The safety of transurethral prostatectomy: a cohort study of mortality in 9,416 men.

PURPOSE: We assessed the mortality rate from transurethral resection of the prostate. MATERIALS AND METHODS: From 1976 to 1984, 4,708 patients undergoing transurethral resection of the prostate for benign prostatic hypertrophy (BPH) were compared retrospectively to an age-matched group of 4,708 randomly selected Kaiser Permanente Medical Care Program members not undergoing surgery. The risk of mortality associated with transurethral resection of the prostate relative to no surgery was determined using proportional hazards models. RESULTS: The relative risk for surgery versus no surgery for the total group was 0.88 (95% confidence interval 0.82 to 0.95). Similarly, the results for each 5-year age group demonstrated a relative risk of 0.77 to 0.95. CONCLUSIONS: This cohort study showed no excess mortality for patients undergoing transurethral resection of the prostate compared to age-matched comparison subjects randomly selected from health plan members who did not undergo surgery. Information from this study about the safety of transurethral resection of the prostate can be shared with patients when discussing treatment options.

The safety of overnight hospitalization for transurethral prostatectomy: a prospective study of 200 patients.

PURPOSE: Our goal was to determine the appropriateness, safety and cost-effectiveness of catheter removal and hospital discharge 1 day after transurethral prostatectomy. MATERIALS AND METHODS: A prospective study of 200 patients who underwent transurethral prostatectomy during a 23-month period was done. On the morning of postoperative day 1 catheters were removed from 156 patients (78%) who had normal vital signs, adequate urine output, absence of clots and acceptable character of the catheter effluent. RESULTS: Among the 156 patients whose catheters were removed 4 of 5 went home on postoperative day 1. Two of these patients were rehospitalized within 30 days, as were 2 others whose catheters were removed later. Overall length of patient stay was 1.6 days. CONCLUSIONS: Overnight hospitalization after transurethral prostatectomy is an appropriate, safe and cost-effective pathway of patient care that is readily applicable to any urology practice.

Comparison of laparoscopic and minilaparotomy pelvic lymphadenectomy for prostate cancer staging in a community practice.

OBJECTIVES: To compare the cost-effectiveness and morbidity of minilaparotomy (MINILAP) and laparoscopic pelvic lymphadenectomy (LAP) in a community practice setting. METHODS: We reviewed our experience with 44 consecutive patients with prostate cancer who had staging pelvic lymphadenectomy from January 1992 through April 1995 in a general health maintenance organization urology practice. Of this group, 22 men had LAP and 22 men had MINILAP. RESULTS: MINILAP and LAP groups were similar in age (mean 67 years). Gleason score (mean 7.2 and 6.8), prostate-specific antigen level (mean 46 and 49 ng/mL), and clinical stage (T1 to T3). Operative time was statistically significantly shorter for MINILAP (mean 1.2 hours) than for LAP (mean 2.9 hours). Complication rate was 9.1% for MINILAP and 31.8% for LAP. Lymph node metastasis was found in 45% of MINILAP patients and in 27% of LAP patients. Mean initial hospital stay was 1.0 day for MINILAP and 1.6 days for LAP. Total hospital stay including hospital readmission for complications was 1.5 days for MINILAP and 2.6 days for LAP. Cost of MINILAP was at least $1900 less than that of LAP because of shorter total hospital stay, shorter operation time, and lower equipment cost. CONCLUSIONS: Compared with LAP, MINILAP was more cost-effective and produced less morbidity. Patient satisfaction with the procedures was similar. MINILAP is an excellent alternative to LAP for prostate cancer staging in general urology practice.

Can hematuria be a predictor as well as a symptom or sign of bladder cancer?

In a case-control study of urinalysis screening in the prevention of death from bladder cancer, hematuria was present in a higher proportion of cases than controls as long as five or six years before the diagnostic evaluation that led to the diagnosis of bladder cancer. In a separate cohort study data base that permitted the follow-up of 1046 persons with a physician's diagnosis of hematuria, 11 cases of bladder cancer were diagnosed more than two (mean 7.4) years after the hematuria diagnosis (4.3 cases expected; age-sex standardized morbidity ratio, 2.5; 95% confidence interval, 1.3-4.5). Bladder cancer was ruled out initially by cystoscopy in 8 of the 11 cases. Although we cannot be certain that preexisting bladder cancer or bladder cancer risk factors did not cause the bleeding, we hypothesize that hematuria can be a predictor as well as a manifestation of bladder cancer, based on a tendency for bladder mucosa with premalignant changes to bleed. The implications for screening and clinical practice remain to be determined.

Dog bites to the male genitalia: characteristics, management and comparison with human bites.

Dog bites to the external male genitalia occur infrequently. We present 4 new cases and review 4 others described previously. Victims tend to seek medical care quickly. Thus, morbidity is directly related to the severity of the initial wound and delayed infectious complications appear to be minimal. Guidelines for management include irrigation, debridement as necessary, empiric antibiotics, consideration of tetanus and rabies immunization, and primary wound closure or surgical reconstruction. The differences between dog bites and human bites to the genitalia--primarily interval to presentation and subsequent likelihood of infection--are summarized. Measures to prevent dog bites are discussed.

Reoperation and mortality after surgical treatment of benign prostatic hypertrophy in a large prepaid medical care program.

The incidence of reoperation and mortality after prostatectomy was studied in 8,219 men who underwent surgical treatment for benign prostatic hypertrophy between 1976 and 1987 while they were members of the Kaiser Permanente Medical Care Program, Northern California Region. The vast majority (94.5%) received transurethral prostatectomy (TURP). The cumulative 8-year probability of a second prostatectomy was 7.6% after TURP and 2.1% after open prostatectomy. The risk of mortality associated with transurethral prostatectomy relative to open prostatectomy was 1.6 (95% confidence interval 1.2, 2.1) 8 years postsurgery. The increased risk of mortality associated with transurethral prostatectomy was most prominent during the first 5 years postsurgery (relative risk 1.8, 95% confidence interval 1.3, 2.5) and declined to 1.1 (95% confidence interval 0.8, 1.6) for deaths occurring after the first 5 years. The finding of an increased risk of mortality associated with transurethral prostatectomy is consistent with other studies and is unexplained.

Incidence of surgically treated benign prostatic hypertrophy and of prostate cancer among blacks and whites in a prepaid health care plan.

The incidence of surgically treated benign prostatic hypertrophy and of prostate cancer was examined to December 1987 in 14,897 men (2,175 blacks and 12,722 whites) who received multiphasic health checkups during 1971-1972 while members of the Kaiser Permanente Medical Care Program (San Francisco-Oakland, California). Prostate cancer incidence was higher in blacks than in whites for all age groups (age-adjusted relative risk (RR) = 1.8, 95% confidence interval (CI) 1.4-2.3). The incidence of benign prostatic hypertrophy was somewhat higher in blacks than in whites until age 65 years, after which it was higher in whites. In contrast to the risk of prostate cancer, the age-adjusted risk of benign prostatic hypertrophy was the same for blacks as for whites (RR = 1.0, 95% Cl 0.8-1.2).

Vasectomy and the risk of prostate cancer in a cohort of multiphasic health-checkup examinees: second report.

The relationship of vasectomy to prostate cancer was studied in 5,119 men men with a self-reported history of vasectomy, identified at multiphasic health checkups undergone during 1977-82 while members of the Northern California Kaiser Permanente Medical Care Program. Three unvasectomized comparison subjects were identified for each vasectomized man, matched for age, race, marital status, and date and location of the examination. Follow-up for incident prostate cancer was conducted for a mean length of 6.8 years. The relative risk of prostate cancer associated with vasectomy was 1.0 (95% confidence interval = 0.7 - 1.6); the relative risk was approximately one, regardless of length of interval (less than 10 years, 10-20 years, more than 20 years) between vasectomy and multiphasic health checkup or the age at vasectomy (less than 40 years vs more than 40 years). These data support earlier findings reported in this study group of the lack of an association of vasectomy with subsequent risk of prostate cancer.

Risk factors for surgically treated benign prostatic hyperplasia in a prepaid health care plan.

The relationship of age, medical history, personal habits, and urologic symptoms to the incidence of surgically treated benign prostatic hyperplasia (BPH) was studied in a cohort of 16,219 men, aged forty years and over, who received multiphasic health checkups (MHCs) during 1971 and 1972 in Oakland or San Francisco while members of the Northern California Kaiser Permanente Medical Care Program, a large prepaid health care program. Follow-up was carried out for surgically treated BPH from the date of the MHC to the date of the earliest of the following: surgery for BPH (n = 1,027); incidence of prostate cancer (n = 329), bladder cancer (n = 119), or both (n = 10); other prostate surgery (n = 5); death (n = 2,525); membership termination (n = 4,235); or December 31, 1987 (n = 7,969). The mean length of follow-up was twelve years. In multivariate analysis utilizing the Cox proportional hazards model, the following characteristics were positively associated (p less than 0.05) with risk of surgically treated BPH: age, low body mass index, nonsmoking (vs. current smoking), urine pH greater than 5, history of kidney x-ray and of tuberculosis, and each of five urologic symptoms (dysuria, loss of bladder control, trouble starting urination, nocturia, slow urine stream). The risk of BPH associated with obstructive urologic symptoms decreased markedly with age. Some of these findings are consistent with those from other studies (age, nonsmoking), while others (high urine pH, history of tuberculosis) are new and should be examined in other study populations.

Necrotising soft tissue infections of the perineum and genitalia. Bacteriology, treatment and risk assessment.

Necrotising soft tissue infections of the perineum and genitalia are associated with a high rate of mortality and morbidity. We reviewed the records of 29 consecutive patients to investigate the possible correlation between clinical outcome and number of types of bacteria cultured, focus of infection, presence of diabetes, patient age, renal function and delay until presentation. The patients had an average of 3.9 bacterial organisms cultured intra-operatively (range 1-9). Patients with a rectal focus of infection had a greater number of bacteria and required longer hospitalisation and more operative procedures than patients with dermal or urethral foci. Those over the age of 60 had significantly longer hospital stays and higher mortality. Diabetes and impaired renal function did not increase mortality or morbidity. Suprapubic cystostomy was required in 24 patients (83%), diverting colostomy in 9 (31%) and orchiectomy in 3 (10%). Six patients (21%) died despite broad spectrum antibiotics and aggressive and frequent surgical debridement.

Necrotizing soft-tissue infections of the perineum and genitalia. Etiology and early reconstruction.

Necrotizing fasciitis of the perineum and genitalia is a rare, rapidly progressive, often fatal infection whose unique bacterial involvement has frequently been ignored. From our experience with 14 patients, we recommend the following: early, aggressive surgical debridement and drainage to reduce morbidity and mortality; prompt institution of antimicrobial therapy directed at both aerobic and anaerobic organisms, with subsequent tailoring to the specific bacteria cultured, and early surgical reconstruction to avoid extensive scarring and cosmetic deformity and to allow earlier skin closure and a reduced hospital stay. In our series, long-term complications occurred in 3 patients, and 3 of the 14 died.

Preoperative manual detorsion of the torsed spermatic cord.

During a 10-year period 35 of 104 patients with torsion of the spermatic cord had preoperative manual detorsion. The detorsion was performed at the initial physical examination, most commonly without analgesia or sedation. In 34 evaluable patients all of the testes were salvaged without any evidence of atrophy. One patient whose testis appeared viable at operation was not available for followup. Recurrence was prevented by subsequent orchiopexy. The elapsed time between urological consultation and surgery ranged from 1 hour 40 minutes to 2 months. Six patients underwent an elective operation. Torsion did not recur between the time of manual detorsion and orchiopexy. Preoperative manual detorsion should be attempted at the initial physical examination because, if successful, the relief of testicular ischemia converts an acute urological emergency into an urgent or elective surgical procedure. More important, 100 per cent of the testes are salvaged.

Hemiacidrin renal irrigation: complications and successful management.

The complications of hemiacidrin irrigation of the kidneys for postoperative residual struvite calculi can test the ingenuity and perseverance of the clinician. The complications encountered during the irrigation of 9 kidneys in 8 patients included Candida urinary tract infection, irrigant extravasation, ureteral obstruction and chemical cystitis. Some causes and the management of these problems are discussed. Although the period of irrigation and the hospitalization are prolonged by these complications hemiacidrin irrigation remains a safe procedure when used meticulously.

Massive hemospermia: a new etiology and simplified treatment.

Hemospermia is a common urologic symptom that is usually benign and self-limited, and required no clinical investigation. Massive hemospermia causing hematuria, with clot formation and occasional urinary retention, occurs in a subset of patients. Three patients are reported in whom cystourethroscopy demonstrated nonvaricose abnormal posterior urethral vessels. Treatment consisted of fulguration of the vessels. One patient was cured, 1 had no symptoms for 3 years and 1 improved slightly. Endoscopically, this is a safe simple outpatient surgical procedure that is recommended for massive hemospermia due to abnormal posterior urethral vessels.

High testicular salvage rate in torsion of the spermatic cord.

Acute, nontraumatic scrotal emergency operations were done on 104 patients. The testes were saved in 79 per cent of 67 patients with torsion of the spermatic cord. When the patients who presented late are excluded, aggressive treatment allowed a 93 per cent testicular salvage rate. Spontaneous or manipulative detorsion preoperatively resulted in a 100 per cent testicular salvage rate. If the patient seeks medical advice early a high testicular salvage rate can be obtained by proper diagnosis and prompt, aggressive detorsion either by manipulation when examined initially or at operation. These maneuvers are combined with bilateral orchiopexy to ensure permanent cure.

Branched calculi: shapes and operative approaches.

Branched calculi (infection stones) typically arise in intrarenal pelves. They expand to touch the pelvic wall and then grow peripherally, keeping contact with the walls of the pelvis and greater than or equal to 1 infundibula. Filling the infundibulum obstructs the calix and allows terminal expansion of the stone. From study of a series of stones such a sequence might be reconstructed. The shape of the calculus and collecting structures was traced and classified from excretory urograms of 50 consecutive renal units. The funnel pelvis, usually intrarenal, contained a stone either extending into the ureteropelvic junction (24 cases) or stopping short of it (9 cases). Pelvic or infundibular and caliceal dilatation around the stone was found in the remaining 8 and 9 cases, respectively. These patterns of growth of branched calculi directly bear on the approaches and technique for the operative removal. Because typical branched calculi arise in the intrarenal pelvis a high transverse intrahilar incision is necessary. Less intrahilar dissection is needed for cases in which the pelvis is dilated above and around the stone. Counter-incisions through the parenchyma or anatrophic nephrolithotomy is reserved for those patients with infundibular obstruction and resulting expanded caliceal stones.

Ureteral endometriosis.

Ureteral endometriosis poses a problem to the clinician because of its nonspecific clinical presentation and its possible confusion with ureteral tumor. To facilitate early diagnosis and the application of appropriate treatment, the gynecologist should obtain an excretory urogram on all patients with pelvic endometriosis advanced enough to require surgery, and the urologist should suspect the disease when a premenopausal woman presents with distal ureteral obstruction of unknown cause.

Massive renal angiomyolipoma: preoperative infarction by balloon catheter.

A case of a renal angiomyolipoma supplied by 2 renal arteries is reported. Preoperative, percutaneous transluminal infarction by a balloon catheter facilitated surgical removal of this massive neoplasm.