Multiphasic helical CT criteria for differentiation of recurrent neoplasm and desmoplastic reaction after laparoscopic resection of renal mass lesions.

BACKGROUND AND PURPOSE: Differentiation of recurrent neoplasm and desmoplastic reaction following laparoscopic resection of renal mass lesions poses a problem. The usefulness of multiphasic helical CT-generated criteria based on enhancement and morphologic characteristics was investigated. PATIENTS AND METHODS: The findings in 5 female and 12 male patients aged 29 to 68 years having renal-cell carcinoma (11-38 mm; N = 15) or solitary angiomyolipomas (N = 2) treated by laparoscopic resection (N = 15) or open segmental surgery (N = 2) were analyzed. Multiphasic helical CT was performed in the preenhancement, arterial corticomedullary, parenchymal, and excretory phases generating 2.5- to 7-mm slices. RESULTS: Both recurrent neoplasms showed median postcontrast enhancement of 119 HU in the arterial corticomedullary phase; the median enhancement of desmoplastic masses was 48 HU. In the parenchymal and excretory phase, recurrent neoplasms showed progressive loss of enhancement, whereas desmoplastic lesions sustained enhancement at about the same level. Recurrent neoplasms presented a defined mass with characteristic spiculation, whereas desmoplastic reaction was characterized by an ill-defined mass with spidery projections extending to abutting fat and residual fascial planes. On 2- to 3-month follow-up scans, recurrent neoplasms showed progressive increases in size and desmoplastic reaction a sharp decrease. CONCLUSION: Enhancement of the mass at the operative site on arterial corticomedullary-phase CT to >90 HU strongly suggests recurrent renal-cell carcinoma, while progressive decrease in size on 1- to 3-month follow-up CT suggests a desmoplastic reaction.

Multiphasic helical CT diagnosis of early medullary and papillary necrosis.

PURPOSE: The feasibility of identifying early manifestations of renal papillary necrosis (RPN) and medullary necrosis (RMN) on multiphasic helical CT, leading to prompt treatment for the causative conditions, and its impact on reducing the incidence of late-stage RML and RPN, was investigated. PATIENTS AND METHODS: Sixty-eight patients (35 male, 33 female) aged 19 to 88 years were examined by multiphasic helical CT for complaints of microscopic hematuria (N=49), macroscopic hematuria (N=2), bacteriuria (N=45), pyuria (N=10), fever (N=15), and flank pain (N=27). Preenhancement, arterial corticomedullary, parenchymal, and excretory phase scans generated 1.25 to 7-mm-thick slices. Follow-up CTs were performed at 1 month (N=62) and 3 months (N=58). RESULTS: While the attenuation coefficients of areas suspect for RMN and RPN were similar on preenhancement CT, they differed substantially on the arterial corticomedullary phase (lesions 55 HU mean; normal medulla 120 HU mean) and parenchymal phase (lesions 58 HU mean, normal medulla 210 HU mean). Investigation for predisposing conditions identified diabetes in 18 patients, upper urinary-tract infections in 48, sickle-cell disease or trait in 17, urinary obstruction in 7, and cirrhosis of the liver in 1. On follow-up examinations, enhancement had normalized in 26 compromised areas of 14 patients at 1 month, and 47 areas (23 patients) at 3 months, remained stationary in 28 patients at 1 month and 9 at 3 months, and progressed in 20 at 1 and 26 at 3 months (P<0.001; Fisher's exact test). Patients (N=35) treated for underlying conditions causing ischemia showed reperfusion in 12 cases at 1 month and 20 at 3 months, while of the untreated patients (N=10), none showed reperfusion, and all lesions increased in size. CONCLUSIONS: Multiphasic helical CT is recommended for identification of RMN and RPN at a stage when effective treatment of underlying causative conditions can arrest or reverse the process of devascularization and prevent loss of medullary tissue.

Detection of medullary and papillary necrosis at an early stage by multiphasic helical computerized tomography.

PURPOSE: Multiphasic helical computerized tomography (CT) is advocated to identify early manifestations of papillary and medullary necrosis based on decreased enhancement of circumscribed areas in the medullary pyramid. At this stage the devascularizing process can be reversed if causative conditions such as infections or diabetes mellitus are effectively treated. MATERIALS AND METHODS: Multiphasic helical CTs were performed in 31 male and 26 female patients with complaints of microscopic hematuria (41), macroscopic hematuria (2), bacteriuria (39) and pyuria (9). Pre-enhancement, arterial, early corticomedullary, parenchymal and excretory phase helical CTs generated 1.25 to 5 mm. thick slices. Followup examination included multiphasic helical CT at 1 and 3 months, and excretory urography for some patients at 3 months. RESULTS: Bacteriuria was identified as the probable cause of medullary and papillary necrosis in 39 patients, of whom 28 were treated with effective antibiotic therapy, resulting in normalization and re-perfusion of the initial lesion in 16, no change in 5 and progressive disease in 7 at 3-month followup. Of 8 lesions not treated with specific antibiotic therapy 4 progressed and 4 remained unchanged. CONCLUSIONS: Multiphasic helical CT unlike the excretory urogram can identify medullary and papillary necrosis at an early stage when effective treatment of the underlying cause can reverse the process of devascularization and prevent sloughing of medullary tissues.

Radical transurethral resection in the management of muscle-invasive bladder cancer.

The morbidity of radical cystectomy and early reports of good results have stimulated interest in radical transurethral resection of bladder tumors (TURBT) for muscle-invasive transitional-cell carcinoma of the bladder. Various investigators have used surgery alone or with adjuvant or neoadjuvant chemotherapy or radiation. Further research is necessary to define the indications, but at present, radical TURBT for muscle-invasive cancer appears to be appropriate for patients too ill to undergo radical cystectomy, those who decline the open operation, and those enrolled in clinical trials of this approach to bladder cancer.

Nonoperative treatment of patients with presumed penile fracture.

PURPOSE: Immediate surgical intervention is the basis for treatment of penile fractures due to the high risk of complications associated with conservative management. Unfortunately, patient refusal to undergo surgery has led to conservative treatment of a small group of patients with presumed penile fractures at our institution. We followed these patients in regard to clinical outcome. MATERIALS AND METHODS: Between 1992 and 1999, 5 patients were evaluated after blunt trauma to an erect penis. Patient age at presentation ranged from 19 to 31 years (mean 25). The interval from time of injury to presentation was 24 to 72 hours. Of these patients 4 had been injured during sexual intercourse, while 1 had been injured during masturbation. All 5 patients refused immediate surgical exploration for presumed penile fracture. RESULTS: No patient had any immediate complications. At 6 and 12-month followup all patients reported erections adequate for intercourse without associated pain. One patient reported only mild curvature for which he did not seek treatment. CONCLUSIONS: We report on a subset of young males with presumed penile fracture who refused diagnostic evaluation and therapy, and were able to maintain normal erectile and voiding function. However, longer followup and radiographic evidence will be necessary to corroborate or refute these initial observations.

Results from different patient populations using combined therapy with alprostadil and sildenafil: predictors of satisfaction.

OBJECTIVE: To evaluate the outcome of combined therapy (using intraurethral alprostadil and oral sildenafil) in private and clinic patients with erectile dysfunction, and thus assess predictors of satisfaction. PATIENTS AND METHODS: In all, 360 men were treated for erectile dysfunction using single and/or combined therapy, comprising 214 private-practice and 166 clinic patients. Responses were evaluated using the International Index for Erectile Function (IIEF) questionnaire before and after treatment. Serum testosterone levels, education and socio-economic status were also assessed. Group 1a consisted of 33 private patients and Group 1b of 24 clinic patients who tried the maximum dose of intraurethral alprostadil monotherapy initially, followed by the maximum dose of sildenafil monotherapy, and remained dissatisfied. Group 2a consisted of 32 private patients and group 2b of 31 clinic patients who tried the maximum dose of sildenafil monotherapy initially, followed by the maximum dose of alprostadil monotherapy, and were also dissatisfied. These two groups of 65 private and 55 clinic patients then underwent combined therapy. RESULTS: The mean (SD) score for erectile function was 24.1 (2) for combined therapy (a 123% improvement), and 19.8 (1. 8) (83% improvement) and 15.2 (1.6) (41% improvement) for sildenafil and alprostadil monotherapies (P < 0.05 for both patient groups). The men also reported an improvement in their satisfaction with intercourse. However, at 18 months, 60 of the 65 private patients but only 40 of the 55 clinic patients continued with combined therapy; thus, the discontinuation rate was three times greater among clinic than among private patients. Furthermore, the private patients had an overall improvement in the satisfaction score of 128%, compared with 51% for the clinic patients. CONCLUSION: Although there were no significant differences in erectile function improvement within the two satisfied combined therapy groups, the differences in overall satisfaction and long-term withdrawal rates suggests that other factors beside motivation must be involved for success, e.g. education, persistence, realistic expectations, and certain psychological factors. Combined therapy should be considered for those patients who have a suboptimal response to monotherapy and refuse or are not candidates for surgical options. Generally, those patients with a higher education, greater persistence and more realistic expectations were more satisfied with combined therapy.

Initial results utilizing combination therapy for patients with a suboptimal response to either alprostadil or sildenafil monotherapy.

OBJECTIVE: Intraurethral alprostadil and oral sildenafil are useful in selected patients. However, there continues to be a significant treatment failure rate. Since their mechanisms of action are different, we wanted to evaluate the effectiveness of combination therapy. MATERIALS AND METHODS: Of 214 patients treated for erectile dysfunction (ED), 65 were not fully satisfied with the firmness of their erections via monotherapy. Responses were evaluated using the International Index for Erectile Function (IIEF) questionnaire before and after treatment. Group I consisted of 33 patients who tried maximal dose intraurethral alprostadil monotherapy initially, followed by the maximal dose of sildenafil monotherapy, and were still unsatisfied. Group II consisted of 32 patients who tried the maximal dose sildenafil monotherapy initially, followed by the maximal dose of alprostadil monotherapy, and were also unsatisfied. There 65 patients then underwent combination therapy. RESULTS: 60 out of the 65 patients stated they were satisfied with combination therapy. Questionnaire scores for erectile function were 23.1+/-2.0 (114%) for combination therapy vs. 19.2+/-1.8 (77%) and 15.2+/-1.6 (41%) for sildenafil and alprostadil monotherapies (p<0.05). There were no significant differences in responses between the two groups. The men also reported improvement in intercourse and overall satisfaction. CONCLUSIONS: Combination therapy may be an option for motivated patients who have a suboptimal response from monotherapy.

Is there a difference in outcome when treating traumatic intraperitoneal bladder rupture with or without a suprapubic tube?

PURPOSE: Primary bladder repair with a suprapubic tube is considered to be effective for managing intraperitoneal bladder injury. We compared the outcomes of suprapubic tube placement and no suprapubic tube for this injury. MATERIALS AND METHODS: We reviewed the charts of 31 men and 3 women with a mean age of 28.5 years who required emergency operative repair without a cystogram of traumatic bladder injury from 1992 to 1997. Patient characteristics, mechanism of injury, associated injuries, and short and long-term complications were reviewed. RESULTS: Penetrating and blunt trauma occurred in 28 (82%) and 5 (15%) patients, respectively, while 1 had spontaneous bladder rupture. After primary bladder repair the bladder was drained with a suprapubic tube in 18 cases (53%) and a urethral catheter only in 16 (47%). There were no significant differences between the 2 groups with respect to mechanism of injury, patient age, location of injury in the bladder, coexisting medical illnesses, stability in the field or emergency room, or the bladder repair technique. The 18 patients treated with a suprapubic tube had an associated injury that resulted in 2 deaths, while 13 of the 16 treated with urethral catheter drainage only had an associated injury and 1 died. Urological and nonurological complications in the suprapubic tube versus urethral catheter only group developed in 28 and 33 versus 19 and 19% of the cases, respectively (p <0.05). Followup ranged from 1 month to 4 years. No significant long-term morbidity was noted in either group. CONCLUSIONS: These data indicate that intraperitoneal bladder injuries may be equally well managed by primary bladder repair and urethral catheter drainage only versus suprapubic tube drainage.

Long-term consequences from bladder perforation and/or violation in the presence of transitional cell carcinoma: results of a small series and a review of the literature.

PURPOSE: Perforation of the bladder during transurethral resection is a worrisome complication for most urologists. Little is known about the consequences of seeding of tumor cells into the peritoneum or retroperitoneum. We reviewed several hospital patient databases as well as the literature to determine the outcome of such situations. MATERIALS AND METHODS: We performed a local multi-institutional case and MEDLINE review using key words, such as bladder neoplasm, neoplasm seeding, perforation, rupture, transurethral resection, peritonitis and tumor. We also contacted several urologists and oncologists at major cancer centers in the United States and Europe regarding the incidence and followup of perforated/violated bladder cancer cases. RESULTS: There were 16 bladder violations in the presence of transitional cell carcinoma, including 2 partial cystectomies that had negative margins and no subsequent metastatic recurrences, a bladder tumor that was detected during suprapubic prostatectomy and perforations during transurethral resection (extraperitoneal in 4 cases and intraperitoneal in 9). Two patients died of sepsis and existing metastatic disease, respectively. The only recurrence among the remaining 11 patients developed after intraperitoneal bladder perforation during transurethral resection for Ta grade 2 tumor. Several anecdotal reports discussed local and distal tumor recurrences, suggesting that even superficial transitional cell carcinoma can behave aggressively if grown in an environment outside the bladder. However, these reports are rare. Any benefit of prophylactic chemotherapy was not proved. CONCLUSIONS: While perforation of the bladder during transurethral resection for cancer and the possibility of tumor implantation are matters of concern, our review demonstrates that few patients return with an extravesical tumor recurrence either locally or distally compared to those with a nonruptured bladder after resection. Although our patient sample is small and there are a limited number of reports in the literature, the risk of recurrence still exists and the urologist should be aware of its possibility. Since recurrences are usually rapid, they may easily manifest to the urologist at followup. However, one should also consider chest x-rays and/or computerized tomography to rule out recurrences that are not clinically obvious.

An analysis of microvessel density, androgen receptor, p53 and HER-2/neu expression and Gleason score in prostate cancer . preliminary results and therapeutic implications.

OBJECTIVES: To investigate relationships between microvessel density (MVD), androgen receptors (AR), mutant p53 and HER-2/neu expression and Gleason score (GS) to further understand the tumor biology of prostate cancer (CAP). METHODS: Slides of CAP from patients who underwent radical prostatectomy or channel transurethral resection of the prostate (TURP) were tested for androgen receptors by immunocytochemical assay and MVD was analyzed by staining with antibodies to the endothelial cell membrane molecule PECAM-1/CD-31. The p53 monoclonal antibody D07 and HER-2 9G6 mouse monoclonal antibody were used to assess p53 and HER-2/neu expression, respectively. The results were correlated with GS and clinical stage by multivariate analysis. RESULTS: We found a fourfold greater expression of MVD in prostate cancer specimens compared to neighboring normal prostate tissue. We observed a greater concentration of MVD in the higher Gleason scores (r = 0.40, p = 0. 06), and a correlation of Gleason score with mutant p53 expression (r = 0.57, p <0.05). We did not observe any associations between AR or HER-2/neu to Gleason score. More than half of the patients with specimens with 50% or greater expression of mutant p53 were in stage D2 (T4NxM1b) at the time of biopsy. CONCLUSIONS: We observed a correlation between mutant p53 and GS, and a greater concentration of MVD in the higher GS. Since the neovascularity of prostate tumors can be attenuated by radiation and hormones, while mutant p53 may confer resistance to such treatment, it appears that p53 expression may also play an important role in addition to angiogenesis in the virulence of prostate cancer. These data may aid in allocating patients to different treatment modalities.

Age specific prostate specific antigen reference ranges: population specific.

PURPOSE: We determined whether 60 to 79-year-old men with a negative digital rectal examination and a serum prostate specific antigen (PSA) within age specific PSA reference ranges could safely forgo prostate biopsy. MATERIALS AND METHODS: We reviewed the medical records of all 60 to 79-year-old men at the Brooklyn Veterans Administration Medical Center who had a PSA assay, digital rectal examination and subsequent prostate biopsy for an abnormal rectal examination and/or PSA greater than 4.0 ng./ml. from January 1991 through August 1995. We compared our results using the standard reference range of 0 to 4.0 ng./ml. with those obtained had we used any of 4 different age specific PSA reference ranges. RESULTS: We performed 1,280 prostate biopsies in 1,046 men with available PSA and digital rectal examination data. Using age specific PSA reference ranges 73 of 1,280 biopsies (5.7%) would have been avoided. Of those 73 avoided biopsies 15 (20.5%) had cancer that would have gone undetected and 9 of 15 (60%) undetected cancers had unfavorable histology. Results were not statistically significantly different among the 4 age specific PSA reference ranges. Regarding race, cancer detection rates were significantly higher for black compared with white men but there was no statistically significant difference for missed cancers or missed cancers with unfavorable histology. CONCLUSIONS: In contrast to previous reports of unfavorable histological characteristics in only 5% of missed cancers using age specific PSA reference ranges, 60% of missed cancers in our patients exhibited unfavorable histology. We conclude that age specific PSA reference ranges did not safely eliminate the need for prostate biopsy in our study population. In 60 to 79-year-old men with a negative digital rectal examination we continue to use PSA greater than 4.0 ng./ml. as an indication for prostate biopsy.

Preliminary results comparing the recovery of basic fibroblast growth factor (FGF-2) in adipose tissue and benign and malignant renal tissue.

PURPOSE: Basic fibroblast growth factor (bFGF or FGF-2) is mitogenic to numerous epithelial, mesodermal and endothelial cells, and thus may play a role in the neovascularity and progression of several tumors. Furthermore, FGF-2 is reported to be elevated in the serum and urine of patients with various cancers, including renal cancer. Obesity, with increased body fat, is a risk factor for renal cancer through unknown mechanisms. Since adipose tissue is a source of FGF-2, we determined the quantity and quality of activity of FGF-2 in omental adipose tissue and compared it to normal and cancerous renal tissue. MATERIALS AND METHODS: Using heparin-Sepharose chromatography we extracted proteins from human omental adipose tissue, renal cell carcinoma (RCC) and benign renal tissue (BRT). Using FGF-2 antisera we performed western blot analysis to confirm their homology to FGF-2. We also assessed recovery, mitogenicity and angiogenicity of each of the proteins using thymidine incorporation into human umbilical vein endothelial cells (HUVEC) and the chorioallantoic membrane (CAM) assay. RESULTS: Each of the three purified mitogenic proteins eluted with NaCl concentrations between 1.4 M. and 1.8 M., similar to control FGF-2. There was greater recovery of FGF-2 from omental adipose tissue compared with renal cell carcinoma or benign renal tissue (42 microg. vs. 24 microg. and 18 microg., respectively; ANOVA p <0.05). Moreover, FGF-2 from adipose tissue had greater mitogenic activity (96.% versus 68% and 38%; p <0.05) and greater angiogenic activity (5.5 vessels versus 2.7 and 1.6 vessels; p <0.05) on the CAM assay. CONCLUSIONS: We suggest that human omental adipose tissue FGF-2 may demonstrate greater mitogenic and angiogenic activity than either benign or cancerous renal tissue FGF-2. It is not known if FGF-2 from adipose tissue may play a role in the relationship between obesity and renal cancer.

Urethrography and cavernosography imaging in a small series of penile fractures: a comparison with surgical findings.

OBJECTIVES: To compare our results of preoperative corporal cavernosography and retrograde urethrography in penile fractures with the clinical and intraoperative findings. METHODS: From January to October 1996, 7 cases of penile fracture were diagnosed at our inner city trauma center. All cases were associated with sexual activity and patients underwent preoperative retrograde urethrography and corpus cavernosography with immediate surgical intervention. RESULTS: We found that 2 patients who presented with blood at the meatus had intact urethras, whereas 2 of the 3 patients who had urethral lacerations did not have a bloody meatus. In 2 cases the urethrogram and cavernosogram revealed lacerations that were not initially detected surgically. However, in another 2 cases, the urethrogram and cavernosogram were falsely negative. Two of the seven corporal fractures were bilateral and five were unilateral. CONCLUSIONS: On the basis of this small sample, it appears that preoperative cavernosography and retrograde urethrography may show additional sites of tears in the corpora and urethra because hematoma formation may mask some ruptures. However, the presence or absence of a bloody meatus may not necessarily correlate with the status of the urethra, and the urologist also should be wary of a false-negative imaging study. We suggest that all cases of penile fracture be explored surgically, but preferably by a subcoronal degloving incision that allows careful examination of the urethra and corpora. Results of a larger series may determine if the routine use of these imaging modalities is justified intraoperatively.

Current trends in prostate cancer diagnosis and staging among United States urologists.

PURPOSE: We analyzed current practice patterns and determined whether urologists are diagnosing and staging prostate cancer in accordance with one another and with available literature. MATERIALS AND METHODS: An anonymous questionnaire was mailed to 1,500 randomly selected practicing American Urological Association members throughout the United States, categorized according to practice setting and decade of residency training completion. RESULTS: There were 624 respondents (41.6%). Annual routine prostate cancer detection is being aimed toward the right of the age spectrum. More than half of respondents use age specific prostate specific antigen (PSA), while fewer than half use PSA density in determining need for biopsy. The vast majority will perform radical prostatectomy on patients whose age suggests that they will not benefit from surgery. High PSA values and Gleason scores often are disregarded as independent precluding factors when deciding to perform radical prostatectomy. Computerized tomography and radionuclide bone imaging are used routinely far in excess of what the literature suggests is appropriate. Regardless of preoperative staging results, most urologists still perform lymphadenectomy with all radical prostatectomies. CONCLUSIONS: Discrepancies exist in practice patterns between urologists as well as inconsistencies in logic within individuals. There is little variation between individuals in different practice settings. Our results reflect the often confusing and conflicting data published during the last decade.

Differences in prostate and adipose tissue basic fibroblast growth factor: analysis of preliminary results.

OBJECTIVES: Basic fibroblast growth factor (bFGF or FGF-2) is mitogenic to human prostate epithelial and stromal cells, and it is reported to be elevated in the serum and urine of patients with various cancers, including prostate cancer. Obesity, with increased body fat, is a risk factor for prostate cancer through unknown mechanisms. Because adipose tissue is a source of FGF-2, we determined the quantity and quality of activity of FGF-2 in omental adipose tissue and compared it with normal and cancerous prostate tissues. METHODS: Using heparin-Sepharose chromatography, we extracted proteins from human omental adipose tissue, adenocarcinoma of the prostate, and benign prostatic hypertrophic (BPH) tissues. Each of the mitogenic proteins eluted with NaCl concentrations between 1.4 M and 1.8 M, similar to control FGF-2. Using FGF-2 antisera (which inhibited the mitogenic activity of the proteins), we performed Western blot analysis to confirm their homology to FGF-2. We also assessed recovery, mitogenicity, and angiogenicity of each of the proteins using thymidine incorporation into human umbilical vein endothelial cells and the chorioallantoic membrane assay. RESULTS: There was greater recovery of FGF-2 from omental adipose tissue compared with cancerous or BPH homogenates (40 micrograms [2.0 micrograms/g] versus 25 micrograms [1.25 micrograms/g] and 20 micrograms [1.0 microgram/g], respectively). Moreover. FGF-2 from adipose tissue had greater mitogenic activity (96.2% versus 74.8% and 54%; P < 0.05) and a greater angiogenic activity (5.1 vessels versus 2.9 and 1.8 vessels; P < 0.05) on the chorioallantoic assay. CONCLUSIONS: We suggest that human omental adipose tissue FGF-2 may demonstrate greater mitogenic and angiogenic activity than either BPH or prostate cancer tissue FGF-2. It is not known whether FGF-2 from adipose tissue qualitatively or quantitatively may underlie the relationship between obesity and prostate cancer.

Spontaneous renal hemorrhage associated with renal tumors.

Spontaneous ruptures of the kidney sometimes require emergency surgery, at which time the etiology for the rupture becomes evident. Because the patient with previously existing renal pathology is asymptomatic, when these ruptures do occur one should be suspect of underlying disease. We present a case and discuss the relevant aspects of such entities.

Munchausen's syndrome: a medico-legal dilemma.

In his or her life-long career, the physician will eventually encounter a patient with factitious disorder, or Munchausen's syndrome. We discuss two patients complaining of renal colic that were identified as having Munchausen's syndrome. We review the literature to identify certain aspects of the disease and to discuss the medical and legal implications for the treating physician and hospital.