1997 American Urological Association Gallup survey: Changes in diagnosis and management of prostate cancer and benign prostatic hyperplasia, and other practice trends from 1994 to 1997.

PURPOSE: The American Urological Association first commissioned the Gallup Organization to conduct a study to assess urologist practice patterns in 1992. We present the results of the 1997 survey, the sixth consecutive Gallup survey performed for the Association. MATERIALS AND METHODS: A random sample of 502 American urologists who had completed urological residency and practiced at least 20 hours weekly in 1996 was interviewed by telephone in February and March 1997. RESULTS: Emerging trends showed significant changes since 1994 in how urologists diagnosed and treated prostate cancer. The survey revealed a significant change in the tests routinely ordered to stage newly diagnosed prostate cancer and for diagnostic evaluation of patients with benign prostatic hyperplasia. CONCLUSIONS: Urologists are becoming more cost conscious and effective in ordering pretreatment testing. Urologists are becoming more oriented toward medical treatment for the management of benign prostatic hyperplasia, and less laser surgery is being performed.

Atypical renal adenocarcinoma with features suggesting collecting duct origin and mimicking a mucinous adenocarcinoma.

We report a case of an atypical renal adenocarcinoma of the renal medulla associated with a marked desmoplastic response and interstitial mucin production. Collecting duct epithelium of the renal medulla throughout the kidney showed cytologic atypia. These features have been described by others as suggestive of a collecting duct histogenesis. This case represents the fifteenth reported case known to us of a renal adenocarcinoma of collecting duct origin. Prior reports, however, have not described the extensive mucin production that may be associated.

Simple urodynamic evaluation of incontinent elderly female nursing home patients. A descriptive analysis.

We present a descriptive analysis of the functional, mental, and urodynamic status of a population of incontinent elderly female nursing home patients. One hundred fifty-five intermediate care female patients with a mean age of 85.5 years were identified as being incontinent of urine at least once daily. After urologic evaluation, each patient was classified into one of four categories: incontinence with normal cystometrogram 68 (44%), detrusor instability (DI) 52 (34%), stress incontinence (SI) 27 (17%), or overflow incontinence (OI) 7 (4%). Thirteen weeks later, patients were again studied using simple water cystometry. At follow-up evaluation, 45 patients (33%) had urodynamic findings which differed from the initial evaluation. Of these women, 10 with DI, 12 with SI, and 2 with OI were found to have normal cystometric parameters at the time of follow-up study, while 19 (14%) who initially had normal cystometric findings had evidence of DI (11) or SI (3). Strong correlation between urinary incontinence in patients with normal cystometric findings and moderate to severe cognitive impairment was present. Simple urodynamic evaluation did identify patients with SI and OI who might benefit from specific therapy. Urodynamic evaluation of incontinent elderly female nursing home patients is indicated and may provide direction for planning treatment strategies.

The efficacy of transrectal ultrasound and prostate cancer.

An increased interest in the diagnosis and treatment of prostate cancer, particularly in the last few years, is reflected in the literature. Numerous articles have been published since 1980 on the subject of imaging of the prostate gland. This article is a review of transrectal ultrasound and its efficacy in the diagnosis and treatment of prostate cancer. Included is a review of the normal prostate anatomy, typical and atypical sonographic features, clinical and radiographic staging of prostate cancer, efficacy of the digital rectal examination, role of ultrasound in prostate cancer screening, surgical treatment, and radiotherapy of prostate cancer.

Cardiovascular evaluation before circulatory arrest for removal of vena caval extension of renal carcinoma.

The use of cardiopulmonary bypass, deep hypothermia and circulatory arrest has decreased the risks of hemorrhage, tumor embolization, incomplete thrombus resection, and warm hepatic and renal ischemia associated with resection of renal cell carcinoma extending into the inferior vena cava above the hepatic veins. Patients about to undergo this operation frequently have significant coronary artery and carotid artery disease, and are at risk for perioperative myocardial infarction and stroke. Preoperative evaluation of the coronary artery and carotid artery circulation by coronary angiography, duplex carotid artery scan and digital subtraction carotid angiography is recommended. Depending upon the severity and location of the cardiovascular disease a sequential or simultaneous operation may be performed. This surgical approach can be used in selected patients to facilitate complete tumor thrombectomy with a low operative risk.

Transitional cell carcinoma in an ileal conduit.

A 73-year-old man with a history of invasive transitional cell carcinoma of the urinary bladder developed synchronous recurrent transitional cell carcinoma at the ureteroileal anastomosis and the right renal pelvis. Hematuria was the presenting sign in six of the seven previously reported patients with ileal conduit cancer. The pathologic findings, diagnostic procedures and treatment are briefly reviewed.

Pheochromocytoma of the prostate: an unusual location.

We report a case of pheochromocytoma of the prostate. The clinical presentation, diagnostic evaluation, therapy and pathological findings are discussed.

Importance of acid phosphatase in response criteria for prostate cancer.

The role of acid phosphatase in the definition of response to treatment for prostate cancer is unclear. To better define its predictive value, especially regarding survival rate, we reviewed the clinical course of 76 men with Stage D2 prostate cancer who were treated with combination chemotherapy.

Androgen priming and response to chemotherapy in advanced prostatic cancer.

A total of 67 patients with progressive stage D2 prostatic cancer refractory to orchiectomy was entered in a controlled clinical trial to test whether androgen priming enhances the efficacy of cytotoxic drugs. All patients were treated continuously with aminoglutethimide and hydrocortisone to lower adrenal androgen secretion and were given cyclic intravenous chemotherapy. In addition, the 34 patients randomized to the stimulation arm received fluoxymesterone for 3 days before and on the day of chemotherapy. There was 33 controls. The median duration of followup was 24 months. A modestly higher response rate (objective remission plus disease stabilization) was observed in the stimulation arm (85 versus 72 per cent, p less than 0.05) when the analysis was restricted to the evaluable patients. However, a larger fraction of unevaluable patients was present in the stimulation group (41 versus 16 per cent), mostly as a result of toxicity from fluoxymesterone, which prompted early discontinuation of treatment. Thus, when data analysis included all patients the response rate actually was slightly higher in the control than in the stimulation arm (60 versus 50 per cent, p not significant). No difference was observed in median duration of response (9 months in both groups) or over-all survival. Our data suggest that at least in those patients with advanced disease androgen priming does not seem to enhance significantly the antitumor effect of the combination of amino-glutethimide and chemotherapy, and is associated with significant toxicity. These largely negative results may be explained by the large number of hormone-resistant cells present in tumors that have become refractory to orchiectomy.

Metastatic seminoma with regression of testicular primary: ultrasonographic detection.

We report a case of seminoma of the testis metastatic to the retroperitoneum. Biopsy of the retroperitoneal mass revealed anaplastic seminoma. No testicular mass could be palpated. Testicular ultrasonography showed a hypoechoic 3 X 2 cm. area in the left testis suggestive of a primary testicular tumor, most likely a seminoma. Histological evaluation of the resected testis revealed fibrous tissue but no definable tumor.

Spontaneous retroperitoneal hemorrhage secondary to a renal cause.

Spontaneous rupture of normal renal parenchyma must indeed be rare. Virtually all patients in this paper had a significant abnormality that presented with bleeding. Our Case 5 is the only one without a clear underlying pathologic entity. We should stress the high incidence of associated disease in kidneys that bleed "spontaneously" and therefore the need for exploration and/or nephrectomy.

Adrenal cortical carcinoma: case report.

Adrenal cortical carcinoma is a rare malignant tumor, comprising only 0.02 to 0.04% of all cancers [Nader et al, Cancer 52: 707-11, 1983; Didolkar et al, Cancer 47: 2153-61, 1981; Hajjar et al, Cancer 35: 549-54, 1975]. The mean age of presentation for females is 36.6 years and for males, 48 years. In general, women have a higher percentage of functioning adrenal tumors. Functional tumors are hormonally active with excess steroid production in serum and urine with associated clinical signs and symptoms.

The synthesis of prostaglandins by the Nb rat prostate tumor.

Carcinomata of the prostate animal model systems have been used in the past to evaluate chemotherapy. The Nb rat model is an ideal model to study prostate cancer, as it has two separate tumor types, one that is androgen-insensitive and one that is androgen-sensitive. In this paper the results of the prostaglandin synthesis release assay on an antigen-insensitive tumor are presented. This is a means to further characterize this tumor.

Clinical effect of aminoglutethimide, medical adrenalectomy, in treatment of 43 patients with advanced prostatic carcinoma.

The initial treatment of patients with Stage D prostatic carcinoma with orchiectomy or estrogens is successful in giving objective and subjective improvement for variable periods of time. However, after initial endocrine treatment patients generally relapse, and go on to further progression of their disease. However, a subgroup of approximately 22% of these Stage D prostatic cancer patients respond to either surgical adrenalectomy or hypophysectomy, indicating some degree of continued hormonal responsiveness. Forty-three previously castrated patients with Stage D prostatic carcinoma were treated with 1000 mg of aminoglutethimide and 40 mg of hydrocortisone daily and have been evaluated using the criteria of the National Prostatic Cancer Project. Progression of disease after initial hormonal therapy has varied from 3 to 25 months. One patient has had a complete response, and continues in remission after 290 weeks of therapy. Partial objective responses have been observed in 6 patients, and 10 patients have remained objectively stable for an average of 35 weeks in this latter group.

Bladder cancer: results of radical cystectomy for invasive and recurrent superficial tumors.

The operative management of bladder carcinoma was reviewed retrospectively in 76 patients: 57 had muscle invasion and 19 had rapidly recurring or extensive superficial tumors requiring aggressive therapy. Of the patients 9 had been managed initially elsewhere with radiation treatment for cure and underwent salvage cystectomy at our institution. The results are discussed comparing patients receiving no radiation (11 of 20 alive) and 4,000 rad given preoperatively (11 of 20 alive), and patients with no muscle invasion but recurrent or extensive superficial tumors (14 of 19 alive).

Cystectomy and urinary diversion: a safe procedure for elderly patients.

Cystectomy and urinary diversion have been done on 28 patients more than age seventy with a zero perioperative mortality. Nine female patients with an average age of 77.6 years and 19 male patients with an average age of 74.4 years with 3 patients being greater than age eighty, are the subject of this review. Complication rate, blood loss, and hospital stay were not significantly different from patients having cystectomy and urinary diversion who were seventy years of age or less. Twenty-seven of the 28 patients had muscle-invading tumors; 12 patients are alive with a median survival of greater than thirty months. Five of 10 patients who did not receive radiation therapy are alive; 7 of 18 patients who received some form of radiation therapy are alive. Six patients had been treated initially with 7,000 rad for definitive therapy of bladder carcinomas. In carefully selected patients, when appropriate attention is paid to general patient status, cardiovascular system, pulmonary function, and fluid and electrolyte status, cystectomy and diversion can be completed with an acceptable rate of morbidity.

Clinical and biochemical effect of aminoglutethimide in the treatment of advanced prostatic carcinoma.

Treatment of male patients with advanced prostatic carcinoma and disease progression after initial endocrine therapy frequently is unsatisfactory. However, approximately 20 per cent of these patients respond to surgical adrenalectomy or hypophysectomy, indicating continued hormonal responsiveness. A total of 25 previously castrated men with stage D carcinoma received 1,000 mg. aminoglutethimide and 40 mg. hydrocortisone daily. The patients were evaluated using the criteria of the National Prostatic Cancer Project. One patient has had a complete response and is in remission after 275 weeks of therapy. A partial response was noted in 4 patients, while the disease was objectively stable in 6. Pre-treatment testosterone and dihydrotestosterone levels were measured in 9 of 25 patients and were significantly reduced statistically during aminoglutethimide therapy (p less than 0.01). Response and drug toxicity are discussed.

Fungal cystitis: awareness, diagnosis and treatment.

We report 4 cases of fungal cystitis. All patients had severe urgency, frequency and nocturia with sterile pyuria and microhematuria. Significant fungal growth was observed on routine blood agar cultur. Bladder biopsy was necessary to rule out tumor. Of the patients none responded to watchful waiting, 1 responded to intermittent daily bladder instillation of amphortericin B, 2 improved with oral 5-fluorocytosine, in addition to amphotericin B bladder instillations, and 1 required intravenous amphotericin B after unsuccessful response to 5-fluorocytosine and amphotericin B bladder treatments.