A prospective quality-of-life study in men with clinically localized prostate carcinoma treated with radical prostatectomy, external beam radiotherapy, or interstitial brachytherapy.

PURPOSE: To prospectively assess the health-related quality of life (HRQOL) and changes in HRQOL during the first year after 3 different treatments for clinically localized prostate cancer. METHODS AND MATERIALS: Ninety men with T1-T2 adenocarcinoma of the prostate were treated with curative intent between May 1998 and June 1999 and completed a quality-of-life Functional Assessment of Cancer Therapy-Prostate (FACT-P) questionnaire before treatment (T0) and 1 month (T1), 3 months (T3), and 12 months (T12) after treatment. Forty-four men were treated with permanent source interstitial brachytherapy (IB), 23 received external beam radiotherapy (EBRT), and 23 men were treated with radical prostatectomy (RP). The mean age of the entire study population was 65.9 years (median 67, range 42-79). The mean pretreatment prostate-specific antigen level of the entire study population was 6.81 ng/mL (median 6.25, range 1.33-19.6). The Gleason score was

Transrectal ultrasound and biopsy in the early diagnosis of prostate cancer.

BACKGROUND: Historically, the prostate was evaluated for cancer by simple digital rectal examination, and biopsy to obtain a tissue diagnosis of cancer was performed blindly. The advent of ultrasound technology offered a new way to evaluate the prostate, and biopsy techniques were soon developed to incorporate ultrasound guidance. METHODS: The authors review the role of transrectal ultrasound (TRUS) of the prostate and ultrasound-guided biopsy of the prostate in the diagnosis of prostate cancer. These techniques are traced from their origins to the current standards of care, with attention paid to developments and controversies in recent literature. RESULTS: Early experience with TRUS led to the description of "classic" sonographic findings of prostate cancer. To obtain a tissue diagnosis of cancer, these regions were initially targeted in ultrasound-guided biopsies. Concomitant with the development of TRUS, though, was the development of the prostate-specific antigen (PSA) assay. Over the past decade, there has been a profound stage migration due to earlier detection of prostate cancer. Most patients now diagnosed with prostate cancer have no palpable abnormality or specific sonographic findings. In response, ultrasound-guided biopsies have become more systematic, rather than lesion-specific, in nature. CONCLUSIONS: TRUS continues to play an important role in the evaluation of the prostate when malignancy is suspected. Although the optimal method of prostate biopsy is controversial, ultrasound is critical in ensuring accurate sampling of the gland.

Are coagulation studies necessary before percutaneous nephrostomy?

PURPOSE: Performance of coagulation studies for patients undergoing percutaneous nephrostomy (PCN) has been advocated by some investigators. We performed a retrospective study to assess this practice. MATERIALS AND METHODS: The medical records of 180 patients subjected to PCN for various reasons between October 1991 and July 1998 were reviewed. This represents a subset of patients in whom PCN was performed by an experienced interventional radiologist at our institution. Patients were excluded if they had a history of active liver disease, hematologic or bleeding disorder, current use of heparin or warfarin, or platelet count <100,000. The remaining 160 patients were separated into two groups. Group 1 consisted of 153 patients with a normal prothrombin time (PT) and partial thromboplastin time (PTT). Group 2 comprised 7 patients with an abnormal PT or PTT. Demographic and laboratory data including PT, PTT, complete blood, and platelet counts were analyzed to determine if a hemorrhagic complication could be predicted by an abnormal PT or PTT. RESULTS: In group 1 the mean PT was 12.2 seconds and the mean PTT was 25.0 seconds; in group 2 the mean PT was 13.9 seconds and the mean PTT was 30.3 seconds. The hemorrhagic complication rates were not statistically different between the two patient cohorts (p = .203). Demographic and standard laboratory data were not predictive of abnormal coagulation parameters. CONCLUSIONS: Screening coagulation studies are unnecessary in the standard patient subjected to PCN.

Is there a learning curve in diagnosing urolithiasis with noncontrast helical computed tomography?

OBJECTIVE: To report one department's experience with helical computed tomographic (HCT) evaluation of patients with suspected renal colic to diagnose ureteral calculi; to determine whether there is a learning curve in performing HCT in this context; and to determine whether HCT for the evaluation of renal colic exposes patients to more radiation than the standard intravenous pyelography (IVP) combined with nephrotomography. METHODS: All patients presenting to the emergency department with flank or abdominal pain were evaluated with nonreformatted noncontrast HCT. To determine changes in diagnostic accuracy, patients were divided into 2 groups: those evaluated between September 1996 and January 1997 (group 1, 67 patients), and those seen from February to June 1997 (group 2, 53 patients). A radiation exposure study was performed using phantoms, and radiation exposure for HCT, IVP and nephrotomography was measured. RESULTS: Review of HCT scans to diagnose ureteral calculi had a sensitivity of 91.7%, specificity of 82.6%, and accuracy of 87.2% in group 1, and a sensitivity of 95.5%, specificity of 86.7%, and accuracy of 91.9% in group 2. Patients undergoing IVP with nephrotomography were exposed to an effective dose equivalent of 343 mrem (dSv) (for men) and 664 mrem (for women). The effective dose equivalent for an HCT scan was 180 mrem. CONCLUSION: HCT offers excellent, rapid diagnostic accuracy without the need for intravenous contrast medium and with a lower radiation exposure level than IVP in evaluating patients with acute flank pain. There is a small but real learning curve in evaluating patients with acute flank pain with HCT.

Thoracoabdominal radical nephrectomy: is a postoperative thoracostomy tube necessary?

OBJECTIVES: To report our results of patients undergoing thoracoabdominal radical nephrectomy without intraoperative placement of a thoracostomy tube. It has been routine in our hospital to not place a thoracostomy tube in patients undergoing thoracoabdominal radical nephrectomy since 1988. METHODS: We conducted a retrospective review of 47 thoracoabdominal radical nephrectomies performed from January 1988 through November 1998 at our institution. Of the 47 patients, 39 did not have a thoracostomy tube placed intraoperatively; the other 8 patients did. The development of all postoperative complications, length of hospital stay, and hospital charges were noted. RESULTS: No postoperative mortality was noted in our study. Of the 47 patients in the study, 20 patients had a total of 29 complications. The overall number of complications was not increased in the group without a thoracostomy tube compared with the group with a thoracostomy tube (P = 0.104). No patient treated without a thoracostomy tube required subsequent placement of a tube for persistent pneumothorax. The mean length of hospital stay in patients with a thoracostomy tube after radical nephrectomy was 9.14 +/- 2.65 days; in patients without a thoracostomy tube, the mean length of stay was 7.07 +/- 3.97 days (P = 0.071). CONCLUSIONS: In patients without parietal pleural injury, thoracoabdominal radical nephrectomy without the placement of a thoracostomy tube can be performed safely and effectively, with a low risk of postoperative complications and a decrease in the overall hospital stay and hospital charges.

A prospective analysis of patient-reported quality of life after prostate brachytherapy.

The purpose of this study was to prospectively assess the patient-reported quality of life (QOL) and changes in QOL during the first 3 months after prostate brachytherapy (PB). Seventy-four men treated with PB between September 1997 and December 1998 completed a QOL questionnaire (Functional Assessment of Cancer Therapy-Prostate [FACT-P]) and a measurement of urinary symptoms (International Prostate Symptom Score [IPSS]) before treatment (T0), 1 month (T1), and 3 months (T3) following PB. All participants were treated with (125)I alone. The mean score (and standard deviation) at T0, T1, and T3 FACT-P questionnaire are as follows: 139.2 (15.7), 125.4 (20.2), and 133.0 (18.2). For the global test across time, statistically significant differences were observed for the cumulative scores of FACT-P (P < .0001). Examination of the subscales within the FACT-P instrument demonstrated statistically significant changes over time for the following: physical well-being, functional well-being and the prostate cancer subscale. The mean score (and standard deviation) at T0, T1, and T3 for the IPSS questionnaire are as follows: 9.1 (5.9), 20.0 (7.8), and 16.6 (7.2). For the global test across time, statistically significant differences were observed for the IPSS scores (P < .0001). Clinically meaningful decreases in QOL are evident within weeks after PB. Moderate to severe urinary symptoms persist for at least 3 months following PB.

A preliminary analysis of health-related quality of life in the first year after permanent source interstitial brachytherapy (PIB) for clinically localized prostate cancer.

PURPOSE: To prospectively assess the health-related quality of life (HRQOL) and changes in HRQOL during the first year after permanent source interstitial brachytherapy (PIB). METHODS AND MATERIALS: Thirty-one men treated with PIB between September 1997 and March 1998 completed a quality of life (functional assessment of cancer therapy-prostate: FACT-P) and a urinary symptom questionnaire (international prostate symptom score: IPSS) prior to treatment (T0), 1 month (T1), 3 months (T3), 6 months (T6), and 12 months (T12) following PIB. All participants were treated with 125I alone. Repeated measures analyses of variance (ANOVA) were conducted on all quality of life and urinary outcome measures for all 31 patients at all time points. RESULTS: The median age of the study population was 66 (range 51-80). All men had clinical T1c-T2b prostate cancer. The Gleason score was < or =6 in 27/31 (87%). Median pretreatment PSA was 7.8 ng/ml (range 1.1-20.6). The mean score (and standard deviation) at T0, T1, T3, T6, and T12 for the FACT-P questionnaire are as follows: 140.5 (13.5), 132.7 (15.3), 137.2 (17.4), 140.1 (16.0), and 142.4 (15.3). For the global test across time, statistically significant differences were observed for the cumulative scores of FACT-P (p<0.0012). The decrease in HRQOL was most marked 1 month following PIB. Examination of the subscales within the FACT-P instrument demonstrated statistically significant changes over time for the following: physical well-being (PWB), functional well-being (FWB), and prostate cancer (PCS). By 3 months, all HRQOL measures had returned to near baseline. The mean score (and standard deviation) at T0, T1, T3, T6, and T12 for the IPSS questionnaire are as follows: 8.3 (5.5), 18.4 (8.0), 15.7 (7.4), 13.7 (7.4), and 10.2 (5.7). For the global test across time, statistically significant differences were observed for the IPSS scores (p<0.0001). The maximum increase in IPSS occurred 1 month following PIB. CONCLUSION: The results of this preliminary analysis suggest that clinically meaningful decreases in HRQOL, as measured by the FACT-P instrument, are evident within weeks after PIB. By 3 months, however, FACT-P scores return to near baseline levels. A validated instrument designed to measure urinary symptoms (IPSS) demonstrates that moderate to severe urinary symptoms persist for at least 3-6 months following PIB. One year following PIB, the scores on the FACT-P and IPSS questionnaires had returned to baseline.

Postimplant analysis of transperineal interstitial permanent prostate brachytherapy: evidence for a learning curve in the first year at a single institution.

PURPOSE: The utilization of transperineal interstitial permanent prostate brachytherapy (TIPPB) is increasing in the United States. Quality assessment of TIPPB is in its infancy, and to date, dosimetric analyses have only been reported from centers with a large experience in prostate brachytherapy. The purpose of this report is to critically analyze the dosimetric coverage achieved following TIPPB in the first 63 cases performed by a multidisciplinary group of investigators with no prior experience with TIPPB. METHODS AND MATERIALS: The information in this report concerns the first 63 men treated with TIPPB alone at our institution between September 1997 and September 1998. All men were treated similarly, adapting the methods described by Blasko and Grimm. All men were treated with 125I. The prescription dose was 144 Gy according to the TG43 formalism. TIPPB was performed jointly by a radiation oncologist and a urologist. One month following TIPPB, all men underwent a computed tomography (CT) scan of the pelvis according to a protocol using 3-mm abutting slices. CT images were transferred by a local area network to a commercially available treatment planning system and dose-volume histograms were calculated with 0.5-mm pixel spacing. A variety of dosimetric endpoints were examined. A single measure of dose homogeneity, the dose-homogeneity index (DHI), is defined as the volume within the prostate that receives 100-150% of the prescription dose (144-216 Gy) divided by the volume within the prostate that receives 100% of the prescription dose (144 Gy). Three measures of target (prostate) dosimetric coverage are provided. C100 is defined as the percentage of the prostate volume defined on postimplant CT that receives at least 100% of the prescription dose. C90 and C80 are similar but represent the percentage of the prostate volume that receive 90% and 80% of the prescription dose, respectively. Statistical analyses were performed using commercially available computer software. To investigate any changes with time the first 30 cases (group 1) are compared to cases 31-63 (group 2). All p-values are two-sided. RESULTS: The mean C100, C90, and C80 for all 63 patients were 80.7% (SD 10.1), 85.1% (SD 10.2), and 89.3% (SD 9.5). The quantifiers of implant adequacy were all improved in the most recent 33 patients compared to the first 30 patients, (group 1: C100, 75.8% [SD 12.2], C90 79.9% [SD 11.4], C80 84.3% [SD 11.1]; group 2: C100, 85.2 [SD 7.0], C90 89.9% [SD 5.8], C80 93.8% [SD 4.2]; p<0.001). The mean DHI was 0.538 SD (0.124). A multivariate model incorporating a number of variables (ultrasound volume, CT volume, total activity, activity/ seed, implant number) with C100 as the dependent variable found that the implant number was the only statistically significant predictor of C100 (p = 0.0001). Using C90 and C80 as the dependent variable produced similar results (C90, p = 0.0001; C80, p = 0.0001). CONCLUSION: In this single institution experience with the first 63 men receiving TIPPB by a multidisciplinary group of investigators, there is evidence for a learning curve. All quantifiers of implant adequacy improved as clinicians gained experience. In the most recent group of patients, quantifiers of implant adequacy are similar to those reported from other groups with significantly more experience with TIPPB.

Early quality of life assessment in men treated with permanent source interstitial brachytherapy for clinically localized prostate cancer.

PURPOSE: We prospectively assessed quality of life changes with time using validated instruments in men with clinically localized prostate cancer treated with permanent source interstitial brachytherapy. MATERIALS AND METHODS: A total of 46 men consecutively treated with permanent source interstitial brachytherapy between September 1997 and June 1998 completed quality of life (Functional Assessment of Cancer Therapy-Prostate [FACT-P]) and urinary symptom (International Prostate Symptom Score [I-PSS]) questionnaires before (T0), and 1 (T1) and 3 (T3) months after treatment. All participants were treated with 125iodine alone. Repeated measures analyses of variance were conducted on all quality of life and urinary outcome measures for 44 patients with data at all 3 time points. RESULTS: Median patient age was 68 years (range 51 to 80). All men had clinical T1c to T2b prostate cancer, Gleason score was 6 or less in 36 (78%) and median pretreatment prostate specific antigen was 7 ng./ml. (range 1.1 to 20.6). Mean score (and standard deviation) at T0, T1 and T3 for each questionnaire was FACT-P 138.9 (14.4), 128.6 (19.4) and 136.7 (17.4), TO versus T1 p = 0.0005 and T0 versus T3 p = 0.6612, and I-PSS 8.3 (5.4), 19.7 (9.0) and 15.7 (7.2), T0 versus T1 p = 0.0001 and T0 versus T3 p = 0.0001. For the global test across time statistically significant differences were observed for the cumulative scores of FACT-P, I-PSS, physical well-being and prostate cancer subscales of the FACT-P and the Trial Outcome Index. By 3 months all quality of life measures had returned to baseline. Urinary symptoms as measured by I-PSS persisted for at least 3 months. CONCLUSIONS: Clinically meaningful decreases in quality of life, as measured by the FACT-P instrument, were evident within weeks after permanent source interstitial brachytherapy. However, by 3 months FACT-P scores returned to near baseline levels. A validated instrument designed to measure urinary symptoms (I-PSS) demonstrated that moderate to severe urinary symptoms persisted for at least 3 months following permanent source interstitial brachytherapy. An instrument specifically designed to measure urinary symptoms can provide additional clinical information when combined with FACT-P.

Prostate cancer diagnosed by the 5 region biopsy method is significant disease.

PURPOSE: The 5 region method of prostate biopsy takes standard sextant biopsies and additional systematic biopsies of the far lateral and middle aspects of the prostate gland. This method has been shown to increase the cancer detection rate of prostate biopsy by 35% over the standard sextant biopsy method, and it is most effective in patients with prostate specific antigen less than 10. Concern has arisen that by taking additional biopsies, cancers are being detected which would otherwise be clinically insignificant. We compare pathological findings of radical prostatectomy specimens detected by the 5 region and sextant biopsy methods to determine if there is a significant difference between tumors diagnosed by each method. MATERIALS AND METHODS: A total of 21 patients enrolled in the 5 region prostate biopsy study with biopsy proved prostate cancer underwent radical prostatectomy. Prostatectomy specimens of 5 zone detected cancers in 11 cases were compared to sextant method detected cancer in 10. Radical prostatectomy specimens were analyzed for tumor volume, ploidy status, Gleason score and TNM pathological stage. Tumor volumes were determined by point counting morphometric analysis using an overlying grid. Tumor ploidy status was determined by deoxyribonucleic acid (DNA) image analysis. RESULTS: Mean tumor volume was 2.4 cc (range 0.10 to 9.6, median 1.4) for 5 region detected cancers versus 1.9 cc (range 0.10 to 6.1, median 1.0) for sextant method detected cancers. This difference was not statistically significant (p = 0.643). Mean DNA index was 1.1 (range 0.93 to 1.64) for 5 region detected cancer compared to 1.4 (range 0.96 to 2.2) for sextant method detected cancer. Overall there were 8 diploid tumors and 3 aneuploid tumors in the 5 region group compared to 4 diploid tumors and 6 aneuploid tumors in the sextant group. Mean Gleason scores were not significantly different for the 5 region (6.5) and sextant (6.7) groups (p = 0.672). Final tumor stage for the 5 region group was 4 pT3 (36%) and 7 pT2 (64%) tumors compared to 2 pT3 (20%) and 8 pT2 (80%) tumors for the sextant group. CONCLUSIONS: Our data demonstrated no significant difference in tumor volume, DNA ploidy status, Gleason score or final pathological tumor stage between tumors diagnosed using the 5 region versus sextant biopsy techniques.

Manpower needs in urology in the twenty-first century.

Physician supply factors are based on a number of variables. These include the base supply and retirements, which presently show that around 200 urologists are retiring per year. Death rates of both patients and physicians are significant. The rate of entry of graduating residents is important. Population changes (which certainly will continue to increase in the United States) are important. Needs-based projections, demand-needs based projections, and benchmarked projections are important issues. The immigration of physicians is important. So far, I think we have seen little emigration of physicians from the United States. A number of confounding variables can have impact and are almost impossible to predict at present. These include technology changes, disease patterns, and methods of care delivery. The Strategic Planning Committee thought we should aim for a band of 200 to 250 chief residents finishing one per year. We have already reached the 250 level. At 200 finishing per year, we would have 2300 fewer urologists in the year 2020 than we presently have. AT 225/year, we would have 1700 fewer urologists. At 250 (our present level), we will have 1100 fewer than now. These 8800 urologists would be caring for 60 million more patients, of whom 20 million would be Medicare patients. These patients would provide over 500 additional patient visits/year/urologist. I hope that I have convinced you that the system is correcting and responding to multiple market forces. I predict that urologists in practice in 2020 will be busy and that we will not have too many urologists if the graduating numbers are kept stable. If they drop much more, we could well have too few.

Puboprostatic ligament sparing improves urinary continence after radical retropubic prostatectomy.

OBJECTIVES: To determine whether a puboprostatic ligament-sparing technique of prostatic apical dissection provided improved urinary continence after radical retropubic prostatectomy. METHODS: A total of 43 men with clinically localized prostate cancer underwent radical retropubic prostatectomy (standard apical dissection in 25, puboprostatic ligament-sparing technique in 18). Patients were evaluated by independent observer questionnaire to determine their continence status. The questionnaire was tested in a control group of 25 men who had not undergone prostate surgery. The overall continence rate and time to achieve continence was compared between the two surgical groups. In addition, the clinical and pathologic stages and both the rate and location of positive margins were assessed. RESULTS: Mean patient age and serum prostate-specific antigen values were not significantly different between the two groups. Clinical and pathologic stages were also similar. The mean follow-up period for the puboprostatic ligament-sparing group was 35 weeks compared with 57 weeks for the standard group (P < 0.05). The median time until continence was achieved after surgery was significantly shorter (P = 0.01) for the puboprostatic ligament-sparing group than for the standard method (6.5 and 12 weeks, respectively). However, the overall continence rate at 1-year follow-up for the two groups was similar (100% and 94%, respectively). The positive margin rate and location of positive margins were not different with the puboprostatic ligament-sparing technique. CONCLUSIONS: The puboprostatic ligament-sparing technique improves the rapidity of return of urinary continence after radical prostatectomy without significantly enhancing overall continence or interfering with the therapeutic efficacy of the procedure.

Systematic 5 region prostate biopsy is superior to sextant method for diagnosing carcinoma of the prostate.

PURPOSE: The number of patients undergoing prostate biopsy has dramatically increased due to prostate specific antigen screening. The low specificity of this screening tool requires prostate biopsy for diagnosis of prostate cancer. The sextant biopsy technique has been used widely with success in diagnosing carcinoma of the prostate. However, concern has arisen that the original sextant method may not include an adequate sampling of the prostate. For many years we have used a method of prostate biopsy that, in addition to sextant biopsies, takes additional biopsies in a systematic fashion, which we call the 5 region prostate biopsy. We conducted a prospective study to determine if our 5 region prostate biopsy technique significantly increases the chances of finding carcinoma of the prostate compared to the sextant biopsy technique. MATERIALS AND METHODS: A total of 119 patients underwent transrectal ultrasound guided needle biopsy of the prostate. In addition to sextant biopsies, cores were taken from the far lateral and mid regions of the gland. Pathological findings of the additional regions were compared to those of the sextant regions. RESULTS: Of the 48 patients with prostate cancer 17 (35%) had carcinomas only in the additional regions, which would have remained undetected had the sextant biopsy technique been used alone (p < 0.05). Of these additional cancers 83% had Gleason scores of 6 or more. CONCLUSIONS: We introduce the 5 region technique of prostate biopsy as a means of significantly increasing the diagnostic yield of prostate biopsy in finding carcinoma of the prostate. We have found this technique to be safe, efficacious and superior to the sextant method of biopsy in identifying prostate cancer at an early but significant stage. The greatest use of the 5 region biopsy technique is in patients who have prostate specific antigen levels between 4 and 10 ng./ml.

Physiologic variations of serum testosterone within the normal range do not affect serum prostate-specific antigen.

OBJECTIVES: To determine the relationship between endogenous total serum testosterone levels and serum prostate-specific antigen (PSA) concentrations. If a correlation exists between these two parameters, then use of testosterone-specific reference ranges may enhance the utility of PSA as a marker for prostate cancer. METHODS: Data were obtained from 150 men without previous history of prostate cancer. PSA was measured by the Abbott IMX microparticle enzyme immunoassay and total testosterone determined by the Coat-A-Count radioimmunoassay. RESULTS: No correlation was found between testosterone and PSA, even when corrected for age and weight. CONCLUSIONS: The data suggest that determination of the total serum testosterone level does not improve the sensitivity or specificity of PSA as a tumor marker.

Xanthogranulomatous pyelonephritis, the gatekeeper's dilemma: a contemporary look at an old problem.

OBJECTIVES: To review 12 patients with a clinicopathogenic diagnosis of xanthogranulomatous pyelonephritis (XGP) and to determine if a computed tomography (CT) scan is the imaging procedure of choice for diagnosis. METHODS: A retrospective review, over the last 12 years, of patients with XGP at our institution. RESULTS: Nine of 10 patients (90%) who were evaluated by CT scan had the correct diagnosis made prior to nephrectomy. The most common presenting symptoms and signs were flank pain (64%), leukocytosis (73%), and anemia (82%). Seventy-five percent of the patients had a ureteropelvic junction stone or a staghorn stone in the affected kidney at the time of clinical presentation. Proteus was the most common organism cultured. CONCLUSIONS: After reviewing the clinical features of these 12 patients, we recommended CT scan to evaluate the patient in whom clinical suspicion of XGP is entertained. CT has proven to be the most accurate imaging study to evaluate this disease.

Inguinal lymphadenectomy and primary groin reconstruction using rectus abdominis muscle flaps in patients with penile cancer.

OBJECTIVES: The use of deep inferior epigastric artery (DIEA) rectus abdominis muscle flaps in conjunction with inguinal lymphadenectomy to treat patients with squamous cell carcinoma (SCC) of the penis having high-volume inguinal lymph node metastases causing skin breakdown and secondary infection is described. METHODS: Three patients with invasive SCC of the penis who had extensive unilateral inguinal nodal metastases with skin breakdown and secondary infection underwent pelvic lymphadenectomy and attempted wide resection of the superficial and deep inguinal lymph nodes. One patient had unresectable deep inguinal metastases and received postoperative radiation therapy. A DIEA rectus abdominis muscle flap was utilized to close the resulting groin defect. RESULTS: Pathologic analysis demonstrated no pelvic lymph node metastases in any of the patients, superficial inguinal lymph node metastases in 1, and superficial and deep inguinal lymph node involvement in 2. All wounds healed well. The 2 patients with deep inguinal metastases experienced local disease progression. One patient died 7 months postoperatively of complications from chronic renal failure but had no evidence of tumor recurrence or wound problems. Another patient died of recurrent disease. CONCLUSIONS: A rectus abdominis muscle flap may be a useful adjunct for managing certain patients with penile cancer and extensive suppurative inguinal lymph node metastases.

Nephrolithiasis Clinical Guidelines Panel summary report on the management of staghorn calculi. The American Urological Association Nephrolithiasis Clinical Guidelines Panel.

The American Urological Association Nephrolithiasis Clinical Guidelines Panel recommendations for managing struvite staghorn calculi are based on a comprehensive review of the treatment literature and meta-analysis of outcome data from the 110 pertinent articles containing viable, unduplicated data. The panel concluded that the 3 most significant outcome probabilities are those of being stone-free, undergoing secondary unplanned procedures and having associated complications. Panel guideline recommendations for most standard patients are that neither shock wave lithotripsy monotherapy nor open surgery should be a first-line treatment choice but that a combination of percutaneous stone removal and shock wave lithotripsy should be used.