Variation in the use of postoperative radiotherapy among high-risk patients following radical prostatectomy.

BACKGROUND: We used data from the Michigan Urological Surgery Improvement Collaborative (MUSIC) to investigate the use of adjuvant and salvage radiotherapy (ART, SRT) among patients with high-risk pathology following radical prostatectomy (RP). METHODS: For patients with pT3a disease or higher and/or positive surgical margins, we examined post-RP radiotherapy administration across MUSIC practices. We excluded patients with <6 months follow-up, and those that failed to achieve a postoperative PSA nadir ⩽0.1. ART was defined as radiation administered within 1 year post RP, with all post-nadir PSA levels <0.1 ng ml(-1). Radiation administered >1 year post RP and/or after a post-nadir PSA ⩾0.1 ng ml(-1) was defined as SRT. We used claims data to externally validate radiation administration. RESULTS: Among 2337 patients undergoing RP, 668 (28.6%) were at high risk of recurrence. Of these, 52 (7.8%) received ART and 56 (8.4%) underwent SRT. Patients receiving ART were younger (P=0.027), more likely to have a greater surgical Gleason sum (P=0.009), higher pathologic stage (P<0.001) and received treatment at the smallest and largest size practices (P=0.011). Utilization of both ART and SRT varied widely across MUSIC practices (P<0.001 and P=0.046, respectively), but practice-level rates of ART and SRT administration were positively correlated (P=0.003) with lower ART practices also utilizing SRT less frequently. Of the 88 patients not receiving ART and experiencing a PSA recurrence ⩾0.2 ng ml(-1), 38 (43.2%) progressed to a PSA ⩾0.5 ng ml(-1) and 20 (22.7%) to a PSA ⩾1.0 ng ml(-1) without receiving prior SRT. There was excellent concordance between registry and claims data κ=0.98 (95% CI: 0.94-1.0). CONCLUSIONS: Utilization of ART and SRT is infrequent and variable across urology practices in Michigan. Although early SRT is an alternative to ART, it is not consistently utilized in the setting of post-RP biochemical recurrence. Quality improvement initiatives focused on current postoperative radiotherapy administration guidelines may yield significant gains for this high-risk population.

Pituitary gonadal dysfunction in adolescents with varicocele.

Gonadotropin-releasing hormone stimulation testing was performed on 104 adolescent males with a unilateral left varicocele to determine the frequency of testicular dysfunction in this group of patients. An abnormal test result was noted in approximately 30 percent of varicocele patients. We believe that an abnormal test result indicates a higher risk for future fertility problems, and early treatment may reduce this risk.

Transient acute renal failure in the neonate.

We have observed a transient renal insufficiency in newborns associated with ultrasonographic finding of hyperechoic renal pyramids. This condition rapidly resolves, coinciding with both normalization of the renal ultrasound and the occurrence of significant proteinuria. Others have recognized a similar state of oliguria and cylindruria associated with a prolonged nephrogram on intravenous urography in newborns. There is evidence to suggest that hyaline cast deposition within the collecting tubules may account for these imaging abnormalities. The precise events surrounding the protein deposition are unknown, and it may be either the cause or the result from the transient renal dysfunction. Our 2 cases add to the evidence that there is a distinct entity of acute renal dysfunction, with identifying characteristics, in neonates associated with a good prognosis and rapid resolution.

A new technique for ureteral stent placement during pregnancy using endoluminal ultrasound.

Endoluminal sonography using the IVUS is a minimally invasive procedure performed using a flexible 6.2F catheter with a 20 megahertz transducer that can easily be passed endoscopically to image the urethra, bladder, ureter and renal pelvis. In the current study, a woman patient in her third trimester of pregnancy with a renal pelvic stone and persistent colic was safely treated with placement of an indwelling ureteral stent. Because it is minimally invasive and does not require the use of roentgenograms, we believe the IVUS will be a useful tool to assist with the management of ureteral colic in patients who are pregnant in whom intervention is required.

The management of injuries to the urethra, bladder or vagina encountered during difficult placement of the artificial urinary sphincter in the female patient.

Between 1977 and 1989, an artificial urinary sphincter was implanted in 57 female patients. In 6 patients inadvertent intraoperative injuries to pelvic organs occurred, 5 of whom had a history of an average 2.8 previous operations for incontinence (range 2 to 4). The remaining patient was a 16-year-old girl with primary internal sphincter incompetence. All 6 patients presented with total incontinence. Intraoperative injury included 4 women who sustained vaginal perforations, while 1 had an anterior bladder perforation and in 1 the urethra was entered. Mechanisms of injury were sharp perforation of structures adherent to the pubis and blunt tears of distorted urethrovaginal tissues. Primary closures of the urethra, bladder and vaginal defects followed by insertion of the artificial urinary sphincter were accomplished successfully. Postoperative management included vaginal antiseptic packs, appropriate antibiotics and delayed sphincter activation. Of the 6 patients 5 remained dry after initial placement with a mean followup of 32 months (range 7 to 77). The remaining patient required replacement with a higher pressure balloon and a smaller cuff, which resulted in complete continence.

The significance of elevated scrotal temperature in an adolescent with a varicocele.

Simultaneous measurements of left and right scrotal, and axillary skin temperatures were recorded in 58 consecutive adolescents (mean age 14.4 years) with a grade II-III left sided varicocele, and nine control adolescents without genital pathology (mean age 15.7 years). Left and right testicular volumes were determined in both groups. The adolescents with a varicocele had a significant bilateral elevation of the scrotal temperatures compared to the control subjects. This relative hyperthermia was present in both supine and standing positions. The mean left scrotal temperature of varicocele patients was significantly higher in the standing position than in the supine position, which may reflect the dependent venous filling of the varicocele. Those varicocele patients who maintained a left scrotal temperature at least 1.4 degrees C cooler than axillary did not have significant left testicular volume loss, whereas those whose left temperature was approximately equal to axillary did have significant growth retardation of the left testis. Following successful varicocele surgery, left scrotal temperatures were significantly cooler, and statistically indistinguishable from controls. The left testicular volumes were also significantly improved with respect to corresponding right testicular volumes. These observations suggest that adolescents with a moderate to large left varicocele have a significant bilateral loss of testicular thermoregulation. In those individuals with a significantly warmer left hemiscrotum, there is a definite increased potential for left testicular volume loss. Varicocele surgery can reverse this process.

Testicular calcifications and neoplasia in patient treated for subfertility.

A subfertile male with a history of left cryptorchism underwent scrotal ultrasound that revealed stippled calcifications, without associated mass, in the right testicle. Six months later, while on a regimen of clomiphene citrate, a testicular tumor became palpable. This was sonographically confirmed to be surrounding the calcifications. Testicular calcifications are most commonly associated with benign conditions. We review the literature regarding their relationship to neoplasms and the significance of the ultrasonic findings. Furthermore, this is the sixth reported case of testicular tumor developing during hormonal treatment for oligospermia. Although these cases may be circumstantial, closer surveillance and screening ultrasound may be indicated for subfertile males taking clomiphene citrate.