Malignant cytological washings from prostate specimens: an independent predictor of biochemical progression after radical prostatectomy.

PURPOSE: Malignant cells have previously been identified in the cytological washings of prostate specimens obtained at radical prostatectomy for clinically localized prostate cancer. We investigated whether malignant cells in the cytological washings of radical prostatectomy specimens predict biochemical progression. The affect of total androgen blockade on cytological washings was also examined. MATERIALS AND METHODS: Cytological washings were obtained from radical prostatectomy specimens in 147 consecutive patients undergoing the procedure for clinically localized prostate cancer between November 1993 and April 1998. Of the 147 patients 54 were randomly selected to receive 1 month of total androgen blockade immediately before prostatectomy. To obtain the cytological specimen the extirpated prostate was subjected to a normal saline bath, as previously described. The cytology specimen was examined by a single cytopathologist blinded to preoperative and pathological findings. Biochemical progression, defined as prostate specific antigen 0.15 ng./ml. or greater, was determined using the Kaplan-Meier method. We also performed multivariate analysis of factors related to progression, including prostate specific antigen, pathological stage, margin status, Gleason grade and cytology status. Median followup was 37 months (range 13 to 66). RESULTS: Followup was available in 146 of 147 cases. Cytological washings were malignant in 14 of 92 patients (15%) who did not receive total androgen blockade preoperatively. In this group without androgen blockade the biochemical progression rate was significantly higher in those with positive cytology (p < 0.001). Positive cytology was an independent predictor of progression on multivariate analysis and a stronger predictor of progression than Gleason grade. No malignant cells were observed in cases of preoperative total androgen blockade (p < 0.001). However, biochemical progression was similar in the groups with and without androgen blockade (p = 0.355). CONCLUSIONS: Malignant cells may be identified in the cytological washings of radical prostatectomy specimens and they are an independent predictor of biochemical progression. One month of total androgen blockade preoperatively significantly decreases the rate of positive cytology but does not appear to change the rate of early biochemical failure.

Risk factors for vesicourethral anastomotic stricture after radical prostatectomy.

OBJECTIVES: Preoperative comorbidities associated with microvascular disease may contribute to the development of bladder neck contracture (BNC) by alteration of anastomotic healing. We investigated potential risk factors for development of BNC after radical prostatectomy (RP) and reviewed management of this complication. METHODS: A retrospective review of 467 consecutive patients (mean age 63.2 years) undergoing RP between 1991 and 1999 was performed. In all cases, the bladder neck was tailored to 20 to 22F in a racket handle fashion. After mucosal eversion of the reconstructed bladder neck, a mucosa-to-mucosa vesicourethral anastomosis was created over an 18 to 22F catheter using 4 to 6 anastomotic sutures. The relationship between comorbidities identified preoperatively by patient interview and medical record review (coronary artery disease [CAD], diabetes mellitus [DM], hypertension [HTN], cerebral vascular accident, chronic obstructive pulmonary disease, and smoking history) and the incidence of BNC was determined. Risk factors including prior transurethral prostatectomy (TURP), estimated blood loss (EBL), and operative time (OR time) were also evaluated. Factors were evaluated for their ability to predict BNC using both univariate and multivariate analysis. Treatment results for BNC were also assessed. RESULTS: A total of 52 (11.1%) patients developed BNC. Current cigarette smoking resulted in a significantly higher (26%) rate of BNC (P <0.001). The BNC rate was also increased in patients with CAD (26%, P <0.001), HTN (19%, P = 0.015), and DM (21%, P = 0.030). Average OR time was longer (271 versus 249 minutes, P = 0.025) and EBL was greater (1639 versus 1092 mL, P <0.001) in patients developing a BNC. In multivariate analysis, current cigarette smoking was the strongest predictor of BNC and independent of other factors (P <0.001). BNC was not related to prior TURP, type of anastomotic suture used, size of catheter, or duration of catheterization. Patients were treated with transurethral dilation (73%) or transurethral incision (27%) and 58% responded to the initial treatment. No patient became incontinent as a result of the treatment for BNC.Conclusions. Several comorbidities associated with microvascular disease are significant risk factors for development of BNC after RP. Current cigarette smoking in particular is a strong predictor. Transurethral dilation and transurethral incision are equally effective as initial treatment of BNC.

Immediate and postoperative complications of transurethral prostatectomy in the 1990s.

PURPOSE: We compare the morbidity, mortality, hospitalization and urethral catheter time of contemporary transurethral prostatectomy to historical series, and evaluate recent trends in hospitalization and urethral catheter time during the last 8 years. MATERIALS AND METHODS: A retrospective chart review of 520 consecutive patients who underwent transurethral prostatectomy between 1991 and 1998 at a single institution for symptomatic benign prostatic hyperplasia was performed. Inpatient and outpatient charts, clinic records, operative reports and discharge summaries were reviewed. For each patient 43 data points were collected. Telephone followup was performed when data were lacking. All retrieved data were compiled in a computer database. Perioperative and late postoperative morbidity and mortality, hospitalization and urethral catheter time were analyzed. RESULTS: A total of 520 patients were identified with an average age of 67 years (range 44 to 89). Significant co-morbidity (2 or more co-morbid disease processes) was identified preoperatively in 30.3% of the patients. The most common indications for transurethral prostatectomy were lower urinary tract symptoms (80.9%) and urinary retention (15.2%). Average preoperative International Prostate Symptom Score was 23.8. Average weight of resected tissue was 18.8 gm. There was no perioperative patient mortality. Blood transfusion rate was 0.4%. The rate of intraoperative and immediate postoperative complications was 2.5% and 10.8%, respectively. Average hospital stay was 2.4 days, and 1.1 from 1997 through 1998. The rate of late postoperative complication was 8.5% and the average postoperative symptom score was 6.4 with an average followup of 42 months (range 6 to 84). CONCLUSIONS: Contemporary perioperative and postoperative complications of transurethral prostatectomy are significantly lower than rates in historical series. The average hospital stay and urethral catheter time have steadily decreased during the last 8 years.

Malignant cytological washings from radical prostatectomy specimens: a possible mechanism for local recurrence of prostate cancer following surgical treatment of organ confined disease.

PURPOSE: Local recurrence of prostate cancer following complete and successful resection of organ confined disease has been variably reported in men. We hypothesized that observed secretions from the cut distal urethra during radical prostatectomy may contain malignant prostatic epithelial cells and contribute to this problem. MATERIALS AND METHODS: A prospective study was done of prostate cytology specimens from 50 consecutive men with clinically organ confined adenocarcinoma of the prostate undergoing radical retropubic or radical perineal prostatectomy. Direct cytological evaluation by 1 examiner was used to identify malignant or benign cells in these washings. RESULTS: Of 33 radical perineal and 17 radical retropubic prostatectomy specimens organ confinement was confirmed in 58%. Malignant prostatic epithelial cells were observed in 24% of all cytology specimens. Of cytological washings from prostates with pathologically confirmed organ confined cancers 17% showed malignant cells. While perineural invasion was noted in a majority of tumors with positive washings, only Gleason grade was a statistically significant predictor of recurrence (p = 0.009). Surgical approach did not alter the rate of positive cytology. CONCLUSIONS: Malignant prostatic epithelial cells can be identified in the prostatic washings from men with pathologically organ confined prostate cancer. Surgical approach did not change the cytological findings. Gleason grade is a statistically significant predictor of cytological malignancy. These cells may represent a mechanism of failure following successful radical prostatectomy.

Ultrasound evaluation of the prostate after abdominoperineal resection.

Prostate evaluation after abdominoperineal resection is hampered by the inability of the physician to perform digital rectal examination and transrectal ultrasound. Laboratory evaluation alone is not specific, and computerized tomography and magnetic resonance imaging are costly while yielding unclear results. We evaluated 23 men with prostate specific antigen, prostatic acid phosphatase and transperineal ultrasound of the prostate, using an elevated prostate specific antigen level and/or hypoechoic focus as indications for biopsy. Ten men underwent transperineal biopsy of the prostate and in 2 biopsies revealed prostate carcinoma. Transperineal ultrasound allows for accurate evaluation of the prostate in men following abdominoperineal resection as well as accurate biopsy when indicated.

Transurethral surgery using intravesical bupivacaine and intravenous sedation.

We report our experience using intravesical 0.5% bupivacaine as a topical anesthetic along with intravenous fentanyl and midazolam sedation to perform a variety of transurethral procedures in 78 patients. We achieved adequate pain control in all patients and observed no anesthetic complications. Use of this combination of intravesical topical anesthesia and intravenous sedation provided safe, adequate anesthesia to our patients undergoing various transurethral procedures in an outpatient clinic setting.

Adenomatoid tumor of testicle.

A rare case of intratesticular adenomatoid tumor is described. Pathologically and clinically this tumor is associated with the seminiferous tubules and the rete testis. The patient underwent left inguinal exploration to confirm the testicular tumor. A radical orchiectomy was performed. We believe this is the first case of documented intratesticular adenomatoid tumor that did not arise from either tunica albuginea or epididymis. The cytologic origin of adenomatoid tumors and an unusual finding of decreased spermatogenesis with marked atrophy of the testes are also presented.

Migration of intravascular balloon after percutaneous embolotherapy of varicocele.

Migration of an intravascular balloon following embolic therapy for varicocele is uncommon. A third case is reported of migration of a left internal spermatic vein embolic balloon to the right lung in an otherwise healthy twenty-five-year-old male who was treated for a symptomatic left varicocele. The patient, a student naval aviator in the jet pilot program, has had his career adversely affected by this complication.

Focal xanthogranulomatous pyelonephritis associated with renal cell carcinoma.

A case of focal xanthogranulomatous pyelonephritis (XGP) with an associated renal cell carcinoma is presented. The tumor was discovered incidentally during a general surgical procedure. Subsequent evaluation showed a 3 cm mass in the lower pole of an otherwise normal kidney with no evidence of calculus or infection. Radical nephrectomy revealed classic findings of focal XGP with coexistent clear cell carcinoma. The literature describing the rare association between these conditions is reviewed.

Preliminary results of three-dimensional reconstruction of previously imaged prostates.

In patients with biopsy proven prostate cancer, preoperative transrectal magnetic resonance imaging (MRI) and ultrasound were performed, followed by total prostatectomy. Generally, the findings with MRI correlated well with the histopathologic findings, including infiltration of and extension through the capsule into periprostatic tissue and the seminal vesicles. False negative results with MRI included centrally located tumors and small tumors. False positive results with MRI included lobular atrophy, cystic hyperplasia, cystic atrophy, florid glandular hyperplasia and scars with chronic inflammation.

Renal cell carcinoma with solitary metachronous contralateral adrenal metastasis. Experience with 2 cases and review of the literature.

We report on 2 cases of renal cell carcinoma with solitary metachronous contralateral adrenal metastasis occurring up to four years after radical nephrectomy. Both patients were treated with adrenalectomy and steroid replacement. One patient died with distant metastases twenty-eight months after adrenalectomy and the other is alive with no evidence of disease four years postoperatively. Such a presentation of hypernephroma is rare, with only 1 such case having been found in the literature.

Urethrovaginal reconstruction using a perineal artery axial flap.

A 19-year-old woman was born with a cloacal malformation and a common urogenital sinus. We describe a method of urethral and vaginal reconstruction to correct these anomalous problems. A neourethra was constructed from tubularized anterior vaginal epithelium. A perineal artery based axial flap was used to cover the neourethra plus widen the vaginal orifice.

Acute management of the zipper-entrapped penis.

A zipper-entrapped penis is a painful predicament that can be made worse by overzealous intervention. Described is a simple, basic approach to release, that is the least traumatic to both patient and provider.

Renal devitalization using 95 per cent ethyl alcohol.

Preoperative embolization of renal arteries with solid material before nephrectomy is a standard procedure for the treatment of renal cell carcinoma. However, it often is difficult to use these materials and sometimes special equipment is required. We have used 95 per cent ethyl alcohol in 3 patients to devitalize kidneys with tumors. Our results show 95 per cent ethyl alcohol to be safe, effective and easy to use. When combined with epidural anesthesia alcohol embolization is well tolerated by the patient, and its destructive effect is complete and limited to the selected organ.