Risk management and pollution prevention: thinking outside the box.

The Medical University of South Carolina's risk management department received a 12-month grant from South Carolina's General Assembly "Hazardous Waste Management Research Fund" for the purpose of identifying pollution prevention opportunities within South Carolina healthcare facilities. One hundred and one healthcare facilities were invited to participate in this study. Facilities ranged in size from zero-licensed beds (clinics) to more than 300 beds. Seventy-six South Carolina facilities (75%) participated in this project.

Efficacy and safety of luteinizing hormone-releasing hormone antagonist cetrorelix in the treatment of symptomatic benign prostatic hyperplasia.

As the life expectancy for men increases, more cases of benign prostatic hyperplasia (BPH) will be expected. Symptomatic BPH causes morbidity and can lower the quality of life. We investigated whether short term administration of the LH-releasing hormone antagonist cetrorelix could provide an improved treatment for men with BPH. Thirteen patients with moderate to severe symptomatic BPH were treated with cetrorelix (5 mg, s.c., twice daily for 2 days followed by 1 mg/day, s.c., for 2 months). Patients were evaluated at baseline, during treatment, and up to 18 months after therapy. We determined the effects of cetrorelix on the International Prostate Symptom Score (IPSS), Quality of Life score, sexual function, prostate size, uroflowmetry, and hormonal levels. Treatment with cetrorelix produced a decline of 52.9% (P < 0.0001) in IPSS, a 46% improvement in the Quality of Life score (P < 0.001), a rapid reduction of 27% (P < 0.006) in prostatic volume, and an increase in peak urinary flow rates by 2.86 mL/s. Serum testosterone fell to castrate levels on day 2, but was inhibited only by 64-74% during maintenance therapy, and after cessation of treatment returned to normal. During long term follow-up, most patients continued to show a progressive improvement in urinary symptoms (decline in IPSS from 67% to 72% at weeks 20 and 85, respectively) and an enhancement of sexual function, and prostatic volume remained normal. Our study demonstrates that in patients with symptomatic BPH, treatment with cetrorelix is safe and produces long term improvement.

The effect of age, ethnicity and geographical location on impotence and quality of life.

OBJECTIVE: To estimate the prevalence of impotence in men over 40 years of age and correlate impotence to age, geographical location, ethnicity and quality of life. SUBJECTS AND METHODS: While attending 'The Prostate Cancer Awareness Week' in Madison, WI, USA, New Orleans, LA, USA and New York, NY, USA, 1680 men were asked to complete a questionnaire regarding impotence, age, geographical location, ethnicity and quality of life. RESULTS: Impotence was found to be significantly associated with age, was less associated with geographical location but independent of ethnicity. Men living in Madison reported a lower potency score compared with men living in New Orleans and New York. However, potency score for men living in Madison did not appear to decline as rapidly with age when compared with men living in New Orleans and New York. Impotence and quality of life were also found to be associated even when the quality of life estimates were adjusted for age, geographical location, and age by geographical location. CONCLUSION: This study indicates that impotent men have a lower quality of life than potent men and has confirmed previous findings that age is associated with impotence. Surprisingly, answers to impotence questions were also associated with geographical location.

Effect of age, educational status, ethnicity and geographic location on prostate symptom scores.

We evaluated the effect of patient age, educational status, ethnicity and geographic location upon the American Urological Association benign prostatic hyperplasia symptom scores. Using patients attending Prostate Cancer Awareness Week, we collected additional data on the symptom score and also on education received. A total of 2,245 records was obtained from 4 different centers. Of the population 72% were white and 13% were black. Regression analysis of patient age versus symptom score demonstrated an increase with patient age from 4.59 at age 40 years to 8.17 at age 70 years. Analysis of covariance revealed significant differences in age-adjusted scores between sites from 6.24 in New Orleans, Louisiana to 8.58 in Madison, Wisconsin. No effect was noted for education or ethnicity on symptom scores.

One-stage laparoscopic pelvic lymphadenectomy and radical perineal prostatectomy.

Laparoscopic pelvic lymph node dissection is currently an accepted procedure for staging adenocarcinoma of the prostate. To assess the feasibility and efficacy of performing laparoscopic pelvic lymph node dissection and radical perineal prostatectomy during the same anesthesia, we retrospectively analyzed 98 patients with clinically localized adenocarcinoma of the prostate who were candidates for radical prostatectomy. Of the patients 12 (12%) underwent laparoscopic pelvic lymph node dissection only since they had metastatic disease to the pelvic lymph nodes on frozen section evaluation (the Gleason pathological grade was 2 to 4 in 2 patients, 5 to 7 in 8 and 8 in 2). Of the remaining 86 patients who underwent radical perineal prostatectomy for definitive management 76 (88%) underwent 1-stage radical perineal prostatectomy immediately after laparoscopic pelvic lymph node dissection, while 10 (12%) in the initial stages of our series underwent delayed perineal prostatectomy following laparoscopic pelvic lymph node dissection (2-stage). The average postoperative hospital stay in the 1-stage group was 3.11 days, yet 19 (25%) patients were discharged from the hospital within 48 hours and another 39 (51%) within 72 hours. Thus, 76% of the patients were discharged from the hospital within 72 hours of laparoscopic pelvic lymph node dissection and radical perineal prostatectomy. The advent of laparoscopic pelvic lymph node dissection and radical perineal prostatectomy has found a resurgence at our institutions, with its lower morbidity rate and more rapid return to normal activity for these patients. Based on our results, we recommend laparoscopic pelvic lymph node dissection followed by radical perineal prostatectomy as a 1-stage treatment option for localized adenocarcinoma of the prostate.

Single-dose regimen of cefonicid for the treatment of uncomplicated infections of the lower urinary tract.

Fifty-three women with symptoms of lower urinary tract infection were randomly assigned to treatment with cefonicid administered intramuscularly in a single 1-g dose or to treatment with 500 mg of amoxicillin administered orally three times a day for five to seven days. Urine cultures were obtained before therapy and again at five to 18 days and six to seven weeks after termination of therapy. Forty-one patients had greater than or equal to 2 X 10(4) colony-forming units (cfu)/ml of catheterized urine or greater than or equal to 10(5) cfu/ml of midstream urine. In the cefonicid-treated group, 19 (90%) of 21 patients demonstrated bacteriologic cure at early follow-up. Of the 18 patients seen at late follow-up, 15 were cured and three were reinfected. One patient was lost to late follow-up. In the amoxicillin-treated group, 16 (80%) of 20 patients demonstrated bacteriologic cure at early follow-up. Of the 15 patients available at late follow-up, 14 were cured and one was reinfected. One patient was lost to late follow-up. Cefonicid is an effective single-dose agent in uncomplicated lower urinary tract infection.

Renal cell carcinoma: the Ochsner Medical Institution experience (1945-1978).

We reviewed 161 patients operated upon for renal cell carcinoma between 1945 and 1978. Life table and survival analyses were computed to compare the effects of stage, tumor differentiation, cell type, surgical technique, renal vein involvement and sex on the years of survival. Patients with stage I and well differentiated tumors had the best prognosis. All patients surviving 10 years or more had well differentiated tumors. The type of nephrectomy did not affect survival and lymphadenectomy was only of value in staging the disease. The stage and differentiation of the tumor were more important to outcome than choice of therapy.

Critical evaluation of 1-stage cystectomy--reducing morbidity and mortality.

Although it is a major surgical effort removal of the bladder can be done with reasonable safety. In our opinion cystectomy and urinary diversion by an ileal conduit can be performed as a conjoined procedure without need for staging to reduce risks. Mortality up to 3 months postoperatively was 3.9 per cent and the major complication rate for surviving patients was 18.6 per cent. Minor complications occurred in 28.7 per cent of all patients but were treated easily. We did not note increased morbidity after radical cystectomy compared to other types of cystectomy. A higher complication rate was noted in patients who had undergone preoperative radiation treatment, and wound infection rate was higher in patients with neurogenic bladder dysfunction and chronic cystitis. The advantages of 1-stage compared to 2-stage cystectomy would include the fact that it eliminates the need for a second operation, saves considerable expense by virtue of shortened hospitalization and an earlier resumption of the patient's productivity, achieves early removal of the malignancy, decreases the chances of infection by avoiding a second laparotomy in the presence of a stoma and allows better exposure in the absence of previous ureteroileal anastomoses.

Treatment of condylomata acuminata with carbon dioxide laser.

Ten patients with condyloma acuminatum were treated successfully with carbon dioxide laser photocoagulation. There are no side effects, damage to the surrounding tissue is minimal, and, in our experience, the lesions have not recurred. It is particularly useful for lesions which are recalcitrant to other types of therapy. We now initially treat patients who have lesions in the urethral meatus with the carbon dioxide laser.

Simple cyst arising in a transplanted kidney: a case report.

A 17-year-old girl was hospitalized for evaluation of gradually decreasing function of a kidney transplanted 8 years earlier. A plain film of the abdomen showed a possible renal calculus. Excretory urography proved that this calcification was slightly anterior to the kidney but in the upper pole a well rounded mass was discovered. An echogram confirmed the diagnosis of benign renal cyst. Malignant cystic lesions obviously must be differentiated from those that are benign. Patients on immunosuppressive therapy are known to have a higher incidence of malignancy than the general population. A malignant tumor may require withdrawal of immunosuppressive therapy and removal of the transplanted organ, whereas a benign cyst would require no therapy unless it becomes infected or produces obstruction.

Adenocarcinoma of the bladder as seen at Ochsner Medical Institutions.

Adenocarcinoma of the bladder is an uncommon malignancy comprising less than 2% of all bladder tumors. Eleven cases of adenocarcinoma of the bladder were seen from 1947 to 1977 at the Ochsner Medical Institutions. Six of the tumors were urachal in origin, and five involved the base and lateral walls of the bladder. Six patients were treated with total cystectomy, four with segmental cystectomy, and one with radiation therapy only. The average survival time for the patients with urachal adenocarcinoma was 2.8 years and for those with vesical adenocarcinoma, 2.4 years. Although segmental cystectomy is recommended by some, the authors recommend radical cystectomy for all patients with adenocarcinoma of the bladder.

Partial cystectomy in the treatment of transitional cell carcinoma of the bladder.

Between 1950 and 1974, 35 men and 10 women underwent partial cystectomy for transitional cell carcinoma of the bladder. Indications, contraindications and the principles of technique for partial cystectomy as therapy for transitional cell tumors of the bladder are discussed. All patients were evaluated postoperatively, with cystoscopic examination every 3 months for 1 year, every 6 months for 3 years and then at yearly intervals if no tumors had been detected. None of the patients received preoperative irradiation. Eight ureters were re-implanted and 6 prostate glands were enucleated at the time of partial cystectomy. There was 1 death in the immediate postoperative period. Complications developed in 13 patients, 3 of which were considered major. When recurrences were noted appropriate therapy was performed as indicated. Irradiation was the most commonly used method to treat distant metastases. The over-all 5-year survival rate is 57.7% (26 patients). Thirty-four patients were followed for 10 years. The survival rate for this group of patients was 32.4% (11 patients). The results of this study correlate well with other published reports.

Congenital giant hydronephrosis in adults.

Giant hydronephrosis is the term designating the presence of more than 1,000 ml. of fluid in the collecting system. Of 4 cases of congenital hydronephrosis found over a three-year period at the Ochsner Medical Institutions, 2 were associated with unsuspected carcinomas. Hydronephrosis may first be detected as a mass palpable in the abdomen and displacing the intestines on gastrointestinal films. Excretory urography, retrograde pyelography, and angiography confirm the diagnosis. The treatment of choice is nephrectomy.

Partial cystectomy in the treatment of transitional cell carcinoma of the bladder.

Between 1950 and 1974, 35 men and 10 women underwent partial cystectomy for transitional cell carcinoma of the bladder. Indications, contraindications and the principles of technique for partial cystectomy as therapy for transitional cell tumors of the bladder are discussed. All patients were evaluated postoperatively, with cystoscopic examination every 3 months for 1 year, every 6 months for 3 years and then at yearly intervals if no tumors had been detected. None of the patients received preoperative irradiation. Eight ureters were re-implanted and 6 prostate glands were enucleated at the time of partial cystectomy. There was 1 death in the immediate postoperative period. Complications developed in 12 patients, in 3 of whom they were considered major. When recurrences were noted appropriate therapy was performed as indicated. Irradiation was the most commonly used method to treat distant metastases. The over-all 5-year survival rate is 57.7 per cent (26 patients). Thirty-four patients were followed for 10 years. The survival rate for this group of patients was 32.4 per cent (11 patients). The results of this study correlate well with other published reports.