Adenocarcinoma of bladder.

Twenty-five patients with pure primary adenocarcinoma of the bladder were treated in a fifteen-year period. Practically all patients presented with some combination of gross hematuria, irritative lower urinary tract symptoms, or obstruction. Almost half the lesions were at the dome of the bladder. Most of the lesions were high grade and invasive. Transurethral resection is, at best, only diagnostic and palliative, and radiotherapy has been of little value. Radical cystectomy seems to produce five-year survival almost twice that of segmental resection. However, solitary lesions at the dome of the bladder, which usually represent neoplasia in a urachal remnant, seem to behave somewhat differently from lesions elsewhere in the bladder. Indeed, five-year survival of patients with lesions at the dome of the bladder who underwent segmental resection approximated that of those with similar lesions who underwent total cystectomy.

The treatment of renal cell carcinoma with solitary metastasis.

Between 1950 and 1970, 44 patients (2.5 per cent) with renal cell carcinoma and a solitary metastatic lesion were treated at our clinic. Generally, treatment was aggressive, involving nephrectomy and excision of the metastatic lesion when possible. Patients presenting with the primary and metastatic lesion at the same time did not do as well as patients who presented with metastasis after nephrectomy. An operation for the metastatic lesion seemed to offer the best results in patients who presented with the solitary metastatic lesion after nephrectomy. The prognosis was uniformly poor in patients presenting with the primary and secondary lesion together, regardless of the mode of therapy. However, an operation seemed to be better marginally and did produce an occasional long-term survival.

Tuberculous prostatitis.

A study of 5 patients with tuberculosis prostatitis revealed that (1) there is a greater chance of striking a noncaseating granuloma than a caseating lesion by needle biospy when both are present; (2) the absence of caseation on biopsy does not necessarily rule out tuberculosis; and (3) special stains may be negative for tuberculosis because of the small size of the tissue sample. Thus, if the clinical suspicion of tuberculous prostatitis is high and if noncaseating lesions are found, a second biopsy specimen should be taken for culture only.

Ureterosigmoidostomy after pelvic irradiation.

The records of 34 patients who underwent ureterosigmoidostomy after pelvic irradiation were reviewed and the incidence of complications was found to be similar to that in other series of ureterosigmoidostomy without prior irradiation. No difference was established between the use of linac or cobalt 60 therapy in relation to postoperative complications. No conclusions could be reached concerning the effect of the preoperative dose of radiotherapy on the operation because of the small number of patients but it did appear that the incidence of postoperative complications was great after doses in excess of 5,000 rads. Ureterosigmoidostomy after pelvic irradiation is considered to be a feasible procedure with doses of less than 5,000 rads.

Non-specific granulomatous prostatitis.

Between 1963 and 1972, 86 patients with non-specific granulomatous prostatitis were seen. Symptomatology was suggestive of a lower urinary tract infection in the majority of the cases. The most important feature on prostatic examination was the likelihood of confusion with prostatic carcinoma. Management by whatever means yielded uniformly good results. The natural history of this disease seems to be that of gradual resolution.

Management of ruptured posterior urethra in childhood.

Seven boys with fracture(s) of the bony pelvis and associated partial or complete rupture of the posterior urethra were managed by the time-honored technique of early suprapubic cystostomy and concomitant primary realignment of the urethra over a catheter. Of the 4 children who had a functionally significant urethral stricture 3 were cured within a few months by 1 or 2 simple urethral dilatations and 1 by subsequent transperineal lysis of the angulated urethra from its surrounding fibrous tissue. Followup data for 8 to 22 years (mean 14 years) indicate that all 7 patients void with an excellent stream and are continent, free of infection and potent. In fact, 3 of the 4 married boys have fathered children.

Primary transitional cell carcinoma of the prostate.

The symptoms and physical findings in patients with transitional cell carcinoma of the prostate were similar to those in patients with prostatic adenocarcinoma. Usually the neoplasm was poorly differentiated and advanced when the diagnosis was first established. Osseous metastases were commonly osteolytic. Frequently, elevations of serum alkaline or acid phosphatase levels were associated with metastasis. Tartrate-inhibited fractions of the serum acid phosphatase were not elevated. The best form of treatment is radical ablation of the prostate and radiation therapy is next best. Because these neoplasms are not hormonally dependent, hormonal manipulation is not indicated. Prognosis for patients with this malignancy is guarded.

Foreign body in bladder and perivesicular inflammation masquerading as pelvic lipomatosis.

Inverted teardrop-shaped bladder deformity ofetn is caused by pelvic lipomatosis or perivesical accumulation of extravasated blood or urine, or both. A foreign body (toothpick) lodged in the bladder and resulting in urinary infection and perivesical inflammation also was found to be capable of causing this unusual bladder deformity. The bladder contour returned to normal after removal of the foreign body and treatment of infection.

Renal vein thrombosis.

The manifestations, clinical course and treatment of 14 patients with non-malignant renal vein thrombosis are described. Most patients (10 of 14) had generalized vague illness and nephrotic syndrome but 4 were initially seen with acute symptoms of flank pain, hematuria or hypertension. Renal vein thrombosis affected young men 2.5 times more often than women and occurred on the left side 2.6 times more commonly than on the right or both sides. Red blood cell casts in the urinary sediment, heavy proteinuria and hypoalbuminemia were useful indicators of the disease. Excretory urographic signs were suggestive of renal vein thrombosis in all patients and these were corroborated by angiographic studies. Systemic anticoagulation with or without a renal failure program and diuretics, or simply a combination of the last 2 modalities, was used in 9 patients. In 2 of the 9 patients who were unresponsive the adjuvant use of cyclophosphamide and steroids effected a cure. The remaining 5 patients underwent nephrectomy or thrombectomy. All 14 patients were followed for 1 to 7 years (mean 1.6 years). Ten patients were cured or improved, 1 patient was unchanged, and in the remaining 3 patients the condition deteriorated and they subsequently required a renal allograft. The rationale for various forms of treatment is discussed.

Nephropexy: fact or fiction?

At the Mayo Clinic, from 1940 through 1974, 21 patients have undergone nephropexy for nephroptosis. Fourteen of the 16 patients with long-term follow-up were cured; 2 of the 16 patients were partially relieved. An additional 2 patients who had one-year follow-up examinations were asymptomatic. Three patients were lost to follow-up. In this series results with the various methods of fixation did not differ, and results in patients who retained their normal position postoperatively as compared with those whose kidneys reverted to their preoperative level also did not differ. Patients who had psychologic disorders fared as well as those who did not. Greater use of renography probably could be made in the assessment of symptoms. Although this review does not suggest that nephropexy for primary nephroptosis be restored to its former appeal of the 1930s, we suggest that its use be considered again in urologic surgery.