Testosterone replacement therapy following radical prostatectomy.

INTRODUCTION: Controversy exists regarding testosterone replacement therapy (TRT) in men following radical prostatectomy (RP). Many clinicians are hesitant to offer patients TRT after an RP, out of concern that the increased androgen levels may promote tumor progression or recurrence from residual tumor. Recently, several small studies have demonstrated the use of TRT in men following an RP and have shown an improvement in serum testosterone levels with no increase in prostate-specific antigen (PSA) values. AIMS: The aim of this article is to assess changes in PSA and testosterone values in hypogonadal patients on TRT after RP and also to evaluate the impact of pathologic Gleason grade on ultimate PSA values. METHODS: All hypogonadal men who were treated with TRT by members of our department following RP were retrospectively reviewed. PSA values before RP, after RP, and after TRT were evaluated. Serum testosterone levels before and after TRT were also examined. Only patients with undetectable PSA values and negative surgical margins on pathologic specimen were offered TRT and included in the study. MAIN OUTCOME MEASURES: Main outcome measures were changes in PSA and testosterone values after initiation of TRT. RESULTS: Fifty-seven men, ages 53-83 years (mean 64), were identified as having initiated TRT following RP. Men received TRT for an average of 36 months following RP (range 1-136 months). Patients were followed an average of 13 months after initiation of TRT (range 1-99 months). The mean testosterone values rose from 255 ng/dL before TRT to 459 ng/dL after TRT (P < 0.001). There was no increase in PSA values after initiation of TRT and thus no patient had a biochemical PSA recurrence. CONCLUSION: TRT is effective in improving testosterone levels, without increasing PSA values, in hypogonadal men who have undergone RP.

Prostatic biology, histologic patterns and clinical consequences of transitional cell carcinoma.

PURPOSE OF REVIEW: To review the current fund of knowledge about prostatic transitional cell carcinoma and the implications for diagnostic and management strategies particularly as they relate to radical cystectomy. RECENT FINDINGS: Prostatic transitional cell carcinoma (TCC) is present in up to 48% of patients undergoing radical cystoprostatectomy. Transurethral resection biopsies of the prostatic urethra are a sensitive means of detecting prostatic TCC and whole-mount step sectioning is the most accurate method for determining the presence and extent of prostatic TCC. Prostatic TCC may affect prognosis independent of the primary bladder tumor stage. Preoperative detection of prostatic TCC enables accurate staging and treatment planning, including assessment of the risk of cancer at the apical urethral margin and the risk of a second primary tumor of the retained urethra, all of which factor into decision-making around urinary diversion and urethrectomy. Recognition of true T4a stage requires consideration of neoadjuvant chemotherapy and the need for extended pelvic and iliac lymphadenectomy in order to optimize an integrated treatment strategy. SUMMARY: Prostatic involvement with TCC in patients with bladder cancer is a common event. In patients with recurrent high-grade nonmuscle invasive cancer and patients undergoing radical cystoprostatectomy, a thorough assessment of the prostatic urethra and stroma is imperative for accurate staging and treatment planning.

Hand-assisted laparoscopic nephroureterectomy with open cystotomy for removal of the distal ureter and bladder cuff.

BACKGROUND AND PURPOSE: While performing laparoscopic nephroureterectomy, different techniques are used for removal of the distal ureter and bladder cuff. We present a series of patients with urothelial carcinoma of the renal pelvis or ureter who underwent hand-assisted laparoscopic nephroureterectomy (HALNU) with open cystotomy for removal of the distal ureter and bladder cuff. PATIENTS AND METHODS: From January 2000 to August 2004, 34 patients underwent HALNU. The hand-port device was placed in a lower-midline infraumbilical incision in all cases. After laparoscopic removal of the kidney and ureter down to the bladder, the hand port incision was extended caudally to allow open cystotomy. Intravesical dissection was performed at the ureteral orifice, and the bladder cuff and distal ureter were removed in a traditional open fashion. RESULTS: The mean operative time was 317 +/- 150 (SD) minutes, but the median operative time was 247 minutes. The mean estimated blood loss was 252 +/- 146 mL. The mean length of stay was 7.6 +/- 6.0 days, but the median stay was 5 days postoperatively (range 3-25). The mean morphine equivalent required postoperatively was 33 +/- 22 mg. The time of Foley catheter removal ranged from 3 to 15 days (mean 6.1 +/- 3.8 days), with no cases of extravasation by cystography at removal. Within a mean follow-up of 13.9 months, no recurrence of urothelial carcinoma was seen at the site of the excised ureteral orifice. CONCLUSION: A HALNU utilizing an open cystotomy for removal of the entire distal ureter with a bladder cuff provides excellent oncologic control while not adding significantly to the operative time or the morbidity of the procedure.

Early detection of a cavopulmonary tumor embolus with the use of transesophageal echocardiography.

Pulmonary tumor embolization from renal cell carcinoma is associated with severe cardiopulmonary morbidity and high perioperative mortality rates. We report the case of a 71-year-old woman who presented with right-sided abdominal pain. Magnetic resonance images revealed a mass originating from the upper pole of the right kidney and extending into the infrahepatic portion of the inferior vena cava. Transesophageal echocardiography was continuously used to monitor the mass during intended radical nephrectomy and tumor resection. When the right kidney was mobilized, intracaval thrombus detached and migrated to the patient's right atrium, causing severe hemodynamic instability. After emergent sternotomy and during the initiation of cardiopulmonary bypass, the mass was no longer echocardiographically detectable in the heart; it was soon removed completely from the left pulmonary artery. The mass was a renal cell carcinoma. We recommend the use of transesophageal echocardiography as an efficient diagnostic tool in the early detection of pulmonary tumor embolization during the resection of renal cell carcinoma that involves the inferior vena cava.

Could scrotoschisis mimic an iatrogenic injury? A case report.

Scrotoschisis is a rare congenital defect of the scrotal sac associated with extrusion of one or both testicles. Only 9 cases have been reported in the literature. The exact mechanism causing this rare congenital defect is unknown. We describe a case of unilateral scrotoschisis in a 35-week preterm infant delivered by cesarean section. The defect was repaired under local anesthesia within a few hours after birth, with good healing noted on follow-up. Scrotoschisis in an infant after delivery by cesarean section has been reported only once before. Although a laceration of scrotum during cesarean section was considered, it seemed unlikely.

Correlation between risk factors for vascular disease and the American Urological Association Symptom Score.

OBJECTIVE: To evaluate the correlation between risk factors for vascular disease and the American Urological Association Symptom Score (AUA-SS), by comparing the presence of these risk factors with the degree of lower urinary tract symptoms (LUTS). PATIENTS AND METHODS: We retrospectively reviewed the medical history, AUA-SS, and prostate volume of men who had a radical prostatectomy. The degree of LUTS in men with and without risk factors for cardiovascular disease was compared. RESULTS: The mean AUA-SS was 7.2 for the entire cohort, 5.6 in men with no risk factors, and 7.9 in men with at least one risk factor (P < 0.05). In men with one to four risk factors, the mean AUA-SS was 6.9, 7.9, 10.7, and 19.5, respectively. There was no correlation between the AUA-SS and prostate size in the entire cohort or among any groups. CONCLUSIONS: Men with risk factors for vascular disease are more likely to have a higher AUA-SS than men without these risk factors. These findings suggest the possibility of an association between vascular disease and the development and severity of LUTS in men.

Dysfunctional elimination syndrome is a negative predictor for vesicoureteral reflux.

PURPOSE: We investigated the likelihood of finding vesicoureteral reflux (VUR) in patients with urinary tract infections (UTIs), accompanied by fever or dysfunctional elimination syndrome (DES). MATERIALS AND METHODS: Two hundred consecutive voiding cystourethrograms performed in 1997-2002 for a diagnosis of UTI were reviewed. Fever, DES, and the grade and laterality of VUR were recorded. Patients were stratified into two groups by age to allow for assessment of DES symptoms in the older patient population: <2 years (n=68) and > or =2 years (n=132). Ratios were compared using a two-tailed Fisher's exact test. RESULTS: Of the children> or =2 years old, 64/132 (48%) had VUR. Patients who were non-febrile with DES were less likely than patients who were febrile without DES to have VUR [12/34 (35%) vs 23/34 (68%), P=0.02], whereas the risk of dilating VUR [5/34 (15%) vs 11/34 (32%), P=0.15] and bilateral VUR [4/34 (12%) vs 11/34 (32%), P=0.08] was not statistically different. In febrile patients, the presence of DES was associated with a lower risk of VUR [22/51 (43%) vs 23/34 (68%), P=0.03] and dilating VUR [5/51 (10%) vs 11/34 (32%), P=0.01], but not bilateral VUR [8/51 (16%) vs 11/34 (32%), P=0.11]. CONCLUSIONS: Children with non-febrile UTI and DES have a significantly lower risk of having VUR compared to children with febrile UTI and no DES. Among children with a history of UTI, DES is a negative predictor for VUR.