Synchronous metastatic renal cell carcinoma to the genitourinary tract: two rare case reports and a review of the literature.

Synchronous metastasis of renal cell carcinoma (RCC) to the ureter or the bladder represents an extremely rare event. We report one case of synchronous metastasis of RCC to the ipsilateral ureter and one case of solitary synchronous metastasis of RCC to the urinary bladder. We review the literature and discuss possible mechanisms of dissemination. We discuss the surgical management of metastases from RCC as well as the surgical options in the treatment of these rare occurrences.

Radical prostatectomy in patients with indwelling inflatable penile prosthesis.

Patients with impotence who have undergone placement of an inflatable penile prosthesis (IPP) and then subsequently are diagnosed with carcinoma of the prostate (CaP) present a surgical dilemma. We performed radical retropubic prostatectomy on 3 patients with clinically localized CaP and an indwelling IPP. At laparotomy all 3 patients had the IPP reservoir relocated to facilitate dissection. In each case the reservoir was relocated to the left hypogastrium within the extraperitoneal space without disrupting the vacuum tubing system. There were no complications related to IPP, no IPP was injured, and each IPP was reactivated successfully 6 weeks after surgery.

Surgical results with artificial urinary sphincter.

From June, 1974, until January, 1977, eleven AMS 721 genitourinary sphincters were installed in 9 men and 2 females. Long term success was achieved in 2 men. Failures were encountered in 9 patients (82 per cent) with urethral erosions (3 patients), infection (1 patient), and mechanical failure (5 patients) accounting for the complications necessitating prosthetic removal. From January, 1979, until May, 1981, 15 males had the revised AMS model AS 742 (b) or (c) sphincter installed. Long term continence was achieved in 9 patients (60 per cent). Urethral erosion in 4 patients (27 per cent) and infection of the prosthesis in 2 men (13 per cent) accounted for fathers. An improved surgical technique involving the installation of the device in a defunctionalized state with secondary activation is anticipated to improve future results.

Carcinoma of penis treated with neodymium YAG laser.

Sixteen men with squamous cell carcinoma of the penis were treated primarily with the Neodymium Yttrium Aluminum Garnet (Nd:YAG) laser. Five patients had TIS, 9 had T1 tumors, and 2 had T2 carcinoma. All patients had refused traditional therapy of partial penectomy and gave informed consent as to the investigational nature of the Nd:YAG laser photoradiation therapy. Circumcisions and deep tissue biopsies were performed on all patients prior to tumoricidal neodymium photoradiation treatment. The patients were followed from twelve to thirty-six months. At follow-up, 5 patients with TIS had no evidence of recurrent cancer. Of the 9 patients with T1 squamous cell carcinoma of the penis, 6 (67%) were tumor-free at a mean follow-up of twenty-six months. The 2 men with T2 carcinoma of the penis had reduction of the tumor mass but were not cured. The obvious advantage of the Nd:YAG laser in treating carcinoma of the penis is preservation of the penis eliminating disfiguring amputation.

Surgical success with AMS M800 GU sphincter for male incontinence.

Forty-two incontinent males were treated with the surgical implantation of the AMS M800 GU sphincter from 1982 to 1987. Patients' ages ranged from twenty-four to eighty-four years. All patients had the M800 GU sphincter deactivated from six to sixteen weeks post implantation. Patients were followed from seven to sixty months postoperatively with a mean follow-up of 26.2 months. Thirty-two males (76%) were completely continent post insertion of the M800 GU sphincter while 4 men (9%) experienced minimal to moderate stress incontinence. Two patients (5%) were unable to manipulate the device secondary to physical and/or mental incapacity. Four patients (9%) required removal of components or the entire GU sphincter secondary to infection and/or erosion. Two of these men were subsequently reimplanted with the M800 sphincter and are now totally continent.

Carbon dioxide laser therapy of subclinical condyloma found by magnified penile surface scanning.

The etiology and treatment of condyloma caused by the human papilloma virus (HPV) and the association of HPV with cervical dysplasia and/or carcinoma is a major issue in current gynecologic literature. This study examined results of carbon dioxide (CO2) laser treatment of 127 high-risk males with biopsy-proved subclinical HPV infections found by magnified penile surface scanning (MPSS). At a mean follow-up of four months a 66 per cent recurrence rate of microscopic condyloma was encountered. A discussion of the causes of such a high recurrence rate is given, with conclusions on this and prior condyloma treatment series.

Reliability of AMS M700 inflatable penile prosthesis.

Two hundred ninety patients have been followed up for at least one year or longer after implantation of the AMS M700 inflatable penile prosthesis. One hundred twenty-seven males have been followed up for two years or longer. Eighty-six impotent men had a follow-up of eighteen months or longer. The remaining 77 patients were studied for at least twelve months or longer. There have been 3 mechanical failures of cylinders implanted secondary to nonabsorbable surgical sutures remaining from previous prosthetic surgery. There were no reservoir or pump malfunctions. Eight patients had a slow leak from the nonkinking tubing. Since a revision of the manufacturing process of the nonkinking tubing in September, 1983, there have been no further leaks. Life table analysis for survival in this group of patients showed a probability of survival at three years of 97.9 per cent. The satisfaction rate among patients is greater than 90 per cent.

Laser treatment of urethral condyloma: a five-year experience.

OBJECTIVE: Twenty cases of men treated with the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser for meatal and/or urethral condyloma over five years were reviewed. METHOD: All patients underwent Nd:YAG laser treatment of visible lesions as outpatients under general anesthesia using the visual urethrotome sheath and 0 degree lens. Follow-up urethroscopy was performed at three-month intervals. Cure of the gross disease was defined as negative findings on two sequential follow-up urethroscopies. RESULTS: All patients with gross condylomatous disease were verified to have type 6/11 human papillomavirus. Ninety-five percent had meatal condylomata of which 42 percent had concomitant distal urethral lesions. Thirty percent were cured of gross disease after one treatment, while 40 percent needed two, three, four, or five separate treatments before gross cure was obtained. Thirty percent had insufficient follow-up. Only 2 of the patients experiencing recurrence did so after negative finding on one follow-up urethroscopy. CONCLUSIONS: We believe attempts at cure of gross urethral condylomatous disease should be made because of its unsightliness and symptoms such as split stream and bleeding. Cure of gross disease with the Nd:YAG laser, as evidenced by our results, is possible. However, it may require several treatments. Follow-up urethroscopy is recommended in all patients because of the high incidence of recurrence and concomitant distal urethral involvement in those patients with meatal disease.

Extraperitoneal laparoscopic urethropexy with Marlex mesh.

OBJECTIVES: Extraperitoneal laparoscopic urethropexy (ELU) has recently been developed as a minimally invasive procedure for the treatment of female stress urinary incontinence (SUI). Use of the laparoscopic stapling device and Marlex mesh in the extraperitoneal space may allow for a technically easier procedure and shorter operative times compared with other laparoscopic techniques without compromising long-term efficacy. We present our initial results and 2.5-year interim analysis with this alternative method of laparoscopic urethropexy. METHODS: Twenty-four consecutive patients with urodynamically demonstrated genuine SUI underwent attempted ELU at a single institution from December 1994 to December 1995. Operative data were collected from the patient chart, and follow-up data were obtained by telephone interview. Treatment was considered successful if, at last follow-up, a patient was using one or fewer pads daily and would recommend the procedure to a friend. RESULTS: ELU was completed in 22 of 24 patients. In 1 patient with a prior history of pelvic surgery, the preperitoneal space was not accessible. Of the 22 patients, 20 were available for follow-up. The mean operative time was 69 minutes. There were no intraoperative complications. At initial follow-up (mean 10.5 months), 18 (90%) of 20 patients reported subjective cure of SUI (one or fewer pads daily). At a mean follow-up of 29 months (range 23 to 34), 16 (80%) of 20 patients had subjective cure of SUI. Six patients would not recommend the procedure to a friend, all of whom had de novo urgency and/or urge incontinence. Thus, using our strict criteria, ELU was successful in 14 (70%) of 20 patients at a mean follow-up of 2.5 years. No patient has had permanent urinary retention. CONCLUSIONS: ELU can be performed rapidly and safely in patients without previous pelvic surgery. De novo urgency incontinence may be problematic. Future analysis of this subset of patients will determine whether this procedure is durable in the long term.

Bladder outlet obstruction treated with transurethral ultrasonic aspiration. One-year follow-up on 59 patients.

Fifty-nine males with bladder outlet obstruction were treated with transurethral ultrasonic aspiration of the prostate. Utilizing a 26.5F urethral sheath, surgery was accomplished with a 10F, 0-700-micron-vibration-level ultrasonic tip with an excursion rate of 39 kHz. Complete removal of the adenoma was accomplished followed by transurethral electrocautery biopsies of both lateral lobes to compare pathologic specimens. One year follow-up revealed satisfactory voiding patterns in 57 of 59 men (96%). Bladder neck contractures developed in 2 men. Pathologic comparisons showed 100 percent correlation between aspirated and TUR specimens (56 BPH, 3 adenocarcinoma). Forty-seven men were active sexually preoperatively (6 with inflatable penile prostheses). Post ultrasonic aspiration, 46 men had erectile function similar to preoperative levels with 1 patient suffering erectile dysfunction. Forty men (85%) had antegrade ejaculation while 7 (15%) experienced retrograde or retarded ejaculation. No patients were incontinent.

KTP-532 laser ablation of urethral strictures.

In 1988 the KTP-532 laser was used to ablate a series of benign urethral strictures. Rather than using a single incision as in urethrotomy, strictures were treated with 360-degree contact photoradiation. Thirty-one male patients, average age 53.2 years, received thirty-seven treatments; 6 patients underwent a second laser treatment. Stricture etiology was commonly iatrogenic (32%), traumatic (16%), and postgonococcal (10%). Stricture location included mainly bulbar (49%), membranous (20%), and penile (12%) areas. The surgical technique consisted of circumferential ablation, followed by Foley catheter placement (mean, 10 days). Follow-up on 29 of 31 patients ranged from one to sixteen months (mean 9.7). Complete success occurred in 17 patients (59%) who had no further symptoms or instrumentation. Partial success was seen in 6 patients (20.5%) with symptom, but not stricture, recurrence. Six patients (20.5%) failed therapy, requiring additional surgery or regular dilations. No complications were seen. Although longer assessment is required, KTP-532 laser ablation of urethral strictures appears efficacious.

Treatment of urinary complications after total joint replacement in elderly females.

Urinary retention and the possible consequence of infection after total joint replacement is an important subject to urologists and orthopedic surgeons. A prospective, randomized study was performed in 77 elderly female patients with total joint replacement to test whether twenty-four-hour catheterization perioperatively or straight catheterization postoperatively in the recovery room might reduce the control group's incidence of postoperative urinary tract infection (9%), urinary retention (57%), and subsequent urinary catheterizations. In 16 percent of the patients who had straight catheterization in the recovery room a urinary tract infection developed postoperatively, and 65 percent of these patients required at least one more catheterization with 13 percent requiring a subsequent indwelling Foley catheter. The patients who had perioperative (immediately preoperatively and for 24 hours postoperatively) catheter drainage had a zero incidence of retention and only a 4 percent incidence of urinary tract infection. We recommend this regimen for elderly female patients undergoing total joint replacement under spinal anesthesia.

Magnified penile surface scanning in diagnosis of penile condyloma.

To determine the incidence of penile condyloma in a group of high risk males, we have performed magnified penile surface scanning and biopsy of suspicious lesions in 51 men. All men were partners of women with proven condyloma. Of these men, 45 were found to have histologic evidence of condyloma, only 8 of which were grossly visible.

Renal preservation utilizing neodymium:YAG laser.

Six patients with malignancies in a solitary kidney were treated with conservative renal parenchymal-sparing surgery utilizing the Neodymium Yttrium Aluminum Garnet (Nd:YAG) laser. Three patients had transitional cell carcinoma in an upper pole calyx of a solitary kidney. The transitional cell carcinoma was treated definitively by the Nd:YAG laser through a nephroscope prior to partial nephrectomy. The 3 patients have been followed up for twenty-eight, eighteen, and six months, respectively. None of the patients has shown evidence of recurrent cancer on follow-up retrograde ureterograms or on urine cytology obtained from the renal pelves. Three patients with renal cell carcinoma in a solitary kidney had the tumor surgically excised utilizing the Nd:YAG laser in conjunction with standard surgical techniques. All the patients were elderly with compromised renal vasculature that prevented bench surgery with autotransplantation or occlusion of the renal artery. At sixteen, fourteen, and three months, respectively, there is no evidence of recurrent cancer on CAT scans obtained on these patients.

Human papillomavirus associated with bladder cancer.

Recently published data have suggested a link between active human papillomavirus (HPV) infection and the development of bladder cancer. This study was undertaken to test for HPV genomic material in the tumors of patients without evidence of ongoing viral infection. Twenty-three consecutive patients with clinical evidence of intravesical neoplasia and no history of HPV infection or clinical evidence of intercurrent disease, underwent cystopanendoscopy and biopsy as part of the routine evaluation and treatment of their tumor. Routine pathologic evaluation and southern blot analysis of biopsy material were done to establish the presence or absence of HPV DNA in the bladder tumors. Twenty-one tumors were identified by routine histology: 20 were low-to-moderate grade transitional cell carcinomas; 1 was found to be squamous cell carcinoma; 1 patient had moderate dysplasia; and 1 patient had evidence of inflammation. Four of the 20 transitional cell tumors (20%) were found to contain HPV DNA. In addition, the patients with dysplasia and cystitis were also shown to have HPV genomic material in their biopsy specimens. Viral types 6/11, 16/18, and 31/33 were found. The 20 percent incidence of HPV genomic material in bladder tumors from patients without clinical evidence of viral infection is in keeping with the observations of other investigators. We present the implication of these findings within the context of our current understanding of viral oncogenesis in the urinary bladder.

Urologic tumors presenting as neurosurgical masses.

Metastases from urologic neoplasms often occur to the central nervous system or surrounding bony structures. Usually these metastases are discovered after the primary tumor has been identified. However, these tumors may present primarily with only manifestations of their central nervous system metastases. Five cases of different urologic tumors presenting as neurosurgical masses are presented, along with a brief review of the pertinent literature.

Management of simple ureterolithotomy closure.

Two methods of ureterotomy closure, loose adventitial closure and an unsutured incision, were evaluated and compared in 89 cases of simple ureterolithotomy. The loose adventitial closure was associated with a significantly shorter period of postoperative urinary drainage and a lower incidence of ureteral narrowing found at follow-up urographic examination.