Risk stratification for long-term outcome after elective coronary angioplasty: a multivariate analysis of 5,000 patients.

OBJECTIVES: We attempted to develop a statistical model to facilitate risk stratification for long-term outcome after elective coronary angioplasty. BACKGROUND: Our understanding of factors related to long-term outcome after coronary angioplasty is limited. Adequate assessment of risk indexes could potentially lead to more appropriate use of percutaneous revascularization. METHODS: We studied 5,000 consecutive patients and assessed 19 clinical and anatomic variables as predictors of long-term event-free survival. Events were defined as death of any cause, myocardial infarction, bypass surgery or repeat percutaneous transluminal coronary angioplasty. Cox proportional hazards models were used to develop an equation for predicting event-free survival in a subset of 4,000 patients. The equation was validated with the remaining 1,000 patients. Variables that were significantly associated with an adverse outcome in the multivariate model included age > 60 years, extent of disease, Canadian Cardiovascular Society functional class, previous coronary angioplasty, male gender, history of diabetes mellitus, history of hypertension and history of congestive heart failure. RESULTS: The statistical model was used to develop a simplified scoring system, and the patients were assigned to three risk subgroups. Event-free survival curves for the three groups were significantly different (p = 0.0001). High risk patients had worse outcomes for each of the end points compared with low and moderate risk patients (p < 0.02). CONCLUSIONS: We demonstrated that clinical and anatomic variables can be used to risk-stratify long-term outcome after angioplasty, that a simplified scoring system can be used for risk stratification and that high risk patients have a low event-free survival.

Splenectomy in advanced chronic lymphocytic leukemia.

Between February 1972 and February 1989, splenectomies were performed in 30 patients with chronic lymphocytic leukemia (CLL) and three with prolymphocytic leukemia (PLL) at our institution. Indications for splenectomy included anemia and/or thrombocytopenia (hypersplenism) in 31 patients and symptomatic splenomegaly in two patients. Median time from the diagnosis of CLL to splenectomy was 25 months. Twenty (87%) of the 23 patients splenectomized for thrombocytopenia with or without anemia had platelet increments of greater than or equal to 50 x 10(9)/liter. Hemoglobin increments of greater than or equal to 3 gm/dl were noted in 12 (71%) of 17 patients splenectomized for anemia with or without thrombocytopenia. The median duration of platelet response was 18 months for 19 evaluable patients, and the median duration of hemoglobin response was 62 months for 10 evaluable patients. Median survival time from splenectomy was 36 months. Median survival from diagnosis was 103 months for 10 patients with stage III or IV disease at diagnosis and 79 months for 10 patients with stage II. A prospective study of the effect of splenectomy in a larger number of patients with advanced CLL should be considered.

Vocational adjustment and general well-being of young adults with IDDM.

The vocational experiences and general well-being of 58 young adult subjects (mean age 24.3 yr) with insulin-dependent diabetes mellitus (IDDM) diagnosed during their adolescence were compared with that of 55 healthy matched control subjects with linear logistic discriminant function analyses. Assessment measures included the Rand General Well-Being Scale and the Rand Functional Limitations and Physical Abilities Batteries. Diabetic subjects, on average, reported significantly lower general well-being than control subjects, particularly in terms of health-related fears and feelings of depression. However, diabetic subjects did not report a pervasive functional deficit relative to control subjects and experienced similar employment rates and problems in the workplace. These results suggest that this group of young adult diabetic subjects has adjusted well to the demands of the workplace despite lower reports of general well-being. The results are discussed in light of relevant sampling issues.

Symptoms associated with infant teething: a prospective study.

CONTEXT: Studies of infant teething have been retrospective, small, or conducted on institutionalized infants. OBJECTIVES: To conduct a large, prospective study of healthy infants to determine which symptoms may be attributed to teething and to attempt to predict tooth emergence from an infant's symptoms. DESIGN: Prospective cohort. Setting. Clinic-based pediatric group practice. PATIENTS: One hundred twenty-five consecutive well children of consenting Cleveland Clinic employees. OUTCOME MEASURES: Parents daily recorded 2 tympanic temperatures, presence or absence of 18 symptoms, and all tooth eruptions in their infants, from the 4-month well-child visit until the child turned 1 year old. RESULTS: Daily symptom data were available for 19 422 child-days and 475 tooth eruptions. Symptoms were only significantly more frequent in the 4 days before a tooth emergence, the day of the emergence, and 3 days after it, so this 8-day window was defined as the teething period. Increased biting, drooling, gum-rubbing, sucking, irritability, wakefulness, ear-rubbing, facial rash, decreased appetite for solid foods, and mild temperature elevation were all statistically associated with teething. Congestion, sleep disturbance, stool looseness, increased stool number, decreased appetite for liquids, cough, rashes other than facial rashes, fever over 102 degrees F, and vomiting were not significantly associated with tooth emergence. Although many symptoms were associated with teething, no symptom occurred in >35% of teething infants, and no symptom occurred >20% more often in teething than in nonteething infants. No teething child had a fever of 104 degrees F and none had a life-threatening illness. CONCLUSIONS: Many mild symptoms previously thought to be associated with teething were found in this study to be temporally associated with teething. However, no symptom cluster could reliably predict the imminent emergence of a tooth. Before caregivers attribute any infants' signs or symptoms of a potentially serious illness to teething, other possible causes must be ruled out.teething, tooth eruption, teeth, deciduous dentition.

Gender differences for coronary angioplasty.

To determine if differences in early and late outcome after angioplasty were related to gender or body surface area, 5,000 consecutive patients (1,274 women and 3,726 men) were studied. Baseline variables, procedural outcome, and long-term and event-free survival were assessed. Baseline variables included age, history of hypertension, diabetes mellitus, heart failure, myocardial infarction, prior angioplasty or bypass surgery, familial coronary disease, Canadian heart classification, extent of angioplasty, left ventricular function, and body surface area. Overall and event-free survival (freedom from infarction, repeat angioplasty, bypass surgery and death) were assessed at follow-up. The results showed that, compared with men, women were older (p < 0.0001), had a higher prevalence of diabetes (p < 0.0001), familial coronary disease (p = 0.002), hypertension (p < 0.0001), prior infarction (p = 0.004), and more involvement of the anterior descending artery (p = 0.017). Whereas men had similar extents of angioplasty and worse left ventricular function (p = 0.012), women more often had unstable angina (p < 0.0001). The success rates were similar, yet women had a higher procedural mortality (1.1% women, 0.3% men, p = 0.001). When corrected for body surface area, however, women were at no greater risk than men. Follow-up was complete for 97.4% of patients (mean 4 +/- 2 years). Event-free survival was significantly better in women, even after correcting for body surface area. Men were at higher risk for late death and repeat angioplasty on follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Early and late results of coronary angioplasty and bypass in octogenarians.

Early and late results were evaluated for octogenarians undergoing first time revascularization with percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG). The study group consisted of 142 patients with CABG and 53 with PTCA. The groups with PTCA and CABG differed with respect to number of patients with angina class III to IV (92 and 67%, respectively; p less than 0.001), number with 3-vessel disease (34 and 77%, respectively; p less than 0.001), presence of left main trunk disease (2 and 24%, respectively; p less than 0.001) and number with normal or mildly impaired left ventricular function (82 and 65%, respectively; p less than 0.034). The groups with PTCA and CABG had similar procedural complications, including myocardial infarction (6 and 4%, respectively) and stroke (0 and 4%, respectively). Hospital mortality was low (6% with CABG and 2% with PTCA). Three year survival, excluding hospital mortality, was 87% in patients with CABG and 81% in those with PTCA (p = 0.493). Octogenarians underwent revascularization procedures with relatively low morbidity and mortality. In regard to the excellent long-term survival, "very" elderly patients with severe coronary artery disease should be considered for revascularization despite advanced age.

Anergic response to delayed hypersensitivity skin testing. A predictor of early mortality in heart transplant recipients.

STUDY OBJECTIVE: We set out to determine if there is a significant difference in the morbidity and mortality between the anergic and reactive groups. DESIGN: A retrospective study of the heart transplant population was performed. SETTING: We studied the results of delayed hypersensitivity skin tests (DHSTs) in all cardiac transplant recipients at the Cleveland Clinic between May 1985 and November 1991 to determine whether DHST results were of prognostic significance. RESULTS: Preoperative skin testing was reactive to two or more antigens in 90 of the 127 patients whose DHSTs were interpretable, and the remainder were anergic. Anergic response was associated with increased bilirubin and decreased albumin levels, but gender, race, primary underlying heart disease, age at transplantation, creatinine level, hematocrit, glucose level, and ejection fraction were not related to anergy. Anergic patients had significantly higher mortality at 30, 60, and 90 days after transplantation, but long-term mortality was not significantly different from patients reactive on DHSTs (p = 0.267). CONCLUSION: We conclude that the DHSTs provide useful information regarding risk of early mortality after heart transplantation.

Atheroembolism from the ascending aorta. An emerging problem in cardiac surgery.

As the ages of patients undergoing cardiac operations have increased, noncardiac causes of death have increased. To identify these causes of death, we analyzed the autopsy findings in 221 patients undergoing myocardial revascularization or valve operations between 1982 and 1989. Mean age was 65.6 +/- 9.5 years and the range was from 32 to 94 years; 130 patients (58.8%) were male. Autopsies were complete in 129 patients (58.4%) and limited to the chest and abdomen in the remainder. Embolic disease was identified in 69 patients (31.2%). Atheroemboli or abnormalities consistent with atheroemboli were identified in 48 patients (21.7%). Fourteen patients had thromboembolism and 7 had disseminated intravascular coagulation. The prevalence of atheroembolic disease increased dramatically from 4.5% in 1982 to 48.3% in 1989 (p = 0.001). Atheroembolic disease was found in the brain in 16.3% of patients, spleen in 10.9%, kidney in 10.4%, and pancreas in 6.8%. Thirty (62.5%) of the 48 patients had multiple atheroembolic sites. Atheroemboli were more common in patients undergoing coronary artery procedures (43/165; 26.1%) than in those undergoing valve procedures (5/56; 8.9%) (p = 0.008). There was a high correlation of atheroemboli with severe atherosclerosis of the ascending aorta. Atheroembolic events occurred in 46 of 123 patients (37.4%) with severe disease of the ascending aorta but in only 2 of 98 patients (2%) without significant ascending aortic disease (p less than 0.0001). Forty-six of 48 patients (95.8%) who had evidence of atheroemboli had severe atherosclerosis of the ascending aorta. There was a direct correlation between age, severe atherosclerosis of the ascending aorta, and atheroemboli. Incremental risk factors for atheroembolic are peripheral vascular disease and severe atherosclerosis of the ascending aorta.

The Carpentier-Edwards pericardial aortic valve. Ten-year results.

To evaluate the function of the Carpentier-Edwards pericardial valve in the aortic position, we analyzed the results of 310 aortic valve replacements performed between 1982 and 1985. Mean age was 64.2 +/- 10.8 years (range 22 to 95 years); 190 patients (61.3%) were male patients. There were 18 hospital deaths (5.8%), and none were valve related. Follow-up of the 292 survivors was 100% complete at a mean of 7.8 +/- 2.9 years; 2290 patient-years of follow-up were available for analysis. There were 133 late deaths (45.5%). Actuarial survivals at 5 and 10 years were 82.5% and 45.9%, respectively. The 10-year actuarial freedom from events was 88.7% +/- 2.1% for thromboembolism, 90.9% +/- 1.8% for hemorrhage, 94.3% +/- 1.6% for endocarditis, and 91.2% +/- 2.6% for structural deterioration. The 153 hospital survivors 65 years of age or older had an extremely low incidence of structural valve deterioration, with only four explants and 95.5% actuarial freedom from explantation at 10 years, and a linearized rate of 0.3 +/- 0.2 per patient-year compared with 88.6% and 0.7 +/- 0.2 for patients younger than 65 years of age. Twelve valves were explanted for structural deterioration. Of these, 11 (93%) had leaflet calcification causing stenosis and one had a wear-related leaflet tear. The Carpentier-Edwards pericardial valve has a low incidence of valve-related complications. The freedom from structural valve deterioration is low at 10 years, particularly in patients 65 years of age and older.

Determinants of clean surgical wound infections for breast procedures at an oncology center.

OBJECTIVE: To determine the clean surgical wound infection rate for breast procedures and the risk factors predisposing patients to these infections. DESIGN: A survey study. SETTING: Oncology center. PATIENTS: A consecutive sample of adult female patients who underwent surgical breast procedures for suspected carcinoma of the breast. Patients undergoing excisional biopsy, lumpectomy, or mastectomy from January 1985 to January 1987 were included in the study. INTERVENTION: Clean surgical wound infection rates were derived overall and for each procedure type. The medical records of all patients were then reviewed to extract data on patient characteristics and operative information in order to assess the risk factors for infection. RESULTS: Among the breast procedures performed on 448 patients, the overall clean surgical wound infection rate was 8.7% (39/448). The clean surgical wound infection rate for each procedure type was as follows: biopsy 2.3%, lumpectomy 6.6%, and mastectomy 19%. In addition to the type of procedure, factors significantly (p less than .05) associated with the development of clean surgical wound infection in the univariate analysis included: presence of surgical drains (p less than .01); closed suction drainage (odds ratio [OR] = 16.5, 95% confidence interval [CI95] = 5.0-54.7); location of the drain (OR = 3.3, CI95 = 1.7-6.6); prolonged preoperative stay (OR = 1.2, CI95 = 1.0-1.5); length of surgery (OR = 2.2, CI95 = 1.7-3.0); and greater mean age (OR = 1.6, CI95 = 1.2-2.1). CONCLUSION: Clean surgical wound infections are not uncommon in patients undergoing breast procedures. Factors relating to both the patient and operative techniques contribute to the clean surgical wound infection rate. Further consideration should be given to perioperative antibiotic prophylaxis for selected breast procedures, and the role of surgical drains should be reassessed.

Clinical presentation of enterocele.

OBJECTIVE: To characterize preoperative signs and symptoms in women with and without enteroceles. METHODS: Three hundred ten women completed preoperative questionnaires and had prolapses graded according to the International Continence Society system. Signs and symptoms in 77 women (25%) with enteroceles confirmed at surgery were compared with those in 233 women without enteroceles. Comparisons were tested for statistical significance with chi(2) tests, Fisher exact tests, Wilcoxon rank-sum tests, and analysis of covariance. RESULTS: Women with enteroceles were statistically significantly older (median 67 versus 59 years, P <.001) and more likely to be postmenopausal (88% versus 76%, P =.04). More women with enteroceles had histories of hysterectomies (76% versus 39%, P =.001) and vaginal prolapse repairs (24% versus 11%, P =.008). Women with enteroceles had more advanced prolapses at points Ap, Bp, and C (all P <.001) but not point D. There were no significant differences in symptoms related to bowel function (infrequent bowel movements, straining, manual evacuation, and fecal incontinence) in women with and without enteroceles. Women with enteroceles were more bothered by symptoms caused by vaginal prolapse than women without enteroceles, but not after we controlled for stage of prolapse. CONCLUSION: Women with enteroceles have more advanced apical and posterior vaginal prolapses than women without enteroceles, but do not differ from them in bowel function.

Risk factors for endometrial hyperplasia and cancer among women with abnormal bleeding.

OBJECTIVE: To identify independent risk factors for endometrial neoplasia in women with abnormal perimenopausal or postmenopausal bleeding and to use those factors to develop and test a predictive model. METHODS: We conducted a case-control study of women with abnormal perimenopausal or postmenopausal bleeding who had endometrial samplings; cases had endometrial cancer or complex hyperplasia and controls had benign endometrial histologies. Multivariate logistic regression models identified factors associated with risks of endometrial neoplasia. The predictive abilities of our models and a published model were assessed using the area under receiver operating characteristic (ROC) curves, for which an area of 1.0 indicated perfect positive predictive ability and an area of 0.5 was expected by chance. RESULTS: There were 57 cases of endometrial hyperplasia or cancer and 137 controls. Parity was related inversely (odds ratio [OR] 0.70; 95% confidence interval [CI] 0.56, 0.88; P = .002) and weight directly (OR 1.02 per kg; 95% CI 1.01, 1.04; P = .018) to the risk of endometrial neoplasia. Age (OR 1.04 per year; 95% CI 1.00, 1.08; P = .06) and diabetes (OR 3.50; 95% CI 0.99, 12.33; P = .052) were significant marginally. The area under the ROC curve for our model was 0.75, indicating moderate predictive ability; the area under the ROC curve for the published model was lower at 0.66. CONCLUSION: Current clinical predictive models based on case-control studies do not have sufficient predictive ability to determine if women with abnormal perimenopausal or postmenopausal bleeding should have diagnostic testing.

Functional and anatomic follow-up of enterocele repairs.

OBJECTIVE: To identify the functional and anatomic outcomes in women who have surgery for pelvic organ prolapse with enterocele repair. METHODS: Fifty-four women had surgery for pelvic organ prolapse which included enterocele repair. Preoperative and postoperative examinations were done by a research nurse, including a pelvic examination using the International Continence Society staging system and standardized questionnaires about bowel function, sexual function, and prolapse symptoms. RESULTS: Fifty-four women had enterocele repairs as part of their surgery. Mean follow-up time was 16 months (range 6-29 months). Postoperatively five women were excluded from the analysis because of fluctuation in stage of prolapse over time. At the apex and posterior wall of the vagina, 33 women had stage 0 or I prolapse, and 16 had stage II prolapse. None had stage III or IV prolapse. Fifty-three percent of women had improvement in bowel function and 91% had improvement in vaginal prolapse symptoms. Functional outcomes were not significantly different in women with and without stage II prolapse at follow-up. CONCLUSION: Most women who had surgery for pelvic organ prolapse with enterocele repair reported improvement in vaginal prolapse symptoms. Functional outcomes did not differ significantly between women with stage 0 and I prolapse and women with stage II prolapse at the vaginal apex and posterior vaginal wall. This was an observational study and the lack of statistically significant findings could result from inadequate sample size; however, the observed differences were judged to be not clinically significant.

Determinants of voiding after three types of incontinence surgery: a multivariable analysis.

OBJECTIVE: To determine the time to normal voiding in women after various surgical procedures for genuine stress urinary incontinence (GSUI) or urethral hypermobility. METHODS: One hundred one women had bladder neck suspensions. Suprapubic catheters were used in 94 women and intermittent self-catheterization in seven to manage urinary retention after surgery. We used a standardized protocol to record days to adequate postoperative voiding. Univariable and multivariable regression analyses were used to determine clinical, urodynamic, and surgical factors that independently influenced time to adequate postoperative voiding. RESULTS: Women met the criteria for adequate voiding a mean of 7.1 days after modified open Burch procedures (n = 43), 9.5 days after anterior colporrhaphies with suburethral plication (n = 24), and 19.1 days after vaginal wall sling procedures (n = 34). The type of bladder neck suspension was independently associated with increasing time to void (P =.001). Multivariable regression analysis determined other factors significantly associated with longer time to adequate postoperative voiding: advancing age, previous vaginal bladder neck suspension, increasing volume at first sensation on bladder filling, higher postvoid residual urine volume (preoperative), and postoperative cystitis. Detrusor pressure, abdominal straining on pressure flow voiding study, and other concurrent surgeries were not significantly associated with postoperative voiding time in this model. CONCLUSIONS: Time to adequate voiding after bladder neck suspension was influenced by type of surgical procedure, postoperative cystitis, and several demographic and urodynamic factors. This study does not support using pressure flow studies to predict women at risk of voiding dysfunction.

Prevalence of hydronephrosis in patients undergoing surgery for pelvic organ prolapse.

OBJECTIVE: To determine the prevalence of hydronephrosis in patients undergoing surgery for pelvic organ prolapse and to determine whether hydronephrosis is associated with the type and severity of prolapse. METHODS: The charts of 375 consecutive patients undergoing surgery for pelvic organ prolapse at the Cleveland Clinic Foundation between January 1, 1990, and December 31, 1993 were reviewed. Preoperative renal ultrasounds and intravenous pyelograms (IVP) were evaluated for hydronephrosis based on the final diagnosis established by the radiologists. The severity of prolapse was determined from the preoperative office examination or from the examination under anesthesia at the time of surgery. RESULTS: Of 375 patients, 323 had either a preoperative renal ultrasound or IVP. The mean age was 66.0 +/- 10.2 years (range 35-93) and median parity was 3.0 (range 0-10). Of the 323 patients, 25 (7.7%, 95% confidence interval 5, 11) had hydronephrosis. Thirteen patients (4.0%) had mild hydronephrosis, nine (2.8%) had moderate hydronephrosis, and three (0.9%) had severe hydronephrosis. The prevalence of hydronephrosis increased with increasing severity of prolapse. Two patients with hydronephrosis had evidence of renal insufficiency (creatinine > or = 1.6), and both had severe bilateral hydronephrosis and complete procidentia. The prevalence of hydronephrosis was lower in patients with vaginal vault prolapse versus uterine prolapse (3.9% compared with 12.6%, P < .01), CONCLUSION: The prevalence of hydronephrosis in patients undergoing surgery primarily for pelvic organ prolapse is low, increases with worsening pelvic organ prolapse, and is lower in patients with vaginal vault prolapse that in those with uterine prolapse.

Abdominal pain in neutropenic patients.

The records of 50 patients with abdominal pain and severe neutropenia were retrospectively reviewed to identify factors that may have influenced survival and surgical decisions. Ninety-two percent of these patients had hematologic malignant neoplasms. The patients were divided into four groups: 23 treated nonsurgically who died in the hospital, 10 treated nonsurgically who survived, 10 treated surgically who survived, and 7 treated surgically who died. Abdominal distention was the only symptom or sign found to be associated with mortality. Ninety-five percent of survivors recovered their white blood cell count above 1.0 x 10(9)/L, while 70% of nonsurvivors did not. No symptom or sign was found to be pivotal in the decision for or against surgical intervention. Overall, 60% of the patients in this series died. Thirty-four percent of patients underwent a surgical procedure, the majority of whom survived. We designed an algorithm for the evaluation and treatment of neutropenic patients with abdominal pain.

Effects of single dose, postinduction dexamethasone on recovery after cardiac surgery.

BACKGROUND: Corticosteroids have been recommended to facilitate rapid recovery after cardiac surgery. We previously reported that dexamethasone given after induction of anesthesia decreases the incidence of postoperative shivering. We performed a post hoc analysis of the data obtained during that study, focusing on secondary outcomes. METHODS: A total of 235 adult patients undergoing elective coronary or valvular heart surgery were randomized to receive dexamethasone 0.6 mg/kg or placebo after induction of anesthesia. Patients who had pharmacologically treated diabetes mellitus, had hypersensitivity to dexamethasone, or were receiving treatment with corticosteroids were excluded. RESULTS: We found that, compared with placebo, patients receiving dexamethasone were more likely to remain tracheally intubated for 6 hours or less (26.4% vs 10.0%, p = 0.020) and had a lower incidence of early postoperative fever (20.2% vs 36.8%, p = 0.009) and new-onset atrial fibrillation during the first 3 days postoperatively (18.9% vs 32.3%, p = 0.027). However, we could not demonstrate a statistical difference in the intensive care unit or hospital length of stay, or in overall morbidity and mortality. The dexamethasone-treated patients were also more likely to have a higher blood glucose on admission to the intensive care unit (186 mg/dL vs 143 mg/dL, p = 0.012). CONCLUSIONS: Dexamethasone facilitates early tracheal extubation and is associated with a lower incidence of early postoperative fever and new-onset atrial fibrillation. Apart from a treatable decreased glucose tolerance, dexamethasone treatment was not shown to affect morbidity or mortality significantly.

Cryptorchidism in newborns with gastroschisis and omphalocele.

A retrospective study was undertaken to determine if there exists an association between cryptorchidism and the intra-abdominal wall defects of gastroschisis and omphalocele. The records of 25 newborn male infants (13 with omphalocele, 12 with gastroschisis) were examined. In this sample there was no statistically significant association between these defects and cryptorchidism in either the premature or the full-term infants, when compared with a healthy population. Further clinical studies with larger numbers of patients are recommended.

Enuresis and the voiding cystourethrogram: a re-evaluation.

Eighty-three children with a chief complaint of nocturnal enuresis and no history of urinary tract infection (UTI) were prospectively evaluated with a contrast voiding cystourethrogram (VCUG). The following four historical details of presentation were noted: primary vs. secondary enuresis, daytime wetting, urgency, and frequency. Each of these four symptoms were treated as a dichotomous variable, and the prognostic value with respect to vesicoureteral (VUR) reflux was assessed using a linear logistic regression model. Nineteen ureters in 13 patients (16%) demonstrated VUR: grade I, 7 ureters; grade II, 5 ureters; grade III, 3 ureters; grade IV, 4 ureters; and grade V, 0 ureters. Three patients demonstrated renal scarring (16%) and 2 patients underwent surgery. The linear regression analysis revealed that no one symptom, group of symptoms, or absence of all four symptoms segregated those patients likely to have reflux with statistical validity. One of 6 children, therefore, who present with nocturnal enuresis and sterile urine will have reflux. Screening these children with a VCUG should be considered.

Open pelvic lymph node dissection for prostate cancer: a reassessment.

OBJECTIVES: To provide a risk-to-benefit analysis of open staging pelvic lymph node dissection (PLND) for prostate cancer. METHODS: The medical records of all patients presenting with prostate cancer from July 1989 to April 1994 were reviewed. A total of 245 patients with clinically localized disease were selected to undergo radical retropubic prostatectomy (RRP) preceded by open PLND. Univariate and multivariate analyses were performed to evaluate the predictive value of the preoperative serum prostate-specific antigen (PSA) concentration, clinical stage, and Gleason score with regard to final nodal status. The cost and morbidity associated with PLND in the setting of RRP was also defined. RESULTS: Overall, only 16 patients (6.5%) had lymph node metastases. Lymph node involvement correlated significantly with elevated serum PSA values (P = 0.0001), high Gleason score (P = 0.0022), and advanced clinical stage (P = 0.0001). Lymph node metastases were particularly uncommon in patients with nonpalpable tumors (1 of 67 [1.5%]), PSA values less than 10 (2 of 154 [1.3%]), and Gleason score less than 6 (1 of 26 [3.8%]). Overall, 179 patients (73.1%) presented with at least one or more of these favorable characteristics, and only 4 (2.2%) had lymph node involvement. Complications related to the lymphadenectomy occurred in 10 patients (4.1%). The cost per metastasis diagnosed in patients with low-risk characteristics was approximatley $43,600. CONCLUSIONS: An open staging PLND may no longer be justified on a routine basis in patients undergoing radical retropubic prostatectomy.