Eosinophilic cystitis in adults.

PURPOSE: We describe the largest clinical experience with the diagnosis and management of largely anecdotally reported eosinophilic cystitis. MATERIALS AND METHODS: Five women and 12 men 18 to 84 years with proved eosinophilic cystitis were treated in a 23-year period. Some combination of hematuria, irritative voiding, dysuria and suprapubic pain was present in 14 cases (82%). The remaining 3 patients (18%) were asymptomatic and the diagnosis was made by cystoscopy done because of a history of bladder carcinoma. Available data included no peripheral eosinophilia in 10 of 10 patients studied, pyuria in 12 (92%), microhematuria in 11 of 13 (84%), sterile urine in all 17, abnormal urine cytology in 2 of 17 (12%), bilateral hydronephrosis in 1 and a bladder mass or thickening in 2. Cystoscopy showed erythema in all cases and tumor-like lesions or edema in 3 (17.6%). Histological studies revealed eosinophilic cystitis in all 17 patients, while in 1 with no history of bladder carcinoma eosinophilic cystitis coexisted with carcinoma. RESULTS: Two patients were lost to followup and the remaining 15 were followed 1 to 37 months. After biopsy and fulguration of the lesions 10 patients received no further treatment, including 6 with complete symptom resolution and 1 with improvement. The 3 asymptomatic patients with a history of bladder carcinoma remained asymptomatic and disease-free. Another 4 patients underwent medical therapy and improved, of whom 1 had recurrence that was successfully re-treated medically. The remaining patient, who was symptomatic, underwent cystoprostatectomy for end stage bladder disease. CONCLUSIONS: Manifestations of eosinophilic cystitis indistinguishably mimic those of other inflammatory and malignant bladder disorders that may precede or coexist with it. The condition usually follows a benign course in most cases but occasionally its relentless progression causes crippling disease.

Primary localized amyloidosis of the urinary bladder: a case series of 31 patients.

OBJECTIVE: To evaluate the presentation and prognosis of primary localized amyloidosis of the urinary bladder. PATIENTS AND METHODS: The medical records of 31 patients with primary localized amyloidosis of the urinary bladder were reviewed. Immunohistochemical amyloid typing was performed on bladder biopsy specimens from 27 patients. RESULTS: The median age of the 22 men and 9 women was 55 years. Twenty-four patients (77%) presented with gross hematuria (associated with irritative urinary tract symptoms in 6 patients), and 7 (23%) had only irritative lower urinary tract symptoms. Multiple bladder areas were involved in 20 patients (65%), a single area was involved in 8 (26%), and diffuse involvement was present in 3 (10%). Twenty-four patients had immunoglobulin light chain, and 3 had transthyretin-related amyloid. Local recurrences were common. None of the patients developed systemic amyloidosis. CONCLUSION: Primary localized amyloidosis of the urinary bladder can be easily confused with a neoplasm. Immunohistochemical amyloid typing is important. Transthyretin-related amyloid of the bladder requires no further work-up. Repeated work-ups for systemic amyloidosis are unnecessary for patients with light chain-related amyloidosis of the urinary bladder. Early eradication with fulguration or laser therapy is indicated. Cystoscopic follow-up is necessary.

High power potassium-titanyl-phosphate laser vaporization prostatectomy.

PURPOSE: We prospectively studied a cumulative cohort of men with obstructive benign prostatic hyperplasia who underwent potassium-titanyl-phosphate (KTP) laser vaporization prostatectomy to determine the safety and efficacy of this procedure. MATERIALS AND METHODS: A total of 55 men with symptomatic bladder outlet obstruction due to benign prostatic hyperplasia were treated with a 60 W. KTP laser produced by a prototype Laserscopedagger generator and delivered through a side-deflecting fiber with a 22Fr continuous flow cystoscope. Sterile water was used for irrigation. The prostatic lobes were vaporized to within capsular fibers. Mean lasing time plus or minus standard deviation was 44 +/- 19 minutes. RESULTS: Mean prostate volume plus or minus standard deviation was 43 +/- 14 ml. No patient had any significant blood loss or fluid absorption, or required blood transfusion. Foley catheters did not require irrigation and were removed less than 24 hours postoperatively. All patients remained satisfied with voiding outcome, which changed significantly (p <0.0001). Mean improvement in American Urological Association symptom score at 3, 6, 12 and 24-month intervals was 75%, 79%, 82% and 82%, respectively. Mean increase in peak flow rate at the same intervals was 250%, 242%, 255% and 278%, respectively. Complications included mild transient dysuria in 7%, bladder neck contracture in 2% and delayed hematuria in 4% of patients. None of the patients required re-catheterization or reoperation, or had incontinence or newly developed impotence. Of the sexually active patients 15% and 9% had retrograde ejaculation at 1 and 2 years, respectively. CONCLUSIONS: Our observation in a 2-year period indicates that 60 W. KTP laser vaporization prostatectomy is safe and effective for quickly relieving bladder outlet obstruction with minimal postoperative complications, a high rate of patient satisfaction and, to date, a generally good outcome.

Squamous papilloma of the urinary tract is unrelated to condyloma acuminata.

BACKGROUND: To the authors' knowledge, there is no previous report of squamous papilloma of the urinary tract. It is uncertain whether there is a correlation between squamous papilloma, condyloma acuminatum, and verrucous carcinoma. METHODS: The authors evaluated the clinical and pathologic features of squamous papilloma (5 of the bladder, 2 of the urethra), condyloma acuminatum (3 cases), and verrucous carcinoma (3 cases) of the urinary bladder and performed human papillomavirus (HPV) DNA in situ hybridization studies to determine whether HPV was a common feature shared by these lesions. In addition, DNA ploidy evaluation by image cytometry and p53 immunohistochemical staining were performed. RESULTS: Squamous papilloma of the urinary tract occurred in elderly women and followed a benign clinical course with infrequent recurrence. All squamous papillomas were HPV DNA negative and DNA diploid with no or minimal p53 nuclear accumulation. Condyloma acuminata of the bladder contained HPV DNA, increased p53 protein expression, and aneuploid DNA content. All three cases of condyloma acuminata were associated with coexistent condylomata of the external genitalia, and two required pelvic exenteration for uncontrolled expansile growth. Verrucous carcinoma of the bladder occurred in elderly patients. All three cases of verrucous carcinoma were negative for HPV DNA and DNA aneuploid, and they exhibited consistent p53 expression. CONCLUSIONS: These data indicate that squamous papilloma is a distinct entity not related to condyloma or verrucous carcinoma. These lesions are benign, HPV DNA negative, DNA diploid, and they lack p53 overaccumulation.

Laser therapy of squamous cell dysplasia and carcinoma of the penis.

OBJECTIVES: To analyze the influence of etiologic factors and practical issues regarding the merits, limitations, and long-term results of aggressive laser treatment of premalignant and malignant squamous cell lesions of the penis. METHODS: Preparation of genital skin with 5% acetic acid and mapping biopsies of lesions and the surrounding field-of-change were performed in 52 men evaluated and subsequently treated with laser during a 10-year period. Most men (81%) were or had been smokers, and many (46%) had female sexual partners infected with human papillomavirus. Carbon dioxide laser was used for low-stage lesions; potassium-titanylphosphate/532 or neodymium:yttrium-aluminum-garnet laser was used for more histologically advanced lesions. Not only the lesions but also the entire human papillomavirus-induced field-of-change was treated. Circumcision was performed simultaneously in 28 previously uncircumcised patients. RESULTS: All lesions demonstrated aceto-whitening and histologic changes of human papillomavirus infection. Human papillomavirus DNA was detected in 93.5% of the specimens from 31 patients studied. Of the 52 patients, 22 (42%) had dysplastic premalignant penile intraepithelial neoplasia, and the remaining 30 (58%) had squamous cell carcinoma. Forty-four patients were available for follow-up from 12 to 117 months (average 58). Overall, 5 patients (11.4%) experienced a recurrence: 3 were successfully re-treated with laser, and 2 patients underwent partial penectomy, 1 of whom with squamous cell carcinoma Stage T2 died of metastatic disease. CONCLUSIONS: Aggressive laser therapy of the visible lesions and of the entire dysplastic premalignant field-of-change produces excellent cosmetic results. The entire penis and, therefore, its full sexual functional potential are preserved. The low rate of local recurrence over the long term in all but deeply invasive (T2) lesions compares favorably with the outcome of other, more conventional therapies. Irrespective of therapeutic approach, close and long-term surveillance of all patients and counseling for their sexual partners are mandatory.

High-power potassium titanyl phosphate laser vaporization prostatectomy.

In a search for potential therapeutic strategies for benign prostatic hyperplasia (BPH) that would be associated with less morbidity than transurethral resection of the prostate, various types of laser prostatectomy have been used. Although the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser allows performance of prostatectomy in an almost bloodless field and without absorption of irrigant, the remaining necrotic tissue causes bladder outlet obstruction and related symptoms for 5 to 7 days after treatment. In contrast, the potassium titanyl phosphate (KTP) laser has been found to vaporize tissue with minimal coagulation of the underlying structures. With use of the KTP laser, heat is concentrated into a small volume, the tissue is ablated by rapid vaporization of cellular water, and a 2-mm rim of coagulated tissue is left. After favorable results were obtained in studies of canine prostates and human cadavers, we implemented clinical use of 60-W KTP laser prostatectomy in selected patients. In 10 patients with symptomatic BPH who ranged in age from 52 to 80 years, outpatient KTP laser prostatectomy yielded significantly increased mean peak urinary flow rates (from 8.0 mL/s preoperatively to 19.4 mL/s within 24 hours after the procedure). No patient had hematuria, dysuria, or incontinence after removal of the catheter, and no patient required recatheterization. One patient, however, had urgency, and two other patients became febrile during the 24-hour observation period. Overall, KTP laser vaporization prostatectomy can provide immediate relief from obstructive symptoms of BPH and is not associated with dysuria.

High-power potassium-titanyl-phosphate (KTP/532) laser vaporization prostatectomy: 24 hours later.

OBJECTIVES: To study the feasibility and immediate postoperative outcome of vaporization prostatectomy by high-power potassium-titanyl-phosphate (KTP/532) laser in 10 men with bladder outlet obstruction due to benign prostatic hyperplasia (BPH) and to evaluate their clinical and voiding outcome 24 hours postoperatively. METHODS: The KTP/532 laser at 60 W was produced by a prototype Laserscope generator and delivered through a side-deflecting fiber with a 22F continuous-flow cystoscope. Sterile water was used for irrigation. The prostatic lobes were readily vaporized to within capsular fibers. The mean lasing time was 29 +/- 8 minutes, during which a mean of 104.6 +/- 30 kJ of energy was delivered. RESULTS: The prostate volumes ranged from 22 to 60 mL (mean 38.4 +/- 9.7). None of the 10 patients had any significant blood loss or any fluid absorption. Foley catheters were removed in less than 24 hours postoperatively. All patients were satisfied with their voiding outcome. The mean peak urine flow rate increased from 8 +/- 1.3 mL/s preoperatively to 19.4 +/- 8.4 mL/s (142%, P = 0.003266) 24 hours postoperatively. Postvoid residual volumes remained essentially unchanged from their preoperative levels, as expected (P = 0.767423). One patient had urgency, but none had dysuria, hematuria, or incontinence or required recatheterization. Three patients have returned for 3-month follow-up; all 3 patients have had excellent results and are very satisfied with the outcome. CONCLUSIONS: Our very early and limited experience indicates that high-power KTP/532 laser vaporization prostatectomy is feasible and appears to be safe and effective for quickly relieving bladder outlet obstruction due to BPH. Larger randomized clinical trials to compare this technique with standard transurethral resection of the prostate and more follow-up data are needed to determine its long-term efficacy and durability.

High-power (60-watt) potassium-titanyl-phosphate laser vaporization prostatectomy in living canines and in human and canine cadavers.

OBJECTIVES: We studied the safety and efficacy of 60-W potassium-titanyl-phosphate (KTP) laser prostatectomy in living dogs and compared the efficacy with that in fresh human and dog cadavers. METHODS: Ten dogs underwent 60-W KTP laser prostatectomy and were sacrificed 3 hours (n = 5) or 7 weeks (n = 5) after operation. Two thawed fresh-frozen human cadaver prostates and two thawed fresh-frozen canine prostates were also vaporized with the 60-W KTP laser. All prostates were weighed, measured, serially sectioned, and whole mounted for histologic analysis. RESULTS: In dogs, the in vivo procedure was hemostatic, and no irrigant absorption was detected. Prostatic defects with a mean diameter of 3.0 and 2.5 cm at 3 hours and 7 weeks postoperatively, respectively, were produced. With experience, resection time was reduced to 14 minutes. Of the 5 dogs that were studied for 7 weeks, 4 voided immediately after removal of the urethral catheter on the morning after operation, and 1 dog required recatheterization but voided with a strong stream when the urethral catheter was removed 4 days later. All 5 dogs were continent and had normal erectile function postoperatively. Defects of 2.0 and 2.5 cm were produced in the two human cadaver prostates (weight, 29.5 and 55 g) with resection times of 26 and 54 minutes, respectively. Human and canine cadaver prostates required similar energies for tissue vaporization (15.2 and 13.7 kJ/cm3 cavity created, respectively, P > 0.6), whereas living canine prostates required only 7.0 kJ/cm3 cavity created (P < 0.01 compared with cadaver tissue). CONCLUSIONS: The 60-W KTP laser allows technically easy, safe, rapid, and hemostatic removal of canine prostatic tissue in vivo. Furthermore, there is no difference in the efficacy of KTP laser vaporization between human and canine cadaver prostates. These findings suggest that KTP laser vaporization may be as effective in living human prostates as it is in living dogs, and thus it may be a useful technique in the surgical treatment of human benign prostatic hyperplasia.

Detection of human papillomavirus DNA in primary squamous cell carcinoma of the male urethra.

OBJECTIVES: The prevalence of human papillomavirus deoxyribonucleic acid (DNA) in primary squamous cell carcinoma of the male urethra and corresponding control tissue was studied. METHODS: The technique of polymerase chain reaction DNA amplification was used to detect specific human papillomavirus DNA sequences in archival pathologic and control tissue. We analyzed 16 cases of primary squamous cell carcinoma of the male urethra and 22 specimens of normal male urethra stratified by location within the urethra. RESULTS: Primary squamous cell carcinoma of the pendulous urethra was significantly associated with human papillomavirus type 16 DNA (6 of 6 cases), but the control tissue from the pendulous urethra was not (0 of 12, P < 0.001). Primary squamous cell carcinoma of the bulbous and posterior urethra was not associated with human papillomavirus infection. CONCLUSIONS: Infection of the male urethra with human papillomavirus type 16 may have a role in the pathogenesis of primary squamous cell carcinoma of the pendulous urethra, for which it has a strong predilection, vis-à-vis the bulbous and posterior urethra.

Potassium-titanyl-phosphate laser vaporization of the prostate: a comparative functional and pathologic study in canines.

OBJECTIVE: We compared the functional and pathologic results of potassium-titanyl-phosphate (KTP) laser vaporization prostatectomy with those of neodymium:yttrium-aluminum-garnet (Nd:YAG) laser vaporization and coagulation prostatectomy in dogs. METHODS: The prostates of 41 dogs were treated with KTP laser vaporization (n = 21), Nd:YAG laser vaporization (n = 10), or Nd:YAG laser coagulation (n = 10). Dogs were sacrificed 2 days or 8 weeks after treatment. Prostates were weighed, measured, serially sectioned, and whole-mounted for histologic analysis. RESULTS: All techniques were hemostatic, and no irrigant absorption was detected. KTP laser vaporization produced a prostatic defect with a mean diameter of 3.0 and 2.4 cm at 2 days and 8 weeks postoperatively, respectively. Smaller defects (P < 0.0005 at 2 days and P < 0.02 at 8 weeks) were produced by Nd:YAG laser vaporization (2.0 and 1.4 cm, respectively) and coagulation (0.5 and 0.9 cm, respectively). No dog treated with KTP laser vaporization was incontinent or developed urinary retention, including 5 dogs whose urethral catheters were removed within 24 hours of surgery. CONCLUSIONS: KTP laser vaporization prostatectomy not only provides hemostasis similar to that obtained with Nd:YAG laser coagulation, but also removes tissue at the time of operation, allowing dogs to void without straining within 24 hours of treatment. In addition, the procedure is technically simple, and the operator has excellent control over exactly which tissue is removed and which is left intact. These findings suggest that KTP laser vaporization may be useful in the treatment of human benign prostatic hyperplasia.

Laser prostatectomy: two and a half years' experience with aggressive multifocal therapy.

OBJECTIVES: The aim of this study was to evaluate patient outcome 1 to 2 1/2 years after aggressive neodymium: yttrium-aluminum-garnet (Nd:YAG) laser prostatectomy alone or combined with potassium titanyl phosphate (KTP/532) laser therapy. METHODS: In 32 men with symptomatic bladder outlet obstruction caused by benign prostatic hyperplasia, Nd:YAG laser energy (40 W) was delivered to six or more locations on the prostatic lateral lobes and one or more on the median lobe. In a subgroup of 15 of these patients, the prostate was also incised and sculpted with KTP/532 laser to create a better channel. RESULTS: In the 32 men, voiding parameters improved: mean peak flow rate increased from 10 to 21 mL/s (110%), residual volume decreased from 167 to 64 mL (62%), and American Urological Association (AUA) symptom score decreased from 24 to 9 (63%). Catheters were removed after 3 days. Of the 17 patients treated with the Nd:YAG laser alone, 12 (70.5%) required recatheterization, whereas only 5 of the 15 (33%) who received KTP/532 laser therapy after Nd:YAG treatment required recatheterization (P < 0.001). In the entire group of 32 patients, complications included predictably prolonged retention (14 to 60 days) in 4 patients (12.5%) with hypotonic bladders, prolonged dysuria in 4 (12.5%), vesical neck contracture in 2 (6%), and significant hematuria in 1; none had incontinence. All 25 sexually active men remained potent (100%), but among these patients retrograde ejaculation developed in 5 (20%). CONCLUSIONS: Aggressive Nd:YAG laser prostatectomy is safe and effective for obstructive prostates up to 70 mL in volume and produces good results that are sustained for up to 2 1/2 years. Adjunctive KTP/532 laser therapy apparently creates an unobstructed channel more quickly and reduces the rate of postoperative retention, but it does not alter other voiding parameters.

Treatment of extensive urethral hemangioma with KTP/532 laser.

BACKGROUND AND OBJECTIVE: Urethral hemangiomas are rare. They vary in size from pinpoint masses to extensive honeycomb-shape deformities leading to significant hematuria. For extensive lesions, therapeutic options have included extensive surgical resection and reconstruction or multistaged neodymium:yttrium-aluminum-garnet (Nd:YAG) laser photocoagulation. We report our experience with the use of potassium titanyl phosphate (KTP/532) laser for treatment of the extensive form. STUDY DESIGN/MATERIALS AND METHODS: A 7-year-old boy presented with a 2-week history of urethral bleeding. He had extensive hemangiomas of the genital and perineal regions. Cystourethroscopy disclosed diffusely scattered honeycomb-shape hemangiomatous malformation of the anterior urethra. KTP/532 laser energy was delivered transurethrally to the hemangiomatous areas until they blanched. RESULTS: The Foley catheter was removed 24 hours postoperatively, and the patient voided clear urine without difficulty. He has remained trouble-free for more than 2 years. CONCLUSION: Judicious endoscopic single-stage therapy with KTP/532 laser may obviate open surgical intervention in most cases of extensive and symptomatic urethral hemangiomas. In view of our observation and the literature, KTP/532 laser therapy should be considered the first line of treatment.

The detection of human papillomavirus deoxyribonucleic acid in intraepithelial, in situ, verrucous and invasive carcinoma of the penis.

PURPOSE: We study the prevalence of human papillomavirus deoxyribonucleic acid (DNA) in squamous cell carcinoma and control tissue of the penis. MATERIALS AND METHODS: The technique of polymerase chain reaction DNA amplification was used to detect specific human papillomavirus DNA sequences in archival pathological and control tissues. We analyzed 42 cases of invasive squamous cell carcinoma, 13 of carcinoma in situ, 12 of penile intraepithelial neoplasia, 3 of verrucous carcinoma and 25 of balanitis xerotica obliterans, as well as 29 routine neonatal circumcision specimens and 32 adult circumcision specimens. RESULTS: Overall, the detection rates for human papillomavirus DNA in the study and control tissues were 55% (23 of 42 cases) for invasive squamous cell carcinoma, 92% (12 of 13) for carcinoma in situ, 92% (11 of 12) for penile intraepithelial neoplasia, 0% (0 of 3) for verrucous carcinoma, 4% (1 of 25) for balanitis xerotica obliterans, 0% (0 of 29) for neonatal circumcision and 9% (3 of 32) for adult circumcision. In all groups human papillomavirus type 16 was the most common genotype identified. CONCLUSIONS: The prevalence of human papillomavirus DNA is significantly greater in carcinoma of the penis than in control tissue. Moreover, the prevalence is greater in noninvasive lesions (carcinoma in situ and penile intraepithelial neoplasia) than in invasive carcinoma.

Visual laser ablation of the prostate: a preliminary report.

OBJECTIVE: To report our preliminary experience with visual laser ablation of the prostate (VLAP) for treating bladder outlet obstruction caused by benign prostatic hyperplasia (BPH) and to evaluate its short-term outcome. DESIGN: We reviewed our laser technique in 47 men with symptomatic obstruction caused by BPH who underwent VLAP between July 1992 and April 1993 at our institution, and we compared our results with those reported in the literature. MATERIAL AND METHODS: Our 47 patients were from 43 to 87 years old (mean, 69.6). The mean pretreatment American Urological Association symptom score was 22, mean peak flow rate was 9.5 mL/s, and mean postvoid residual urinary volume was 136 mL. Neodymium:yttrium-aluminum-garnet laser energy was delivered at the 2-, 4-, 8-, and 10-o'clock positions and, when necessary, to the median lobe by one of two lateral-firing laser probes. All but the first four patients were treated on an outpatient basis, and all patients were catheterized (Foley catheter) for 2 to 10 days after VLAP. RESULTS: Of the 47 patients, 32 had data pertaining to a mean follow-up of 5 months; they had a mean symptom score of 10, mean peak flow rate of 15.7 mL/s, and mean postvoid residual volume of 63 mL. In 12 patients, data from a mean follow-up of 11 months were available; they had a mean symptom score of 6, mean peak flow rate of 18.8 mL/s, and mean postvoid residual volume of 10 mL. Perioperative complications (myocardial infarction, thrombophlebitis, and epididymitis) in three patients responded to conservative therapy. Urinary retention occurred for 2 to 60 days after initial removal of the Foley catheter in 12 patients, who then had resumption of spontaneous voiding. In three patients who stated their condition was worse postoperatively, conventional transurethral resection of the prostate was done 6 months after VLAP, and a fourth patient had a persistently obstructive bladder neck incised 8 months after VLAP. CONCLUSION: Our early experience and that reported in the literature indicate that VLAP is a safe and efficacious alternative treatment of obstructive BPH. Although the early results of VLAP rival those of transurethral resection of the prostate, the success rate in treating large prostates should be improved, and long-term results should be assessed to determine the durability of the beneficial effects.

Infundibulopelvic stenosis: a long-term followup.

We followed 21 patients with congenital infundibulopelvic stenosis, a rare obstructive disorder of the intrarenal collecting system, for a median of 11 years (range 2 to 28 years). Of these patients 19 (90%) had evidence of bilateral renal disease. In particular, 10 patients had bilateral infundibular pelvic stenosis, 6 a contralateral cystic dysplastic kidney and 3 a congenitally absent kidney. Extended observations of the patients with this disorder revealed that end stage renal disease or renal insufficiency developed in 8 patients (37%), all with bilateral renal anomalies. Renal biopsies in patients with end stage renal failure revealed widespread areas of renal dysplasia proximal to the stenotic infundibulum with focal or global glomerulosclerosis of the glomeruli, which was not involved in the dysplastic process. These pathological findings are consistent with the presence of a renal hyperfiltration injury. Our data suggest that the prognosis of infundibulopelvic stenosis is dependent upon the extent of total renal mass involved with the disease process and the duration of followup.

Urethroscopy and urethral cytology in men with external genital condyloma.

OBJECTIVE: To develop guidelines as to which asymptomatic male patients with genital human papillomavirus (HPV) infection need further evaluation of the urethra, we studied two screening methods: urethroscopy and voided urethral cytology. METHODS: In a four-year period, 135 asymptomatic men underwent complete screening for HPV infection. They were evaluated because of HPV-related genital disease in their female sex partners or visible genital lesions, or both. RESULTS: Of the 135 patients, 21 (16%) had no clinical, subclinical, cytologic, or urethroscopic evidence of disease, and 114 (84%) had biopsy-proven HPV infection. Of these 114 patients, only 14 (12.3%) had intraurethral condyloma. All of these 14 patients had current or historical evidence of meatal or perimeatal "sentinel" lesions. They constituted 29.8 percent of 47 such patients with sentinel lesions. In 5 patients (4%), results of voided urine cytology were positive for condyloma cells, but only 1 of these had visible intraurethral disease. Of the 14 patients with urethral disease, only 1 (7%) had positive results of urine cytology. CONCLUSIONS: These observations suggest that any asymptomatic male patient undergoing screening for condyloma acuminatum who has a history of or demonstrable subclinical or grossly visible perimeatal or meatal HPV infection should undergo urethroscopy and that voided urine cytology is not a reliable or cost-effective test for the detection of visible intraurethral disease.

Laser treatment of benign prostatic hyperplasia.

With the increasing longevity of the population, the incidence of symptomatic bladder outlet obstruction due to benign prostatic hyperplasia (BPH) is expected to increase. Transurethral resection of the prostate (TURP) is currently considered the standard surgical treatment for this disease. However, TURP is an invasive procedure associated with some morbidity and, rarely, mortality. During the past several years, several alternative treatments for BPH have emerged. Visual laser ablation of the prostate (VLAP) is one of the more attractive choices among these alternatives. The use of laser energy to treat BPH has several advantages over TURP. Laser energy causes coagulation of the blood vessels, thus minimizing blood loss and fluid absorption. VLAP is an outpatient procedure performed under direct vision utilizing a standard or continuous-flow cystoscope. The technique of VLAP is relatively easily learned and has a much shorter learning curve than that of TURP. To date, clinical trials have confirmed the efficacy and safety of VLAP and the minimal associated morbidity. In the short-term follow-up, improvement in both subjective (symptom score) and objective (urinary flow rate) factors is similar to that after TURP. Although the results obtained with this laser technology are exciting and encouraging, further study and long-term follow-up are needed to confirm the durability of these results.

Human papillomavirus infection and intraepithelial, in situ, and invasive carcinoma of penis.

The role of human papillomavirus (HPV) infection and other reported cofactors in the genesis, evolution, and clinical manifestations of precancerous and cancerous squamous cell lesions of the penis were studied in 34 men. Clinically, all lesions demonstrated aceto-whitening. Histologic changes of HPV infection formed a field-of-change that involved the components of the preputial cavity in all patients. These changes were associated with minor grades of penile intraepithelial neoplasia (PIN I and II) in 19 patients, major grades of PIN/carcinoma in situ (PIN III/Tis) in 7, and invasive squamous cell carcinoma (SCCa, Stages T2 and T3) in 8. Most of the patients (79.4%) were heavy smokers; 52.9 percent had a history of HPV infection, PIN, or invasive penile SCCa; and 60 percent of 30 patients had female sexual partners who had HPV-related genital neoplasia. A pilot virologic study of specimens obtained from 20 representative patients utilizing polymerase chain reaction amplification detected HPV DNA in 80 percent. Laser therapy was aimed at the entire field-of-change in 30 patients; recurrent minor-grade PIN or SCCa developed in 2 of 23 patients (8.7%) followed for up to three years. Of the 4 remaining patients treated with local excision or partial penectomy, 3 (75%) had development of recurrent minor-grade PIN when followed for up to four years. The combination of the host of carcinogenic factors and currently rampant immunologic disorders will likely lead to an increase in the historically low incidence of SCCa of the penis in the United States.

Renal angiomyolipoma in association with pulmonary lymphangioleiomyomatosis: forme fruste of tuberous sclerosis?

From 1976 to 1989, 27 patients with pulmonary lymphangioleiomyomatosis were seen at our institution. Twenty-five had no signs or symptoms of tuberous sclerosis; 21 of these had abdominal imaging or surgical exploration to make the diagnosis of renal angiomyolipoma in seven patients, all female. Three presented with symptoms secondary to renal disease, three with pulmonary manifestations, and one with both. Renal disease was bilateral in four patients; four patients underwent nephrectomy and two tumors were embolized. All patients experienced spontaneous pneumothoraces during the course of their disease. There was one respiratory death. It is our belief that any patient presenting with angiomyolipoma and a history of pulmonary problems should be evaluated for pulmonary lymphangioleiomyomatosis with a limited computed tomography scan of the chest at the time of abdominal imaging. The surgical treatment of angiomyolipoma when associated with lymphangioleiomyomatosis is predicated on the ability to adequately manage the complicating lung disease perioperatively.