A novel surveillance protocol for stage I nonseminomatous germ cell testicular tumours.

OBJECTIVES: To report the results of a novel surveillance policy for stage I nonseminomatous germ cell tumours (NSGCTs). PATIENTS AND METHODS: Between 1978 and 2000, 132 patients (median age 28 years, range 16-52) who were regularly followed were included in a new surveillance policy. All pathology specimens were studied retrospectively by the same pathologist for embryonal carcinoma, yolk sac tumour and lymphovascular invasion components. A loose surveillance protocol was designed in which computed tomography (CT) was used only for the first year. RESULTS: The median (range) follow-up was 38 (6-265) months; the relapse rate was 24% and all occurred before 23 months, with 87% diagnosed within the first year. Platinum-based chemotherapy was given to patients with relapse, and surgery used after chemotherapy in seven. Among all the risk factors, an embryonal carcinoma component was the only significant predictor of relapse. The overall survival rate was 99%. CONCLUSION: The presence of embryonal carcinoma in the primary pathology is the only risk factor determining the relapse rate of the present surveillance policy for stage I NSGCTs. The overall survival was no different from those reported for retroperitoneal lymph node dissection and primary chemotherapy. Decreasing the frequency of CT in the first year and totally eliminating it after 1 year reduces the cost of surveillance. The possible compliance problems of patients are also minimized, without changing the overall survival. This surveillance protocol for patients with stage I NSGCT has reduced costs and provided a better quality of life for the patients, without jeopardizing the final outcome.

Repeated transurethral resection and intravesical BCG for extensive superficial bladder tumors.

PURPOSE: We report our experience with repeat transurethral resection (TUR) in a group of patients with superficial bladder tumors in whom complete resection in one session was impossible because of the extensive tumor burden. PATIENTS AND METHODS: Only the patients with such extensive (>10 g of resected tissue) tumors that we were unable to perform complete TUR initially were included in the present study. The patients underwent repeat TUR(s) 4 weeks after the previous one until complete resection of the tumor was achieved. After complete TUR, if the pathology examination confirmed superficial disease, the patients received intracavitery immunotherapy and were followed up thereafter. If pathology examination documented muscle-invasive disease, cystectomy was suggested. RESULTS: Of the 43 patients undergoing repeat TUR, 15 needed a second and 5 needed a third session to achieve complete resection. Of the patients, 28 (65%) had stage T1 and 15 (35%) has stage Ta tumor. Eight patients (19%) otherwise regarded as having superficial tumor were found to have muscle-invasive disease following repeat TURs. The mean follow-up of the remaining 35 patients with superficial disease was 34 months (range 1-126 months). Four of the patients with superficial disease progressed to T2 tumor. However, 16 patients achieved a state of complete response with no tumor recurrences during a mean of 38 months (range 4-126 month). The present protocol achieved bladder sparing in a total of 22 (63%) of the 35 patients with superficial disease. CONCLUSIONS: From the presented series, we suggest that one can use the combination of repeat TUR and intravesical immunotherapy in the management of bulky superficial bladder tumors in an effort to preserve the bladder.

Combination of transcutaneous electrical nerve stimulation and ondansetron in preventing cisplatin-induced emesis.

OBJECTIVE: To find out whether the combination of transcutaneous electrical nerve stimulation (TENS) and ondansetron had an increased antiemetic effect. MATERIALS AND METHODS: Fourteen testis and 11 bladder cancer patients were scheduled for 4 cycles of bleomycin-etoposide-cisplatin (BEP) or methotrexate-vinblastine-etoposide-cisplatin (MVEC) combination chemotherapy, respectively. At each cycle the whole cisplatin dose was given in 1 day that is 100 mg/m(2)/day in the BEP and 70 mg/m(2)/day in the MVEC protocols. Ondansetron was given at a dose of 12 mg/day and TENS was applied by commercially available 'Relief Band'(Maven Labs, Inc., Citrus Heights, Calif., USA). The first 3 cycles of each case were blindly randomized to one of the following regimens; TENS vs. ondansetron vs. a combination of both. The regimens were applied during the administration of cisplatin and the patients were asked to report their nausea according to a scale between 0 to 10. Also for each regimen the number of emetic attacks experienced during the administration of cisplatin was recorded by the same observer. Then the scores of each regimen were compared. RESULTS: The mean nausea scores for regimens TENS, ondansetron and TENS + ondansetron were found to be 5.12 +/- 2.54, 3.0 +/- 1.71 and 0.8 +/- 0.96, respectively. Ondansetron was better than TENS in preventing nausea (p = 0.000). However the combination of TENS and ondansetron resulted in a significant decrease in nausea scores when compared to TENS alone (p = 0.000) or ondansetron alone (p = 0.000). The mean number of emetic attacks for the TENS, ondansetron and TENS + ondansetron regimens were 3.16 +/- 1.84, 1.64 +/- 1.44 and 0.56 +/- 0.82, respectively. A statistically significant difference was present between the number of emetic attacks observed with the TENS + ondansetron combination and TENS alone (p = 0.000) or ondansetron alone (p = 0.001). Ondansetron was again better than TENS in preventing emetic attacks (p = 0.001). CONCLUSION: The use of TENS as an adjunct to ondansetron therapy has provided significant benefit in preventing nausea and emetic attacks caused by cisplatin.

The application of appendiceal Mitrofanoff principle to Stanford pouch.

OBJECTIVE: The present paper reports the functional aspects of a novel continent cutaneous reservoir. PATIENTS AND METHODS: A continent cutaneous reservoir was constructed by the application of appendiceal Mitrofanoff principle to Stanford pouch in four male and three female patients between 1995-1998 in our clinic. The mean age of the patients was 45.6 years (7-67 years) and the etiological factor was carcinoma of the bladder in four, interstitial cystitis in one and extrophy-epispadias complex in two cases. Patients were followed with arterial blood gas determination, serum biochemistry, urinalysis and urine culture at postoperative 3 weeks and by 3-month intervals thereafter. Additionally, pouch graphy, abdominal ultrasonography and urodynamic tests were performed every 6 months. RESULTS: After the operation all the patients were continent. Stoma was transferred from the umbilicus to the right lower quadrant in one case (14.3%) because of difficulty in catheterisation. Pouch graphy at postoperative 6 months revealed low-grade vesicoureteral reflux in two (28.6%) patients and one (14.3%) of them required suppressive antibiotic therapy because of pyelonephritis episodes. Another patient developed hyperchloremic metabolic acidosis and needed oral alkaline supplementation. The mean pouch capacity measured at postoperative 6 months was 423 (350-550) ml and the mean end-filling pressure was found as 21 (18-25) cmH2O. After a mean follow-up period of 37 (18-45) months all the patients remained continent and stable. CONCLUSION: The continent cutaneous reservoir presented herein is our alternative to orthotopic neobladder in female patients undergoing radical cystectomy. It also provided continence as well as good quality of life in patients with extrophy-epispadias complex and male patients after radical cystectomy and urethrectomy.

Combined use of prostate-specific antigen derivatives decreases the number of unnecessary biopsies to detect prostate cancer.

The authors evaluated the prostate cancer detection rate in Turkish patients with prostate-specific antigen (PSA) levels of 4 ng/ml to 10 ng/ml and who had normal digital rectal examination (DRE) findings. They also aimed to evaluate the value of PSA density and percent free PSA in minimizing unnecessary prostate biopsies for these PSA ranges. This prospective study included 134 consecutive men referred for early prostate cancer detection or lower urinary tract symptoms. All men underwent transrectal ultrasound with systematic sextant needle biopsies. The ability of PSA density and percent free PSA to improve the power of PSA in the detection of prostate cancer was evaluated with statistical analyses as well as receiver operating characteristics curves. Among the 134 men, 124 (92.5%) had a benign histology and 10 (7.5%) had cancer diagnosed on the initial biopsies. Despite the disappointing results in regard to the sensitivity and specificity of PSA derivatives alone, the combination of PSA density and percent free PSA significantly increased the area under the curve compared with the use of each test alone. To increase the specificity of PSA in this patient population, the authors recommend combining two PSA derivatives in deciding whether to perform a biopsy. In a PSA range of 4 ng/ml to 10 ng/ml and with normal DRE, a percent free PSA < 21% and a PSA density > 0.18 yields highest specificity with 90% sensitivity.

A case against elective nephron sparing surgery for renal cell carcinoma.

A 62-year old man who incidentally was discovered to have a mass lesion in the lower pole of the left kidney underwent left radical nephrectomy. The mass was 32 millimetres in its largest diameter. Although the left adrenal gland was radiologically and macroscopically normal, histopathological examination revealed microscopic foci of metastasis. The present case urges us to be more cautious in offering partial nephrectomy for left sided tumours even though it is incidentally detected and small.

Clinical, urodynamic and endoscopic characteristics of the stanford pouch ileal neobladder constructed with absorbable staples.

PURPOSE: The clinical, urodynamic and endoscopic aspects of the Stanford pouch ileal neobladder formed with absorbable staples were investigated. METHODS: A Stanford pouch ileal neobladder was formed using absorbable staples after radical cystoprostatectomy in 30 male patients with the diagnosis of muscle invasive carcinoma of the bladder between 1995 and 1998. The mean age of the patients was 62 (range 41-70) years. Patients were followed with arterial blood gas, serum biochemistry, pouch cystography, urodynamic tests and endoscopy. RESULTS: Five (16.7%) patients had early postoperative complications and three were related to the neobladder. One year postoperatively, low grade (I, II) vesicoureteral reflux was present in five (16.7%) cases. The mean preoperative and 6 months postoperative serum creatinine levels were 1.07+/-0.3 mg/dL and 1.2+/-0.4 mg/dL, respectively, but the difference was not statistically significant (P=0.1). Six months postoperatively the mean serum chloride level was 109+/-4.5 (range 100-113) mmol/L and the mean arterial blood pH was 7.37+/-0.2 (range 7.3-7.4). Two (6.7%) patients required oral alkaline supplementation because of high chloride levels. All the patients except one were continent throughout the day after 1 year. However, nocturnal enuresis was present in 25 (83.3%) cases. The pouch capacity was increased gradually up to 12 months postoperatively and the mean pouch capacity 12 months postoperatively was 460+/-95.8mL. Micturition occurred spontaneously in most patients while some needed abdominal straining. None of the patients had a residual urine of more than 60 mL. The mean maximum flow rate 6 months postoperatively was 9.8 (range 5.4-15.0) mL/s. After 6 months the stapled edge was noticed as a nodular line. One year postoperatively only a white scar could be observed at the suture line. CONCLUSION: The Stanford pouch ileal neobladder constructed using absorbable staples was able to provide a good capacity low pressure reservoir with a low rate of complications.

The relation between p53 overexpression and lymph node metastases in clinical stage t2 and t3a transitional cell bladder carcinoma.

Mutant p53 protein overexpression is generally associated with poorly differentiated invasive bladder tumors. The survival in such cases is also expected to be poor. The objective of the present study was to determine whether immunohistochemical staining for p53 was predictive of lymph node metastases in early muscle invasive transitional cell bladder cancer. Immunohistochemical staining for mutant p53 was performed on formalin fixed transurethral resection specimens of 31 patients who underwent radical cystectomy. Eleven tumors were grade II and 20 tumors were grade III. There were 16 stage T2 and 15 stage T3a tumors. Staining with p53 was categorised as positive if distinct nuclear staining was observed in > or = 20% of the cells. Results were compared according to grade, stage (T2 versus T3a) and lymph node metastases. Seventeen tumors (55%) were positive for mutant p53. Eleven cases had lymph node metastases which could not be assessed preoperatively. The distribution of p53 positive rate between grade II and grade III cases, and T2 and T3a tumors was not different. All the 11 patients with lymph node metastases had positive tumors for p53. We assume that p53 positive rate can be used to distinguish high risk patients for lymph node metastasis. Patients with stage T2 or T3a and p53 positive bladder cancer should be considered for early aggressive treatment options.

Prognostic factors and the role of nephrectomy in metastatic renal cell carcinoma.

The objective of this study is to evaluate the prognostic factors and the role of nephrectomy in metastatic renal cell carcinoma. We reviewed 62 cases of metastatic renal cell carcinoma to document the factors influencing survival and to evaluate the role of nephrectomy. Sex and age of patients, size of primary tumor, site and number of metastases, nephrectomy, cell type and grade of tumor and medical treatment were analyzed as prognostic factors. Age and sex, cell type and type of medical treatment cannot be considered reliable predicting factors. However, improved survival was correlated with tumor size < or = 7 cm in diameter, low grade histology, metastasis limited to single organ and removal of the primary tumor. When these parameters were analyzed in a multivariate model, the presence of nephrectomy was the sole significant parameter. We therefore suggest that nephrectomy should be considered in all patients with metastatic renal cell carcinoma, as long as the morbidity of the operation is acceptable.

A solitary hydatid cyst of the retrovesical region.

A 70-year-old man presented with a large suprapubic mass. Ultrasonography revealed that the mass was cystic and displaced the bladder anteriorly and superiorly. Computed tomography suggested that the mass could be an echinococcal cyst. Computed tomography also showed that the patient had bilateral hydroureteronephrosis. Echinoccocal haemagglutination was positive at 1:320 dilution. The patient underwent surgical exploration during which the cyst was found to be located in the retrovesical region. The cyst was completely excised and the pathologic examination confirmed the diagnosis.

Quantitative evaluation of biopty gun testis needle biopsy. Correlation between biopsy score of varicocele-bearing testis and sperm count.

OBJECTIVE: To investigate the applicability of quantitative evaluation of needle biopsy of the testis and any correlation between biopsy score and sperm parameters in infertile or subfertile men with varicocele. STUDY DESIGN: A total of 45 infertile men with clinical left varicocele were included in the study. All patients underwent left varicocelectomy and bilateral biopty gun needle biopsy of both testes. Spermiograms were obtained before and three months after the operation. The biopsy specimens were evaluated for Johnsen and Agger score, Leydig cell score, germ cell/Sertoli cell ratio, mean tubular diameter, peritubular fibrosis, and tubular and basement membrane hyalinization. RESULTS: Mean sperm count, motility and normally configured motile sperm counts increased 20%, 25% and 60% by month 3, respectively (P < .05). We did not observe any significant change in normally configured sperm counts. A mean of 14 tubuli per testis were obtained with single-pass needle biopsy. Johnsen and Agger scores, Leydig cell scores, mean tubular diameter and germ cell/Sertoli cell ratios of both testes were comparable. However, there was significantly less peritubular fibrosis, tubular hyalinization and basal membrane hyalinization in the right testis when compared to the varicocele-bearing left testis (P < .05). We found positive correlations between Johnsen and Agger score of varicocele-bearing left testis and preoperative normally configured motile sperm counts (Pearson's r = .34 and P < .05 and Pearson's r = .41 and P < .05, respectively). The Leydig cell score of varicocele-bearing testis correlated inversely with sperm counts (Pearson's r = -0.37, P < .05). CONCLUSION: These observations may prove of prognostic value in infertile or subfertile men with varicocele.

Analysis of meatal location in 1,244 healthy men. Definition of the normal site justifies the need for meatal advancement in pediatric anterior hypospadias cases.

The normal site of the external urethral meatus on the glans penis and the need for meatal advancement in patients with anterior hypospadias was studied. The location of the external meatus was analyzed in 1,244 men (mean age 28 years) with classification of the meatal position in relation to the tip of the glans and corona. The quality of erections and sexual intercourse, the presence of a penile curvature, urinary stream, and ability to void in a standing position were assessed in an interview. In 1,198 men (96.3%) the meatus was located on the distal third of the glans, in 43 (3.5%) on the middle third, (B), and in 3 (0.2%) on the posterior third. In no case was it located below the corona. One of the 3 men with the meatus on the posterior third had an associated mild penile curvature that did not cause difficulty in sexual intercourse. This study suggests that the normal site of the external meatus is at the tip of the glans. The definition of the normal site and the percentage of men with a normal meatal position justifies the need for meatal advancement in patients with anterior hypospadias when the goals of current hypospadias surgery are considered.

Comparison of grading systems for estimating the prognosis of renal cell carcinoma.

In this study histologic slides of 165 patients who were diagnosed as RCC between 1983 and 1993 were re-evaluated and each tumour was graded according to Thoenes, Fuhrman, Arner and Skinner's grading systems. According to Thoenes' system, patients with grade (G) 2 and 3 tumours had significantly shorter survival compared to patients with G 1 tumours. The survival difference between the subgroups of Fuhrman and Skinner's grading systems did not reach statistical significance. When the histologic differentiation was grouped as low grade (G 1&2) and high grade (G 3&4) tumours in Fuhrman and Skinner's systems, a statistically significant difference was noted between the groups in terms of survival.

Prognostic factors in renal cell carcinoma.

In this study we evaluated some morphological and clinical prognostic factors in 166 patients with renal cell carcinoma (RCC). Patients' ages, sex and localization of the tumor had no effect on survival. Tumor diameter and the weight of the nephrectomy specimen revealed prognostic value. Stage of the tumor, especially the presence of metastasis, is the most important prognostic factor for RCC (p < 0.001). Tumor grade had prognostic value (p = 0.0146). The survival difference between cell types was not significant (p > 0.05). Renal vein invasion, the presence of pseudocapsules and tumor in the intravascular space, mitotic rate, the presence and the number of lymphocytes and macrophages, along with the presence of calcifications had no prognostic value (p > 0.05). The presence of necrotic areas was significant (p = 0.0102). The patients with "infiltrative growth pattern" showed poorer prognosis than patients with "pushing type growth pattern", regardless of the existence of a pseudo capsule (p = 0.0045).

Effects of the 5 alpha-reductase inhibitor finasteride on serum levels of gonadal, adrenal, and hypophyseal hormones and its clinical significance: a prospective clinical study.

In the present study, we investigated the effects of a steroid 5 alpha-reductase inhibitor, finasteride, when given orally (5 mg/day), on the serum levels of gonadal, hypophyseal, and adrenal hormones and the clinical significance of these effects. Forty-eight patients with a mean age of 63 (range 49-81) were included in the study. All patients had symptoms of benign prostatic hyperplasia. Serum levels of testosterone, dihydrotestosterone, follicle-stimulating hormone (FSH) luteinizing hormone (LH), prolactin, aldosterone, cortisol, and dehydroepiandrosterone were determined before the study. The degree of symptoms in each patient and serum prostate specific antigen levels were determined together with uroflowmetric studies. Sexual status of the patients was also assessed with a self-administered questionnaire. All patients received finasteride, 5 mg/day, for 6 weeks. All of the above mentioned studies were repeated at month 3 and month 6. All of the patients had baseline hormonal values within the normal range. At month 3, the dihydrotestosterone level decreased by 60%, while the testosterone level increased by 15%. FSH and LH levels decreased by 24% and 16%, respectively. The changes in the serum levels of these hormones were further evident at month 6. No significant changes were noted in the serum levels of prolactin, aldosterone, cortisol, and dehydroepiandrosterone. Thirty-six patients (75%) were judged to be potent before the treatment. Finasteride caused erectile dysfunction in 8 patients (22%) by month 3 and in 12 (33%) by month 6. A substantial improvement was noted in symptoms of benign prostatic hyperplasia in all patients. The serum prostate specific antigen level decreased by 42% and 50% at month 3 and at month 6, respectively. Continued administration of finasteride, 5 mg/day alters the serum levels of testosterone, dihydrotestosterone, FSH, and LH significantly. Finasteride also causes sexual dysfunction in a substantial number of patients and should be offered with caution to patients who have an active sexual life.

Erectile dysfunction following treatments of benign prostatic hyperplasia: a prospective study.

The effects of open prostatectomy, transurethral resection, transurethral vaporization, doxazosin and finasteride on sexual functions of men were investigated in a total of 305 patients with benign prostatic hyperplasia. The sexual functions of the patients were assessed with a questionnaire before treatment and 3 and 6 months after the treatment. A total of 212 (70%) patients were judged to be potent before the treatment. At 3 months, open prostatectomy and transurethral resection caused erectile dysfunction in 2 of 40 (5%) and 5 of 89 (6%) potent patients, respectively. At 6 months, one of the patients from the former and 2 of the patients from the latter groups who developed erectile dysfunction at 3 months stated improvement. Transurethral vaporization caused loss of erectile functions in 4 of 14 potent patients (29%) at the 3-month follow-up and, one of these patients recovered erectile functions at 6 months. Only one of the 33 patients (3%) using doxazosin stated that he lost his erectile functions both at 3 months and 6 months. At 3 months follow-up, finasteride caused loss of erectile functions in 8 of 36 potent patients (22%). Four of these patients underwent surgery (transurethral resection) after 3 months of finasteride use. At the 6-month follow-up, 4 more patients suffered from loss of erectile functions. We suggest that finasteride and transurethral vaporization have the greatest potential of impairing the sexual functions among the treatment options investigated in this study and that they must be carefully offered to the potent patients.

Prognostic factors and the role of nephrectomy in metastatic renal cell carcinoma.

The objective of this study was to evaluate the prognostic factors and role of nephrectomy in metastatic renal cell carcinoma. We reviewed 62 cases of metastatic renal cell carcinoma (RCC) at presentation to document the factors influencing the survival and to evaluate the role of nephrectomy. Sex and age of the patients, size of the primary tumour, site and number of the metastases, nephrectomy, cell type and grade of the tumour and type of the medical treatment were analyzed as prognostic factors. The age and sex of the patients, cell type and type of the medical treatment did not appear to be significant predictors of prognosis. However, improved survival was correlated with tumours < or =7 cm in diameter, low grade tumours, metastasis limited to single organ and removal of the primary tumour. When these parameters were analyzed in a combined manner patients who had undergone nephrectomy showed consistently longer survival. We suggest that nephrectomy should be considered in all patients with metastatic RCC, as long as the morbidity of the operation is predicted to be acceptable.

Lessons from 197 Mathieu hypospadias repairs performed at a single institution.

Over a 15-year period, 197 Mathieu hypospadias repairs were performed at our institution. The present study reports our experience with this operation with an analysis of factors associated with unfavorable results. Cosmetic results were either excellent or satisfactory in all but 4 cases (2%). Overall, 42 patients (21%) voided with a fistula. A history of a previous operation, flap length, type and structure of the suture, suturing technique, existence of chordee and torsion, and circumcision status were analyzed as prognostic factors. Fifteen years were divided into three equal time intervals, and the success rates of these intervals were also compared. The length of the flap, (< vs >/=20 mm), suture structure (monofilament versus multifilament), and suture type (6-0 vs 5-0) were found to be factors with a significant influence on success rates (P < 0.05). The fistula rates of the three 5-year intervals were 52%, 28%, and 11%, respectively. The difference between time periods was also significant (P < 0.01). On multivariate analysis, only the difference between time intervals remained significant. The present analysis suggests that experience could be considered the most important factor affecting the success rate of hypospadias surgery. We recommend not changing the type of operation so often that not enough experience can be gained. The best results can be achieved in the most experienced hands.

Long-term treatment of nocturnal enuresis with desmopressin intranasal spray.

The purpose of this study was to determine the efficacy and safety of long-term treatment of nocturnal enuresis with desmopressin intranasal spray. Sixty-five children with primary nocturnal enuresis with a mean age of 11.3 years (range 7-17) underwent a 2-week observation period followed by dose titration period of 1 week. Those children completely dry with desmopressin entered a randomized, placebo-controlled, double-blind phase lasting 2 weeks, followed by a 6-month open treatment. The enuretic status of the children was documented for 2 weeks after the treatment was stopped. Eleven children had no change from baseline wetting with desmopressin. Thirty-two children receiving 20 mg and 9 children with 40 mg desmopressin were completely dry. Thirteen children were wet 1-2 nights per week, which was better than in the pretreatment period. During the 6-month open-treatment period, the effect of desmopressin was found to be stable. No side effects or adverse reactions were encountered. Two weeks after the treatment was stopped, 25 children were still completely dry (38% of the initial study population, 50% of the responders). The cure rate appeared to continue beyond 18 months after discontinuation of the treatment.

13 years' experience of penile fracture.

Thirty-two cases of penile fracture in 1983-1996 were retrospectively reviewed and the patients were recalled for assessment of current status. The time from injury to repair ranged from 8 to 31 hours. The tear in the tunica albuginea was repaired with absorbable interrupted sutures. All patients were discharged on the day after operation. Skin loss required dermal grafting one month postoperatively in one patient. Erectile function returned within 2 days and coitus was achieved on average 13 days after the repair. Two patients had slight penile curvature which did not impede coitus. At long-term follow-up all patients reported satisfactory function.