Yang) provided valuable additional information in this series. Post-TUR PSA levels increased with increasing residual cancer volume in the prostate. Below a post-TUR PSA of 1 ng/ml, total residual cancer volume was less than 0.4 cm3 in 7 of 8 cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Pheochromocytoma in the pediatric age group: the prostate--an unusual location.

Pheochromocytomas of the prostate are rare, with only 3 cases in adults reported in the literature. We present the case of an 8-year-old boy with a pheochromocytoma of the prostate and a second tumor in the region of the left internal iliac artery.

Comparison of selective internal iliac pharmaco-angiography, penile brachial index and duplex sonography with pulsed Doppler analysis for the evaluation of vasculogenic (arteriogenic) impotence.

Between July 1987 and February 1988 selective internal iliac angiography was performed before and after intracavernous injection of papaverine plus phentolamine in 43 patients with erectile dysfunction. In 63% of the patients stenosis or occlusion of the pudendal artery was found. The penile brachial index was calculated and duplex sonography with pulsed Doppler analysis was performed in 23 patients. Angiography and penile brachial index correlated in only 39% of the patients, whereas selective internal iliac angiography and duplex sonography correlated in 91% (21 of 23). In 2 patients duplex sonography with pulsed Doppler analysis rendered better information about penile arterial perfusion than did angiography.