Reduction of length of stay and cost of transurethral resection of the prostate by early catheter removal.

OBJECTIVE: To determine whether early removal of the indwelling Foley catheter after transurethral resection of the prostate (TURP) significantly shortens the hospital stay without causing additional morbidity and thus saves costs. PATIENTS AND METHODS: For the year commencing 1 July 1991, 119 patients who had undergone TURP had their indwelling catheter removed on the first day after surgery. The results and morbidity of this group of patients were compared with those in 152 patients undergoing TURP during the previous year. The economic consequences of this protocol were calculated using both Medicare and CHAMPUS data. RESULTS: The demographics of the patients in both groups were similar. Post-operative complications occurred in 5% of the study patients and in 6.6% of controls; a transfusion was required in 2.5% and 1.3%, clot retention developed in 1.7% and 3.3% and the hospital stay was reduced from 3.1 to 1.28 days in the study and control patients, respectively. Using Medicare data, the mean cost saving of early catheter removal would be $829 and $1406 for patients aged < 70 and > 70 years, respectively. For CHAMPUS patients, the cost saving would be $1983. CONCLUSION: Early removal of the catheter after TURP did not increase morbidity and maintained the efficacy of the procedure. If this practice was adopted nationally, the savings resulting from the reduction in hospital stay would be considerable.

Balloon dilation of the prostate: correlation with magnetic resonance imaging and transrectal ultrasound findings.

Alternative treatments for benign prostatic hyperplasia are under intense scrutiny. Initial reports on balloon dilation therapy showed success rates of 60% to 90%, although follow-up was brief. We present a prospective non-blinded study assessing the efficacy of an investigational balloon dilatation catheter (105 Fr at 3 atm) as well as the MRI findings preoperatively and postoperatively. Twenty-seven men underwent balloon dilation and have been followed for at least 1 year. Twelve patients (44%) ultimately required definitive transurethral prostatectomy during follow-up. A mild improvement was noted in the symptom score and flow rate in the responder group. Fracture of the anterior commissure was accomplished in only 5 patients (18%) despite diligent efforts. The MRI scans showed no change in the prostate in any patients. Intraoperative transrectal ultrasound scanning suggested that proximal balloon migration can occur. Our experience with this balloon system leads us to recommend that it remain an investigational procedure.

Relative performance characteristics of prostate specific antigen and prostatic specific antigen density for the diagnosis of carcinoma of the prostate.

Prostate specific antigen (PSA) has become an important method for early detection of prostate cancer. It has been suggested that prostate specific antigen density (PSAD) may be a more efficient test for early detection than PSA alone. A series of 327 men undergoing prostate biopsy were evaluated by PSA and PSAD. When the receiver operating characteristic curves of both tests were compared, they demonstrated little improvement in the efficiency of detection with the use of PSAD. The five-fold increase in the cost of PSAD over PSA alone does not justify its inclusion in a plan for early detection for carcinoma of the prostate.

Bacillus Calmette-Guérin immunotherapy for refractory interstitial cystitis.

OBJECTIVE: To determine whether or not patients with refractory interstitial cystitis who had failed conservative therapy might benefit from intravesical bacillus Calmette-Guérin (BCG) immunotherapy. METHOD: Five patients with refractory interstitial cystitis who had failed conservative therapy underwent six weekly treatments with intravesical BCG. All 5 patients were evaluated before therapy and quarterly thereafter by water cystometry and symptom questionnaire. RESULTS: The average number of medications used daily per patient decreased from 3.2 to 1.2 after therapy. Average volumes of both first desire to void and cystometric capacity doubled after BCG. Improvement in cystometric capacity, average daytime urinary frequency, nocturia, and global pain/discomfort were statistically significant (P = 0.0277, P = 0.0131, P = 0.0199, and P = 0.0317, respectively). Three patients experienced near total relief of their symptoms with six to twelve months' follow-up (average follow-up equals 33.6 weeks). CONCLUSIONS: Although the mechanism of action of BCG in interstitial cystitis is unknown, we recommend a double-blind placebo controlled trial to confirm these results and determine an optimal dosage and treatment schedule.

Morbidity with contemporary prostate biopsy.

To determine the incidence of complications associated with contemporary prostate biopsy, a review of 670 men undergoing transrectal prostate biopsy using 18 gauge biopsy needles was conducted. Of the men 580 received 1 to 3 days of ciprofloxacin antibiotic prophylaxis. A total of 16 patients (2.1%) suffered complications of whom 4 (0.6%) required hospitalization. These data demonstrate the low morbidity associated with contemporary transrectal prostate biopsy.

Transparenchymal suture fixation and testicular histology in a prepubertal rat model.

We evaluate the effect on testicular histology when fine suture materials are used for transparenchymal suture fixation of the testis during orchiopexy in immature Sprague-Dawley rats. Significant inflammatory reactions were observed in all groups of animals with suture fixation regardless of suture size and material. Only 5% of the animals in the dartos pouch control group had an inflammatory response and no inflammation was noted in the nonoperative controls. Although these findings have not been documented in humans, this evidence raises concerns about the impact of surgical technique on the future reproductive capabilities of these testes. Alternatives to transparenchymal suture fixation of the testis should be considered in patients with cryptorchidism and testicular torsion. Sutureless dartos pouch placement may provide adequate fixation during most orchiopexies without risking injury to testicular structure and function.

Renal tumors in young adults.

Primary renal malignancies are relatively rare in young adults. Eighteen patients between the ages of twenty and forty years underwent nephrectomy for renal tumors at our institution between 1947 and 1989. Data were reviewed in this group regarding method of presentation, duration of symptoms, tumor histology, pathologic stage, and survival. Tumor histology parallels that of older patients, the majority being adenocarcinoma (78%). The duration of symptoms prior to seeking medical attention was long, averaging eighty-four weeks. The overall survival rate, excluding nontumor deaths, was 50 percent. No patient with nodal or distant metastases survived, regardless of histology.

The fate of buried vaginal epithelium.

A new technique in the treatment of stress urinary incontinence utilizes a sling fashioned from a rectangular island of buried vaginal epithelium. We developed a model to study the natural history of vaginal wall covered by an epithelial flap in 12 rabbits sacrificed at intervals to 26 weeks. Histopathologic examination demonstrated an immediate acute inflammatory reaction. This early response was followed by formation of an epithelial lining of the potential space overlying the buried vaginal tissue. Acute inflammatory cells continued to enter this lumen until week 20, when granulomas were first detected. Histopathologic examination at twenty-six weeks showed stratified squamous epithelium lining the lumen. No deleterious inflammatory sequelae were detected, and no dysplastic or malignant changes were identified. These results suggest that buried vaginal epithelium is a safe (short term) tissue alternative for sling creation.

Current urological practice: routine urological examination and early detection of carcinoma of the prostate.

With the increasing incidence of carcinoma of the prostate, the interest in early diagnosis through screening has dramatically increased. Several organizations, including the American Urological Association (AUA) and the American Cancer Society, have promulgated recommendations on suggested early detection methods. To determine the current practice patterns of United States urologists, a survey was sent to a random sample of 10% of all urologist members of the AUA. The survey was designed to determine what are current recommendations for an annual urological checkup for older men, what tests should be included in screening for carcinoma of the prostate and what age groups of men should undergo prostate cancer screening. A total of 562 surveys was returned, constituting a 4.7% sample of all urologist members of the AUA. The use of digital rectal examination was unanimously recommended for the urological examination as well as for prostate cancer detection. Prostate specific antigen was recommended by a majority of respondents for both situations. Screening was recommended for men ages 50 to 80 years. Demographic factors had a significant role in clinical recommendations by urologists.

Surgical treatment of carcinoma of the male urethra.

Despite the distinct rarity of carcinoma of the male urethra, the eventual outcome for a significant proportion of patients presenting with this process hinges on the selection and proper accomplishment of surgical therapy. Lesions of the posterior urethra seem to have a worse prognosis and may warrant aggressive therapy. Close attention must be given to the evaluation and treatment of the regional lymph nodes in all cases. The authors review the nuances of the various surgical options for these cancers.

Presentation and clinical course of patients ultimately succumbing to carcinoma of the prostate.

Ninety-six patients who expired due to carcinoma of the prostate were identified within the primary treatment area of Brooke Army Medical Center between the years of 1981 and 1988. Although 71 patients were noted to have abnormal prostate examinations at the time of diagnosis, 11 had been noted to have a palpably normal prostate within three years of tumor diagnosis. Twenty-four patients had a palpably normal prostate at the time of diagnosis. Fifteen patients had been previously noted to have an abnormal prostate but biopsy in 11 of these had been benign. These data suggest that digital rectal examination of the prostate will not detect a number of patients who will ultimately die of carcinoma of the prostate.

Experience with Duraphase penile prosthesis: its use as replacement device.

The Duraphase Penile Prosthesis is a new, articulating type of semirigid prosthesis which appears to have several advantages over other semirigid penile prostheses. This series describes the experience with this prosthesis in 12 patients and highlights the experience in 4 patients who underwent removal of other types of prostheses due to mechanical or functional problems and replacement with the Duraphase prosthesis. The device has been mechanically reliable during short follow-up, and there has been excellent patient satisfaction.

Sudden death due to disease flare with luteinizing hormone-releasing hormone agonist therapy for carcinoma of the prostate.

Luteinizing hormone-releasing hormone agonist therapy for prostate cancer is a new method of management for metastatic disease. During the initial 1 to 2-week period of administration an increase in serum testosterone concentration can lead to an exacerbation of clinical symptoms (flare phenomenon). Two patients are summarized who received luteinizing hormone-releasing hormone agonist therapy without flare blockade and died suddenly during month 1 of therapy. A review of 765 patients in 9 series found 10.9% who suffered disease flare and 15 who died during disease flare. Of these 17 patients 12 were similar to our 2. These data suggest that any patient placed on luteinizing hormone-releasing hormone agonist therapy for prostate cancer merits some form of flare blockade during the initial 1 or 2 months of therapy.

Extended follow-up of stage A1 carcinoma of prostate.

The prognosis and proper treatment of Stage A1 carcinoma of the prostate remain unsettled. We report on 60 patients with Stage A1 prostate cancer (less than 5 foci of well-differentiated tumor) diagnosed between 1960 and 1980. Mean duration of follow-up was 7.5 years with a range of one to twenty years. Three patients (5%) suffered disease progression at two, five, and nineteen years of follow-up, and all died of their tumor. Thirty-four patients (56%) have died of other causes. Number of tumor foci had no correlation with chance of disease progression. Extended follow-up of these patients suggests that the vast majority with Stage A1 carcinoma of the prostate will not suffer from morbidity or mortality of the disease but will more commonly succumb to other intervening disease processes.

Complete urinary obstruction following periurethral polytetrafluoroethylene injection for urinary incontinence.

We report a unique case of foreign body granulomatous reaction after periurethral polytetrafluoroethylene injection causing complete urinary obstruction. Urinary obstruction in the immediate postoperative period and granuloma formation following polytetrafluoroethylene injection are not unusual. To our knowledge delayed complete urinary obstruction after polytetrafluoroethylene injection has not been described previously in the urological literature.

Spurious impotence after hypospadias repair.

A fifteen-year-old who had undergone multiple hypospadias repairs alleged erectile dysfunction as a result of his surgery. A new method of nocturnal penile tumescence and rigidity monitoring supplied objective evidence to refute this allegation. Attention is drawn to the need for and availability of written documentation when diagnosing the presence or absence of erectile ability.

Surgical treatment of the incontinent female patient with myelomeningocele.

Surgical therapy was required for 42 incontinent female patients with myelomeningocele who had urodynamically documented high pressure bladders. Conservative treatment consisting of cholinolytic and alpha-adrenergic agents, and intermittent self-catheterization had failed. The surgical approach consisted of perivesical denervation (for hyperreflexia), Burch bladder neck suspension, enlargement cystoplasty and ureteral reimplantation when required. Among 33 patients (79 per cent) there was no incontinence on intermittent self-catheterization and 6 (14 per cent) had improvement with rare urgency or stress incontinence. In 3 patients (7 per cent) sphincteric incompetence required a transvaginal sling procedure.