Magnetic resonance arteriography/venography is not accurate to structure management of the impalpable testis.

PURPOSE: Recent studies have shown that magnetic resonance arteriography/venography is a highly sensitive tool to identify impalpable testes in young boys. Due to this and the low risk of cancer in testicular nubbins observation has been proposed after the identification of nubbins by magnetic resonance arteriography/venography. We prospectively examined the accuracy of magnetic resonance imaging and magnetic resonance imaging with magnetic resonance arteriography/venography for identifying impalpable testes in a younger cohort of patients typically seen at a pediatric institution in the United States. MATERIALS AND METHODS: We prospectively studied 26 infants and boys with impalpable testes. Conventional magnetic resonance imaging or magnetic resonance imaging with magnetic resonance arteriography/venography was performed in all patients. All patients subsequently underwent surgical exploration. Surgical and radiological findings were then evaluated for concordance. RESULTS: A total of 26 boys (29 impalpable testes) with a median age of 13 months were evaluated. A subset of 14 boys (14 impalpable testes) also underwent magnetic resonance arteriography/venography. Standard magnetic resonance imaging correctly identified 10 of 12 intra-abdominal testes, 4 of 6 intracanalicular testes, 4 of 10 testicular nubbins and 0 of 1 scrotal testis. Magnetic resonance arteriography/venography correctly identified 4 of 5 intra-abdominal testes, 2 of 3 intracanalicular testes, 2 of 5 testicular nubbins and 0 of 1 scrotal testis. The overall accuracy of magnetic resonance imaging alone and magnetic resonance arteriography/venography for identifying a viable testis or testicular nubbin was 62% and 57%, respectively. The accuracy of magnetic resonance imaging and magnetic resonance arteriography/venography for identifying a viable testis was 74% and 67%, respectively. CONCLUSIONS: Preoperative magnetic resonance imaging or magnetic resonance arteriography/venography does not accurately identify or localize impalpable testes in the age group typically presenting to pediatric urologists. Accuracy at our institution is discrepant with that in previous studies. We do not recommend using magnetic resonance imaging or magnetic resonance arteriography/venography for the possible observation of vanishing testes or nubbins and we recommend surgical exploration in all individuals.

Safety and efficacy of laparoscopic radical nephrectomy with manual specimen morcellation for stage cT1 renal-cell carcinoma.

BACKGROUND AND PURPOSE: Specimen morcellation during laparoscopic radical nephrectomy for renal-cell carcinoma is controversial, and supporting literature remains sparse. We seek to evaluate the safety and efficacy of morcellation for specimen removal after laparoscopic radical nephrectomy for management of renal lesions of malignant potential at a single institution. MATERIALS AND METHODS: We retrospectively reviewed the records of all patients who underwent laparoscopic radical nephrectomy at Northwestern Memorial and Evanston Hospital from 2001 to 2006. Twenty-two patients were identified who underwent specimen morcellation for extraction after laparoscopic nephrectomy that was performed for enhancing solid or cystic renal masses. RESULTS: Laparoscopic radical nephrectomy was performed on all the patients. Patient age ranged from 36 to 96 years old. All patients were clinical stage T(1)N(0)M(0). The specimen was mechanically morcellated within Cook Lap Sac under direct and laparoscopic vision. Average tumor size after morcellation was 3.0 cm. On histologic review of the morcellated specimen, 18 patients were confirmed to have renal-cell carcinoma, 2 had an oncocytoma, and 2 had benign cysts. One patient with renal-cell carcinoma had a pathologic upgrade to stage T(3b). Average operating time was 268 minutes (range 110 to 389 min). With the exception of the patient who became anephric after nephrectomy, average hospital stay was 2.6 days. A mean clinical and radiographic follow-up of 434 days failed to show any known disease progression or port site recurrence in patients with renal-cell carcinoma. CONCLUSIONS: Intracorporeal, mechanical morcellation after laparoscopic radical nephrectomy appears to be safe and effective in clinical stage T1 renal-cell carcinoma. This study adds to current literature that promotes the use of morcellation as an alternative for intact specimen removal in properly selected patients. Further prospective studies are necessary to show long-term oncologic outcomes.

Monocyte chemoattractant protein-1 and macrophage inflammatory protein-1alpha as possible biomarkers for the chronic pelvic pain syndrome.

PURPOSE: The chronic pelvic pain syndrome is characterized by pelvic pain, voiding symptoms and varying degrees of inflammation within expressed prostatic secretions. We evaluated the chemokines monocyte chemoattractant protein 1 (CCL2) and macrophage inflammatory protein-1alpha (CCL3) in expressed prostatic secretions to identify marker increases associated with inflammatory (IIIA) and noninflammatory (IIIB) chronic pelvic pain syndrome. In addition, chemokine levels were correlated with clinical pain as determined by the National Institutes of Health chronic prostatitis symptom index. MATERIALS AND METHODS: Expressed prostatic secretions were collected by digital rectal examination, and evaluated by enzyme linked immunosorbent assays for monocyte chemoattractant protein 1 and macrophage inflammatory protein-1alpha in 154 patients including controls (13), those with benign prostatic hyperplasia (54), chronic pelvic pain syndrome IIIA (37) and IIIB (50). Monocyte chemoattractant protein 1 and macrophage inflammatory protein-1alpha levels were compared between IIIA, IIIB and the control subgroups, and correlated against the chronic prostatitis symptom index and pain subscore using a Spearman test. RESULTS: Mean levels of monocyte chemoattractant protein 1 in the control, inflammatory benign prostatic hyperplasia, noninflammatory benign prostatic hyperplasia, inflammatory chronic pelvic pain syndrome and noninflammatory chronic pelvic pain syndrome were 599.4, 886.0, 1,636.5, 3,261.2 and 2,272.7 pg/ml, respectively. Mean levels of macrophage inflammatory protein-1alpha in the control, inflammatory benign prostatic hyperplasia, noninflammatory benign prostatic hyperplasia, IIIA chronic pelvic pain syndrome and IIIB chronic pelvic pain syndrome were 140.1, 299.4, 238.7, 1,057.8 and 978.4 pg/ml, respectively. For each cytokine both chronic pelvic pain syndrome subtypes had statistically higher levels than the control group and patients with benign prostatic hyperplasia (p = 0.0002). Receiver operating curves using monocyte chemoattractant protein 1 levels greater than 704 pg/ml and macrophage inflammatory protein-1alpha greater than 146 pg/ml identified patients with chronic pelvic pain syndrome with an accuracy of 90% from control patients. Macrophage inflammatory protein-1alpha levels (p = 0.0007) correlated with the pain subscore of the chronic prostatitis symptom index while monocyte chemoattractant protein 1 (p = 0.71) did not. CONCLUSIONS: Monocyte chemoattractant protein 1 and macrophage inflammatory protein-1alpha within the prostatic fluid in both chronic pelvic pain syndrome subtypes provide candidate future biomarkers for chronic pelvic pain syndrome. In addition, macrophage inflammatory protein-1alpha increase in expressed prostatic secretions provides a new marker for clinical pain in chronic pelvic pain syndrome patients. Given these findings prostatic dysfunction likely has a role in the pathophysiology of this syndrome. These chemokines may serve as effective diagnostic markers and modulators against the chemokines could provide an attractive treatment strategy in individuals with chronic pelvic pain syndrome.

Improved stage and grade-specific progression-free survival rates after radical prostatectomy in the PSA era.

OBJECTIVES: Since the initiation of prostate-specific antigen (PSA) screening, the progression-free survival (PFS) rates after radical prostatectomy have markedly improved. However, few studies have evaluated whether PFS has improved for stage and grade-matched patients. Our objective was to examine differences in PFS after radical prostatectomy between the pre-PSA era (before 1992) and the PSA era, controlling for tumor stage and grade. METHODS: From 1983 to 2003, 3456 men underwent radical prostatectomy by one surgeon. The 10-year PFS rates were calculated for each era and stratified by pathologic tumor stage and grade. Kaplan-Meier curves were generated to show biochemical PFS over time. RESULTS: The proportion of patients with pathologically organ-confined disease increased from 64% to 69%, consistent with stage migration. The PFS rate in the PSA era was 87%, 63%, 58%, and 31% versus 71%, 63%, 47%, and 19% in the pre-PSA era for Stage pT2R0, pT3R0, pT2-T3R1, and pT3c/N1 disease, respectively. The PFS rate stratified by Gleason grade in the PSA era was 84%, 63%, and 37% versus 66%, 49%, and 32% in the pre-PSA era for Gleason grade less than 7, 7, and 8 to 10, respectively. The 10-year PFS rate for organ-confined disease improved from 70% in the pre-PSA era to 86% in the PSA era. CONCLUSIONS: Patients treated with radical prostatectomy in the PSA era have improved survival outcomes when controlling for pathologic stage and grade. This is likely attributed to the earlier detection of cancer through PSA screening, better identification of patients amenable to curative therapy, and the effects of lead-time bias.