Interstitial cystitis in men.

OBJECTIVES: To determine the personal characteristics, the mode of presentation, the duration of the delay in diagnosis, the number of misdiagnoses, the means to achieve diagnosis, and previous treatment provided for a group of men with interstitial cystitis (IC). METHODS: A chart review of 29 men diagnosed with IC at our facility from 1988 to 1996 was performed. Basic demographic data, historical information, laboratory findings, and endoscopic and biopsy results were tabulated. RESULTS: IC in this series of men was diagnosed at a mean age of 67.3 years. There was approximately a 4-year diagnostic lag between presentation and diagnosis. The most common prior erroneous diagnoses were prostatitis in 48% and benign prostatic hypertrophy (BPH) in 38% of the men. Ulcers were encountered cystoscopically in about 70% and biopsy specimens uniformly showed nonspecific chronic cystitis at the time of diagnosis. CONCLUSIONS: IC should be considered in the differential diagnosis of voiding disorders accompanied by irritative symptoms and pelvic pain in older men. The diagnosis should be especially considered in men who are refractory to the usual treatments for BPH and prostatitis. Cystoscopy and bladder distention under anesthesia provided the most useful objective information in our hands. Biopsy is useful to rule out inflammatory cancer but adds little to the diagnosis of IC.

Cost-effective evaluation of indeterminate urinary cytology.

PURPOSE: We reviewed our management of indeterminate urinary cytologies to determine which patients warrant urological evaluation. Our goal was to develop a cost-effective evaluation scheme that detects the most cancers. MATERIALS AND METHODS: We analyzed case histories of 389 patients with indeterminate urinary cytology who had undergone complete urological evaluations. Upper urinary tract imaging and cystoscopy were required to exclude malignancy, and tissue biopsy results were recorded in all individuals diagnosed with cancer. Multivariate analysis was used to assess the significance of clinical factors that would suggest the necessity of complete urinary system evaluation. Marginal cost-effectiveness rates were applied to various clinical scenarios. RESULTS: Of 389 patients 60 (15%) had urinary tract malignancy. A history of urothelial malignancy and hematuria were the only significant factors that suggested complete evaluation was necessary. If smoking history were included 59 of the 60 malignancies would have been detected. CONCLUSIONS: Patients with indeterminate urinary cytology who are nonsmokers and have neither hematuria nor a history of urothelial cancer are at low risk for malignancy and do not warrant complete evaluation.

Comparison of the modified vest and the direct anastomosis for radical retropubic prostatectomy.

OBJECTIVES: This retrospective study was undertaken to compare the efficacy of the Vest and direct vesicourethral anastomosis for radical prostatectomy. METHODS: Five hundred six patients who underwent consecutive radical prostatectomies at our institution were analyzed. Two hundred fifty-nine patients underwent vesicourethral anastomosis using the Vest technique and 247 underwent a direct suture anastomosis. The groups were analyzed relative to time until healing, the occurrence of anastomotic strictures, and the continence rate 1 year after surgery. RESULTS: Approximately twice as many patients who underwent the Vest procedure experienced delayed healing and 8.5% developed anastomotic strictures compared with 1.2% of the direct anastomosis group. The Vest group experienced slightly better urinary continence 1 year postoperatively. CONCLUSIONS: The Vest procedure is a reasonable alternative to direct anastomosis for radical prostatectomy and provides similar results. We suggest specific circumstances when the Vest anastomosis may be particularly useful.

The use of radiotherapy for patients with isolated elevation of serum prostate specific antigen following radical prostatectomy.

PURPOSE: An analysis was performed to assess the outcome of patients who received radiotherapy for isolated elevation of serum prostate specific antigen (PSA) levels following radical retropubic prostatectomy. MATERIALS AND METHODS: Forty-six patients were initially treated for localized prostate cancer with radical retropubic prostatectomy following negative pelvic lymphadenectomy. These patients had detectable serum PSA 6 or more months postoperatively. No patient had other clinical evidence of recurrent disease as determined by history, physical examination, bone scan, computerized tomography of the abdomen and pelvis, chest radiographs, complete blood cell counts and serum chemistry profiles. The patients received prostate bed irradiation using 10 MV. x-rays and a 4-field approach. Doses ranged from 60.0 to 67.0 Gy. in 1.8 to 2.0 Gy. fractions. Freedom from failure after radiotherapy was defined as maintaining a PSA of 0.3 ng./ml. or less without hormonal intervention. RESULTS: In 27 of the 46 patients (59%) PSA had decreased to 0.3 ng./ml. or less at last measurement without hormonal intervention. The freedom from failure rate was 50% at 3 and 5 years. More favorable responses to salvage radiotherapy occurred in patients with low grade tumors and serum PSA 1.1 ng./ml. or less at initiation of radiotherapy. Patients, receiving radiation doses of 64 Gy. or more had more favorable response rates than those receiving lesser doses. CONCLUSIONS: Isolated elevations of serum PSA following prostatectomy reflect residual disease. Radiotherapy administered to the prostate bed effectively decreased serum PSA in approximately half of the cases. This effect appears to be accomplished by eradicating tumor cells in the prostate bed.

Detection of residual prostate cancer after radical prostatectomy with the Abbott IMx PSA assay.

OBJECTIVES: This analysis was performed to define the level of serum prostate-specific antigen (PSA) measured with the Abbott IMx assay that indicates residual or progressive prostate cancer after radical retropubic prostatectomy (RRP). METHODS: Since March 1992, we have used the Abbott IMx assay to determine PSA levels. Between March 1992 and June 1994, 102 of those patients having RRPs were found to have pathologic Stage C prostate cancer. Fifty-one of these patients had at least one serum PSA measurement of 0.1 ng/mL or greater. Eight patients were excluded from the analysis because they received postoperative radiotherapy that might have influenced subsequent PSA levels. The remaining 43 patients are the subjects of this analysis and were evaluated to determine the "clinical threshold" or minimal serum PSA level after RRP indicative of progressive disease. Patients were followed for 6 to 36 months (median 23 months) from the date of the RRP. Failure was defined as a subsequent increase of PSA to greater than 0.3 ng/mL. Freedom from failure was determined using the Kaplan-Meier product limit method. RESULTS: Of the patients with at least one postoperative serum PSA level of 0.1 ng/mL, the subsequent freedom from failure was 80% at 23 months as compared with 13% in patients with at least one postoperative PSA level of 0.2 ng/mL (P = 0.003). CONCLUSIONS: Following RRP for pathologic Stage C prostate cancer, a solitary PSA level of 0.1 ng/mL (measured with the IMx assay) was followed by a progressive rise in PSA levels in only a minority of patients within the first 2 years after surgery. In contrast, the majority of patients with a postoperative PSA level of 0.2 ng/mL subsequently had progressively rising PSA levels. This indicates that a serum PSA level of 0.2 ng/mL is reflective of residual prostate cancer.

The result of radical retropubic prostatectomy and adjuvant therapy for pathologic stage C prostate cancer.

PURPOSE: The results of therapy in 288 men with pathologic Stage C prostate cancer who underwent radical retropubic prostatectomy (RRP) were analyzed to determine the effects of adjuvant therapy. METHODS AND MATERIALS: Twenty-seven of the 288 patients received preoperative neoadjuvant hormonal therapy (leuprolide acetate). Postoperatively, 60 patients received adjuvant radiotherapy (RT) to the prostate bed. Follow-up ranged from 3 to 83 months (median = 32 months). Freedom from failure (FFF) was defined as maintaining a serum PSA level of < or = 0.3 ng/ml. RESULTS: The FFF was 61% at 3 years and 45% at 5 years for the entire group. The FFF following RRP plus RT was 75% at 3 years and 57% at 5 years as compared to 56% at 3 years and 40% at 5 years for RRP without RT (p=0.049). The FFF following RRP plus neoadjuvant hormonal therapy was 58% at 3 years and 40% at 5 years as compared to 60% at 3 years and 45% at 5 years following RRP without hormonal therapy (p=0.3). In patients without seminal vesicle (SV) invasion, the FFF was 81% at 3 years and 5 years for RRP plus RT as compared to 61% at 3 years and 50% at 5 years for RRP without RT (p=0.01). In patients with SV invasion, the FFF was 61% at 3 years and 36% at 5 years for RRP plus RT as compared to 44% at 3 years and 23% at 5 years for RRP without RT (p=0.23). The projected local control rate was 83% at 5 years for those with RRP alone as compared to 100% for RRP plus RT (p=0.02). Survival at 5 years was projected to be 92% and was not significantly altered by the administration of adjuvant therapies. CONCLUSIONS: Postoperative RT was associated with significantly improved local control and FFF rates, especially in patients with tumors which did not involve the seminal vesicles.

Prostatic acid phosphatase, beta-glucuronidase and prostate specific antigen assays in fine needle aspirates from benign and malignant prostates.

Enzymatic assays for tartrate-sensitive acid phosphatase and beta-glucuronidase, and radio-immunoassay for prostate-specific antigen, were modified for application to fine-needle aspirate samples from benign and malignant human prostates. When compared to samples from benign prostates, the ratio of acid phosphatase to beta-glucuronidase activities was significantly decreased in needle aspirates from malignant prostates. Prostate-specific antigen values in the aspirates did not correlate with malignancy.

A prospective double-blind trial of intracorporeal papaverine versus prostaglandin E1 in the treatment of impotence.

A randomized prospective, double-blind clinical trial was performed comparing intracorporeal injections of papaverine (30 mg. per ml.) with prostaglandin E1 (10 mcg. per ml.) as pharmacological treatment of impotence. A total of 15 men completed the study, receiving papaverine and prostaglandin E1 in a crossover design. Over-all, 9 of 15 evaluable patients had a full erection with either 1 or both drugs: 3 secondary to papaverine only, 2 to prostaglandin E1 only, and 4 to both drugs. No major complications were observed. We conclude that intracorporeal prostaglandin E1 may be used successfully to stimulate pharmacological erections and that it might be useful in patients not responding to intracorporeal papaverine.

Sucralfate inhibition of tumor cell implantation in the murine urinary bladder.

Superficial transitional cell carcinoma of the bladder has a 50 to 70% recurrence rate. Recurrences may be related to tumor cell implantation during transurethral resection which disrupts the glycosaminoglycan layer of the bladder. This study demonstrated decreased tumor formation in murine bladders which were pre-treated with sucralfate, a synthetic glycosaminoglycan, prior to tumor cell instillation. These results suggest a possible role for sucralfate as a glycosaminoglycan supplement.

Adrenal tumors: involvement of the inferior vena cava.

We report 3 cases of adrenal neoplasms with extension of tumor thrombus into the vena cava. Preoperative documentation of the presence and extent of vena caval involvement is mandatory before surgical extirpation of adrenal tumors.

Effect of renacidin on suture material.

Renacidin solution is used sometimes to irrigate renal units with retained calculi after definitive stone surgery. The effects of this solution on the integrity of suture material utilized to close kidneys have not been determined previously. In an attempt to define the best suture material to use when postoperative renacidin irrigation is contemplated, we studied the effects of this solution on a variety of sutures commonly used in genitourinary surgery.

Chylous ascites complicating genitourinary oncological surgery.

Chylous ascites is an uncommon complication of retroperitoneal surgery. We report 2 cases of intraperitoneal chyle fistulas, one following retroperitoneal lymphadenectomy for testis cancer and the other after radical nephrectomy with regional lymphadenectomy for renal cell carcinoma. Both patients were treated successfully with medium chain triglyceride diets. We believe that most patients with chylous ascites will respond to simple dietary manipulation, and do not require complex and potentially morbid treatment regimens.

Effect of vasectomy on high density lipoproteins.

Primate research has associated vasectomy with accelerated rates of atherogenesis. We have evaluated the effect of vasectomy on serum lipoprotein profiles in healthy men. There was a decrease in high density lipoprotein levels, which was greatest in men with a family history of atherosclerotic disease. With the great number of variables known to affect high density lipoprotein levels further studies are needed to determine if this change can be attributed to the vasectomy.

PIP: The short-term effect of vasectomy on human lipoprotein profiles, a known risk factor for atherosclerosis, was evaluated. The 28 subjects had a single profile measured before vasectomy and 3 months postoperatively. The mean change in high density lipoprotein levels was a decrease of 6.6 mg/dl, which was significant. The mean decrease in cholesterol levels of 22.5 mg/dl was also significant. The decrease in high density lipoprotein levels was noted in 26 of the 28 patients. The 13 patients with a family history of atherosclerotic disease had a mean change in high density lipoprotein levels of -9.3 mg/dl, compared with an average decrease of -4.6 mg/dl among the 15 patients with a negative family history. There was no significant difference in the change in cholesterol levels between the 2 groups. Smoking, obesity, hypertension, diabetes, age, or level of physical activity did not correlate with lipoprotein levels, and there was no association between the change in high density lipoprotein levels and cholesterol or triglyceride levels. Previous primate research has associated vasectomy with accelerated rates of atherogenesis. This is thought to be the 1st study to investigate the influence of vasectomy on lipoprotein profiles in humans. The modest decrease in lipoprotein levels in vasectomized men observed in this study, especially among men with a family history of atherosclerotic disease, raises questions about the longterm safety of vasectomy and calls for futher investigation.

Myxoid fibroepithelial polyp in caliceal diverticulum.

A 58-year-old woman was found to have a myxoid fibroepithelial polyp in a pyelocaliceal diverticulum. This is the first report of such a lesion.

Ability of the inflatable penile prosthesis to withstand rapid changes in altitude.

Small air bubbles unavoidably included in the fluid of the inflatable penile prosthesis will expand upon exposure to increased altitude. Three prostheses with predetermined amounts of air underwent decompressions in an altitude chamber. The device was able to contain the expanded air bubbles with no extravasation of fluid or air or damage to the system.

Nephrogenic adenoma of bladder: a report of 8 cases.

Nephrogenic adenoma is an uncommon lesion of the urinary tract. Current information supports a metaplastic transformation of urothelium as the origin of this tumor. Our experience with 8 additional cases confirms the benign behavior of this lesion.

Inability of cytoplasmic or nuclear androgen receptor content or distribution to distinguish benign from carcinomatous human prostate.

We used exchange saturation analysis at 15 degrees to quantitate total cytoplasmic and nuclear androgen receptor content of 70 patient specimens. Cytoplasmic androgen receptor contents (fmol/mg DNA) for eight specimens of clinically benign hyperplasia, 14 specimens of histologically hyperplastic prostate obtained at cystoprostatectomy, and carcinomatous and noncarcinomatous prostate obtained at radical prostatectomy for prostatic carcinoma, 48 specimens, respectively, were 830 +/- 165 (mean +/- S.E.), 890 +/- 445, 955 +/- 240, and 750 +/- 95. Nuclear androgen receptor contents of these same specimens, respectively, were 275 +/- 40, 235 +/- 30, 345 +/- 25, and 350 +/- 30; whereas, the values of the cytoplasmic/nuclear receptor content, respectively, were 3.25 +/- 0.55, 3.05 +/- 0.80, 2.50 +/- 0.50, and 2.80 +/- 0.40. Multiway analyses of variance of these cross-sectional data showed that there was no significant difference (p greater than 0.05) between group mean values. This result principally reflects the fact that the families of values for the four tissue groups were highly heterogenous with broad overlap. The results would not appear to be unduly influenced by carcinomatous epithelial cell content of the specimens, because cytoplasmic and nuclear androgen receptor content were not related to specimen carcinomatous epithelial cell content. Paired analyses of receptor content in carcinomatous and noncarcinomatous prostate specimens from the same prostate showed enhanced or unchanged receptor content in 58% (cytoplasmic) and 62% (nuclear) of specimens. Our studies show that cross-sectional analyses of androgen receptor content fail to distinguish carcinomatous prostate from noncarcinomatous prostate. However, paired analyses of these tissues from the same gland identify distinguishing differences. The clinical relevance of these observations remains to be examined.