Management of shotgun injuries to the pelvis and lower genitourinary system.

OBJECTIVES: Shotgun injuries are rare, with the extent of injury best determined at time of surgical exploration. There are no defined workup or management guidelines for patients with shotgun injuries to the genitourinary system. Injuries are usually treated on an individual basis. This study was conducted to determine the management and extent of genitourinary tract injuries in 10 patients with shotgun injuries to the pelvis during a 6-year interval. METHODS: Between September 1990 and December 1996, 140 patients were treated for firearm injuries to the lower genitourinary tract, of which 10 were secondary to shotgun blasts. We performed a retrospective hospital and clinic chart review and telephone interview to assess organs injured, initial treatment, follow-up surgeries, mortality, and erectile function. RESULTS: Mean patient age was 20 years at the time of the injury. The mean follow-up was 4 years (range 1 to 7). Two patients died, both with major vascular injuries, one in the operating room and the other 1 week later from sepsis. Eight patients underwent radiographic examinations (1 intravenous urogram and 7 urethrocystograms). The bladder was injured in 5 patients, 2 with concomitant complete posterior urethral transection. Of the 5 patients without bladder injury, one had an incomplete penile urethral injury and one had a complete bulbar urethral transection. The initial management consisted of repairing nongenitourinary injuries in 8 cases (80%), most commonly involving injuries to the rectum and small bowel. All patients were treated operatively, including 8 who required laparotomy and 4 who required suprapubic cystotomy. A total of four urethral injuries were noted. Subsequent reconstructive surgeries included two urethroplasties and one permanent supravesical diversion for 3 patients with extensive urethral loss. Erectile dysfunction was present in 3 of 6 patients available for telephone interview. CONCLUSIONS: Shotgun injuries involving the lower genitourinary tract are associated with significant soft tissue injury and morbidity. Death usually results from major associated vascular injuries. All hemodynamically stable patients should undergo retrograde urethrograms and cystograms to evaluate possible urethral and bladder injuries. Open primary repair should be attempted for distal urethral, testicular, and corporal injuries. Delayed repair with staged urethral reconstruction should be reserved for patients with extensive loss of urethral tissue. Impotence is common in patients with extensive perineal injuries.

Management of neurogenic bladder dysfunction with incontinent ileovesicostomy.

OBJECTIVES: Incontinent ileovesicostomy is an alternative form of urinary management applied to patients with neurogenic vesical dysfunction who are either unable or unwilling to perform clean intermittent self-catheterization or assisted catheterization. We review our operative results, urodynamic data, and complications observed in patients who underwent creation of incontinent ileovesicostomy at our institution. METHODS: Thirteen patients (mean age 43.2 years) with neurogenic bladder dysfunction underwent an incontinent ileovesicostomy between 1994 and 1998. The etiologies of the neurogenic bladder dysfunction were spinal cord injury in 8 patients, multiple sclerosis in 4 patients, and tuberculous meningitis in 1 patient. The preoperative data, surgical records, urodynamic findings, and postoperative complications were assessed. RESULTS: All patients experienced complications of their pretreatment bladder management. The mean operating room time was 242 minutes (range 170 to 395), including 14 additional procedures in 1 1 patients. The mean estimated blood loss was 403.8 mL (range 50 to 2000). No patient required blood transfusion. There were no intraoperative complications. Only 1 patient required reoperation for stomal revision. One patient had a ureteral stone 2 years after surgery; 1 patient has continued to have urinary tract infections despite a negative workup. The mean follow-up was 23 months (range 6 to 57). The mean bladder leak point pressure through the stoma was 8.2 cm H2O. CONCLUSIONS: The incontinent ileovesicostomy is a useful technique in the treatment of patients with neurogenic bladder unable to perform clean intermittent catheterization. It provides patients with a low-pressure urinary conduit that empties readily without an in dwelling catheter.

Prospects of immunotherapy for the treatment of prostate carcinoma--a review.

The treatment of prostate carcinoma is dependent on the stage of the disease. Patients who present with clinically localized cancer or locally advanced tumors can be potentially cured by radical prostatectomy, radiation, and hormonal therapy. However, disease progression can occur in 30-50% of patients diagnosed with clinically localized cancer. The bone is the predominant site of metastases. Metastatic prostate cancer is first treated by androgen blockade but within a few months becomes hormone refractory. Hormone refractory metastatic prostate cancer is not responsive to conventional treatments, and patients have an expected survival of less than a year. It is essential to develop new approaches for the treatment of hormone refractory metastatic disease. Immunotherapy, based on enhancement of the host immune response against the tumor, has been used as an alternative therapy for the treatment of metastatic cancers refractory to conventional therapy in particular for melanoma and renal cell carcinoma. In this review, we will summarize various immunotherapeutic approaches developed over the last 18 years, and we will address the potential of immunotherapy for the treatment of metastatic prostate carcinoma by reviewing preclinical studies and initial clinical trials performed in this field.

Systemic interleukin 2 therapy for human prostate tumors in a nude mouse model.

Once the regional lymph nodes become involved in prostate carcinoma, 85% of patients develop distant metastases within 5 years, and metastatic disease is difficult to treat. We have investigated the effect of systemic interleukin 2 (IL-2) treatment on metastatic prostate carcinoma using a xenograft tumor model. Cells from a PC-3/IF cell line, produced by intrafemoral injection of human PC-3 prostate carcinoma cells, were injected in the prostate of Balb/c nude mice. Prostate tumors and para-aortic lymph nodes were resected, and tumor cells were recultured and passaged in the prostate in vivo to produce new cell lines. On day 6 following prostatic injection of these cell lines, mice were treated with i.p. injections of IL-2 at 25,000-50,000 units/ day for 5 consecutive days. The effect of IL-2 on tumor progression was assessed, and histological studies were performed on prostate tumor and lymph node sections. The tumor cell lines generated by serial prostate injection were tumorigenic and metastasized to regional para-aortic lymph nodes. Tumors of 0.4 cm were obtained by day 16 and grew to 1-1.5 cm by day 40 with metastasis to para-aortic lymph nodes. Following two to three weekly courses of 5 days of 25,000-40,000 units/day of IL-2, the growth of prostate tumors was inhibited by 94%. Higher doses of 50,000 units/ day were toxic. Histologically, prostate sections showed vascular damage manifested by multifocal hemorrhages and an influx of lymphocytes and polymorphonuclear cells into disintegrating tumors and areas of necrosis containing numerous apoptotic cells. In contrast to control mice, para-aortic lymph nodes were not enlarged in responding mice. These findings suggest that systemic IL-2 therapy can induce an antitumor response in prostate tumors and control their growth and metastasis.