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.

Bladder carcinoma presenting with rectal obstruction.

Two patients with bladder carcinoma that caused annular constriction of the rectum are described. A mechanism of local invasion by genitourinary malignancies (bladder and prostate) involves penetration of the rectovesical fascia of Denonvillier and circumferential rectal spread. Treatment of complete or partial obstructing lesions includes surgery, radiotherapy, or chemotherapy (or combination), as well as several new techniques, notably laser destruction and transrectal tumor resection.

Incidental adenocarcinoma after open prostatic adenectomy.

Adenocarcinoma of the prostate occasionally is discovered incidentally in the enucleated gland at open prostatic adenectomy for benign disease. Among 468 men who underwent open prostatic adenectomy, unsuspected adenocarcinoma of the prostate was found on pathological examination in 28 (6.0 per cent). The tumors were stage A1 in 14 patients and stage A2 in 14. Careful tissue review resulted in reassigning 5 cases from stage A1 to stage A2. At a mean followup of 10.6 years disease progression had occurred in 4 patients with stage A2 disease. When stage A adenocarcinoma is discovered after open prostatectomy we recommend careful review of the surgical specimen for accurate staging, and adjuvant therapy for all patients with stage A2 disease an for younger patients (less than 65 years old) with stage A1 disease who have favorable life expectancies.

Amyloidosis of the urethra.

Primary, localized amyloidosis of the urethra is rare. The patient usually presents with hematuria and the appearance of urethral carcinoma. However, the disease is benign and it is treated effectively with local removal. We report our experience with 5 cases.

Adenomatous polyp in defunctionalized colonic segment used as a urinary bladder.

For transitional cell carcinoma of the urinary bladder, an eighty-two-year-old man underwent cystoprostatectomy. His urine was diverted to a defunctionalized right colonic segment used to replace his bladder. Four months after the surgery, gross hematuria appeared; endoscopy disclosed an adenomatous polyp in the substitute bladder. We review the incidence and origin of neoplasia in colonic segments used for urinary diversion.

Malignant melanoma of the penis.

Malignant melanoma of the penis is rare and accounts for only a small percentage of penile carcinomas. We report the largest series and the longest followup of patients with this disease. The tumor usually presents as a small, brown or black lesion, often ulcerating, on the glans penis. Stage I disease (confined to the penis) can be treated conservatively by distal penectomy and results in excellent survival. Palpable inguinal lymph nodes and nodes associated with thick cutaneous lesions require surgical exploration. Stages II (node positive) and III (metastatic) diseases carry a poor prognosis, mainly because of the lack of effective adjuvant systemic therapy.

Neodymium:YAG laser treatment of cystitis glandularis.

We report a case of severe cystitis glandularis of the entire bladder, which caused a large retrovesical mass and bilateral hydronephrosis. Treatment included whole bladder neodymium:YAG laser therapy, a technique not previously reported for this extent of disease. The etiology, diagnosis, treatment and malignant potential of cystitis glandularis are discussed.

Cyclophosphamide-induced bladder toxicity in Wegener's granulomatosis.

In a series of 111 patients with Wegener's granulomatosis who were given cyclophosphamide therapy, hemorrhagic cystitis, diagnosed on the basis of gross hematuria or at cystoscopy (or both), developed in 17 (15%). Most of these patients recovered uneventfully, with or without the discontinuation of cyclophosphamide, but 4 patients suffered a significant loss of blood, and bladder carcinoma developed in 3. New microhematuria also occurred in 52 patients (47%). The dose and duration of cyclophosphamide were greater in the group that had urotoxicity. Long-term followup of patients with hemorrhagic cystitis is mandatory for the detection of late recurrences or the development of bladder malignancy. New therapies are being directed at protecting the bladder from urotoxicity during cyclophosphamide treatment.

Cyclophosphamide-induced hemorrhagic cystitis. A review of 100 patients.

Cyclophosphamide is an alkylating agent used intravenously or orally in the treatment of both malignant and nonneoplastic diseases. A known adverse effect of such treatment is hemorrhagic cystitis. A series of 100 patients with hemorrhagic cystitis induced by cyclophosphamide was studied. Major symptoms were gross hematuria (78%) and irritative voiding symptoms (45%). Microhematuria developed in 93% of patients. Hemorrhagic cystitis developed at significantly lower doses and shorter durations of therapy in patients treated intravenously than in patients treated orally. Cystectomy was required in nine patients and bladder cancer developed in five. Urine cytologic study, urinalysis, and cystoscopy are important in the diagnosis of hemorrhagic cystitis, and these studies plus periodic excretory urography are important for surveillance. In addition, new methods of protecting against the urotoxicity are available.

Cyclophosphamide-induced hemorrhagic cystitis in Ewing's sarcoma.

Recent improvements in survival of patients with Ewing's sarcoma have been made since the addition of cyclophosphamide-based adjuvant chemotherapy to primary surgery and radiation. A potential limitation to cyclophosphamide use is its urotoxicity, primarily in the form of hemorrhagic cystitis. The incidence of this adverse effect in patients treated for Ewing's sarcoma has not been established. In a Mayo Clinic series of 116 patients with Ewing's sarcoma treated with cyclophosphamide, 17 (15%) developed hemorrhagic cystitis diagnosed on the basis of gross hematuria or cystoscopic findings (or both). Microscopic hematuria also occurred in 53% of patients (56 of 105 examined). The dose and duration of therapy appeared to be unrelated to the development of urotoxicity. Most patients recovered uneventfully with or without discontinuation of cyclophosphamide therapy, but a significant loss of blood occurred in three patients, and one patient required a cystectomy because of bladder fibrosis. Long-term follow-up is mandatory in these patients because of late recurrences of hemorrhagic cystitis or the possibility of bladder carcinoma. New therapies, directed at protecting the bladder from urotoxicity during cyclophosphamide treatment, are available.

Prostatic involvement in Wegener's granulomatosis.

Wegener's granulomatosis involving the prostate gland is unusual. We report 3 cases of this condition in which typical necrotizing granulomas with vasculitis were seen histologically. These lesions may cause gross hematuria or obstructive voiding, including urinary retention. Management includes prostatectomy when the symptoms are severe but an initial trial of aggressive medical therapy may be successful. Treatment requires a knowledge of the natural history of Wegener's granulomatosis and its usual response to medical therapy.

Renal lesions in tuberous sclerosis.

The renal lesion classically associated with tuberous sclerosis is angiomyolipoma. Renal cysts are less frequent, occurring alone or in conjunction with angiomyolipomas. We reviewed the records of 274 patients with tuberous sclerosis registered at our clinic. Of 95 patients evaluated for renal lesions 51 (54 per cent) had positive findings: 45 had angiomyolipomas, 17 had renal cysts and 11 had both lesions. These lesions usually are multiple and bilateral, and are diagnosed most effectively with computerized tomography or ultrasound. Surgery (10 kidneys) was done for life-threatening hemorrhage or suspected malignant lesions.

The clinical spectrum of granulomatous prostatitis: a report of 200 cases.

Granulomatous prostatitis, reviewed in 200 tissue-diagnosed cases, occurred in 0.8 per cent of the benign inflammatory prostatic specimens. Often the disease followed a recent urinary tract infection (71 per cent) and was suspicious clinically for prostatic cancer (59 per cent). The diagnosis usually was made by needle biopsy or at transurethral prostatectomy (94 per cent). Most cases of granulomatous prostatitis were classified as nonspecific. The recently identified entity of post-transurethral resection granulomatous prostatitis was found in 49 patients. A proposed new category of granulomatous prostatitis that is secondary to systemic granulomatous diseases was documented in 6 patients. Most cases of granulomatous prostatitis resolved spontaneously and required no specific therapy.

Untreated rupture of the tunica albuginea.

A patient with untreated rupture of the tunica albuginea underwent surgical exploration 6 weeks after acute scrotal trauma. A layer of epithelium had grown across the bulging seminiferous tubules, and no further surgical repair was necessary. This spontaneous repair phenomenon has not previously been reported pictorially in the human testis. The recommended treatment of testicular rupture is surgical exploration and repair.

Intermittent testicular torsion.

Testicular torsion is the most common cause of acute scrotal pain in prepubertal and adolescent boys and should be foremost in the minds of primary care physicians evaluating these children. Intermittent testicular torsion is a separate entity that should be considered in all young males with a history of scrotal pain and swelling. Acute and intermittent sharp testicular pain and scrotal swelling, interspersed with long intervals without symptoms, are characteristic. Physical findings may include horizontal or very mobile testes, an anteriorly located epididymis, or bulkiness of the spermatic cord from partial twisting. Awareness of this entity and early elective orchiopexy will improve testicular salvage in patients with intermittent testicular torsion.