Long-term mechanical reliability of multicomponent inflatable penile prosthesis: comparison of device survival.

OBJECTIVES: To determine the mechanical reliability of multicomponent inflatable penile prosthesis, comparing five different types of devices, as well as the two-piece versus three-piece as a group. METHODS: We followed 83 patients with two-piece and 283 patients with three-piece inflatable penile prostheses for a mean time of 66 months. At a cutoff of 63 months, mechanical complication rates were reviewed and statistically analyzed. RESULTS: Thirty-one device-related complications occurred, and all were secondary to fluid leakage. The Mentor Alpha-1 prosthesis was significantly better than the Mentor Mark-II in terms of mechanical reliability (P = 0.01). A trend was noted toward the AMS 700 Ultrex inflatable penile prosthesis having fewer mechanical complications than the Mentor Mark-II (P = 0.06). In addition, a trend toward all three-piece prostheses being more mechanically reliable than the two-piece was noted (P = 0.08). The Mentor Alpha-1 device had a higher cumulative proportional survival (0.957) than all other devices (0.842 for AMS 700 Ultrex, 0.839 for AMS 700 CX, 0.783 for Mentor GFS, and 0.750 for Mentor Mark-II). CONCLUSIONS: As a group, a trend was noted toward the three-piece prosthesis having better mechanical reliability than the two-piece prosthesis. Comparisons between the individual types of prostheses showed thatthe Mentor Alpha-1 device was significantly more mechanically reliable than the Mentor Mark-II device, and a trend was noted toward the AMS 700 Ultrex device having fewer mechanical complications than the Mentor Mark-II. The Mentor Alpha-1 prosthesis had the highest cumulative proportional survival.

High flow malignant priapism with isolated metastasis to the corpora cavernosa.

Malignant priapism is a rare disease with only 88 reported cases. We present a case of a patient with priapism secondary to isolated metastasis to corpora cavernosa from bladder tumor. Metastasis to penis usually represents evidence of a more widespread disease in 80% to 90% of the patients. Rarely, as in this case, the metastasis is solitary.

Predictors for maximal outcome in patients undergoing salvage surgery for radio-recurrent prostate cancer.

OBJECTIVES: To determine preradiation and preoperative clinical staging and postoperative pathologic factors that can predict disease-free survival in patients undergoing salvage surgery for radio-recurrent prostate cancer. METHODS: A retrospective review was performed on 40 patients who underwent salvage surgery for radio-recurrent prostate cancer. Preradiation and preoperative clinical staging factors, as well as pathologic stage were analyzed as predictors of disease-free survival. Biochemical failure was defined as a persistent serum prostate-specific antigen (PSA) elevation greater than 0.4 ng/mL. RESULTS: As a group, salvage surgery provided excellent clinical disease control in 35 of 40 patients (87.5%). Overall, 18 of 38 (47.4%) patients analyzed had no evidence of biochemical progression. Preradiation clinical stage and pathologically organ-confined disease were statistically significant predictors of disease-free survival (P = 0.03 and P = 0.02, respectively). Seminal vesicle invasion and positive lymph nodes were the worst pathologic prognostic factors. Preoperative clinical T1c disease approached statistical significance in predicting pathologically organ-confined disease and disease-free survival (P = 0.08 and P = 0.07, respectively). CONCLUSIONS: Ideal candidates for salvage surgery should have preradiation and preoperative clinically organ-confined disease. All patients with pathologically organ-confined disease following salvage prostatectomy were disease free at a mean follow-up of 36.1 months. Salvage surgery, although technically feasible, should not be widely advocated as an effective curative treatment in patients with locally advanced disease at the time of diagnosis.

Treatment outcome after radical prostatectomy is not adversely affected by a pre-existing penile prosthesis.

OBJECTIVES: To report on the safety of radical retropubic prostatectomy (RRP) in patients with a penile prosthesis presenting with clinically localized prostate cancer. METHODS: From January 1990 to December 1997, 8 consecutive men with a penile prosthesis underwent RRP for clinically localized prostate cancer. Retrospective data regarding patient population, operating time, estimated blood loss, length of hospital stay, and clinical outcome were evaluated. RESULTS: Mean patient age was 65.4 years (range 57 to 70) at the time of RRP, with a mean preoperative serum prostate-specific antigen level of 11.5 ng/mL. Mean duration of RRP surgery was 183.9 minutes, and the mean estimated blood loss was 1281.8 mL. No complication requiring penile prosthesis removal occurred. In 1 case, the reservoir tubing was punctured during closure of the abdominal fascia wall. This was immediately recognized and fixed. All patients had a functioning penile prosthesis after RRP. CONCLUSIONS: RRP can be safely and expeditiously performed in patients with a pre-existing penile prosthesis. The risk of prosthesis malfunction after RRP is very low. Patients with a penile prosthesis and prostate cancer should not be denied the option of undergoing RRP.

Assessment of psychosexual adjustment after insertion of inflatable penile prosthesis.

OBJECTIVES: To evaluate the psychosexual benefit obtained from multicomponent penile implant surgery in patients with erectile dysfunction. METHODS: A psychosexual questionnaire was given to 35 patients undergoing penile prosthesis implantation before surgery and at 3 months, 6 months, and 1 year after surgery. The questionnaire consisted of 13 questions scored on a scale from 1 through 5. Results of the questionnaire were statistically analyzed for differences among the preoperative, 3-month postoperative, 6-month postoperative, and 1-year postoperative period. RESULTS: The general linear model evaluation showed a significant difference for each overall combination of the following pairs: preoperative versus 3 months postoperative (P=0.0005) and 3 months postoperative versus 6 months postoperative (P=0.002). There was no overall difference between psychosexual total score at 6 months after surgery and 1 year after prosthesis implantation (P=0.85). The patients perceived improvement in their erectile ability and libido. Concern about obtaining and maintaining an erection during intercourse was significantly alleviated. There was an increase in the frequency of sexual activity and an improvement in satisfaction with sex life. A decrease in feelings of sadness, depression, anxiety, anger, frustration, and embarrassment related to sexual activity was also noted. CONCLUSIONS: The current study demonstrates significant improvement in the psychosexual well being of multicomponent penile implant recipients, with attainment of a high level of patient satisfaction up to 1 year after surgery.

Population-based study of pelvic lymph node positivity in clinically localized prostate cancer: a study comparing African Americans and whites.

OBJECTIVES: To evaluate the correlation between race and lymph node metastasis for prostate cancer by analyzing which preoperative parameters may predict lymph node status in both races. METHODS: We analyzed a group of patients (552 American white men [AWM] and 423 African-American men [AAM]) who underwent radical prostatectomy plus modified pelvic lymphadenectomy between January 1991 and June 1997. Patients who received neoadjuvant radiation or hormone therapy were excluded. Univariate and multivariate analyses were performed to determine the influence of race on lymph node positivity, as well as to correlate the preoperative parameters (serum prostate-specific antigen [PSA], biopsy Gleason score, and clinical stage) with lymph node metastasis for each race separately. RESULTS: The AAM presented with significantly higher preoperative Gleason scores and PSA levels than AWM. However, comparing lymph node status by race, the difference of positivity (41 AWM [7.4% and 22 AAM [5.2%]) was not statistically significant (P = 0.16). The percentage of positive nodes was similar in both races for each subset of PSA, Gleason score, and clinical stage. Despite the statistical significance of the three preoperative parameters in univariate analysis, in multivariate analysis only PSA and Gleason score were independent predictors of positive lymph nodes. CONCLUSIONS: There is no influence of race on lymph node metastasis, despite AAM presenting with higher preoperative Gleason scores and PSA levels. In multivariate analysis, preoperative Gleason score and PSA were independent factors for positive nodes regardless of race.

Lymph node size does not correlate with the presence of prostate cancer metastasis.

OBJECTIVES: To determine whether lymph node size is a surrogate marker for lymph node metastasis. METHODS: We reviewed 980 patients who underwent radical retropubic prostatectomy with bilateral pelvic lymph node dissection for clinically localized prostate cancer, of whom 63 had lymph node metastases. A comparable group of patients with prostate cancer undergoing radical prostatectomy who did not have lymph node involvement was identified using the following parameters: serum prostate-specific antigen level, clinical and pathologic stage, and pre- and postoperative Gleason score. The axial and longitudinal dimensions of the nodes from patients with and without metastases were analyzed to assess the significance of lymph node size in predicting the presence of metastases. All patients had negative preoperative computed tomography (CT) and bone scans. Of the 63 patients with lymph node metastases, 48 had tissue available for measuring the dimensions of the lymph nodes. RESULTS: A total of 76 metastatic and 92 negative lymph nodes were identified from the patients with and without metastatic nodes, respectively. The mean nodal longitudinal size was 1.65 cm (range 0.2 to 6.5) and 3.50 cm (range 0.5 to 9) for positive and negative nodes, respectively (P = 0.0001). The mean axial nodal size was 0.8 cm (range 0.2 to 3.2) and 1.0 cm (range 0.2 to 2.2) for positive and negative lymph nodes, respectively. In 56 metastatic nodes (74%), the axial size was less than 1 cm and in 20 (26%) less than 5 mm. CONCLUSIONS: Lymph node size should not be used as a surrogate for the presence of lymph node metastases. Although no patient had enlarged lymph nodes by CT scan criteria (greater than 1.5 cm), 6 (8%) of 48 and 19 (12%) of 48 patients with and without lymph node metastases, respectively, had nodes with an axial dimension greater than 1.5 cm.

Should Gleason score 7 prostate cancer be considered a unique grade category?

OBJECTIVES: To evaluate pathologic characteristics and biochemical survival rate differences between patients with Gleason score 6 or less, 7, and 8 or more prostate cancer. METHODS: A total of 652 patients who underwent a radical prostatectomy for clinically localized prostate cancer between March 1991 and December 1995 were selected for this study. Patients who underwent neoadjuvant or adjuvant hormonal therapy or radiotherapy were excluded. Clinical and pathologic data were obtained from our prostate cancer data base. Serum prostate-specific antigen (PSA) level, pathologic stage, and disease-free survival (DFS) were analyzed between the three Gleason score groups. RESULTS: The overall mean pretreatment serum PSA level was 12.9 ng/mL, being 8.4, 13.4, and 23 ng/mL for Gleason score 6 or less, 7, and 8 or more prostate cancers, respectively (P = 0.0001). Of patients with specimen Gleason score 6 or less, 7, and 8 or more, pathologic organ-confined disease was present in 69.4%, 43.1 %, and 9.2%, respectively (P = 0.001). Extraprostatic extension was present in 30.6%, 56.9%, and 90.8% (P = 0.0001); positive surgical margins, considered independently from the other pathologic findings, were present in 31 %, 47.6%, and 67.8% of patients with Gleason score 6 or less, 7, and 8 or more, respectively (P = 0.0001). DFS was 34.5% for patients with Gleason score 8 or more, 75% for Gleason score 7, and 91.2% for Gleason score 6 or less prostate cancers, at a median follow-up of 34.2 months (P = 0.0001). On multivariable analysis, after adjusting for serum PSA level (10 or less or more than 10 ng/mL) and pathologic stage, Gleason score (6 or less, 7, 8 or more) remained a statistically significant predictor of DFS (P = 0.0001). CONCLUSIONS: Patients with Gleason score 7 prostate cancer should be considered a specific prognostic category. We believe that this distinction is critical to obtain more reliable results from prostate cancer analyses about prognosis of patients treated with curative intent.

Management of primary urethral cancer.

OBJECTIVES: To determine the best therapeutic approach for treatment of patients with urethral cancer according to tumor location and clinical-pathologic stage. METHODS: A retrospective review of 21 consecutive patients diagnosed with primary urethral carcinoma was performed. Clinical-pathologic staging, treatment modality, and outcome were analyzed. RESULTS: The overall survival rate was 62%. In patients with clinical Stage Ta-2N0M0 tumors, 8 of 9 patients (89%) are free of disease compared to 5 of 12 patients (42%) with Stage T3-4N0-2M0 tumors (P = 0.03). Best treatment outcome for patients with Stage T3 disease or higher was obtained when multimodality therapy (neoadjuvant chemotherapy and radiation therapy with or without surgery) was administered, with a disease-free survival rate of 60%. CONCLUSIONS: Clinical-pathologic stage was a strong predictor of disease-free survival rate. For patients with Ta-2N0M0 tumors, multimodality therapy may not be required. Conversely, best treatment outcomes in patients with T3-4N0-2M0 tumors are obtained by administering a multimodal therapy combining chemotherapy and radiation therapy with surgical resection.

Primary adenocarcinoma of the urethra with metastasis to the glans penis: successful treatment with chemotherapy and radiation therapy.

Primary carcinoma of the male urethra accounts for less than 1% of malignancies in males. A 54-year-old man with primary adenocarcinoma of the urethra with metastasis to the glans penis and lymphadenopathy in the right groin was treated successfully by combined chemotherapy (5-fluorouracil and cis-platinum) and external beam radiotherapy (total dose of 75 Gy). Short-term remission using multimodal approach with penile preservation was achieved in the present case.

Salvage surgery or salvage radiotherapy for locally recurrent prostate cancer.

OBJECTIVES: To evaluate the efficacy and toxicity of salvage radiation or surgery for locally recurrent tumor after initial treatment for clinically localized prostate cancer. METHODS: The treatment records of 70 patients with local treatment failure after definitive therapy for clinically localized prostate cancer were reviewed. Initial treatment consisted of external beam radiation therapy (RT) in 27 patients and radical retropubic prostatectomy (RP) in 43 patients. RESULTS: The mean serum PSA levels were similar in both groups before initial treatment: 8.5 and 10.5 ng/mL for the salvage RP and salvage RT groups, respectively (P = 0.09). However, at the time of salvage treatment, the mean serum PSA levels were 9.1 and 1.1 ng/mL for the salvage RP and salvage RT groups, respectively (P = 0.0001). The mean time from tumor recurrence to salvage treatment was 15.6 months for the salvage RP group and 4.9 months for the salvage RT group (P = 0.0001 ). Although there was no statistical difference in the disease-free survival rate (P = 0.38), a trend for better disease control in the salvage RT group was evident (74.4% versus 44.4%). Patients treated with salvage RP had a higher rate of urinary incontinence than those undergoing salvage RT: 63% and 32.6%, respectively (P = 0.01). CONCLUSIONS: The disease-free survival rate was similar between patients receiving salvage RP or RT, despite the significantly higher serum PSA levels at the time of treatment and the delay in time to treatment for the salvage RP patients. Salvage RP is associated with a high rate of urinary incontinence. Earlier identification of tumor recurrence after RT may improve the efficacy and safety of salvage RP.

Urinary diversion-related outcome in patients with pelvic recurrence after radical cystectomy for bladder cancer.

OBJECTIVES: To evaluate the impact of urinary diversion on disease status, complications, and subsequent treatment in patients with pelvic tumor recurrence after radical cystectomy for bladder cancer. METHODS: A retrospective review of 201 consecutive cases of radical cystectomy for bladder cancer, performed at our institution between March 1991 and March 1996, identified 33 patients (16.4%) with disease recurrence in the pelvis with or without systemic metastasis. Urinary diversion in patients with tumor recurrence was an ileal conduit, continent cutaneous diversion, or orthotopic neobladder in 19, 3, and 11 patients, respectively. The mean follow-up for all patients undergoing cystectomy was 25.9 months (range 8 to 75). The mean time to diagnosis of local disease recurrence after cystectomy was 13.9 months (range 5 to 50). RESULTS: In 21 (63.6%) of 33 patients, pelvic recurrence and systemic metastasis were present simultaneously. Disease recurrence was associated with poor outcome: only 8 patients (24.2%) were alive and disease free, 7 of whom had isolated local recurrence without evidence of systemic metastasis. There was no difference in overall survival or type of therapy delivered once disease recurrence was diagnosed between patients with an orthotopic neobladder and those with a cutaneous (continent or incontinent) urinary diversion. The only diversion-related complication resulting from pelvic recurrence was 1 case of tumor invasion into an orthotopic neobladder, requiring conversion to an ileal conduit. CONCLUSIONS: The type of urinary diversion did not impact a patient's risk of complications, the ability to receive salvage treatment, or overall survival once pelvic recurrence was diagnosed. Patients at high risk of pelvic recurrence should not be excluded from receiving an orthotopic urinary diversion.

Review article Salvage surgery for locally recurrent prostate cancer after radiation therapy.

Controversy exists regarding the optimal management of patients with an asymptomatic rising prostate specific antigen (PSA) level and locally recurrent adenocarcinoma of the prostate following definitive radiation therapy. Several treatment options may be offered in this clinical scenario, including salvage surgery, cryotherapy, watchful waiting, or androgen deprivation. Postradiation therapy patients whose residual disease is localized to the prostate may benefit from salvage surgery. Indeed, among all available options, only salvage surgery has been shown to result in long-term disease-free survival. However, treatment must be individualized according to clinical stage, serum PSA level before radiation and surgery, the medical condition of the patient, and expectations of the physician and patient. Herein, we review the available literature and our own experience with salvage surgery for radio-recurrent prostate cancer.

[Treatment of colo-vesical fistulas in one-stage operation]. / Le traitement des fistules colo-vésicales en un seul temps opératoire.

OBJECTIVES: To evaluate the results of one-stage surgical treatment of colo-vesical fistulas. MATERIAL AND METHODS: 24 patients (16 males and 8 females) were treated for colo-vesical fistula by this technique. Sigmoid diverticulosis represented the commonest aetiology. In our study, cystoscopy was the most useful modality for the diagnosis of fistula. RESULTS: No deaths and no recurrent fistulas were observed. However, one case of peritonitis secondary to dehiscence of the colo-colonic anastomosis in a patient suffering from Crohn's disease and two wall abscesses in diabetic patients were observed. CONCLUSION: The morbidity and mortality rates after one-stage treatment of colo-vesical fistulas were low. This method not only improves the patient's quality of life, but is also less expensive, by avoiding a second hospitalisation and can be proposed as first-line treatment.

Inguinal hernia as a rare cause of penile prosthesis malfunction . A report of two cases.

Penile prosthesis malfunction is associated with mechanical failure as well as with infection requiring removal of the prosthesis. We report on the 2 first cases in the literature of inflatable penile prostheses in the presence of inguinal hernia. We advocate early hernia repair in patients with inflatable penile prostheses to avoid malfunction related to hernia.

Case report: acute urinary retention secondary to Isaacs' syndrome.

We report an unusual case of acute urinary retention secondary to Isaacs' syndrome due to external urethral sphincter spasm. The patient was able to resume spontaneous voiding after the treatment of the underlying disease. At 6-month follow-up, there were no voiding complaints.

Angiographic arterial occlusion and extra-anatomical vascular bypass for the management of a ureteral-iliac fistula: case report and review of the literature.

Ureteroarterial fistulas related to nonvascular etiology are rare clinical entities that are difficult to diagnose and manage. Diagnosis is best made by a combination of studies, including digital subtraction angiography. Low morbidity and mortality rates have been described with either percutaneous thrombosis of the iliac artery and extra-anatomic bypass, or by placement of a stented graft in the involved artery. We report on a well-documented case of a ureteroarterial fistula managed successfully with interventional radiologic embolization of the common iliac artery and immediate femoral-femoral arterial bypass. A review of the literature supports this approach.

Urinary diversion following cystectomy in a patient with situs inversus totalis.

Situs inversus totalis is a rare syndrome. The association of malignancies with situs inversus totalis is rare, and only 9 cases were reported. The management of invasive bladder cancer in the presence of situs inversus totalis has not been reported previously, and herein we report the 1st case.

Lipid peroxidation and antioxidant activities in rat testis after chronic cocaine administration.

OBJECTIVES: Our recent study has shown that cocaine has adverse action on spermatogenesis and fertility in male rats. Adverse effects of cocaine on the testes may be mediated by oxidative damage and subsequent lipid peroxidation. Glutathione is a cellular antioxidant and is found in high concentrations in the rat testes. In this study, the effects of chronic cocaine administration on the activities of glutathione peroxidase, the level of testicular reduced glutathione, and lipid peroxidation were investigated. METHODS: Thirty-day-old male Sprague-Dawley rats were given cocaine hydrochloride (15 mg/kg body weight) subcutaneously daily for 90 days. Control animals received equal volumes of normal saline daily for 90 days. Testes were removed at 15, 30, 60, and 90 days after cocaine injection. Tissues were washed and homogenized in ice-cold metaphosphoric acid solution or Tris-HCI buffer. Reduced glutathione, glutathione peroxidase, and malonaldehyde levels were determined by colorimetric assay. Statistical analysis was performed using analysis of variance. RESULTS: Testicular reduced glutathione and glutathione peroxidase were significantly decreased in the treatment testes 15, 30, 60, and 90 days after chronic cocaine injection compared with controls (P <0.05). The testicular malonaldehyde level was 20.8% (P <0.05), 22.1% (P <0.05), 31.2% (P <0.05), and 24.7% (P <0.05) above the control value on days 15, 30, 60, and 90, respectively. CONCLUSIONS: Our findings demonstrate that chronic administration of cocaine to male rats induces a depletion of reduced glutathione and glutathione peroxidase. Adverse effects of cocaine on the testes are at least in part due to impairment of the function of the antioxidant defense and further enhancement of lipid peroxidation.

Racial differences and prognostic significance of tumor location in radical prostatectomy specimens.

BACKGROUND: Our objective was to evaluate radical prostatectomy specimens for possible racial differences in tumor location, as well as to correlate tumor location with pathologic stage and disease-free survival. METHODS: Between January 1991-December 1997, 1,245 patients underwent radical prostatectomy with bilateral pelvic lymphadenectomy for clinically localized prostate cancer. Seven hundred and eighty-five patients who were treated with surgery as monotherapy were evaluated. Tumor location, defined as mainly anterior, mainly posterior, or both (anterior and posterior), was obtained from review of tumor maps prepared from pathological evaluation of completely embedded, resected specimens. RESULTS: Overall tumor location was anterior in 107 (14%), posterior in 459 (58%), and both in 219 (28%) cases. The incidence of anterior tumors was higher in African American men compared to Caucasians (16% vs. 11%, P = 0.045). The rate of positive surgical margins in anteriorly and posteriorly located tumors was 60% vs. 38% in African American men (P = 0.001) and 48% vs. 27% in Caucasians (P = 0.001), respectively. African American men were found to have a higher incidence of positive surgical margins (50%; 174/348) compared to Caucasian men (34%; 150/437; P = 0.001). CONCLUSIONS: Anterior tumors were present in 14% of our patients. African American men have a greater percentage of anterior tumors than do Caucasians. In addition, a higher rate of positive surgical margins was encountered in patients with anterior tumors, especially if they were African American men. In patients with an abnormal serum prostate-specific antigen level and negative sextant prostate biopsies, we recommend biopsy of the anterior zone of the prostate.