Routine radiologic surveillance for obstruction is not required in asymptomatic patients after ureteroscopy.

OBJECTIVE: A retrospective medical record review was performed with the goal of determining the need for radiologic evaluation after ureteroscopy. PATIENTS AND METHODS: Of 183 patients undergoing ureteroscopic procedures at our institution between 1989 and 1993, 131 underwent postoperative radiologic studies capable of diagnosing ureteral obstruction. Of these patients, 110 (84%) were asymptomatic after the procedure, and radiologic procedures capable of displaying obstruction were performed at a median of 60 days (mean 73 days; standard deviation 189 days) after ureteroscopy. RESULTS: None of these asymptomatic patients displayed obstruction at the time of the routine follow-up radiologic procedure. Of those 21 patients (16%) who experienced flank pain subsequent to ureteroscopy, 13 were found to have ureteral obstruction secondary to ureteral calculus. One patient (1/131 or 0.8%) was found to have a ureteral stricture, which occurred after a full-thickness ureteral injury. All cases of postoperative obstruction were heralded by a concomitant display of flank pain. CONCLUSION: Routine postoperative radiologic studies are not necessary in surveillance for obstruction in the asymptomatic postureteroscopy patient, as obstruction should become evident by virtue of flank pain. The exception to this practice may be in patients experiencing a ureteral perforation intraoperatively, who may be at greater risk of stricture.

Organ preservation for the treatment of contralateral testicular seminoma.

PURPOSE: Local excision of germ cell tumor in the remaining testicle followed by a modest dose of irradiation is an alternative to orchiectomy. This organ sparing technique provides superior quality of life and reduces the need for lifelong hormone replacement. MATERIALS AND METHODS: We treated two patients with contralateral seminomas with organ preservation. Both patients received postoperative irradiation to the remaining testicle to a dose of 20 Gy in 10 fractions and 19.8 Gy in 11 fractions. RESULTS: Both patients are alive with no evidence of disease more than 3 years since the completion of their treatments. They both have reduced but preserved androgen production and retained their virility. They both are azospermic. CONCLUSION: We conclude that organ preservation for the treatment of contralateral testicular seminoma is a superior alternative to orchiectomy of the remaining testicle. It preserves male hormone production with equal survival outcome expectations.

Neoadjuvant hormonal deprivation in patients with locally advanced prostate cancer.

A total of 22 patients with locally advanced prostate cancer (stage B2 to C) was entered into a protocol for 3 months of preoperative hormonal deprivation. Of the patients 8 were judged to have clinical stage B2 and 14 to have stage C disease. The protocol regimen consisted of daily administration of flutamide (250 mg. orally 3 times per day) and leuprolide injection (7.5 mg. intramuscularly) every month. Patients with objective evidence of downstaging by prostate specific antigen (PSA) levels and transrectal ultrasound were offered surgical therapy. Of the 22 patients 20 have completed the protocol and are evaluable, and 2 of them did not show significant downstaging and elected radiotherapy. Preoperative hormonal therapy produced an average 33% downsizing of the prostate gland as determined by transrectal ultrasound volumetrics. Decreases in serum PSA values were demonstrated from a pre-hormonal average of 30 micrograms./l. (range 0.7 to 97.7) to an average of 0.53 micrograms./l. (range 0.2 to 5.7) after hormonal therapy. Of the 18 patients who underwent an operation after demonstrating significant downsizing 7 had pathologically confirmed stage B disease, 7 had stage C cancer and 4 had positive pelvic lymph nodes. Of the 8 clinical stage B2 cancer patients 3 had pathological stage B2 disease following the protocol. Of the 12 clinical stage C cancer patients 3 had pathological stage B disease, 4 had positive pelvic lymph nodes and the remainder had pathological stage C cancer. Thus, only 3 of 20 patients (15%) demonstrated pathological downstaging from the clinical stage. Downsizing the prostate volume and PSA changes with hormonal therapy were not predictive of patient outcome either alone or in combination. Preoperative hormonal therapy did not appear to facilitate the surgical procedure. Patients completing neoadjuvant hormonal therapy had an average estimated blood loss of 1,238 ml. and an average operating time of 183 minutes. A group of 20 consecutive patients with stage B2 prostate cancer who underwent radical prostatectomy without preoperative hormone therapy had an average estimated blood loss of 1,296 ml. and an average operating time of 171 minutes.

The contemporary incidence of lymph node metastases in prostate cancer: implications for laparoscopic lymph node dissection.

The incidence of lymphatic metastases in 229 consecutive patients with clinically localized prostatic cancer was assessed. Only 13 patients had nodal metastases, for an incidence of 5.7%. A monoclonal prostatic specific antigen value of more than 40 ng./ml. correlated with a positive predictive value of 53% for nodal metastases. Routine laparoscopic node dissection is unnecessary considering the low incidence of nodal metastases.

Immunotherapy for renal cell carcinoma.

The prognosis for patients with metastatic renal cell carcinoma may be brightening. Immunotherapy may offer an effective alternative approach for this disease. Continuing advances in immunology and molecular biology will probably reinforce the early enthusiasm for this method. Although still investigational, cytokine monotherapy and combination therapy, adoptive immunotherapy, and gene therapy appear to be promising therapeutic modalities for selected patients with metastatic renal cell carcinoma.