Cytogenetic, flow cytometric, and ultrastructural studies of twenty-nine nonfamilial human renal carcinomas.

Multifactorial analysis, including cytogenetic studies, flow cytometry, and light and electron microscopic evaluation, was performed on 29 primary renal cell carcinomas and short-term cultures derived from them. Eleven of the 21 cases that yielded cytogenetic results demonstrated clonal chromosomal aberrations which included trisomy 7 in 8 cases, loss of the Y chromosome in 7, trisomy 12 in 2, and 16q- in 1. Flow cytometry showed that there was preferential growth of near-diploid populations and loss of aneuploid clones in culture with standard media. The ultrastructural features of both the primary and cultured tumors were remarkably similar. They included cytoplasmic vacuolization, reticulated dense nucleoli, and cell surface microvilli. Thus, morphological evidence supported the epithelial and, specifically, the renal tubular origin of the cultured cells. The development of chromosomal abnormalities seemed linked to advanced tumor stage, but the number of such cases was too small to analyze for statistical significance. No other correlations could be made between karyotypic change, DNA analysis, tumor histology, grade, and stage at this point in the patient follow-up.

A syndrome of gonadotropin resistance possibly due to a luteinizing hormone receptor defect.

An 18-yr-old 46,XY man with primary hypogonadism and a microphallus is described whose Leydig cells appear to be partially insensitive to gonadotropin action. The external genitalia were well differentiated though abnormally small. The mean +/- SE baseline plasma testosterone (T) level was 62 +/- 3.9 ng/dl, and androstenedione was 34.5 +/- 7.3 ng/dl. Plasma levels of dehydroepiandrosterone, dehydroepiandrosterone sulfate, 17-hydroxyprogesterone, 17-hydroxypregnenolone, corticosterone, deoxycorticosterone, and 17 beta-estradiol were all normal. After the im administration of hCG, plasma T increased insignificantly from 71 to 78 ng/dl, and androstenedione increased from 22 to 47 ng/dl; there was no significant change in the levels of precursor steroids. The mean +/- SE serum FSH level was 17.4 +/- 3.6 mIU/ml, and LH was 15.4 +/- 1.1 mIU/ml (normal, 5-20); both responded briskly to iv GnRH. Exogenous T therapy resulted in normal virilization, whereas therapy with hCG was ineffectual. Testicular biopsy revealed Leydig cells in normal numbers, some spermatogenesis, and thickened tubular basement membranes. In vitro binding studies using [125I]hCG were performed with testicular homogenates from the patient and three normal subjects. With 7.4 fmol labeled hCG, the specific binding (mean +/- SD), expressed as femtomoles of hCG per mg protein, was 1.16 +/- 0.44 compared to 2.49 +/- 0.41 in normal subjects (P less than 0.05). These data demonstrate partial resistance to hCG and suggest that the defect in Leydig cell function may be at the LH receptor or postreceptor level.

Stage A2 prostatic carcinoma: should staging system be reclassified?

Seventy patients with clinically localized prostatic carcinoma were studied for histologic differentiation of primary tumor and the incidence of lymph node metastasis. Also the urologic literature was reviewed regarding the survival of such patients under similar treatment. The results indicate that clinically staged A2 tumors are more aggressive biologically than tumors staged as B1, reaffirming the need for a change in the current staging system. The authors propose reclassification of clinically unsuspected, diffuse carcinoma from the A to the B2 stage.

Use of profile view of kidney for spatial localization of intrarenal stones.

Profile view of the kidney obtained by "reverse oblique" x-ray projection was found to be useful in the spatial localization of intrarenal stones. The patient's position on the x-ray table is described, and 4 cases of patients with renal stones are illustrated.

Perirenal candidial abscess.

Perirenal candidial abscesses are rare, with few well-documented cases in the literature. We describe a case of a perinephric abscess treated with amphotericin B and nephrectomy.

Adventitious hysterogram during intravenous pyelography.

This study reports our experience with uterine opacification noted during infusion urography. The phenomenon is observed in 21.7 per cent of urograms performed on adult females. Examples of this entity are presented and the pathophysiology of the uterine opacification discussed.

Stage A prostate cancer from pathologist's viewpoint.

Four hundred sixty-five departments of pathology in the United States were asked the following questions pertaining to Stage A prostatic cancer: (1) If a focus of adenocarcinoma is incidentally found in an enucleated specimen, what is the maximum diameter such a lesion may attain and still be considered an A-1 prostatic carcinoma? (2) If adenocarcinoma is incidentally found in a specimen resected transurethrally, how many chips may contain tumor and the lesion still be considered A-1 prostatic carcinoma? (3) What is your "routine pathologic examination" of a prostatic specimen? The majority of pathologists believe that the maximum diameter of a focal (A-1) lesion in an enucleated specimen is 5 mm., and the maximum number of transurethral chips containing tumor in a focal (A-1) lesion is three. The majority of pathologists section every chip when the specimen weighs less than 10 Gm. However, only 12 per cent of the pathologists section every chip when the specimen is greater than 10 Gm., while the others use a random section technique. There is a great diversity of techniques among pathologists in their methods of examining enucleated prostatic specimens.

One-stage hypospadias repair.

A surgical technique for correction of hypospadias with chordee in one stage is described. This technique which brings the ectopic meatus up to the tip of the glans was successfully applied in 3 cases of penoscrotal and in 8 cases of penile hypospadias.

Diagnostic ultrasound of scrotum.

Ultrasound is a proved, safe diagnostic procedure. Its efficacy in the evaluation of 54 cases of scrotal pathology is reviewed. Ultrasound was 100 per cent accurate in the evaluation of hydroceles, hematoceles, and paratesticular masses, but less informative in testicular abscesses (80%) and epididymo-orchitis (77%).

Effect of multidose intracorporeal injection and audiovisual sexual stimulation in vasculogenic impotence.

Erections are inhibited by sympathetic stimulation. Anxiety or psychologic inhibition may produce abnormal response during impotence workup. The use of intracorporeal alpha blockers (phentolamine) and audiovisual sexual stimulation (AVSS) has been used to decrease sympathetic outflow and enhance erectile response. Thirty-three patients with suspected vasculogenic impotence were studied. They underwent pulsed Doppler ultrasound (PDUS) with multiple doses of tri-mix (mix of papaverine, phentolamine, and prostaglandin E1). AVSS was applied after maximal response to tri-mix. Seventeen patients (51.5%) responded to multidose with grade IV or V erection. When AVSS was started, 5 more patients responded, and 7 upgraded to grade V with overall response of 40 percent. AVSS can augment the in-office response to pharmacologic testing above that obtained by "maximal" pharmacologic dosing, thereby increasing the sensitivity and specificity of the test.

Bellevue pouch: ileocolonic continent urinary reservoir.

The technique for the Bellevue Pouch, another continent intestinal reservoir, is described. A large-capacity low-pressure reservoir is created from detubularized ascending colon, cecum, and terminal ileum. Continence is achieved by means of an intussuscepted segment of ileum and a modulating colonic pressure cuff wrapped around it. The operation has been performed on 19 patients, all of whom achieved satisfactory continence. Two patients were converted to free drainage systems at a later date. Average follow-up was twenty-five months.

Primary amyloidosis of urethra.

Primary localized amyloidosis of the urethra is rare; only 17 cases reported to date. Its clinical importance is significant, however, in that its presentation mimics carcinoma and treatment should be conservative. We describe an additional case and briefly review the literature.

Use of gadolinium-DTPA-enhanced MRI to characterize renal mass in patient with renal insufficiency.

A patient with chronic renal insufficiency was found to have an indeterminate renal mass after renal ultrasound, non-contrast CT, and non-contrast MRI studies. The mass was correctly diagnosed as an enhancing tumor with gadolinium-DTPA-enhanced magnetic resonance imaging.

Clinical follow-up in 24 nonfamilial renal tumors cytogenetically characterized in tissue culture.

OBJECTIVE: This study investigates the relationship between clonal chromosomal abnormalities detected in nonfamilial renal cell carcinoma and the clinical outcome, specifically, whether or not patients whose tumors had karyotypic changes have a different prognosis than those whose tumors did not. METHOD: Fresh tumor tissue obtained from 32 cases was grown in tissue culture. Twenty four grew successfully and were harvested and multiple cells of each karyotyped. Clinical follow-up was obtained for at least five years or until the time of death. RESULTS: Fourteen of 24 cases demonstrated karyotypic abnormalities including loss of Y chromosome (64%), trisomy 7 (50%), trisomy 12 (14%), trisomy 9, 10, 14, 15, 16, and 17, monosomy 9 and 20, and long-arm deletion of chromosome 16 (1 case each). Tumors were well-differentiated in 16 cases, moderately differentiated in 5 cases, and poorly differentiated in 1 case; 13 cases were pathologic Stage I, 5 Stage II, and 6 Stage III. Thirty-three percent of the patients demonstrated clinical progression. CONCLUSIONS: No significant difference in prognosis could be found between patients with and without karyotypic abnormalities. The only clinical or pathologic difference which could be established was sex distribution. Significantly greater numbers of males had karyotypic abnormalities than females, but this could be explained by the high number of Y chromosome deletions that were detected. The lack of correlation between karyotypic abnormalities and clinical outcome may reflect a confounding factor in genetic evolution such that clinically determining chromosomal changes present early in a tumor's growth in vivo may no longer be present when the tumor is diagnosed, treated, or after it is grown in culture. This may make demonstration of such clinically significant chromosomal changes very difficult.

Potentiation of drug-induced erection with audiovisual sexual stimulation.

Twenty-five patients underwent audiovisual sexual stimulation (AVSS) after pharmacologically-induced erection. Grade of erection and cavernosal blood flow were assessed after intracorporeal (IC) injection of TRI-MIX or prostaglandin E1, and then after AVSS, using pulsed Doppler ultrasonography (PDUS). After IC injection, 5 patients had a Grade II erection, 8 had Grade III, 10 had Grade IV, and 2 had Grade V. There was an increase in peak arterial flow and arterial diameter which corresponded with the grade of erection obtained. After addition of AVSS, 56.5 percent of patients experienced improved erection. The improvement from Grade III to IV in 13 percent is especially significant because it showed the attainment of adequate erection when IC injection alone failed. Penile blood flow improved among AVSS responders but not in nonresponders. AVSS may enhance pharmacologically-induced erection and may improve the diagnostic accuracy of PDUS.

CAT scanning in staging of prostatic cancer.

Forty-six patients with histologically proved adenocarcinoma of the prostate underwent pelvic lymphadenectomy after CAT scanning. The accuracy, specificity, and sensitivity of the CAT scan in detecting nodal metastasis were 70, 93 and 30 per cent, respectively; this compares favorably with pedal lymphangiography. Seventeen of the patients had radical prostatectomy. The accuracy, specificity, and sensitivity of the CAT scan in depicting local extent of the tumor were 47, 100, and 18 per cent, respectively; although low, no other clinical or biochemical method provides a better result.

Anterior urethral valves.

Three cases of anterior urethral valves, a rare congenital anomaly are reported. Anterior urethral valves probably represent an attempt at duplication of the urethra in the first twelve to fourteen weeks of intrauterine life. The most common type is cusp-like and most frequently located in the bulbar urethra. The presenting complaints are lower tract symptoms, and the diagnosis is usually made by a voiding urethrogram.

Sacrococcygeal teratoma.

Two cases of sacrococcygeal teratomas are presented. One case illustrates the long course of urologic problems produced by a "successful" removal of the tumor. The literature is reviewed, and the characteristics of this congenital tumor are discussed.

Radical prostatectomy for stage D1 prostate cancer. Prognostic variables and results of treatment.

Surgical extirpation of the primary tumor together with the involved regional nodes has been considered ineffective treatment for locally disseminated prostatic carcinoma. We retrospectively reviewed our experience with 42 patients with Stage D1 disease who underwent radical prostatectomy and bilateral pelvic lymphadenectomy and who had a follow-up of one to thirteen years (mean 5 years). The following variables affecting survival and tumor progression were analyzed: (1) tumor grade and local extent; (2) number of positive lymph nodes, and (3) adjuvant therapy. The overall five- and ten-year survival was 79.5 per cent and 28 per cent compared with the expected survival of an age-matched control group of 88 per cent and 28 per cent, respectively. The degree of tumor differentiation had no effect on prognosis, but local tumor bulk and the number of involved lymph nodes significantly changed the disease progression and survival rate. Patients with low local tumor bulk and one positive node survived as long as the age-matched male population group. Our data suggest that radical prostatectomy may represent a valuable treatment in selected patients with Stage D1 prostate carcinoma.

Renal cell carcinoma: survival and prognostic factors.

Three hundred twenty-six patients treated at New York University from 1970 to 1982 were studied for survival in relationship to surgical stage, type of therapy, and pathologic characterization of the primary tumor. At the time of diagnosis 25.5 per cent of tumors were Stage I, 15 per cent Stage II, 28.5 per cent Stage III, and 31 per cent Stage IV. The retrospective study showed that patients with tumor confined within the capsule achieved the highest five- and ten-year survivals of 88 per cent and 66 per cent, respectively. Survivals decreased as tumor invaded perirenal fat (67% and 35%) or regional lymph nodes (17% and 5%). Tumor invasion into the renal vein alone did not significantly change five-year survival (84%) but lowered ten-year survival to 45 per cent. Patients with metastases at the time of nephrectomy did poorly regardless of site of metastases or kind of adjuvant therapy, except for those managed by surgical extirpation of the secondary lesion. Certain tumor characteristics were associated with a better prognosis, e.g., size below 5 cm in diameter, lack of invasion of collecting system, perirenal fat or regional lymph nodes, and predominance of clear or granular cells growing into a recognizable histologic pattern.