A testosterone-producing adrenal cortical adenoma in an elderly woman.

A 76-year-old woman with virilization had menopausal levels of circulating LH and FSH, and a markedly elevated concentration of plasma testosterone (9130 pg/ml) into the range for adult men. Plasma cortisol and androstenedione levels andurinary 17-ketosteroid secretion were normal. Ethinyl estradiol suppressed plasma testosterone, LH, and FSH levels into the normal range for premenopausal women, but the testosterone concentration was unaffected by the administration of dexamethasone or ACTH. Retrograde venous sampling and angiography localized a right adrenal adenoma preoperatively. Following adrenalectomy, there was a prompt fall in testosterone, but there was no change in the LH concentration. Thus, this patient had an adrenal adenoma which secreted only testosterone and appeared to be gonadotropin-responsive. Testosterone levels in the adult male range failed to suppress gonadotropins. The significance of these findings is discussed.

A preliminary analysis of health-related quality of life in the first year after permanent source interstitial brachytherapy (PIB) for clinically localized prostate cancer.

PURPOSE: To prospectively assess the health-related quality of life (HRQOL) and changes in HRQOL during the first year after permanent source interstitial brachytherapy (PIB). METHODS AND MATERIALS: Thirty-one men treated with PIB between September 1997 and March 1998 completed a quality of life (functional assessment of cancer therapy-prostate: FACT-P) and a urinary symptom questionnaire (international prostate symptom score: IPSS) prior to treatment (T0), 1 month (T1), 3 months (T3), 6 months (T6), and 12 months (T12) following PIB. All participants were treated with 125I alone. Repeated measures analyses of variance (ANOVA) were conducted on all quality of life and urinary outcome measures for all 31 patients at all time points. RESULTS: The median age of the study population was 66 (range 51-80). All men had clinical T1c-T2b prostate cancer. The Gleason score was < or =6 in 27/31 (87%). Median pretreatment PSA was 7.8 ng/ml (range 1.1-20.6). The mean score (and standard deviation) at T0, T1, T3, T6, and T12 for the FACT-P questionnaire are as follows: 140.5 (13.5), 132.7 (15.3), 137.2 (17.4), 140.1 (16.0), and 142.4 (15.3). For the global test across time, statistically significant differences were observed for the cumulative scores of FACT-P (p<0.0012). The decrease in HRQOL was most marked 1 month following PIB. Examination of the subscales within the FACT-P instrument demonstrated statistically significant changes over time for the following: physical well-being (PWB), functional well-being (FWB), and prostate cancer (PCS). By 3 months, all HRQOL measures had returned to near baseline. The mean score (and standard deviation) at T0, T1, T3, T6, and T12 for the IPSS questionnaire are as follows: 8.3 (5.5), 18.4 (8.0), 15.7 (7.4), 13.7 (7.4), and 10.2 (5.7). For the global test across time, statistically significant differences were observed for the IPSS scores (p<0.0001). The maximum increase in IPSS occurred 1 month following PIB. CONCLUSION: The results of this preliminary analysis suggest that clinically meaningful decreases in HRQOL, as measured by the FACT-P instrument, are evident within weeks after PIB. By 3 months, however, FACT-P scores return to near baseline levels. A validated instrument designed to measure urinary symptoms (IPSS) demonstrates that moderate to severe urinary symptoms persist for at least 3-6 months following PIB. One year following PIB, the scores on the FACT-P and IPSS questionnaires had returned to baseline.

Postimplant analysis of transperineal interstitial permanent prostate brachytherapy: evidence for a learning curve in the first year at a single institution.

PURPOSE: The utilization of transperineal interstitial permanent prostate brachytherapy (TIPPB) is increasing in the United States. Quality assessment of TIPPB is in its infancy, and to date, dosimetric analyses have only been reported from centers with a large experience in prostate brachytherapy. The purpose of this report is to critically analyze the dosimetric coverage achieved following TIPPB in the first 63 cases performed by a multidisciplinary group of investigators with no prior experience with TIPPB. METHODS AND MATERIALS: The information in this report concerns the first 63 men treated with TIPPB alone at our institution between September 1997 and September 1998. All men were treated similarly, adapting the methods described by Blasko and Grimm. All men were treated with 125I. The prescription dose was 144 Gy according to the TG43 formalism. TIPPB was performed jointly by a radiation oncologist and a urologist. One month following TIPPB, all men underwent a computed tomography (CT) scan of the pelvis according to a protocol using 3-mm abutting slices. CT images were transferred by a local area network to a commercially available treatment planning system and dose-volume histograms were calculated with 0.5-mm pixel spacing. A variety of dosimetric endpoints were examined. A single measure of dose homogeneity, the dose-homogeneity index (DHI), is defined as the volume within the prostate that receives 100-150% of the prescription dose (144-216 Gy) divided by the volume within the prostate that receives 100% of the prescription dose (144 Gy). Three measures of target (prostate) dosimetric coverage are provided. C100 is defined as the percentage of the prostate volume defined on postimplant CT that receives at least 100% of the prescription dose. C90 and C80 are similar but represent the percentage of the prostate volume that receive 90% and 80% of the prescription dose, respectively. Statistical analyses were performed using commercially available computer software. To investigate any changes with time the first 30 cases (group 1) are compared to cases 31-63 (group 2). All p-values are two-sided. RESULTS: The mean C100, C90, and C80 for all 63 patients were 80.7% (SD 10.1), 85.1% (SD 10.2), and 89.3% (SD 9.5). The quantifiers of implant adequacy were all improved in the most recent 33 patients compared to the first 30 patients, (group 1: C100, 75.8% [SD 12.2], C90 79.9% [SD 11.4], C80 84.3% [SD 11.1]; group 2: C100, 85.2 [SD 7.0], C90 89.9% [SD 5.8], C80 93.8% [SD 4.2]; p<0.001). The mean DHI was 0.538 SD (0.124). A multivariate model incorporating a number of variables (ultrasound volume, CT volume, total activity, activity/ seed, implant number) with C100 as the dependent variable found that the implant number was the only statistically significant predictor of C100 (p = 0.0001). Using C90 and C80 as the dependent variable produced similar results (C90, p = 0.0001; C80, p = 0.0001). CONCLUSION: In this single institution experience with the first 63 men receiving TIPPB by a multidisciplinary group of investigators, there is evidence for a learning curve. All quantifiers of implant adequacy improved as clinicians gained experience. In the most recent group of patients, quantifiers of implant adequacy are similar to those reported from other groups with significantly more experience with TIPPB.

A prospective quality-of-life study in men with clinically localized prostate carcinoma treated with radical prostatectomy, external beam radiotherapy, or interstitial brachytherapy.

PURPOSE: To prospectively assess the health-related quality of life (HRQOL) and changes in HRQOL during the first year after 3 different treatments for clinically localized prostate cancer. METHODS AND MATERIALS: Ninety men with T1-T2 adenocarcinoma of the prostate were treated with curative intent between May 1998 and June 1999 and completed a quality-of-life Functional Assessment of Cancer Therapy-Prostate (FACT-P) questionnaire before treatment (T0) and 1 month (T1), 3 months (T3), and 12 months (T12) after treatment. Forty-four men were treated with permanent source interstitial brachytherapy (IB), 23 received external beam radiotherapy (EBRT), and 23 men were treated with radical prostatectomy (RP). The mean age of the entire study population was 65.9 years (median 67, range 42-79). The mean pretreatment prostate-specific antigen level of the entire study population was 6.81 ng/mL (median 6.25, range 1.33-19.6). The Gleason score was

Correlation of prostate-specific antigen and prostate-specific antigen density with outcome of prostate biopsy.

OBJECTIVE: We attempt to correlate prebiopsy serum prostate-specific antigen (PSA) concentration and prostate-specific antigen density (PSAD) with histologic results of prostate biopsy. METHOD: Sixty-two consecutive patients underwent prostate biopsy because of elevated PSA greater than 4 ng/mL and/or abnormal findings on digital rectal examination (DRE). PSAD was calculated from dividing the serum PSA concentration by the prostate volume as determined by transrectal ultrasound (TRUS). PSA and PSAD were compared to biopsy outcome. RESULTS: The mean PSAD values of the cancer versus noncancer (benign prostatic tissue, benign prostatic hyperplasia, and prostatitis) groups were significantly different (p < 0.019). However, there was great overlap in individual values. The mean PSA levels of the cancer versus noncancer groups also were significantly different (p < 0.0079). In patients with PSA levels between 4 and 10 ng/mL, 11 of 32 (34%) had positive biopsy findings for cancer. Eleven of 29 patients (38%) with normal DRE findings and elevated PSA levels (> 4 ng/mL) had positive biopsy findings for cancer. Seven of 19 patients (37%) with normal DRE findings and elevated PSA levels between 4 and 10 ng/mL had positive biopsy specimens for cancer. CONCLUSIONS: PSAD, though suggestive, is not definitive for cancer or noncancer. Patients with inflammation (prostatitis) present in their biopsy specimens have serum PSA levels and PSAD values intermediate between those with benign tissue (without inflammation) and cancer. We think that prostate biopsy is important in patients with PSA levels between 4 and 10 ng/mL even if their DRE result is normal, as our data indicate that over one third of these patients harbor detectable prostate cancer.

Thoracoabdominal radical nephrectomy: is a postoperative thoracostomy tube necessary?

OBJECTIVES: To report our results of patients undergoing thoracoabdominal radical nephrectomy without intraoperative placement of a thoracostomy tube. It has been routine in our hospital to not place a thoracostomy tube in patients undergoing thoracoabdominal radical nephrectomy since 1988. METHODS: We conducted a retrospective review of 47 thoracoabdominal radical nephrectomies performed from January 1988 through November 1998 at our institution. Of the 47 patients, 39 did not have a thoracostomy tube placed intraoperatively; the other 8 patients did. The development of all postoperative complications, length of hospital stay, and hospital charges were noted. RESULTS: No postoperative mortality was noted in our study. Of the 47 patients in the study, 20 patients had a total of 29 complications. The overall number of complications was not increased in the group without a thoracostomy tube compared with the group with a thoracostomy tube (P = 0.104). No patient treated without a thoracostomy tube required subsequent placement of a tube for persistent pneumothorax. The mean length of hospital stay in patients with a thoracostomy tube after radical nephrectomy was 9.14 +/- 2.65 days; in patients without a thoracostomy tube, the mean length of stay was 7.07 +/- 3.97 days (P = 0.071). CONCLUSIONS: In patients without parietal pleural injury, thoracoabdominal radical nephrectomy without the placement of a thoracostomy tube can be performed safely and effectively, with a low risk of postoperative complications and a decrease in the overall hospital stay and hospital charges.

Lumbar ureteral shunt--an unusual cause of ureteral obstruction.

In a neurosurgical patient with a lumbar ureteral shunt in place for many years ureteral obstruction and hydronephrosis developed. The shunt tubing was removed surgically from the ureter leaving a portion of the shunt in the subarachnoid space without sequelae. Historically, most patients undergoing this type procedure had an ipsilateral nephrectomy performed at the time of shunt placement; however, this patient did not. It is important to be aware of this "antique" procedure as it may cause urologic complications.

Extracorporeal shock-wave lithotripsy in hemophiliac patient.

We report on a patient with hemophilia A who underwent successful extracorporeal shock-wave lithotripsy without incident. We are aware of two other reported cases in the literature. The relative risks of alternative methods of stone management and the indications and risks of blood product therapy in this condition are reviewed.

Xanthogranulomatous pyelonephritis, the gatekeeper's dilemma: a contemporary look at an old problem.

OBJECTIVES: To review 12 patients with a clinicopathogenic diagnosis of xanthogranulomatous pyelonephritis (XGP) and to determine if a computed tomography (CT) scan is the imaging procedure of choice for diagnosis. METHODS: A retrospective review, over the last 12 years, of patients with XGP at our institution. RESULTS: Nine of 10 patients (90%) who were evaluated by CT scan had the correct diagnosis made prior to nephrectomy. The most common presenting symptoms and signs were flank pain (64%), leukocytosis (73%), and anemia (82%). Seventy-five percent of the patients had a ureteropelvic junction stone or a staghorn stone in the affected kidney at the time of clinical presentation. Proteus was the most common organism cultured. CONCLUSIONS: After reviewing the clinical features of these 12 patients, we recommended CT scan to evaluate the patient in whom clinical suspicion of XGP is entertained. CT has proven to be the most accurate imaging study to evaluate this disease.

Puboprostatic ligament sparing improves urinary continence after radical retropubic prostatectomy.

OBJECTIVES: To determine whether a puboprostatic ligament-sparing technique of prostatic apical dissection provided improved urinary continence after radical retropubic prostatectomy. METHODS: A total of 43 men with clinically localized prostate cancer underwent radical retropubic prostatectomy (standard apical dissection in 25, puboprostatic ligament-sparing technique in 18). Patients were evaluated by independent observer questionnaire to determine their continence status. The questionnaire was tested in a control group of 25 men who had not undergone prostate surgery. The overall continence rate and time to achieve continence was compared between the two surgical groups. In addition, the clinical and pathologic stages and both the rate and location of positive margins were assessed. RESULTS: Mean patient age and serum prostate-specific antigen values were not significantly different between the two groups. Clinical and pathologic stages were also similar. The mean follow-up period for the puboprostatic ligament-sparing group was 35 weeks compared with 57 weeks for the standard group (P < 0.05). The median time until continence was achieved after surgery was significantly shorter (P = 0.01) for the puboprostatic ligament-sparing group than for the standard method (6.5 and 12 weeks, respectively). However, the overall continence rate at 1-year follow-up for the two groups was similar (100% and 94%, respectively). The positive margin rate and location of positive margins were not different with the puboprostatic ligament-sparing technique. CONCLUSIONS: The puboprostatic ligament-sparing technique improves the rapidity of return of urinary continence after radical prostatectomy without significantly enhancing overall continence or interfering with the therapeutic efficacy of the procedure.

The gravity suit: a useful device in complicated urologic hemorrhage.

External counterpressure with a gravity suit was used to control intractable postoperative bleeding in 4 urologic patients. Two patients had coagulation defects, and 2 had been unsuccessfully reexplored prior to application of the G-suit. The bleeding was controlled with preservation and restoration of vital signs in each case. In 3 cases external counterpressure may have been lifesaving.

"Positive" bone scan--a contraindication to surgery?

Eleven patients with urologic cancer had an abnormal 99mTc (technetium-99m) bone scan as the sole evidence of metastatic disease. Potentially curative therapy should not be withheld on the basis of a "positive" bone scan if such an area is accessible to selected bone biopsy and proves to be negative for tumor histologically.

Physiologic variations of serum testosterone within the normal range do not affect serum prostate-specific antigen.

OBJECTIVES: To determine the relationship between endogenous total serum testosterone levels and serum prostate-specific antigen (PSA) concentrations. If a correlation exists between these two parameters, then use of testosterone-specific reference ranges may enhance the utility of PSA as a marker for prostate cancer. METHODS: Data were obtained from 150 men without previous history of prostate cancer. PSA was measured by the Abbott IMX microparticle enzyme immunoassay and total testosterone determined by the Coat-A-Count radioimmunoassay. RESULTS: No correlation was found between testosterone and PSA, even when corrected for age and weight. CONCLUSIONS: The data suggest that determination of the total serum testosterone level does not improve the sensitivity or specificity of PSA as a tumor marker.

Inguinal lymphadenectomy and primary groin reconstruction using rectus abdominis muscle flaps in patients with penile cancer.

OBJECTIVES: The use of deep inferior epigastric artery (DIEA) rectus abdominis muscle flaps in conjunction with inguinal lymphadenectomy to treat patients with squamous cell carcinoma (SCC) of the penis having high-volume inguinal lymph node metastases causing skin breakdown and secondary infection is described. METHODS: Three patients with invasive SCC of the penis who had extensive unilateral inguinal nodal metastases with skin breakdown and secondary infection underwent pelvic lymphadenectomy and attempted wide resection of the superficial and deep inguinal lymph nodes. One patient had unresectable deep inguinal metastases and received postoperative radiation therapy. A DIEA rectus abdominis muscle flap was utilized to close the resulting groin defect. RESULTS: Pathologic analysis demonstrated no pelvic lymph node metastases in any of the patients, superficial inguinal lymph node metastases in 1, and superficial and deep inguinal lymph node involvement in 2. All wounds healed well. The 2 patients with deep inguinal metastases experienced local disease progression. One patient died 7 months postoperatively of complications from chronic renal failure but had no evidence of tumor recurrence or wound problems. Another patient died of recurrent disease. CONCLUSIONS: A rectus abdominis muscle flap may be a useful adjunct for managing certain patients with penile cancer and extensive suppurative inguinal lymph node metastases.

Testicular germ cell tumors in HLA-genotype non-twin brothers.

The diagnosis of metastatic testicular carcinoma in a thirty-three-year-old man and his nineteen-year-old brother is reported. Histologically, the tumor of the older brother consisted predominantly of embryonal carcinoma with minor components of seminoma and adult teratoma; the tumor of the younger brother consisted entirely of embryonal carcinoma. Since previous reports suggest the possibility that the HLA genotype may be a factor in the etiology of testicular cancer, we typed the parents and four children of this family. The two affected brothers shared a paternal HLA-A3, Cw-,B7,DR2 haplotype that had not been transmitted to the two other living siblings. Analysis of the distribution of HLA haplotypes of the affected non-twin brothers of this family and those of three other non-twin pairs of brothers that have been reported showed that the affected pairs in each family shared one HLA haplotype. The differences between the expected and the observed distribution of HLA haplotypes in the four sibling pairs is not statistically significant, perhaps because of the small number of patients typed. Two of the four pairs shared a common haplotype. Additional family studies are required to establish a genetic origin of testicular tumors and to determine whether or not a "testicular carcinoma disease" gene is linked to the HLA complex. A large number of multicase families will be required for linkage analysis.

Manpower needs in urology in the twenty-first century.

Physician supply factors are based on a number of variables. These include the base supply and retirements, which presently show that around 200 urologists are retiring per year. Death rates of both patients and physicians are significant. The rate of entry of graduating residents is important. Population changes (which certainly will continue to increase in the United States) are important. Needs-based projections, demand-needs based projections, and benchmarked projections are important issues. The immigration of physicians is important. So far, I think we have seen little emigration of physicians from the United States. A number of confounding variables can have impact and are almost impossible to predict at present. These include technology changes, disease patterns, and methods of care delivery. The Strategic Planning Committee thought we should aim for a band of 200 to 250 chief residents finishing one per year. We have already reached the 250 level. At 200 finishing per year, we would have 2300 fewer urologists in the year 2020 than we presently have. AT 225/year, we would have 1700 fewer urologists. At 250 (our present level), we will have 1100 fewer than now. These 8800 urologists would be caring for 60 million more patients, of whom 20 million would be Medicare patients. These patients would provide over 500 additional patient visits/year/urologist. I hope that I have convinced you that the system is correcting and responding to multiple market forces. I predict that urologists in practice in 2020 will be busy and that we will not have too many urologists if the graduating numbers are kept stable. If they drop much more, we could well have too few.