Adenocarcinoma of the testicular adnexa presenting with metastatic disease.

Primary epididymal adenocarcinoma is a rare malignancy with fewer than 30 documented cases. We report a case of a 57-year-old patient with a paratesticular mass in the presence of retroperitoneal metastatic disease. Histology confirmed the presence of primary paratesticular adenocarcinoma. In this report we review the index case, the pertinent literature and discuss adjuvant therapy.

Mechanical reliability, surgical complications, and patient and partner satisfaction of the modern three-piece inflatable penile prosthesis.

OBJECTIVES: The modern three-piece inflatable penile prosthesis (IPP) has undergone multiple revisions since its introduction in 1973. We reviewed devices placed since the last major revision by American Medical Systems (AMS) in 1987. METHODS: A retrospective chart review was refined with data from an independent patient and partner survey. RESULTS: Two hundred twelve consecutive penile prosthetic devices placed by a single surgeon over an 8-year period are reviewed. One hundred sixty-nine of the devices were three-piece inflatables with 146 being primary implants. The average device has been in place 36.5 months (range 9 to 102). The infection rate in 146 primary three-piece devices was 2.1%. The infection rate in 46 secondary implants or revisions was 6.5%, excluding seven salvage attempts. Mechanical failure in 122 primary AMS devices placed was 4.1%. Mechanical failure in 24 Mentor devices was 4.2% if one discounts connector failures that were revised in 1990. A surgical complication and revision rate of 1.4% was noted in the 146 primary implants. An independent telephone survey achieved a 57% and 24% response rate in patients and partners with three-piece devices placed. In the group of 86 patients with a primary three-piece device placed and complete follow-up, the probability of having a normally functioning device placed in a single operative procedure was 90.6% at 3 years. On a 1 to 10 scale looking at all primary devices, secondary devices, revisions, and infections, the average and median satisfaction rate was as follows: 8.2, 8.5; 8.4, 9.0; 7.7, 7.75 for the Ultrex patients, CX 700 and Mentor patients, and all partners, respectively. CONCLUSIONS: The modern three-piece IPP is an excellent surgical option offering a very safe, reliable return to sexual activity for our patients.

Pubovaginal slings using fascia lata for the treatment of intrinsic sphincter deficiency.

PURPOSE: Various materials and techniques have been used to construct a pubovaginal sling. We believe that fascia lata has several advantages and report our experience. MATERIALS AND METHODS: A total of 32 female patients with urodynamically proved intrinsic sphincter deficiency underwent a pubovaginal sling procedure using fascia lata. An unscarred fascial strip 24 to 28 x 2 cm. was attached to itself over a 3 to 4 cm. bridge of abdominal wall fascia. Results were tabulated by chart review and an independent patient survey. RESULTS: Chart review revealed that 28 of 32 patients (87%) required no pads, and 3 improved and 1 did not. An independent patient survey revealed that 70% of patients (21 of 30) required no pads, 20% required 1 to 3 small pads and 10% required more than 3 small pads per day. Of the patients 80% would undergo the procedure again. CONCLUSIONS: Excellent results can be obtained with fascia lata for the treatment of intrinsic sphincter deficiency. A long, wide strip of fascia attached to itself allows for precise tensioning and good urethral closure, and minimizes the risk of obstruction.

Timing of penile color flow duplex ultrasonography using a triple drug mixture.

Duplex ultrasonography is an accepted method to assess noninvasively arterial inflow to the penis. Optimal pharmacological agents as well as timing of the scan and stimulation during the scan continue to be debated. In an effort to achieve a more complete smooth muscle relaxation and capture what we perceived was a wide variation in interval to maximum arterial velocity, we revised our duplex protocol in January 1991. We report on 280 consecutive patients evaluated in this manner. Patients received 0.25 or 0.5 cc of a triple drug mixture containing 22.5 mg./cc papaverine, 0.83 mg./cc phentolamine and 8.33 micrograms/cc prostaglandin E1. Scans were performed at 0, 5, 15 and 30 minutes after injection in all patients. Any patient not having a full erection at 15 minutes performed private self-stimulation while in the standing position for at least 5 minutes before the 30-minute scan. If we conservatively define normal arterial inflow as a peak Doppler velocity of 25 cm. per second or greater in the best artery, only 35% of our patients achieved this velocity at 5 minutes. Of the remainder 26% and 22% did not reach normal velocity values until 15 and 30 minutes, respectively, after the injection. By delaying initial measurements of velocity until 5 minutes, could the highest inflow velocity be missed and patients diagnosed incorrectly? The group at risk would be those who had good tumescence at 5 minutes and who had presumably already decreased the inflow velocities. Of the 280 patients 74 (26%) had greater than 10% tumescence at 5 minutes. Only 6 of these 74 patients did not reach velocities of 25 cm. per second or more in the best artery at some time during their study. In conclusion, our study clearly supports delaying the initial scan until 5 minutes, since only 6 of our 280 patients (2.1%) may have been incorrectly diagnosed. The study also strongly argues for additional scans until 30 minutes and self-stimulation when necessary.

Correlation of the cystoscopic appearance and functional integrity of the female urethral sphincteric mechanism.

OBJECTIVES: Urologists in the past, and many today, rely on the cystoscopic appearance of the female urethra as a guide to its functional integrity. To assess the accuracy of this approach better, we compared the cystoscopic appearance of the bladder neck and proximal urethra to the functional integrity of this mechanism during videourodynamic studies. METHODS: One hundred consecutive videourodynamic studies were reviewed on female patients with more complex types of urinary incontinence. Reports of their cystoscopic examinations were reviewed and results compared. RESULTS: Significant dysfunction of the intrinsic mechanism was noted in 36% of the patients (26% moderate dysfunction and 10% severe dysfunction) on video studies. Cystoscopy underestimated these deficits 74% and 44% of the time, respectively, in the moderate and severe dysfunction groups. CONCLUSIONS: We conclude that the cystoscopic appearance of the bladder neck proximal urethra cannot predict the functional integrity of this mechanism.

Experience with triple-drug therapy in a pharmacological erection program.

A group of 170 impotent men achieved usable erections during a 26-month period with a combination of papaverine, phentolamine and prostaglandin E1 (triple-drug therapy) injected intracorporeally. Of the patients 146 elected to enter a pharmacological erection program using this combination. Patient age ranged from 24 to 85 years and the average duration on the program was 11.2 months. Average injection volume was 0.36 cc per injection (range 0.1 to 1). Among those patients managed by our nurse clinician, only 3 episodes of priapism were encountered (1.7%). Scarring was documented in 7 of 170 patients (4.2%) 1 week to 21 months after starting the injections. Pain was encountered in 6 of 170 patients (3.5%). A superior dose response coupled with a low incidence of priapism, pain and scarring have led us to use triple-drug therapy as our agent of choice in the pharmacological management of erectile dysfunction.

Surgical management of traumatic posterior urethral strictures in children.

We review our recent experience with the treatment of traumatic strictures of the posterior urethra in children. Five males, ages six to seventeen years with dense posterior urethral strictures, have required open reconstructive procedures. Four patients had injury secondary to pelvic fractures, and 1 patient had an iatrogenic injury from surgery for imperforate anus. Two patients were repaired perineally, 2 with a combination retropubic-perineal approach, and 1 patient required a transpubic approach. Excision and direct anastomosis was achieved in 3 patients, and a foreskin interposition tube graft was used in 2 patients. Excellent results were achieved with return of urethral voiding and preservation of continence in all patients. Complications were seen in 3 patients. One secondary internal urethrotomy was required. Erectile capability was preserved in all patients who were potent before surgery. Posterior urethral strictures in children can be successfully managed with a variety of surgical approaches. This experience demonstrates that the surgical procedure must be individualized depending on the anatomy of the injury.

Primary adenocarcinoma of bladder.

Between April 1983 and December 1987, we have treated and followed 16 patients at the University of Southern California for adenocarcinoma of the bladder. In 10 patients, the cancer originated from a nonurachal source; all underwent radical cystectomy, bilateral pelvic lymph node dissection, and urinary diversion. The other 6 patients had an apparent urachal origin of their cancer. Half of these patients were treated with radical cystectomy and urinary diversion and half were treated initially with segmental cystectomy. Presenting characteristics (age, sex ratio, and symptoms) were similar for both groups. Three-year adjusted acturial tumor-free survival rates for the two groups were 48 percent and 31 percent, respectively. We advocate an aggressive approach of radical cystectomy, bilateral pelvic lymph node dissection, and urinary diversion for all invasive adenocarcinoma of the bladder, regardless of location.

Pulsed dye laser fragmentation of ureteral calculi: a review of the first 50 cases performed at Virginia Mason Medical Center.

During the preceding 2 1/2 years 50 patients have undergone laser fragmentation of ureteral calculi at our medical center. Of these 50 patients 48 (96%) became free of stones without the need for an open operation: 44 (88%) were managed in 1 setting and 4 required adjunctive extracorporeal shock wave or ultrasonic lithotripsy, or a repeat session with the laser. Two patients (4%) eventually required an open operation: 1 required ureterolithotomy for a large impacted stone overlying the bony pelvis after a ureteroscope could not be advanced to this level and 1 had a good initial result with the laser but a persistent ureteral stricture developed and he required ureteroureterostomy 4 months later. Both open procedures were necessitated by mid ureteral stones, and the ureteral stricture was believed to be related to ureteroscopy and the impacted nature of the stone, rather than any damage by the laser probe.

Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival.

In 1972 we first reported that vena caval extension by tumor thrombus was a potentially curable lesion provided that complete removal could be achieved. We have developed a technique for safe removal of extensive vena caval thrombi extending up to the right atrium without the need for cardiopulmonary bypass or hypothermic cardioplegia. Cardiopulmonary bypass, however, is advocated for some type III thrombi, but the addition of the pump and heparinization compounds the magnitude of the procedure. We use a right thoracoabdominal approach for tumors arising from either kidney with vascular isolation of the vena cava from its insertion into the right atrium to the iliac bifurcation. From 1972 to 1988, 56 patients ranging in age from 31 to 76 years were evaluated and 53 underwent radical nephrectomy with en bloc vena caval tumor thrombectomy. Of these patients, 21 had subhepatic caval thrombus extension (level 1); 24 had extension into the intrahepatic vena cava (level 2), and 8 had thrombi extending into the heart (level 3). Overall 1-, 3-, and 5-year survival was 56%, 34%, and 25%, respectively. Crucial to survival was complete surgical excision. Successful extirpation of all apparent tumor was possible in 75% of the patients in this series. With an expected 5-year survival rate of 57% for those without metastatic disease to other organs, we continue to advocate an aggressive optimistic approach for patients if there is no preoperative evidence of metastatic disease.

Mesenchymal-epithelial interactions between normal and transformed human bladder cells.

Epithelial cells obtained from normal human urothelium, a cell line derived from a papillary bladder carcinoma, and cells derived from an invasive carcinoma were grown in a serum-free fully defined medium. The interaction between these cell types and normal bladder stromal cells obtained by explant culture in serum were investigated in mixed cultures. These studies showed that normal urothelium was not responsive to the growth factors produced by cultured bladder fibroblasts and the cells did not grow at increased rates in association with living fibroblast layers. Cells derived from a papillary human bladder carcinoma cell line also did not associate well with fibroblast layers or show marked stimulation of growth by preformed layers of fibroblast cells. On the other hand, cells of the EJ carcinoma line, originally derived from a patient with highly invasive disease, easily infiltrated fibroblast layers and were strongly stimulated to grow by the presence of the stromal cells. This model system might therefore be used to determine key elements associated with malignant progression in human bladder carcinoma.

The potency-sparing radical cystectomy: does it compromise the completeness of the cancer resection?

Anatomical radical cystectomies with en bloc pelvic lymph node dissections were performed post mortem on 10 male cadavers. The traditional technique of radical cystectomy was used on 1 side and the potency-sparing technique was used on the opposite side. The tissue responsible for the differences in the surgical margins with the 2 procedures was examined by routine surgical pathological techniques to determine if it contained lymph nodes. Lymph nodes were identified in the bundle of tissue left in the pelvis with the nerve-sparing radical cystectomy in 6 of the 10 dissections (60 per cent). Because these lymph nodes may represent the potential first site of metastatic disease leaving the bladder, the reader is cautioned about adopting the nerve-sparing radical cystectomy as part of the management of invasive bladder cancer until the long-term sequelae of the procedure are known.

Unsuspected prostatic adenocarcinoma in patients who have undergone radical cystoprostatectomy for transitional cell carcinoma of the bladder.

In 45 of 165 male cystectomy patients with bladder cancer (27 per cent) incidental adenocarcinoma of the prostate was found during the diagnostic evaluation or histological examination of the cystoprostatectomy specimens. Of the patients 37 had stage A1 or A2 and 8 had stage C or D1 prostate cancer. Clinical presentation, stage and grade distributions for each primary and prognostic variable are reviewed. Over-all, 67 per cent of the patients currently are alive with a 3-year actuarial survival rate of 60 per cent. The presence of incidental stage C or D1 prostate cancer in the surgical specimen implies incomplete surgical excision and it may warrant additional postoperative treatment. However, a significantly increased mortality rate among these patients has not been identified during the limited median followup of 25 months.

Preoperative magnetic resonance imaging of vena caval tumor thrombi: experience with 5 cases.

Magnetic resonance scans were performed preoperatively in 5 patients who underwent surgical removal of renal or adrenal tumors with direct extension of the tumor into the vena cava. Of the patients 4 had renal cell carcinoma and 1 had adrenocortical carcinoma. Magnetic resonance imaging staged correctly the level of vena caval tumor thrombus involvement in 4 patients and missed the presence of right atrial tumor extension in 1. This noninvasive imaging modality can be used instead of contrast venography in most patients to assess the presence and extent of vena caval tumor involvement by renal cell carcinoma. Contrast venography should be used for those patients with suspected cardiac involvement and for those whose tumor thrombus extent remains unclear after magnetic resonance imaging.

Extension of renal cell carcinoma into the vena cava: clinical review and surgical approach.

Between 1972 and 1983, 25 patients were treated for renal carcinoma with tumor extension into the vena cava but without other clinical evidence of disseminated disease. Of these patients 12 had vena caval tumor thrombus extension up to the level of the hepatic veins (group 1), 10 had extension into the intrahepatic vena cava (group 2) and 3 had tumor extending into the right atrium (group 3). A perioperative management plan and an anatomical surgical approach have been developed to allow safe en bloc removal of these extensive tumor thrombi without removal of the vena cava. Successful management is dependent upon preoperative evaluation to determine precisely the extent of the disease, prophylaxis against pulmonary embolism and a well planned surgical method. For patients without evidence of metastatic or perinephric disease, the 5-year actuarial survival rate of 33 per cent is comparable to that of other patients without thrombus. Complete resection was possible in 20 patients (80 per cent), with a 5-year actuarial survival rate of 36 per cent. While patients with metastatic tumor cannot be cured, short-term palliation can be achieved for patients who have an imminent risk of vena caval occlusion or pulmonary embolism by an en bloc removal of tumor and thrombus, even for those with intra-atrial extension. Over-all, operative intervention was successful, with 22 of 25 patients leaving the hospital alive.

A simple and practical technic for detecting cancer cells in urine and urinary bladder washings by flow cytometry.

DNA measurement by flow cytometry has been demonstrated to be a potentially useful technic in the diagnosis of bladder cancer by detecting neoplastic cells in bladder washings and urine specimens. The authors' goal was to develop a simple and practical method utilizing the new generation of cytofluorographs designed for use in the clinical laboratory. This method combined direct fixation with cell lysis yielding fixed intact nuclei. Following RNase and pepsin digestion, the nuclei were separated from debris and aggregates on a sucrose barrier, stained with ethidium bromide, and analyzed with an argon laser analytic cytofluorograph. Urines and bladder washings from 14 patients with positive urinary cytology and histologically diagnosed bladder cancers were compared with specimens from patients without urothelial malignancies. DNA histograms clearly delineated aneuploid from diploid populations and often identified S, G2M, and G1 phase nuclei. Aneuploid populations have been detected in all tumor specimens with positive cytologies studied to date.

Seminoma with elevated human chorionic gonadotropin. The case for retroperitoneal lymph node dissection.

An elevated serum level of human chorionic gonadotropin (HCG) in a patient whose primary tumor histologically appears to be a pure seminoma implies the presence of syncytiotrophoblastic giant cells either detectable by careful step sectioning of the primary tumor or present in metastatic disease. Inasmuch as the malignant potential and radioresponsiveness of syncytiotrophoblastic giant cells are unknown and the serum elevation of HCG may signal metastatic embryonal carcinoma, retroperitoneal lymph node dissection with adjuvant chemotherapy dependent on pathologic staging should be considered for patients with seminoma and postorchiectomy elevated HCG levels. An illustrative case is herein reported.

Embryonal carcinoma with falsely positive elevation of serum alpha-fetoprotein after curative therapy: a case report.

An elevated serum alpha-fetoprotein is an important serum and cell marker in nonseminomatous testicular cancer. While the sensitivity of an elevated alpha-fetoprotein is 20 to 70 per cent, depending upon clinical stage subgrouping, the specificity is 100 per cent, since no falsely positive elevation of alpha-fetoprotein has been reported. We report a case of persistent falsely positive elevation of alpha-fetoprotein after curative therapy of embryonal carcinoma.

Hypothermic renal preservation during vascular anastomosis.

During the vascular anastomotic portion of renal transplantation, handling is facilitated, the kidney is cushioned, and deep hypothermia is maintained while the kidney is held in a simple sling made of polyethylene foam.