Transurethral Vapor Ablation in Patients with Intermediate-Risk Localized Prostate Cancer.

Purpose: We report results of a prospective, multicenter single-arm study of transurethral vapor ablation (TUVA) of prostate tissue in patients with unilateral, intermediate-risk, localized prostate cancer (PCa). Materials and Methods: Men ≥45 years of age with biopsy-confirmed unilateral Gleason grade group 2 (GGG2) adenocarcinoma of the prostate, prostate volume of 20-80 cc, and prostate-specific antigen (PSA) ≤15 ng/mL were enrolled. Cystoscopy and transrectal ultrasound (TRUS) guidance were used to deliver ∼103°C water vapor to prostate zones for unilateral hemigland ablation, including destruction of cancers detected by multiparametric MRI (mpMRI) and confirmed by biopsy. The primary outcomes were device-related serious adverse events (SAEs). At 7 days and 6 months postprocedure, the ablation extent was assessed by mpMRI; MRI/TRUS fusion biopsies were completed at 6 months. Quality of life (QOL) was assessed with validated questionnaires. Results: All subjects underwent a single hemigland TUVA procedure. No SAEs occurred. Grade 2 procedure-related AEs included transient urinary retention (n = 4) and erectile (n = 1) or ejaculatory dysfunction (n = 1). At 7 days, mpMRI revealed complete ablation of 14/17 (82%) visible lesions. At 6 months, biopsies showed no Gleason pattern ≥4 or ≥GGG2 cancer on the treated side of prostates in 13/15 (87%) subjects. Ten of 15 (67%) subjects were biopsy negative. Of the 5 biopsy-negative subjects, 2 had one core each of 3 + 4 disease and 3 had one core each of 3 + 3 disease with ≤5% involvement. Median prostate volume was reduced by 40.7% and PSA by 58%. Extensive QOL assessments showed, on average, no appreciable negative effects of treatment. Conclusions: Initial evidence suggests that TUVA is safe in men with intermediate-risk PCa. Preliminary results demonstrate the absence of ≥GGG2 disease on the treated side in 87% of men and a favorable QOL profile.

Postmortem Sperm Retrieval in the Emergency Department: A Case Report and Review of Available Guidelines.

Postmortem sperm retrieval (PMSR) requests and retrievals are increasing in the emergency department (ED) setting. Few EDs have protocols in place, and many emergency physicians (EP) lack the knowledge of how to proceed when such situations arise. We report the case of a 31-year-old male cardiac-arrest victim who expired in the ED, after which his wife requested PMSR. We review the guidelines, procedures, and issues of consent that arise with PMSR. EPs must be aware of their institution's policies and consultant availability should a request for PMSR arise.

Metastatic cancer to the renal pelvis: a novel approach to management.

We describe a novel application of percutaneous renal surgery for the management of an unusual and challenging urologic problem. Two patients with symptomatic, metastatic adenocarcinoma in the renal pelvis were treated with percutaneous resection. The lesion was in a solitary kidney in 1 patient, and was bilateral in the second. Percutaneous resection resulted in complete relief of symptoms and obstruction. Although both patients ultimately died of their primary disease, their quality of life was significantly improved in the interim. Percutaneous resection of renal pelvic tumors is accepted management for select patients with upper tract transitional cell carcinoma. These 2 cases demonstrated both an unusual presentation for metastatic adenocarcinoma and an expanded application for percutaneous renal surgery.

Surgical management of erectile dysfunction.

Since the introduction of sildenafil citrate, oral systemic therapy has become the first line of therapy for men with erectile dysfunction (ED). Men who are not candidates for or who fail treatment with an oral agent may choose second-line therapies such as intraurethral prostaglandins, penile injection therapy, sex therapy, or a vacuum erection device. These secondline therapies may be unpalatable or inadequate for some men, and these men constitute the candidates for surgical intervention for ED. This article reviews surgical management of vascular ED, surgical management of Peyronie's disease, and penile prosthesis implantation. At the current time, the appropriate candidate for penile revascularization is a young man with proven arterial insufficiency resulting from pelvic trauma. Results in other populations are disappointing. Peyronie's disease with curvature significant enough to interfere with intercourse may be managed with tunical lengthening or shortening procedures in potent men and with prosthetic implantation in men with ED. Modern three-piece penile prostheses are associated with excellent device reliability, high rates of patient satisfaction, and acceptably low complication rates.

Urological manifestations of vascular disease.

We have detailed several of the urological manifestations of vascular disease. With the aging of the North American population, urologists will encounter the urological complications of vascular disease with ever-increasing frequency.

Mechanical failure of the American Medical Systems Ultrex inflatable penile prosthesis: before and after 1993 structural modification.

PURPOSE: The 700 Ultrex (American Medical Systems, Minnetonka, Minnesota) is the only penile prosthesis capable of length and girth expansion. Early experience with the 700 Ultrex showed an increased mechanical failure rate compared with the 700CX, mostly secondary to cylinder failure. In 1993 the Ultrex cylinders were modified. We examined the performance of the Ultrex device before and after modification. MATERIALS AND METHODS: We compared our results with the Ultrex prosthesis before (group 1) and after (group 2) the 1993 modification. We implanted 239 devices from October 1989 to December 1999. A total of 26 patients have died. Followup was obtained on the results of 137 of the remaining 213 implants (64%), including 85 pre-modification devices in 85 patients and 52 post-modification devices in 51, via a mailed questionnaire, telephone survey or chart review. The questionnaire and survey included a 5-point satisfaction scale. Groups 1 and 2 were compared in regard to 3 end points, namely cylinder, mechanical and overall failure. RESULTS: Followup was less than 1 to 136 months (median 92, 25th to 75th percentiles 43 to 108) in group 1 and less than 1 to 92 months (median 46, 25th to 75th percentiles 21 to 75) in group 2. The 5-year Kaplan-Meier estimates of overall, mechanical and cylinder survival in groups 1 and 2 were 64.7%, 70.7% and 80.2%, and 77.7% (p = 0.23), 93.7% (p = 0.017) and 96.2% (p = 0.008), respectively. Overall satisfaction was similarly high in groups 1 and 2 (mean 3.9 and 4 points). CONCLUSIONS: On long-term followup the 1993 modification of the Ultrex cylinders appears to have significantly decreased the propensity of cylinder failure of the pre-modification device.