Urethral catheter removal prior to hospital discharge following radical prostatectomy.

OBJECTIVES: To investigate the feasibility of early catheter removal following radical prostatectomy. METHODS: Fifty-eight consecutive patients underwent radical prostatectomy, with intent of early catheter removal. Catheter removal was based on postoperative cystograms performed on postoperative day (POD) 3 or 4. Charts were retrospectively reviewed and patients were contacted by phone and specifically questioned regarding continence and bladder control. RESULTS: Fifty-one patients (87.9%) had a cystogram performed on POD 3 or 4. In 43 patients (74.1%), the catheter was successfully removed prior to hospital discharge. Eight patients experienced either early or late complications (excluding incontinence); these included 3 patients with a superficial wound infection, 2 patients with hematuria requiring reinsertion of a urethral catheter, 1 patient with a spontaneous pneumothorax, 1 patient who developed a deep vein thrombosis and lymphocele, and 1 patient with a bladder neck contracture. Urinary continence was reported as excellent to good in 86% of the patients at a mean follow-up of 17.4 months. Three patients (5%) underwent placement of an artificial urinary sphincter. CONCLUSIONS: Catheter removal prior to hospital discharge after radical prostatectomy is feasible without any increase in morbidity.

Spinal cord ischemia after post-chemotherapy retroperitoneal lymph node dissection for nonseminomatous germ cell cancer.

PURPOSE: We report and analyze several cases of neurological deficit after post-chemotherapy retroperitoneal lymph node dissection that were though to be related to spinal cord ischemia. MATERIALS AND METHODS: We searched the testis cancer data base at our university, which includes 1,447 retroperitoneal lymph node dissections performed from 1982 to 1994, to identify patients who had postoperative neurological complications. The history and clinical course of patients suspected to have spinal cord ischemia were reviewed and potential risk factors were analyzed. RESULTS: The incidence of spinal cord ischemia after post-chemotherapy retroperitoneal lymph node dissection was 0.56% (4 of 712 patients). CONCLUSIONS: Spinal cord ischemia may complicate the course of post-chemotherapy retroperitoneal lymph node dissection in testis cancer patients. Older age, extensive retroperitoneal dissection, prior therapy and certain anesthetic parameters may predispose nonseminomatous germ cell tumor patients to spinal cord ischemia. These risk factors may be used to define a subset of high risk patients, and active measures should be taken in an attempt to minimize the frequency of spinal cord ischemia in these patients.

Delayed orchiectomy after chemotherapy for metastatic nonseminomatous germ cell tumors.

PURPOSE: We reviewed current experience at our university with delayed orchiectomy after chemotherapy in patients with metastatic nonseminomatous germ cell tumors. MATERIALS AND METHODS: We retrospectively analyzed the records of 160 patients with metastatic germ cell cancer who were given systemic chemotherapy, and subsequently underwent orchiectomy and retroperitoneal lymph node dissection. RESULTS: Analysis of 160 testicular specimens revealed necrosis or scar in 70 (43.7%), pure teratoma in 50 (31.2%) and persistent germ cell cancer in 40 (25%). Corresponding incidences of histopathological findings in the post-chemotherapy retroperitoneal lymph node dissection specimens were significantly different, correlating with less than half of the cases (chi-square, p = 0.002). CONCLUSIONS: Our study confirms the need for delayed orchiectomy after systemic chemotherapy even when there seems to be a partial or complete clinical response at other sites.

Biology of metastases and its clinical implications: testicular germ-cell tumors.

This article deals with observations of the clinical behavior of metastatic germ cell cancers of testicular origin. Therefore, when we speak of biology of metastases, we refer to that seen by the clinician as opposed to the laboratory scientist. First, we will review our experience with chemotherapy for metastatic disease. From this we can gain insight into risk factors for relapse and survival. Furthermore, we can infer there are fundamental differences in the biology of germ cell cancers of testicular origin as opposed to primary mediastinal or primary retroperitoneal origin. Some of these differences are further discussed. We also identify "good risk" parameters and suggest criteria for expectant or conservative management postchemotherapy instead of postchemotherapy surgical management. Second, the diversity of metastases as evidenced by a wide histologic spectrum, is discussed in clinical terms. Among topics discussed are non-germ-cell malignant elements found within metastatic germ cell tumors, and possible mechanisms for their emergence. Third, the increasing awareness of long delayed, late relapse and its relative refractoriness to chemotherapy gives further insight into the clinical biology of metastatic germ cell cancer. The multipotential nature of the germ cell results in a wide variety of metastatic subtypes, each with its own clinical behavior. Therefore, a variety of clinical management strategies may be required based upon these different clinical behaviors.

Early urethral catheter removal following radical prostatectomy: a pilot study.

OBJECTIVES: Postoperative urethral catheter drainage after radical prostatectomy is bothersome to patients. A pilot study was initiated to determine if urethral catheter removal prior to hospital discharge is feasible. METHODS: Thirty-three consecutive men undergoing radical retropubic prostatectomy were prospectively studied and followed for a minimum of 6 months (mean, 8.5). Postoperative cystography was utilized to direct early catheter removal. RESULTS: Of 33 patients, 27 (82%) underwent successful catheter removal at a mean of 4.2 postoperative days. No patient experienced urinary retention, urinoma development, pelvic abscess, or anastomotic stricture. Urinary continence is excellent (no pads required) in 70% and good (stress incontinence requiring 1 to 2 pads/24 hours) in 18% of patients at last follow-up. CONCLUSIONS: Following radical prostatectomy, early catheter removal prior to hospital discharge is feasible. Early results suggest no deleterious consequences. Prospective monitoring of more patients is needed to determine if this practice is widely applicable.

Cystography after radical retropubic prostatectomy: clinical implications of abnormal findings.

OBJECTIVES: In many institutions, cystography is obtained routinely after radical retropubic prostatectomy to assess the integrity of the vesicourethral anastomosis before the removal of the catheter. This study presents the Indiana experience with cystograms performed following radical retropubic prostatectomy. METHODS: The experience with 260 cystograms performed in 245 consecutive patients following radical retropubic prostatectomy was reviewed retrospectively, with a special reference to the clinical implications of abnormal findings. RESULTS: After a standard catheterization period of 14 to 21 days (mean, 19.2), 94.3% of the catheters were removed safely without adverse clinical consequences. The presence of a minimal contained contrast extravasation did not affect outcome after the removal of the catheter. The overall incidence of clinically significant extravasation was found to be 5.7% and was further reduced to 2.4% if extravasation was not suggested clinically in the postoperative course. CONCLUSIONS: Based on the current literature, significant extravasation is a common finding during the first 5 to 8 postoperative days. Therefore, management strategies advocating early urethral catheter removal should include routine cystographic studies. Otherwise, cystographic confirmation of anastomotic integrity before the removal of the catheter following 14 to 21 days of catheterization is not indicated in the routine postradical prostatectomy patient.

Color Doppler flow imaging for deep venous thrombosis screening in patients undergoing pelvic lymphadenectomy and radical retropubic prostatectomy for prostatic carcinoma.

Patients undergoing pelvic lymphadenectomy and radical retropubic prostatectomy are traditionally considered to be at high risk for postoperative venous thromboembolic complications. A prospective deep venous thrombosis screening regimen was initiated at our medical center in 1990 following 2 cases of fatal pulmonary embolism that occurred after hospital discharge. During a 3-year period 245 consecutive patients undergoing radical retropubic prostatectomy for prostate cancer were screened postoperatively for lower extremity deep venous thrombosis using ultrasound duplex scanning with color Doppler flow imaging. The results were correlated only with the development of clinical deep venous thrombosis. No additional diagnostic modalities were used to confirm a normal venous system in asymptomatic patients. Venous thromboembolic complications were encountered in 9 of the 245 patients (3.6%). In 2 patients deep venous thrombosis was associated with nonfatal pulmonary embolism. Only 2 of the 9 cases of deep venous thrombosis were detected by color Doppler flow imaging screening. The striking decrease in the incidence of deep venous thrombosis following radical prostatectomy in the last decade and the low yield of screening at a single point in time may warrant reconsideration of the need for deep venous thrombosis screening among patients undergoing pelvic lymphadenectomy and radical retropubic prostatectomy for prostate cancer.

Prenatal in vivo bulbourethral gland development is not affected by prostaglandin E2 inhibition.

Investigation of bulbourethral gland (BUG) development is useful to study genitourinary (GU) tract growth and differentiation. Understanding GU tract growth and differentiation is relevant to testing the hypothesis that the initial lesion of human benign prostatic hyperplasia involves focal re-expression of inductive processes in the periurethral region of the prostatic transitional zone. Prostaglandins play a role in regulating growth and morphogenesis of different organ systems. Previous reports have proposed that prostaglandin E2 (PgE2) mediates the masculinizing effects of testosterone in the developing neonatal male GU tract. We have previously shown that androgens lower rather than raise BUG PgE2 levels. Further studies led us to conclude that PgE2 does not play a major role in postnatal BUG growth and morphogenesis in vitro. In order to investigate the possible role of PgE2 in prenatal BUG development, indomethacin (INDO, 1.0 mg/kg- day, subcutaneously) was administered to pregnant BALB/c mice on gestational days 12-18. Control pregnant mice were either untreated or injected with dimethylsulfoxide vehicle. Anogenital distances were measured within 12 hours after birth in male and female offspring on day 19. In male neonatal mice, BUGs were examined histologically and PgE2 levels were measured by radioimmunoassay in BUGs and whole genital tracts. We observed no significant morphological differences in INDO-exposed BUGs compared to controls. No significant differences in mean anogenital distances of INDO-exposed male offspring or controls were detected. Mean anogenital distances of female offspring were similar in the three respective groups. Mean BUG PgE2 levels in INDO-exposed neonates were significantly lower (P < 0.05) than in untreated neonates.(ABSTRACT TRUNCATED AT 250 WORDS)

Unusual neoplasms detected in testis cancer patients undergoing post-chemotherapy retroperitoneal lymphadenectomy.

Approximately 30% of patients with disseminated testis cancer who receive platinum-based chemotherapy will experience normalization of tumor markers but have persistent, radiographically evident disease in the retroperitoneum. These patients usually undergo retroperitoneal lymph node dissection. Of 557 patients undergoing post-chemotherapy retroperitoneal lymph node dissection at our university medical center 45 (8.1%) had neoplastic elements distinct from the classical germ cell tumor types within the resected specimens. Examples include various sarcomas in 19 patients (3.7%), other nonsarcomatous nongerm cell cancers in 18 (3.2%) and cystic atypical choriocarcinoma in 8 (1.4%). No distinct patient characteristics or histological patterns in the primary tumor are predictive of these unusual findings in the retroperitoneal lymph node dissection specimen, although sampling error in the orchiectomy specimen could be the reason for this lack of correlation. Surgical resection of these chemoresistant tumors is potentially curative, with disease-free survival in 13 of 19 patients (68.4%) with sarcoma, 10 of 18 (55.6%) with nonsarcomatous cancer and 7 of 8 (87.5%) with cystic atypical choriocarcinoma at a mean followup of 30.6, 42.5 and 24.7 months, respectively.

Long-term histopathological changes observed in rats subjected to augmentation cystoplasty.

Possible development of proliferative lesions in bladders subjected to augmentation cystoplasty is a matter of concern for many clinicians. We have previously reported on the development of bladder papillomas in 5 of 15 rats approximately 18 months after gastrocystoplasty. We now report a followup study designed to investigate histopathological changes occurring in rat bladders approximately 2 years after augmentation cystoplasty using various gastrointestinal segments. Prepubescent Long-Evans female rats were randomly divided into 4 groups and underwent either gastrocystoplasty, ileocystoplasty, colocystoplasty or a sham operation (controls). Animals were sacrificed 14 to 27 months (average 21.5) postoperatively and bladders were examined histologically. Metaplastic and/or hyperplastic changes were observed in the gastrointestinal patches or surrounding urothelium in all bladders having undergone augmentation cystoplasty. Tumors occurred on or adjacent to the lumenal surface of the augmented segment in 4 of 10, 3 of 11 and 2 of 11 rats that underwent gastrocystoplasty, ileocystoplasty or colocystoplasty, respectively. None of the tumors was observed to invade blood vessels, lymphatics or the underlying muscle layers. However, histological features of malignancy characterized by varying degrees of cellular pleomorphism occurred in some tumors. Control rats (10) had only minor changes related to reapposition of tissues and remnants of suture. Possible etiologies and the potential significance of these augmentation cystoplasty related proliferative lesions are discussed.

Parameterizing age patterns of demographic rates with the multiexponential model schedule.

"For nearly 200 years actuaries, statisticians, and demographers have sought to summarize the age pattern of mortality rates by means of a limited number of parameters. Such 'model schedules' have also been useful in representing schedules of rates other than mortality....This paper illustrates a particular general functional form for such model schedules: the multiexponential function. It discusses the changing behavior of this function as its parameters take on different values and examines the quality of the fits of this function to observed data on mortality, fertility, and migration." This is a revised version of a paper originally presented at the 1993 Annual Meeting of the Population Association of America. (SUMMARY IN FRE)

Unusual neoplasms detected in testicular cancer patients undergoing postchemotherapy retroperitoneal lymphadenectomy.

Approximately 30% of patients with disseminated testicular cancer who receive platinum-based chemotherapy will experience normalization of tumor markers but have persistent, radiographically evident disease in the retroperitoneum. These patients are usually subjected to retroperitoneal lymph-node dissection (RPLND). In all, 45 of 557 patients (8.1%) undergoing postchemotherapy RPLND at Indiana University Medical Center (IUMC) were found to have neoplastic elements distinct from the classic germ-cell tumor types within their resected specimens. Examples included various sarcomas in 14 patients (3.7%), other nonsarcomatous non-germ-cell cancers in 18 patients (3.2%), and cystic atypical choriocarcinoma in 8 patients (1.4%). No distinct patient characteristic or histologic pattern in the primary tumor was predictive of these unusual findings in the RPLND specimen, although sampling error in the orchiectomy specimen could be the reason for this lack of correlation. Surgical resection of these chemoresistant tumors is potentially curative, with disease-free survival being obtained in 13 of 19 patients (68.4%) with sarcoma, 10 of 18 patients (55.6%) with nonsarcomatous cancers, and 7 of 8 patients (87.5%) with cystic atypical choriocarcinoma at mean follow-up intervals of 30.6, 42.5, and 24.7 months, respectively.

Stage II nonseminomatous germ-cell testicular tumors--the Indiana experience and risk-benefit analysis.

Controversy exists in the appropriate management of patients with nonseminomatous testicular cancer presenting as clinical stage B disease. Traditional treatment in the United States has included retroperitoneal lymph-node dissection (RPLND). Conversely, in Europe and other places some of these patients have been managed with primary chemotherapy. The experience with RPLND in clinical stage B disease at Indiana University from 1965 to 1989 was reviewed. A total of 174 patients were considered to be in clinical stage B prior to RPLND. After RPLND, 23% of these patients (n = 41) were found to have pathological stage A disease. In all, 77% (n = 133) were determined to be in pathological stage B. Of those pathological stage B patients who did not receive adjuvant chemotherapy, 65% were cured by RPLND alone. The pathological stage B patients who went on the receive postoperative adjuvant chemotherapy displayed an overall 14% chance of relapse. (Patients treated early in the series did not receive cisplatin-based chemotherapy.) The overall survival over the entire period was 96%. In the more modern era, during which cisplatin-based chemotherapy was available, the overall survival was 98%. RPLND is an effective procedure for the management of clinical stage B nonseminomatous testicular cancer. It provides excellent survival in patients found to have pathological stage B disease; additionally, it avoids the unnecessary toxicity of chemotherapy in the 23% of patients who in fact are in pathological stage A.

Military drug positive rates in the European Theater drug rates in Europe.

Urine samples were collected from Air Force and Army service members within the European Theater and analyzed for drugs of abuse employing radioimmunoassay and gas chromatography/mass spectroscopy (GC/MS). Data collected from January 1985 through December 1991 indicate that the total positive rate decreased from 4.67% to 0.69%. Of the drugs tested, tetrahydrocannabinol (THC) was the drug abused most in the European Theater during this time period.

Androgens lower prostaglandin E2 levels in neonatal mouse bulbourethral gland in in vitro cultures.

The neonatal mouse bulbourethral gland (BUG) in vitro culture model is useful to study hormone-induced genitourinary (GU) tract growth and differentiation. Like the prostate, the BUG is a derivative of the urogenital sinus and may have relevance to understanding growth processes involved in normal and pathological GU tract development. Previous studies have reported androgen-induced elevation of prostaglandin E2 (PgE2) levels in mouse GU tract in vivo. PgE2 has been proposed to mediate neonatal GU tract masculinization. In our studies, tissues were obtained from neonatal male mice and cultured in serum-free Dulbecco's Modified Eagle's Medium-Ham's F-12 Medium (1:1) supplemented with varying concentrations of androgen. PgE2 levels were measured by RIA in the medium, and tissue specimens were cultured for 7 days or less. During this period, androgens induced proliferation and glandular morphogenesis in the BUGs. In the absence of androgen, tissue and medium PgE2 levels increased over 7 days. Significant (P < 0.05) PgE2 increases over day 1 control values were observed from days 5-7 in tissues and on day 7 in media. During this same time period, androgen supplementation decreased PgE2 levels. Significant (P < 0.05) PgE2 decreases from day 1 cultures were observed from days 3-7 in tissues and on day 7 in media. PgE2 was decreased significantly (P < 0.05) by androgen compared to control values from days 3-7 in tissues and from days 5-7 in media. On day 7 of culture, PgE2 levels were significantly (P < 0.05) inhibited by androgen in a concentration-dependent fashion in tissues and media. Maximal androgen-induced inhibition of PgE2 levels was 96% and 99% in tissues and media, respectively. Although the addition of indomethacin to control cultures markedly inhibited PgE2 production, BUG morphology was unaffected. In addition, the morphology of androgen-stimulated BUGs does not appear to be affected by the addition of exogenous PgE2. We conclude that although androgens induce development and decrease PgE2 levels, PgE2 does not appear to play a major role in in vitro BUG postnatal growth and morphogenesis. The BUG in vitro culture model may mimic growth and morphogenetic processes occurring in the human GU tract. Further understanding of the role of steroid hormones and PG metabolism may yield additional insight into developmental and proliferative GU tract disorders.

Median raphe cysts of the genitalia.

We report 2 recent cases of midline cysts of the genitoperineal raphe in children, and discuss the embryogenesis, diagnosis and management. Congenital anomalies of an unclear etiology, median raphe cysts are probably more common than has been reported in the literature. Medical attention is usually sought for secondary infections or pain with intercourse. Awareness and prompt identification of these entities by urologists are essential for proper management when differentiation from other more formidable lesions, including urethral diverticula, becomes important. Simple surgical excision is effective in most cases.

Intra-abdominal desmoid tumor: an unusual case of recurrent tumor in a testis cancer patient.

Recurrence of teratoma or carcinoma in testis cancer patients found to have teratoma at post-chemotherapy retroperitoneal lymphadenectomy is well recognized. We report a case of an intra-abdominal desmoid tumor discovered 2 years following post-chemotherapy retroperitoneal lymphadenectomy in a testis cancer patient who had teratoma at the time of lymphadenectomy. To our knowledge this is the first case of an intra-abdominal desmoid tumor discovered in this setting. The characteristics and treatment considerations of this unusual tumor are described. Desmoid tumor should be included in the differential diagnosis of tumor recurrence in testis cancer patients previously subjected to post-chemotherapy retroperitoneal lymphadenectomy.