The role of posterior lumbotomy in the management of surgical stone disease.

A total of 50 consecutive patients underwent posterior lumbotomy for removal of upper third ureteral or renal pelvic stones between June 1983 and October 1986. Morbidity was low, hospitalization was brief and 100 per cent of the patients were rendered free of stones postoperatively. Dorsal lumbotomy compares favorably with other currently available methods for the management of selected patients with calculous disease.

Androgen receptors in biopsy specimens of prostate adenocarcinoma. Heterogeneity of distribution and relation to prognostic significance of receptor measurements for survival of advanced cancer patients.

Needle biopsy specimens of primary adenocarcinoma and surgical specimens of carcinomatous nodal tissue were obtained from previously untreated clinical D stage prostatic adenocarcinoma patients. Assessment of the relation between specimen androgen receptor site content and survival using either scatterplots or Kaplan-Meier analyses showed specimen receptor content was a poor prognostic P greater than 0.1, of survival subsequent to orchiectomy or diethylstilbestrol (DES) therapy. The possibility that heterogeneity of specimen androgen receptor site content contributed to this finding was evaluated by comparing receptor content of multiple small or large tissue specimens from the same prostate gland of patients with benign prostatic hyperplasia or nonmetastatic prostatic cancer. This evaluation showed significant microheterogeneity of human prostate androgen receptor site content which was substantially masked in large tissue specimens. We conclude that microheterogeneity of human prostate androgen receptor site content compromises the use of biopsy specimen androgen receptor measurements as a prognostic of patient survival subsequent to initiation of hormonal therapy.

Epidermoid cyst of testis: a case for orchiectomy.

Epidermoid cyst of the testis is a benign lesion without report of metastasis. It cannot be differentiated reliably from the far more common malignant testicular mass on a clinical basis. Simple excision of the cyst, even with concurrent biopsy of the apparently normal surrounding parenchyma, does not exclude the possibility of a remote scar or focus of viable tumor. The existence of a concurrent malignant lesion along with an epidermoid cyst may be more than coincidental. For such an undetected associated lesion, appropriate highly successful adjunctive therapy is delayed if excision of the epidermoid cyst alone is performed. Consequently, inguinal orchiectomy should be the treatment of choice for epidermoid cyst of the testis with the subsequent burden of proof placed on the pathologist to exclude associated lesions that may alter therapy.

Telecommunications in urology.

Through telecommunications the computer can create a breadth of personal communication, dialogue, and interaction that has never before been possible. Participants may actively contribute, may simply listen in, and may be selective in terms of both their interests and their schedules. Any personal computer equipped with a device to communicate over an ordinary telephone line provides entry. Once a few reasonably simple procedures are learned, this technologic tool can serve the physician extensively.

Renal and perirenal infection: the role of computerized tomography.

Predisposing factors, onset of symptoms to diagnosis interval, computerized tomography findings and the impact of computerized tomography on the outcome were studied retrospectively in 24 patients with renal or perirenal infections. The most common predisposing factors were diabetes mellitus and urinary tract calculi. The mean interval from the onset of symptoms to diagnosis was 6.8 days. The most common computerized tomography findings were thickening of Gerota's fascia, renal enlargement, focal decreased renal attenuation, perirenal fluid and focal gas. Four patients died despite early diagnosis and appropriate therapy. Computerized tomography aided in the diagnosis, assessment of the extent of disease, treatment and followup. Computerized tomography is the most direct method to evaluate patients with suspected renal or perirenal infection, although mortality may not be altered significantly.

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.

Human prostate androgen receptor quantitation: effects of temperature on assay parameters.

When cytoplasmic extracts of human prostatic tissues were split to permit quantitation of total androgen receptor (RCT) content by saturation analysis at 15 degrees and 2 degrees, we observed that 30% (10 of 32) of the specimens yielded statistically increased values for RCT following incubation at 15 degrees as compared to 2 degrees. Considering only those specimens (13 of 32) showing statistically differentiated RCT yield, 77% (10 of 13) yielded greater RCT content following incubation at 15 degrees. The families of association constants (Ka) obtained for RCT determinations at 2 degrees and 15 degrees were not statistically differentiated. The increased yield of RCT content determined at 15 degrees was 95% (mean) and 20 to 350% (range). Nuclear androgen receptor content determined at 15 degrees was greater for 25% (2 of 8) of the patient specimens when compared to split determinations performed at 2 degrees. Incubation of nuclear extracts at 15 degrees resulted in a significant 3-fold reduction in receptor Ka for methyltrienolone (R1881). This did not appear to affect assay precision. These studies showed that incubation at 15 degrees is preferable to incubation at 2 degrees for quantitation of RCT and nuclear androgen receptor content by saturation analysis. Single saturating dose determinations of RCT consistently yielded underestimates. The extent of underestimate was variable from specimen to specimen and was both ligand concentration and assay temperature dependent. Our data suggest that results of single saturating dose determinations of RCT require cautious interpretation.

Bladder cancer immunotherapy.

A randomized controlled prospective evaluation of intravesical and percutaneous bacillus Calmette-Guerin immunotherapy was done in 57 patients with transitional cell carcinoma of the bladder. In addition, 9 patients at high risk for tumor recurrence were treated with bacillus Calmette-Guerin produced a self-limited cystitis and 1 complication (hydronephrosis) of immunotherapy was observed. Of the 57 randomized patients 54 were followed for 3 to 30 months. Tumor recurrence was documented in 13 of 26 controls (50 per cent) and only 6 of 28 patients (21 per cent) treated with bacillus Calmette-Guerin (p equals 0.027, chi-square). The interval free of disease was prolonged significantly with bacillus Calmette-Guerin treatment (p equals 0.014, generalized Wilcoxon test). Importantly, a simple purified protein derivative skin test distinguished those patients who responded to bacillus Calmette-Guerin immunotherapy from those who did not. Only 1 of 17 treated patients (6 per cent) whose purified protein derivative test converted from negative to positive had tumor recurrence compared to 5 recurrences (38 per cent) among the 13 patients whose test remained negative or had been positive before treatment (p equals 0.022, chi-square). Bacillus Calmette-Guerin was given to 10 patients with stage B transitional cell carcinoma who were not candidates for cystectomy and 7 are free of disease. Of 5 patients with carcinoma in situ 3 remain free of tumor after bacillus Calmette-Guerin treatment and 5 of 6 who had multiple recurrences after intravesical chemotherapy responded favorably to bacillus Calmette-Guerin immunotherapy.

Clonogenic assay and in vitro chemosensitivity testing of human urologic malignancies.

Over the past year, we have attempted to grow both primary and metastatic urologic malignancies using a recently developed human tumor cloning system. Formation of colonies in vitro occurred in 125 of 164 primary tumors (76%), including 34 of 47 uroepithelial cancer specimens, 45 of 50 renal cell cancer specimens, 24 of 33 prostatic cancer specimens, and 22 of 34 testicular cancer specimens. A large percentage of metastatic cancers have also been successfully cultured. Growth sufficient for chemosensitivity testing ranged from 43% of the uroepithelial cancers cultured to 64% of the renal cell cancer specimens cultured. When in vitro chemosensitivity testing was performed, the in vitro chemosensitivity results show a striking similarity to clinical response rates for the same agents used for these tumors. Overall the human tumor cloning system appears to be a reasonable model for the study of human urologic malignancies.

Patient survival in cadaveric renal transplantation: report from a small center.

Recipients of cadaveric kidney transplants before 1975 had a 1-year mortality rate (30 per cent) approximately 3 times higher than patients on chronic hemodialysis (10 per cent). Patient survival was no better in large than in small transplant centers. Since 1975 several large and experienced transplant centers (more than 500 transplants) have reported improved patient survival rates (90 per cent). We herein document that a small transplant center (less than 200 transplants) can achieve patient survival rates that are equivalent to larger transplant centers.

Androgen priming and cytotoxic chemotherapy in advanced prostatic cancer.

Hormone manipulation has been standard therapy for metastatic adenocarcinoma of the prostate for many years. Recently cytotoxic drugs have been studied, but their effectiveness has been limited, indicating the need for new therapeutic approaches. Based upon the hypothesis that cytotoxic drugs are most effective against actively proliferating cells, we have designed a clinical pilot study employing cyclical androgen priming to transiently stimulate tumor cells followed by cytotoxic chemotherapy with cyclophosphamide and methotrexate. There were nine responders (43%) out of 21 patients entered in the study, with a median duration of response that has not been reached at 9+ months. Survival was significantly better in responders than in non-responding patients. These results are similar to those of other studies in which chemotherapy was used alone. Chemotherapy toxicity with this schedule was mild. However, the androgen priming frequently resulted in increased bone pain, and there was one episode of spinal cord compression, suggesting that tumor stimulation was achieved. These results demonstrate the need for additional basic studies of the effects of testosterone on tumor cell kinetics before further clinical trials of this approach are initiated.

Pretransplant bilateral nephrectomy and adjuvant operations.

Pretransplant bilateral nephrectomy by the posterior approach has been associated with minimal morbidity and mortality. Unfortunately the posterior approach is not applicable to all patients, e.g., patients with polycystic renal disease or patients who need simultaneously another intraperitoneal adjuvant operation such as splenectomy or vagotomy and pyloroplasty. This article presents 34 patients who had a transperitoneal bilateral nephrectomy and 29 other concurrent adjuvant operations. Morbidity and mortality are comparable to that reported for simple bilateral nephrectomy performed posteriorly. The reduction in morbidity and mortality was believed to be due to a careful application of the basic principles of surgical care and an appreciation of the special problems posed by patients on chronic hemodialysis. Perioperative care will be discussed in detail.

BCG immunotherapy of bladder cancer: inhibition of tumor recurrence and associated immune responses.

Fifty-one patients with confirmed bladder cancer have enrolled in a prospective evaluation of BCG immunotherapy. Following resection of existing tumors, patients were stratified according to tumor grade and number of previous recurrences and randomly assigned to control or BCG treatment groups. Immunotherapy consisted of six weekly administrations of Pasteur strain BCG using 120 mg intravesically and 5 mg percutaneously. Immunotherapy side effects were minimal and no patient required postponement of BCG treatments. Eleven control (46%) compared with five (22%) BCG-treated patients had tumor recurrence (P = 0.078, chi 2). Prolongation of the disease-free interval with BCG treatment was significantly at the P = 0.016 level by Wilcoxon analysis. Four control and two BCG-treated patients had multiple recurrences. Comparing total episodes of recurrence, nineteen of 79 (24%) control and eight of 85 (7%) BCG group cystoscopic examinations revealed tumor (P = 0.006, chi 2). Immunologic correlates of response to immunotherapy were not statistically significant since only five BCG-treated patients had tumor recurrence. However, four of these five patients evidenced impaired LIF response to PPD at the time of tumor recurrence, and impairment of skin test reactivity and BCG humoral antibody response were more commonly seen in this subgroup of patients.

Bacillus Calmette-Guerin immunotherapy of superficial bladder cancer.

Thirty-seven patients were enrolled in a randomized prospective study to compare standard surgical therapy for superficial bladder cancer to standard therapy plus bacillus Calmette-Guerin (BCG). Side effects of BCG have been tolerated well and include dysuria in 95 per cent of the patients, urinary frequency in 83 per cent, hematuria in 39 per cent, fever in 22 per cent and nausea in 22 per cent. Of 19 control patients 8 (42 per cent) had recurrent tumors in the followup period, compared to 3 of 18 patients (17 per cent) treated with BCG. One patient treated wih BCG had 2 recurrences, yielding a recurrence rate of 22 per cent in the group receiving BCG compared to 42 per cent in controls. When the incidence of recurrent tumors in matched intervals before and after entry into the protocol is compared, no change in the rate of tumor recurrence (p equals 0.726 chi-square) occurred in controls, whereas tumor recurrences were reduced significantly in the group treated with BCG (p equals 0.010 chi-square). The reduction in tumor recurrence in patients treated with BCG compared to controls is statistically significant (p equals 0.029 chi-square). Of 4 patients who presented with new bladder tumors remain free of tumor after BCG therapy, while 2 of 5 comparable control patients developed recurrent tumors. Intravesical and percutaneous BCG immunotherapy appears to decrease the rate of tumor recurrence in patients followed for 1 year.

Radiotherapy and bladder cancer: a critical review.

Survival of patients undergoing cystectomy for invasive carcinoma of the bladder has improved significantly in recent decades. Although this improved survival is accredited widely to the use of preoperative radiation therapy review of the available data raises questions regarding the validity of such conclusions. Important disadvantages, including increased morbidity, are associated with long course (4,000 to 5,000 rad) preoperative radiation. Although these disadvantages are minimized with a short course regimen (1,600 to 2,000 rad) the case for its efficacy remains unconvincing.