Intubated cutaneous ureterostomy: option for high-risk patients needing supravesical urinary diversion.

Failure of primary healing between ureter and skin has led to numerous complications and the virtual abandonment of cutaneous ureterostomy. When an indwelling double-J stent can be maintained, primary healing occurs and good ureterocutaneous anastomoses result. Ostomy training is only slightly more difficult than in patients with an ileal conduit urinary diversion and has presented no major problems. We now favor cutaneous ureterostomy in selected high-risk patients because of the lesser magnitude of this form of supravesical urinary diversion and, especially, because intubation has overcome most of the complications of this procedure.

Is semen cryopreservation helpful in testicular cancer?

Currently, semen to be "banked" by cryopreservation must have a minimum sperm concentration of 40 million/ml. and a minimum motility of 60 per cent. In analyzing semen of our patients with testicular cancer after unilateral orchiectomy but before further therapy, we have found that the semen of only 4 per cent (1/25) meets those minimum requirements. The results of this study suggest that cryopreservation may be an unrealistic solution to the infertility that may result from the treatment of testicular cancer.

Sexual function and fecundity after treatment for testicular tumors.

Questionnaires were mailed to patients who had undergone either radiotherapy, lymphadenectomy, or a combination of both as treatment for malignant disease of the testis in an attempt to define the effects of their therapy on sexual function, ejaculation, and fecundity. The forms returned by 29 patients with seminoma treated with irradiation alone indicated that little change had occurred in their sexual performance or sex drive. Diminished semen volume was reported by 10 patients but was severe in only 1. Two of 3 patients who desired children after therapy were successful. In patients with nonseminomatous testis tumor treated surgically, 42 of 50 reported a significant decrease in semen volume, but 7 of 12 who desired children following therapy were successful. The physiology of ejaculation is reviewed, and comments are offered on the means by which retroperitoneal lymphadenectomy may disrupt normal ejaculation.

Complications of single-stage radical cystectomy and ileal conduit.

Single-stage radical cystectomy without pelvic lymphadenectomy and ileal conduit urinary diversion was performed on 241 consecutive patients over a three and one-half-year period. Operative mortality rate was 2.5%; early and late complications occurred in 32 and 34% of patients, respectively. In general, complications were less severe than in the past. Wound complications remain a major source of morbidity, but wound disruption and anastomotic leaks have been virtually eliminated.

Vesical adenocarcinoma occurring in patient with pelvic lipomatosis.

This is the first case reported of adenocarcinoma of the urinary bladder in a patient with pelvic lipomatosis and cystitis glandularis. The abnormal pelvic fat hampered endoscopic evaluation and transurethral biopsy, confused clinical staging, and complicated preoperative irradiation and cystectomy. The development of adenocarcinoma in this patient indicates the potential for malignant transformation of cystitis glandularis and underscores the necessity for endoscopic follow-up of persons with pelvic lipomatosis.

Regional lymph nodes in infants with embryonal carcinoma of testis.

Clinical and pathologic material from 16 infants with embryonal carcinoma of the testis was reviewed specifically as to the route of metastatic spread and the findings obtained from retroperitoneal lymphadenectomy. Hematogenous metastases were noted in 3 patients (19 per cent) and lymphatic metastases were observed in 2 patients (13 per cent). In 12 patients in whom disease was clinically limited to the testis retroperitoneal lymphadenectomy was negative, although a review of the literature suggests that unsuspected metastases might be expected in 6 per cent of such patients. The 2 patients who had lymph node metastases had large, clinically evident but unresectable retroperitoneal lymph node masses. The low yield of retroperitoneal metastases in early disease makes lymphadenectomy suspect as a primary staging or treatment procedure, but the occasional patient presenting with retroperitoneal disease requires that the procedure not be abandoned at this time.

Complications of transabdominal retroperitoneal lymphadenectomy.

Twelve complications occurred in 175 patients (7%) undergoing transabdominal retroperitoneal lymphadenectomy for management of nonseminomatous testicular carcinoma. There was no operative mortality. The low morbidity and rare mortality associated with the operation justifies its continued use both as a staging procedure and as a therapeutic modality.

Cystectomy for superficial bladder cancer.

One hundred nine patients with Stage O or A bladder cancer unmanageable transurethrally underwent radical cystectomy and ileal conduit urinary diversion without lymphadenectomy. Fifty-six were also given planned preoperative radiation therapy. Five-year survival rate was 76 per cent for the entire group. Irradiation eradicated all of the tumor (Po) in 36 per cent of patients, no patient Po after irradiation had recurrent disease, and local recurrence was noted in only 3.5 per cent of the irradiated patients compared with 9.4 per cent of those not irradiated. Urethral cancer was present in 9 per cent of our patients, a finding that does not support our previous impression that patients with multifocal bladder cancer or tumors involving the prostatic urethra had a higher than average incidence of urethral carcinoma.

Alpha fetoprotein determinations in germ cell tumors of testis.

Alpha fetoprotein was demonstrated in 15 of 115 patients with histologically proved germinal testicular neoplasms. Alpha fetoprotein was detected in patients only with embryonal carcinoma and teratocarcinoma; determinations were negative in all cases of pure seminoma, teratoma, and choriocarcinoma. Of 15 patients having detectable alpha fetoprotein, 14 had Stage III disease and one had Stage II disease. When alpha fetoprotein is present, it usually heralds progression of the disease and therefore may serve as a valuable biologic marker to monitor response to therapy.

Continuous postoperative epidural analgesia in management of postoperative surgical pain.

In the last fifteen months we have used continuous postoperative epidural analgesia after open urologic surgery and herein report our experience with the first 64 patients. Incisional pain was completely eliminated in 96 percent of patients. Epidural analgesia diminished pain-related pulmonary complications without sedation. Complications were tolerable and manageable. Hypotension due to sympathetic blockade responds to intravenous fluid administration. Urinary retention is avoidable if the epidural infusion is discontinued prior to removing the urethral catheter. Itching is an undesirable consequence observed by 20 percent of patients when morphine is used.

Microwave: practical cost-effective method for sterilizing urinary catheters in the home.

We used a standard microwave oven to sterilize red rubber catheters used for intermittent self-catheterization. Catheters were incubated for sixty minutes in a suspension of microorganisms isolated from the urine of patients with urinary tract infections. For each trial, 6 catheters were removed from their respective suspensions, placed in separate plastic freezer bags, distributed evenly in a microwave oven (avoiding cold spots), and microwaved simultaneously for twelve minutes. A control catheter was not microwaved. Two strains of each microorganism were tested. The urinary isolates were Escherichia coli, Klebsiella sp., Proteus sp., Enterobacter sp., Pseudomonas sp., Streptococcus sp., Staphylococcus sp., and Candida sp. In each experiment, all 6 catheters were sterilized. Repeat sterilization in the microwave oven did not affect the integrity of the catheters or the plastic bags. A water heat sink of constant volume was employed. A home microwave oven may be used as a method to sterilize red rubber catheters for reuse with a recommended time of twelve minutes at full power. This technique makes aseptic intermittent self-catheterization a practical possibility.

Primary localized amyloidosis of male urethra (amyloidoma).

Amyloidosis of the urethra is extremely rare. The first reported case of amyloidosis of the fossa navicularis is presented.

Preoperative chemotherapy for Wilms tumor.

Preoperative chemotherapy was administered to 19 children with Wilms tumor judged clinically to be unresectable at M. D. Anderson Hospital between January 1, 1962, and September 1, 1980. After 2 to 4 doses of vincristine, marked reduction in tumor size occurred in 16 patients. After chemotherapy 16 tumors could be resected completely, another required irradiation to reduce the tumor, and only 2 tumors could not be excised. Pathologically the most dramatic changes occurred in the undifferentiated interstitial stroma, followed next by changes in the nodular blastema. Differentiated elements were apparently not affected. No serious complications were attributed to the preoperative drug treatment. This experience suggests that in selected instances preoperative chemotherapy can affectively facilitate the therapy of Wilms tumor.

Percutaneous transfemoral renal artery occlusion in patients with renal carcinoma. Preliminary report.

Twenty-four patients have undergone percutaneous transfemoral selective renal artery occlusion as part of their management for renal carcinoma. Preoperative infarction was performed in 7 cases. This facilitated surgery by eliminating the major blood supply to the tumor and resulted in collapse of the large collateral veins and created edema within the perirenal tissue. In 17 patients with visceral metastases, tumor infarction was performed in lieu of nephrectomy for control of the primary lesion and in hopes of stimulating an autoimmune response. The current status of this procedure s discussed in light of its indications, complications, and preliminary results.

Treatment of multiple superficial tumors of bladder with intravesical bleomycin.

Twenty-six patients with superficial Stage O or A transitional cell carcinoma of the urinary bladder, whose lesions were not amenable to transurethral resection, received bleomycin sulfate intravesically at weekly intervals for eight treatments. Five different drug regimens were tried, and the optimal concentration appeared to be 60 units dissolved in 30 cc. of sterile water. Serum determinations failed to reveal any significant absorption. There was a 27% complete response rate in patients with small tumor burdens. An additional 9% had partial responses which allowed the tumors to be readily managed transurethrally. However, no patients with extensive superficial tumor showed complete response to therapy. Although belomycin used intravesically is active against transitional cell carcinoma, the current cost of the drug precludes its routine use and restricts it to situations in which other agents are contraindicated.

Role of intravesical mitomycin C in management of superficial bladder tumors.

Forty-three patients with biopsy-proved Stage O or A transitional cell carcinomas of the bladder, whose tumors were not amenable to transurethral resection, received mitomycin C intravesically at weekly intervals for eight treatments. Five different drug doses were used (20, 25, 30, 40, and 60 mg). Best response rates occurred at doses of 30 mg. or higher. Complete responses occurred in 49% of patients, partial responses in 30%, and improvement in 5%, for an over-all effective rate of 84%. Responses were achieved regardless of tumor extent as long as individual tumors were 1 cm. or less in diameter. Toxicity was minimal. The necessary for maintenance therapy in complete responders remains to be proved.