Adenocarcinoma and dysplasia in an ileal neobladder after ileocystoplasty for interstitial cystitis.

We report a 54-year-old woman with an adenocarcinoma of an ileal neobladder arising upon a background of ileal mucosal dysplasia. We believe that no case study or report has previously documented neobladder ileal mucosal dysplasia adjacent to an ileal neobladder adenocarcinoma. This observation supports the current hypothesis that ileal neobladders are dynamic environments for potential malignancy, and moreover, suggests a sequence of morphologic and molecular derangements similar to that seen in colorectal carcinoma. Those patients status post ileal neobladder are at risk for glandular dysplasia and malignancy and should be followed closely.

Long-term results of treatment for prostate carcinoma by staging pelvic lymph node dissection and definitive irradiation using low-dose rate temporary iridium-192 interstitial implant and external beam radiotherapy.

BACKGROUND: The objective of this study was to evaluate long-term treatment outcome of definitive irradiation by using temporary interstitial implant and limited dose of external beam radiotherapy in treatment of localized prostate carcinoma. METHODS: In total, 536 patients with biopsy-proven adenocarcinoma of the prostate, classification T1-T3, underwent staging pelvic lymph node dissection and brachytherapy delivering an average tumor dose of 30 grays (Gy), supplemented by external beam radiation therapy for an additional dose of 36 Gy delivered over 4 weeks. One hundred of 536 (18%) patients had pathologic D1 disease. A total of 181 patients had undergone transurethral prostatectomy before the treatment. Repeat prostate biopsy was performed on 132 patients 18 or more months after treatment. None of the patients received neoadjuvant or adjuvant hormone therapy. RESULTS: Cumulative disease free survival (DFS) including biochemical DFS at 10 and 15 years for classification T1B,C was 78% and 72%; for T2A, 78% and 78%; for T2B,C, 68% and 66%; and for T3A-C, 45% and 45%, respectively. Cause specific survival for the entire group at 10 and 15 years was 89% and 87%, respectively. Severe complications occurred only in the early developmental phase of the study. CONCLUSIONS: In univariate analysis, the clinical stage, histologic grade, pretreatment PSA level, lymph node status, and results of repeat posttreatment biopsy were all independently significant prognostic factors. However, the authors' study indicates that in multivariate analysis, only two factors emerged with statistical significance-the status of pelvic lymph nodes and the results of posttreatment biopsy. This signifies the importance of local tumor control to achieve ultimate cure and the importance of assessment of pelvic lymph nodes before definitive local therapy other than radical prostatectomy, especially in the high-risk group.

Laparoscopic retroperitoneal renal and adrenal surgery in children.

OBJECTIVE: To retrospectively assess the use of a retroperitoneal laparoscopic approach for simple nephrectomy and adrenalectomy in children. PATIENTS AND METHODS: All retroperitoneal laparoscopic renal and adrenal procedures carried out in children and completed between 1993 and March 2000 were reviewed retrospectively. Analgesic requirements, hospital stay, complications and blood loss were reviewed. The technique is described in detail. RESULTS: Forty-eight retroperitoneal laparoscopic procedures were completed in 48 patients (mean age 5.5 years, range 0.5-16). The procedures included nephrectomy (22), nephroureterectomy (15), renal biopsy (six), cyst ablation (two) and simple adrenalectomy (three). In all, 11 procedures were undertaken in children aged < 2 years. Forty-one (91%) of the children undergoing renal procedures were discharged in < 24 h. Two patients underwent three adrenalectomies. Two children required conversion to open surgery, one undergoing a right-sided adrenalectomy and one a nephrectomy. The mean operative duration for nephrectomy and nephroureterectomy was 75 min, and for adrenalectomy was 115 min. CONCLUSION: Renal and adrenal surgery in children is a safe and rapid procedure with retroperitoneal laparoscopy. The operative duration for nephrectomy and nephroureterectomy are frequently < 1 h. In addition, laparoscopic surgery offers significant advantages in terms of cosmesis and a quicker recovery.

Re-operative hypospadias repair using the Snodgrass incised plate urethroplasty.

OBJECTIVE: To retrospectively assess the results of tubularized incised plate (Snodgrass) urethroplasty in a series of re-operative hypospadias repairs in children. PATIENTS AND METHODS: The study comprised a follow-up (from 1996 until 2000) of 13 patients (mean age 7.5 years, range 13 months to 27 years) who had at least one previous hypospadias repair and who then underwent a reconstruction using the Snodgrass repair. In all cases the urethroplasty was covered with an additional layer of subcutaneous tissue. The original location, associated complications and results were recorded. In some cases, the long-term follow up was conducted by telephone. RESULTS: Associated complications before the Snodgrass repair included urethral stricture in two, fistula in three and persistent chordee in one patient. The mean (range) follow-up was 22 (9-34) months. The cosmetic results were excellent, with two complications (one patient with a glans dehiscence and a urethrocutaneous fistula, and a second with meatal stenosis). The remaining patients required no further procedures and were voiding normally at the last follow-up. CONCLUSION: Excellent cosmetic and functional results can be obtained using the Snodgrass incised plate urethroplasty for re-operative hypospadias repair. Only one patient in this series had an initial operation in which the urethral plate was previously incised. Therefore, caution should be used when considering an incised plate urethroplasty in these patients.

Applications of the KTP laser in the treatment of posterior urethral valves, ureteroceles, and urethral strictures in the pediatric patient.

PURPOSE: We describes our experience using the potassium titanyl phosphate (KTP)-532 laser in treating posterior urethral valves, ureteroceles, and urethral strictures in the pediatric patient. METHODS: A retrospective chart review was performed from 1987 to 1997 on a total of 33 pediatric patients who underwent retrograde endoscopic treatment for posterior urethral valves (PUV), ureteroceles (UC), and urethral strictures using a KTP-532 laser. RESULTS: Overall, our success rate was excellent in the treatment of valves and ureteroceles. With a mean follow-up of three years in the PUV group, no urethral strictures of micturation abnormalities were seen. The majority of ureteroceles were decompressed and only half of our patients required and additional procedure. Our experience with urethral strictures, however, was not as promising. All of these patients ultimately required open urethral reconstruction. CONCLUSION: The desirable thermal characteristics of the KTP laser, along with minimal complications and the availability of delicate pediatric endoscopic instruments have made this operation optimally suited for treating posterior urethral valves and ureteroceles in infants. However, the advantages for treating urethral strictures in children with the laser still remains to be established.

Retroperitoneal laparoscopic nephrectomy in children.

PURPOSE: We report our experience with retroperitoneal laparoscopic nephrectomy and nephroureterectomy in children, and describe our surgical technique. MATERIALS AND METHODS: Five and 15 children 9 months to 17 years old underwent nephrectomy with cystoscopy plus intravesical ureteral stump fulguration for ureteral ablation and nephrectomy only, respectively. Surgical indications were unilateral multicystic dysplastic kidney in 8 cases (parental preference for surgery), a refluxing, chronic pyelonephritic kidney in 5, renal vascular hypertension in 2, and hydronephrosis and chronic pyelonephritis in 5, including 3 in whom a nephrostomy tube was placed percutaneously before laparoscopic nephrectomy. Access was obtained by a 10 mm. incision made posterior to the anterosuperior iliac spine with dissection into the retroperitoneal space and trochar placement. Two and sometimes 3 additional 5 mm. ports were placed retroperitoneally. RESULTS: Average operative time was 1 hour 42 minutes. The most recent cases were performed in less than 1 hour and in 3 nephrectomy only required 30 minutes. All but 1 procedure were completed laparoscopically. One case was converted to open surgery secondary to obscured visibility due to bleeding. Blood loss in all cases was less than 30 cc (average 5 to 10). A total of 13 children were discharged home immediately postoperatively. Five children underwent concomitant procedures, including contralateral ureteroneocystotomy in 4, circumcision in 1 and cystoscopic fulguration of the ureteral stump in 5. Those who underwent ureteral reimplantation were hospitalized for 48 hours. One patient remained hospitalized for 3 days due to fever of unknown origin and 2 were admitted to the hospital for 23-hour observation. All children returned to full activity within 1 week of surgery. Analgesia consisted of 1 dose of ketorolac, bupivacaine injections at the incisional sites at the completion of the procedure, and acetaminophen postoperatively. CONCLUSIONS: As confirmed by parent questionnaire, patient satisfaction was excellent.

Laser treatment of large cavernous hemangiomas of the penis.

PURPOSE: Cavernous hemangiomas of the penis are rare benign tumors commonly excised for cosmesis and bleeding. Reports of laser treatment of these lesions with the patient under local anesthesia indicate good functional and cosmetic results. We report our experience with 4 cavernous hemangiomas treated with the neodymium:YAG laser. MATERIALS AND METHODS: Four patients, 8, 16, 31 and 50 years old, had a total of 8 hemangiomas, which were treated with the neodymium:YAG laser at 5 to 15 watts of power for 3-second pulse durations. RESULTS: All patients had excellent cosmetic and functional results. These treatments were done with essentially no blood loss, on an outpatient basis and without complications. CONCLUSIONS: The treatment of choice for hemangiomas of the penis in the pediatric and adult population is neodymium:YAG laser coagulation.

Laser ablation of renal pelvic transitional cell carcinoma in a solitary kidney: a 9-year follow-up.

Neodymium:yttrium-aluminum-garnet (Nd:YAG) laser ablation of upper-tract urothelial tumors has been well documented in the urologic literature. However, the standard treatment of choice remains radical nephroureterectomy with excision of a cuff of the bladder for most patients. We report on a patient with recurrent superficial transitional cell carcinoma of the renal pelvis in a solitary kidney treated with Nd:YAG laser with a 9-year follow-up.

The results of a five-year early prostate cancer detection intervention. Investigators of the American Cancer Society National Prostate Cancer Detection Project.

BACKGROUND: The American Cancer Society-National Prostate Cancer Detection Project (ACS-NPCDP) is a multidisciplinary evaluation of early prostate cancer detection interventions. This report summarizes the experience of the investigators to date and describes the overall and relative performance of the different detection modalities studied in this project. METHODS: Two thousand nine hundred ninety-nine men aged 55 to 70 years at entry who were not already under evaluation for prostate cancer were recruited to participate in up to 5 annual examinations by prostate specific antigen (PSA), digital rectal examination (DRE), and transrectal ultrasound (TRUS). In the course of 5 years of intervention, ACS-NPCDP investigators have completed 9937 examinations, recommended 1215 biopsies, and detected 203 cancers. RESULTS: Loss to cohort follow-up was greatest in the first year. Overall, TRUS led to twice the number of recommendations for biopsy compared with DRE (8.9% versus 4.4%). Elevated PSA was observed in 13.0% of 9535 measurements performed. The overall cancer detection rate declined significantly during the five years of intervention. Detection was significantly associated with age and symptom status at entry. DRE had lower sensitivity compared with TRUS or PSA, particularly in later years of follow-up. The specificity of TRUS was lower than that for DRE. PSA was elevated in 69.2% of examinations that led to cancer detection, compared with only 10.9% when cancer was not found. PSA level, PSA density, and PSA change were all related to the presence of cancer. Less than 6% of the cancers detected in this study were clinically advanced at the time of diagnosis. CONCLUSIONS: These data quantify the yield of early cancer detection that may be expected when PSA, DRE, and TRUS are used in populations comparable to the men participating in the ACS-NPCDP. Continued follow-up and further research is needed to assess whether men receiving early prostate cancer interventions benefit as a result.

Needle tract seeding after percutaneous biopsy of Wilms tumor.

We report a case of tumor implantation along the needle tract after percutaneous biopsy of Wilms tumor. This is a rare but important complication in the management of Wilms tumor.

Depth of penetration of the neodymium: yttrium-aluminum-garnet laser in the human prostate and clinical results of high-dose laser energy in 50 patients.

We evaluated the treatment of the human prostate with the Nd:YAG laser using a Cytocare Prolase II fiber. We utilized this first in 12 patients prior to radical prostatectomy and then appropriately serially sectioned the prostate to measure the depth of penetration. The studies clearly revealed that 60 W of power and 60 s of pulse duration gave the most consistent depth of penetration in the human prostate model. This depth of penetration averaged 2 cm in the glands that were removed. At the same time there was absolutely no evidence of damage to the neurovascular bundle or to the capsule of the prostate using the above-mentioned dosimetry regime. This study was then transferred to our initial experience in treating 50 patients with benign prostatic hypertrophy and obstructive voiding symptoms. The first 25 patients were also treated with so-called spot radiation of the prostate, whereas the second 25 patients were treated by total photoirradiation of all visible endoscopic tissue. The results reveal that both groups of patients had a fairly highly satisfactory result as measured objectively with American Urological Association (AUA) symptom scores and uroflow studies. In the latter group (photoirradiation of all visible endoscopic tissue) a significantly higher dose of laser energy was utilized and a smaller failure rate was noted on a long-term basis in patients who subsequently came to transurethral resection of the prostate (TURP) because of failure of the laser procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

Depth of penetration of the neodymium:yttrium-aluminum-garnet laser in the human prostate at various dosimetry.

OBJECTIVE: To determine depth of thermal penetration by the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser at various dosimetry in the human prostate and to compare results of two techniques of laser application, single spot versus whole tissue photoirradiation. METHODS: Twelve men with Stage T2 (B) cancer of the prostate consented to laser prostatectomy immediately prior to a planned radical prostatectomy. In the first 3 patients (group I) the prostate was treated with the Nd:YAG laser in one spot area of each lobe. The next 9 patients underwent photoirradiation of all endoscopically visible tissues on one side of the prostate at different dosimetries: 60 W at sixty seconds (group II), 50 W at sixty seconds (group III), and 40 W at ninety seconds (group IV). Depth of laser penetration was measured from both histologic and gross evaluations of removed specimens within twenty-four hours. RESULTS: Thermal necrosis in group I showed an inconsistent depth of penetration even with the same amount of laser energy. Groups II, III, and IV all demonstrated clearly demarcated areas of thermal necrosis. Group II showed the greatest depth of laser effect among all groups, with a mean depth of 1.75 cm. No laser effect is detected near the true capsule of the prostate on any specimen. CONCLUSIONS: High dosage laser energy application at 60 W and sixty seconds of pulse duration with the whole tissue treatment provide the greatest depth of penetration in the human prostate while maintaining safety for the capsular area.

Extensive neodymium-YAG photoirradiation of the prostate in men with obstructive prostatism.

OBJECTIVE: To determine if high-dosage, extensive photoirradiation of the prostate could be used safely in men with large prostate glands and obstruction, coupled with acceptable clinical results. METHODS: Treatment of 25 men consecutively with eight quadrant photoirradiation of the prostate. Treatment of the next 25 men with high-dosage energy up to 109,000 joules. Simultaneous transrectal needle biopsy of the prostate performed on all 50 men after treatment. Patients evaluated with four- to sixteen-month follow-up. RESULTS: Success rate of 86 percent on all patients with mean American Urological Association (AUA) symptom score decreasing by nineteen points and mean peak uroflow rate increasing by 7.9 cc. Needle biopsy after high-dosage laser therapy shows no laser effect on the peripheral zone. CONCLUSIONS: High-dosage laser energy can be used safely, and allows us to treat large prostates with excellent clinical results and minimal complications.

Laser therapy for interstitial cystitis.

Laser treatment for interstitial cystitis patients should be limited to those who are positively diagnosed and have failed more conservative forms of therapy. The results are not as beneficial for patients with intractable pain but show only signs of glomerulation. When the laser is used within the proper power settings and the amount of energy applied during any one operative procedure is limited, the treatment is safe and can be very beneficial.

Cost analysis of neodymium-YAG laser versus transurethral resection treatment of superficial bladder carcinoma.

We have analyzed a group of patients treated by various urologists with both neodymium-YAG laser photoirradiation and transurethral resection in the treatment of superficial bladder carcinoma. The average hospitalization for the group of patients treated by the laser was significantly shorter than the group of patients treated by transurethral resection of the bladder tumor. The complications were similar. The cost savings to patients treated by laser photoirradiation appears to be significantly greater in laser groups of patients as opposed to conventional transurethral resection techniques.

Adenocarcinoma in a müllerian duct cyst.

A case of adenocarcinoma involving a müllerian duct cyst is presented. The presentation, treatment, and pathological and radiological appearance are discussed. The embryology and history of this entity are reviewed.