Clinical follow-up in 24 nonfamilial renal tumors cytogenetically characterized in tissue culture.

OBJECTIVE: This study investigates the relationship between clonal chromosomal abnormalities detected in nonfamilial renal cell carcinoma and the clinical outcome, specifically, whether or not patients whose tumors had karyotypic changes have a different prognosis than those whose tumors did not. METHOD: Fresh tumor tissue obtained from 32 cases was grown in tissue culture. Twenty four grew successfully and were harvested and multiple cells of each karyotyped. Clinical follow-up was obtained for at least five years or until the time of death. RESULTS: Fourteen of 24 cases demonstrated karyotypic abnormalities including loss of Y chromosome (64%), trisomy 7 (50%), trisomy 12 (14%), trisomy 9, 10, 14, 15, 16, and 17, monosomy 9 and 20, and long-arm deletion of chromosome 16 (1 case each). Tumors were well-differentiated in 16 cases, moderately differentiated in 5 cases, and poorly differentiated in 1 case; 13 cases were pathologic Stage I, 5 Stage II, and 6 Stage III. Thirty-three percent of the patients demonstrated clinical progression. CONCLUSIONS: No significant difference in prognosis could be found between patients with and without karyotypic abnormalities. The only clinical or pathologic difference which could be established was sex distribution. Significantly greater numbers of males had karyotypic abnormalities than females, but this could be explained by the high number of Y chromosome deletions that were detected. The lack of correlation between karyotypic abnormalities and clinical outcome may reflect a confounding factor in genetic evolution such that clinically determining chromosomal changes present early in a tumor's growth in vivo may no longer be present when the tumor is diagnosed, treated, or after it is grown in culture. This may make demonstration of such clinically significant chromosomal changes very difficult.

Effect of multidose intracorporeal injection and audiovisual sexual stimulation in vasculogenic impotence.

Erections are inhibited by sympathetic stimulation. Anxiety or psychologic inhibition may produce abnormal response during impotence workup. The use of intracorporeal alpha blockers (phentolamine) and audiovisual sexual stimulation (AVSS) has been used to decrease sympathetic outflow and enhance erectile response. Thirty-three patients with suspected vasculogenic impotence were studied. They underwent pulsed Doppler ultrasound (PDUS) with multiple doses of tri-mix (mix of papaverine, phentolamine, and prostaglandin E1). AVSS was applied after maximal response to tri-mix. Seventeen patients (51.5%) responded to multidose with grade IV or V erection. When AVSS was started, 5 more patients responded, and 7 upgraded to grade V with overall response of 40 percent. AVSS can augment the in-office response to pharmacologic testing above that obtained by "maximal" pharmacologic dosing, thereby increasing the sensitivity and specificity of the test.

Bellevue pouch: ileocolonic continent urinary reservoir.

The technique for the Bellevue Pouch, another continent intestinal reservoir, is described. A large-capacity low-pressure reservoir is created from detubularized ascending colon, cecum, and terminal ileum. Continence is achieved by means of an intussuscepted segment of ileum and a modulating colonic pressure cuff wrapped around it. The operation has been performed on 19 patients, all of whom achieved satisfactory continence. Two patients were converted to free drainage systems at a later date. Average follow-up was twenty-five months.

Potentiation of drug-induced erection with audiovisual sexual stimulation.

Twenty-five patients underwent audiovisual sexual stimulation (AVSS) after pharmacologically-induced erection. Grade of erection and cavernosal blood flow were assessed after intracorporeal (IC) injection of TRI-MIX or prostaglandin E1, and then after AVSS, using pulsed Doppler ultrasonography (PDUS). After IC injection, 5 patients had a Grade II erection, 8 had Grade III, 10 had Grade IV, and 2 had Grade V. There was an increase in peak arterial flow and arterial diameter which corresponded with the grade of erection obtained. After addition of AVSS, 56.5 percent of patients experienced improved erection. The improvement from Grade III to IV in 13 percent is especially significant because it showed the attainment of adequate erection when IC injection alone failed. Penile blood flow improved among AVSS responders but not in nonresponders. AVSS may enhance pharmacologically-induced erection and may improve the diagnostic accuracy of PDUS.

Use of gadolinium-DTPA-enhanced MRI to characterize renal mass in patient with renal insufficiency.

A patient with chronic renal insufficiency was found to have an indeterminate renal mass after renal ultrasound, non-contrast CT, and non-contrast MRI studies. The mass was correctly diagnosed as an enhancing tumor with gadolinium-DTPA-enhanced magnetic resonance imaging.

Multiphasic diagnostic evaluation of arteriogenic, venogenic, and sinusoidogenic impotency. Value of noninvasive tests compared with penile duplex ultrasonography.

Fifty patients with a mean age of fifty-five years (range 25 to 75 years) in whom vasculogenic impotency was suspected clinically were evaluated to determine the type of vascular lesion involved: arterial insufficiency, venous leak, or sinusoidal dysfunction. All patients underwent first, noninvasive diagnostic tests including penile brachial index, penile brachial subtraction index, and penile plethysmogram, followed by penile duplex ultrasonography with papaverine and phentolamine injection. Patients with abnormal ultrasonography were divided into two groups: One group with suspected sinusoidal dysfunction and those with either arteriogenic or venogenic insufficiency but not considered candidates for surgery; they were not subjected to further studies. Another group with suspected proximal arteriogenic lesions and those with suspected venous leakage considered candidates for surgical correction were subjected to angiography and cavernosometry-cavernosography, respectively. The findings of the noninvasive tests were compared with those provided by the invasive tests. The results indicated that noninvasive tests can predict whether or not impotency is arteriogenic in approximately 90 percent of cases. The noninvasive tests, however, were less accurate in predicting venogenic and sinusoidogenic impotency, for which penile duplex ultrasonography seems to be the choice.

Partial nephrectomy for renal cell carcinoma: indications, results and implications.

Of 52 patients who underwent partial nephrectomy for tumor 44 were found to have renal cell carcinoma. The indications for this parenchyma-sparing procedure were categorized according to the initial status of the contralateral kidney and included bilateral tumors or tumor in a solitary kidney in 16 patients (mandatory indications), unilateral carcinoma with compromise of the contralateral kidney by a benign disease process in 9 (relative indications) and small peripheral tumor with a normal contralateral kidney in 19 (elective indications). There were 4 recurrences that accounted for 3 deaths, all in patients with mandatory indications. All patients who underwent partial nephrectomy for relative or elective indications were without definite evidence of recurrent disease at last followup (over-all mean 36 months). Our results suggest that conservative surgery can often provide effective and advantageous therapy for renal cancer and we encourage further consideration of the role of partial nephrectomy as an alternative to radical nephrectomy in selected patients with small peripheral tumors and normal contralateral kidneys.

Perirenal candidial abscess.

Perirenal candidial abscesses are rare, with few well-documented cases in the literature. We describe a case of a perinephric abscess treated with amphotericin B and nephrectomy.

Transpubic approach for lower urinary tract surgery: a 15-year experience.

Surgery on lower urinary tract organs sometimes is hindered by the symphysis pubis, which by its position and bulk could severely restrict maneuverability. Since 1972 we used a transpubic approach to improve surgical exposure in 287 patients operated on for prostate, bladder or urethral cancer, post-traumatic strictures and other conditions. The type of pubectomy performed (total, partial superior or partial inferior) depended upon whether a suprapelvic or infrapelvic diaphragm organ was the primary target of the approach. Total pubectomy was used in 137 patients, partial superior bone resection in 140 and partial inferior resection in 10 patients. Technical details for each type of pubectomy are illustrated. The transpubic approach was particularly useful for repair of posterior urethral strictures or removal of bulky tumors. Among the 3 types of approaches used, total pubectomy was associated with a high complication rate including bleeding, pelvic instability, urinary incontinence and stricture of the vesicourethral anastomosis. Therefore, we have abandoned the technique since 1978. Partial pubectomy provides exposure comparable to that of total pubectomy but with minimal complications, making it an alternative to the standard approach in difficult cases.

Primary amyloidosis of urethra.

Primary localized amyloidosis of the urethra is rare; only 17 cases reported to date. Its clinical importance is significant, however, in that its presentation mimics carcinoma and treatment should be conservative. We describe an additional case and briefly review the literature.

Cytogenetic, flow cytometric, and ultrastructural studies of twenty-nine nonfamilial human renal carcinomas.

Multifactorial analysis, including cytogenetic studies, flow cytometry, and light and electron microscopic evaluation, was performed on 29 primary renal cell carcinomas and short-term cultures derived from them. Eleven of the 21 cases that yielded cytogenetic results demonstrated clonal chromosomal aberrations which included trisomy 7 in 8 cases, loss of the Y chromosome in 7, trisomy 12 in 2, and 16q- in 1. Flow cytometry showed that there was preferential growth of near-diploid populations and loss of aneuploid clones in culture with standard media. The ultrastructural features of both the primary and cultured tumors were remarkably similar. They included cytoplasmic vacuolization, reticulated dense nucleoli, and cell surface microvilli. Thus, morphological evidence supported the epithelial and, specifically, the renal tubular origin of the cultured cells. The development of chromosomal abnormalities seemed linked to advanced tumor stage, but the number of such cases was too small to analyze for statistical significance. No other correlations could be made between karyotypic change, DNA analysis, tumor histology, grade, and stage at this point in the patient follow-up.

Radical prostatectomy for stage D1 prostate cancer. Prognostic variables and results of treatment.

Surgical extirpation of the primary tumor together with the involved regional nodes has been considered ineffective treatment for locally disseminated prostatic carcinoma. We retrospectively reviewed our experience with 42 patients with Stage D1 disease who underwent radical prostatectomy and bilateral pelvic lymphadenectomy and who had a follow-up of one to thirteen years (mean 5 years). The following variables affecting survival and tumor progression were analyzed: (1) tumor grade and local extent; (2) number of positive lymph nodes, and (3) adjuvant therapy. The overall five- and ten-year survival was 79.5 per cent and 28 per cent compared with the expected survival of an age-matched control group of 88 per cent and 28 per cent, respectively. The degree of tumor differentiation had no effect on prognosis, but local tumor bulk and the number of involved lymph nodes significantly changed the disease progression and survival rate. Patients with low local tumor bulk and one positive node survived as long as the age-matched male population group. Our data suggest that radical prostatectomy may represent a valuable treatment in selected patients with Stage D1 prostate carcinoma.

Immunocytochemical localization of hFSH as an index of Sertoli cell function in the human testis.

The FSH receptor in the human testis has not been well characterized in vivo. Using an immunoperoxidase technique we have attempted the immunocytochemical localization of FSH in testicular tissue from patients with a variety of disorders including oligo- or azoospermia (N = 6), cryptorchidism (N = 3), and prostatic carcinoma (N = 3). Specific staining for hFSH was observed inside the seminiferous tubule, generally near the basal membrane in all except the cryptorchid patients. Specific staining was also localized in the luminal area of the seminiferous tubule. In most cases, FSH-positive cells were also found in the interstitium, with a minority of the cells being macrophages. The latter were more prevalent in the undescended testes and in orchiectomy specimens from patients with prostatic cancer. The pattern of FSH localization observed in this study probably represents receptorbound hormone, and may reflect damage to the Sertoli cell and its tight junctions. Further study of the changes in receptor distribution as an indication of Sertoli cell malfunction, may be helpful in our understanding of human testicular disorders.

Spongious bone density determination for staging and follow-up of patients with prostatic cancer.

Quantitative computerized tomography (QCT) of vertebral bodies could reveal metastatic spread of prostatic cancer before such lesions are seen with standard examinations. Focal increase in the density of the spongious bone in face of normal bone scan and serum acid phosphatase is suggestive of metastasis, but certitude is gained only if further increase in density or structural bone changes are demonstrated on follow-up studies. QCT also may provide an objective measurement of tumor response to therapy.

Aggressive treatment of metastatic renal cancer.

Radical nephrectomy and excision of metastases were performed in 21 patients with metastatic renal cell carcinoma. Followup was 12 years. Eight patients had metastases at the time of diagnosis and survived an average of 54 months, with 50 per cent alive 5 years postoperatively. Metastases developed after nephrectomy for localized disease in 13 patients. After extirpation of the secondary lesions these 13 patients survived an average of 38 months and 25 per cent were alive at 5 years. Survival varied with the length of time free of disease. Patients in whom metastases developed later than 2 years after nephrectomy survived 55 months compared to only 22 months for those in whom metastases developed earlier. Survival also was influenced by tumor aggressiveness (reflected by prognostic index number) and completeness of surgical excision of the secondary lesion.

Renal cell carcinoma: survival and prognostic factors.

Three hundred twenty-six patients treated at New York University from 1970 to 1982 were studied for survival in relationship to surgical stage, type of therapy, and pathologic characterization of the primary tumor. At the time of diagnosis 25.5 per cent of tumors were Stage I, 15 per cent Stage II, 28.5 per cent Stage III, and 31 per cent Stage IV. The retrospective study showed that patients with tumor confined within the capsule achieved the highest five- and ten-year survivals of 88 per cent and 66 per cent, respectively. Survivals decreased as tumor invaded perirenal fat (67% and 35%) or regional lymph nodes (17% and 5%). Tumor invasion into the renal vein alone did not significantly change five-year survival (84%) but lowered ten-year survival to 45 per cent. Patients with metastases at the time of nephrectomy did poorly regardless of site of metastases or kind of adjuvant therapy, except for those managed by surgical extirpation of the secondary lesion. Certain tumor characteristics were associated with a better prognosis, e.g., size below 5 cm in diameter, lack of invasion of collecting system, perirenal fat or regional lymph nodes, and predominance of clear or granular cells growing into a recognizable histologic pattern.

Use of profile view of kidney for spatial localization of intrarenal stones.

Profile view of the kidney obtained by "reverse oblique" x-ray projection was found to be useful in the spatial localization of intrarenal stones. The patient's position on the x-ray table is described, and 4 cases of patients with renal stones are illustrated.

Diagnostic ultrasound of scrotum.

Ultrasound is a proved, safe diagnostic procedure. Its efficacy in the evaluation of 54 cases of scrotal pathology is reviewed. Ultrasound was 100 per cent accurate in the evaluation of hydroceles, hematoceles, and paratesticular masses, but less informative in testicular abscesses (80%) and epididymo-orchitis (77%).

Value of scrotal scanning. Report of 62 cases.

A review of sixty-two technetium scrotal scans performed over a one-year period has led to a classification of pathologic states based on the degree of uptake of the radioactive isotope. Absent uptake, or a "cold" scan, is present only with testicular torsion, and rarely with avascular tumors. Increased uptake, or a "hot" scan, is most commonly seen with inflammatory conditions such as acute epididymitis and orchitis, and less commonly with tumor. "Mixed" scans can be associated with abscess, tumor with necrosis, trauma, and late torsion.