Is lymphadenectomy indicated in patients with T1 moderately differentiated penile cancer?

OBJECTIVE: In patients with penile squamous cell carcinomas (SCCs), lymphadenectomy can be curative and should be considered in cases deemed high risk for metastatic spread to regional lymph nodes. Management of patients without palpable lymphadenopathy remains controversial. Current guidelines for T1 penile SCCs based on previous studies have suggested that moderately differentiated tumors are at low risk for metastatic disease; however given our experience with such patients we sought to examine whether such tumors were truly observable or should be treated more aggressively. MATERIALS AND METHODS: A retrospective chart review of penile cancer cases at three institutions was performed. All slides of patients diagnosed with T1 lesions were rereviewed by our reference pathologists to confirm the original diagnosis and stage. These patients were also reviewed regarding lymphadenectomy results and clinical outcomes. RESULTS: Between 1988 and 2004, a total of 34 cases of SCC of the penis were identified, of which 10 were stage T1. Of these 10 cases, seven had moderately differentiated carcinoma without vascular invasion on pathological evaluation. Metastatic disease was present in one patient at the time of diagnosis and subsequently developed in three of the remaining six patients during follow up. Thus a total of 4 (57%) of the patients developed metastatic disease. CONCLUSIONS: Current management protocols place moderately differentiated T1 penile squamous carcinoma without vascular invasion in a low risk category for metastatic disease. As such, expectant management is currently offered as a primary option for these patients. Our experience suggests that patients in this category are in fact at higher risk for metastatic disease, and may be offered early groin dissection in place of expectant management.

Vascular invasion predicts recurrence after radical prostatectomy: stratification of risk based on pathologic variables.

OBJECTIVES: To determine whether vascular invasion (VI) is an independent predictor of prostate cancer recurrence and/or survival and to stratify risk of recurrence in patients with VI. METHODS: Vascular invasion status was documented in 620 radical prostatectomy specimens with an average of 7.5 years of follow-up. The relationship between VI and other clinical and pathologic features was tested. Vascular invasion as an independent predictor of recurrence was investigated by logistic regression analysis. Survival analyses and stratification of VI patients was developed with Kaplan-Meier survival curves. RESULTS: Vascular invasion was identified in 110 patients (18%) and correlated significantly (P <0.0001) with high Gleason grade, extracapsular extension (EPE), seminal vesicle invasion, increasing cancer volumes, positive margins, and elevated preoperative prostate-specific antigen (PSA) levels. Logistic regression analysis demonstrated that VI was a strong and independent predictor for disease recurrence, when considered with grade, EPE, seminal vesicle invasion, lymph node involvement, cancer volume, preoperative PSA levels, and positive margins. At 12 years after radical prostatectomy, patients with VI demonstrated significantly lower disease-specific survival (P = 0.0005). Among patients with VI, stratification of grade, EPE, and the number of VI foci identified three significantly different prognostic groups. CONCLUSIONS: In long-term follow-up, VI was a significant predictor of prostate cancer recurrence and death after radical prostatectomy. In patients with VI, high Gleason grade, EPE, and more than five foci of VI are associated with poor prognosis.

Urinary tract infections in children: treatment.

Urinary tract infection is a frequent diagnosis in children who are referred to the urologist. Infections vary in scope and severity, warranting thoughtful consideration of appropriate therapy. Infections of the genitourinary system may include bacterial,viral, fungal, or parasitic microorganisms. Adequate therapy requires rapid detection and control of these conditions to prevent pyelonephritic renal scarring and its sequelae.

Management of sternal wounds with bilateral pectoralis major myocutaneous advancement flaps in 114 consecutively treated patients: refinements in technique and outcomes analysis.

Because life-threatening sternal wound complications can occur following sternotomy, the optimal management of sternal wound infections remains an important topic. To decrease morbidity following operative treatment of these patients, the authors made a number of refinements in their treatment protocol over the past several years, particularly with regard to the extent of débridement, method of flap apposition, and management of drains. The purpose of this study was to obtain specific outcomes data by reviewing a large series of patients treated by a single surgeon. In this series of 114 consecutive sternal wounds treated by the senior author (Ascherman), patients were managed almost exclusively with débridement and immediate closure with bilateral pectoralis major myocutaneous advancement flaps. There were no intraoperative deaths. The 30-day perioperative mortality rate was 7.9 percent, with only one death directly related to sternal infection. Nineteen patients (16.7 percent) experienced postoperative morbidity, including partial wound dehiscences (5 percent), skin edge necrosis (5 percent), and seromas (3.5 percent). The authors advocate single-stage management of complicated sternal wounds with immediate débridement and bilateral pectoralis major myocutaneous advancement flaps. The procedure is rapid and effective. Refinements in technique have significantly lowered morbidity.