The prognostic significance of S-phase analysis in stage Ta/T1 bladder cancer. A Southwest Oncology Group Study.

OBJECTIVES: An intergroup study (SWOG 8795) comparing two forms of adjunctive therapy (immuno and chemo), bacillus Calmette-Guerin (BCG) and mitomycin C (MMC), furnished preregistration index tumors for 244 patients with superficial, papillary stage Ta/T1 TCC. These were examined by flow cytometry to learn whether DNA ploidy or proliferation (low vs high S-phase fraction (SPF) helped to predict disease recurrence or progression. METHODS: Cell cycle analysis using commercially available (Multicycle) programs was performed on 249 Ta/T1 bladder cancers. Tumor grade, available for 223 cases, was assigned by a single study pathologist. The SWOG statistical office reviewed follow-up information and other data and performed statistical analysis. RESULTS: Disease recurrence occurred in half the cases studied. The most parsimonious model predictive of recurrence included only treatment arm and tumor grade, with the MMC arm and tumor grade greater than I indicating worse prognosis (p = 0. 014). Neither ploidy nor SPF predicted recurrence-free survival or contributed prognostic information that was additive to tumor grade. Within 5 years of follow-up, disease progression or death from bladder cancer occurred for 29/223 (13%) of patients. The most parsimonious model for progression-free survival included only grade greater than I (p<0.001) and high SPF (p = 0.029) (relative risk: tumor grade, 4.3, high SPF, 1.9). CONCLUSIONS: Knowledge of tumor proliferation (low versus high SPF) contributes prognostic information about tumor progression that is additive to tumor grade.

A study of reproductive function in patients with seminoma treated with radiotherapy and orchidectomy: (SWOG-8711). Southwest Oncology Group.

PURPOSE: The results of Southwest Oncology Group Study 8711 (Group 2B) are presented. The objective was to evaluate the natural history of sperm concentration and selected hormonal parameters in patients with testicular cancer treated with orchiectomy and radiotherapy. METHODS AND MATERIALS: Of a total of 207 patients enrolled on SWOG 8711, 53 pure seminoma patients were identified who were treated with orchiectomy and radiotherapy only. Sperm concentration, follicle-stimulating hormone (FSH) levels, and sexual satisfaction scores were the main parameters followed. RESULTS: A fraction of the patients were infertile prior to receiving radiotherapy. Our analysis indicates that incidental radiation dose to the remaining testicle affects time to recovery of fertility, and at an aggregate level, changes in FSH mirror changes in sperm concentration over time. This phenomenon is the same as that described in patients free from testicular cancer. These men evaluated their sexual activity as good after orchidectomy. CONCLUSION: Our data support the use of clamshell-type testicular shields as a means of providing maximum protection to the remaining testicle.

Prognostic significance of DNA ploidy in Ta/Tl bladder cancer: A southwest oncology group study.

While 80% of transitional cell carcinomas (TCC) present as Ta Tl lesions, they account for only 15% of deaths caused by TCC. We have evaluated the ability of DNA ploidy analysis to predict outcome in 228 patients with Ta Tl TCC. All patients were judged to be at increased risk for tumor recurrence due to having two occurrences of Stage TI tumor within 56 weeks, or three or more tumors presenting simultaneously within 16 weeks of registration. Concurrent carcinoma in situ was acceptable. All patients were treated with either bacillus Calmette Guerin (BCG) immunotherapy or mitomycin-C (MMC) intravesical chemotherapy. Patients with nondiploid tumors had higher hazard rates for both tumor progression and death (p = 0.007 and p = 0.016, respectively); however, the prognostic information of DNA ploidy was not additive to tumor grade.

Above and below delayed endoscopic treatment of traumatic posterior urethral disruptions.

Between 1982 and 1990, 10 men with posterior urethral obliterations associated with pelvic fracture were managed with delayed above and below endoscopic reconstruction. After a mean of 43 months (range 7 to 108) of followup, all 10 men void with a peak flow rate of 12 ml. per second or greater and/or have a urethral caliber of 20F or greater. Concomitant prostatic hypertrophy somewhat compromises micturition in 4 older men. Nine patients are totally continent and 1 has mild stress incontinence. Five men who were potent after injury remain so after reconstruction. Of the 10 patients 6 required subsequent visual urethrotomy and/or scar resections, generally as outpatient or short stay procedures. In most instances voiding stabilized within 1 year, and interventions after this interval were unusual and generally trivial. We compare our experience with the results of others using a similar delayed endoscopic approach and conclude that this is a satisfactory method of managing traumatic posterior urethral obliterations, resulting in satisfactory voiding, continence and potency preservation.

Epithelioid sarcoma of the penis.

A rare case of penile epithelioid sarcoma in a 26-year-old white man is presented. The patient had a firm, slow growing, painless mass associated with penile deviation on erection, which was initially misdiagnosed as Peyronie's disease 5 years previously. With the onset of decreased urinary stream the lesion was biopsied, with a resultant diagnosis of epithelioid sarcoma. The patient underwent radical penectomy and perineal urethrostomy, and received 6,000 cGy. external beam radiotherapy postoperatively. Two years postoperatively the patient remained free of clinical disease. We review the pathophysiology, clinical characteristics and treatment of penile epithelioid sarcoma.

Polytetrafluoroethylene injection for post-prostatectomy incontinence: experience with 20 patients during 3 years.

We treated 20 men who were incontinent after prostatectomy and who had failed sphincter exercises with periurethral polytetrafluoroethylene (Teflon or Polytef) injections. Injections were done with the patient under brief general or spinal anesthesia as an outpatient or during a 24-hour hospitalization. Incontinence was due to radical prostatectomy in 17 patients and simple prostatectomy for benign disease in 3. Most patients had more than 1 injection and mean followup was 17 months. Of the 20 men 7 (35%) reported long-term improvement and 4 (20%) recommend the procedure to others. Complications were limited to 1 spontaneously resolving 48-hour bout of urinary retention and 1 episode of perineal polytetrafluoroethylene migration that produced pain for 3 months. We found the procedure to be simple, generally well tolerated and capable of producing clinical improvement in a significant minority of patients in whom it was used.

A randomized trial of intravesical doxorubicin and immunotherapy with bacille Calmette-Guérin for transitional-cell carcinoma of the bladder.

BACKGROUND: In carcinoma of the bladder, both intravesical chemotherapy and immunotherapy can induce tumor regression and reduce the rate of recurrence, but the relative merits of these two therapies are unclear. We conducted a multi-institutional study to address this question. METHODS: Patients with rapidly recurrent (stage Ta and T1) or in situ transitional-cell carcinoma of the bladder were randomly assigned to receive either doxorubicin administered intravesically or bacille Calmette-Guérin (BCG) administered both intravesically and percutaneously. The 262 eligible patients were followed for a median of 65 months. Complete responses to treatment of carcinoma in situ were confirmed by biopsy and cytologic analysis of the urine. RESULTS: For patients with Ta and T1 tumors without carcinoma in situ, the estimated probability of being disease free at five years was 17 percent after doxorubicin, as compared with 37 percent after immunotherapy with BCG (P = 0.015). The median times to treatment failure (termination of treatment, due to persistence, recurrence, or progression of disease) were 10.4 and 22.5 months, respectively. For patients with carcinoma in situ the complete-response probability estimates (i.e., the estimated probability of documented disappearance of disease) were 34 percent for doxorubicin (23 of 67 patients) and 70 percent for BCG (45 of 64 patients) (P less than 0.001); the median times to treatment failure were 5.1 and 39 months, respectively. The probability of being disease-free at five years survival among the patients with carcinoma in situ was 18 percent after treatment with doxorubicin and 45 percent after BCG therapy. Patients treated with BCG had a higher incidence of toxic systemic effects and a larger number of local irritative symptoms than patients treated with doxorubicin, but few of these adverse reactions were severe. CONCLUSIONS: As compared with intravesical doxorubicin, immunotherapy with BCG provides improved protection against the recurrence of superficial bladder cancer.

The Flexi-Flate and Flexi-Flate II penile prostheses.

Our experience with 45 recipients of the Flexi-Flate and Flexi-Flate II prostheses leads us to the following conclusions: 1. The device is readily implantable in approximately 1 hour with techniques familiar to most urologists who have implanted rigid or semirigid rods. 2. With attention to detail, prosthesis sizing is straightforward using intraoperative determination of corporeal girth and total corporeal length. We were unable reliably to predict prosthesis size preoperatively. Hence, as with other inflatable prostheses, we recommend that an entire range of prosthesis sizes be available at implantation. 3. Mechanical reliability is similar to that of more complex inflatable devices. The mechanical malfunction rate has been 11.6 per cent over a 15.1-month follow-up. 4. Patients find the inflation-deflation mechanisms easy to master. 5. Spontaneous deflation does occur during intercourse in some instances, but most patients are able to adjust sexual techniques and position satisfactorily with minimal disruption of enjoyment for themselves and their partners. 6. Among individuals with functional prostheses, a detailed survey of patient and partner response postoperatively revealed a high level of satisfaction for both and a return to premorbid levels of sexual functioning. Concealability was good in the flaccid state, and patients report minimal difficulties or embarassment with everyday functions in public restrooms and shower situations.

Clinical experience with a self-contained inflatable penile implant: the Flexi-Flate.

We implanted 23 Flexi-Flate penile prostheses during a 15-month period beginning July 1985. Of the implants 22 were followed for a mean of 16.1 months and 19 (86 per cent) function well. Satisfaction of individuals with a functioning prosthesis, as determined by interview and questionnaire (79 per cent response rate), has been good. Deflation sometimes occurs with penile shaft bending during sexual activity but this is managed satisfactorily by most couples via technique adjustments with minimal disruption of enjoyment. Reliable preoperative prosthesis size selection based on pubis to mid glans measurements was not possible in our hands secondary to broad variation in intracorporeal lengths found in the population studied.

Diagnosis and management of testicular torsion: pitfalls and perils.

When a patient presents with acute scrotal pain and physical findings do not permit confident exclusion of testicular torsion, the initial step in management is immediate consultation with a urologist, pediatric surgeon, or general surgeon. Scrotal imaging is fallible and takes time that may be critical to salvage of the testis. Manual detorsion may be indicated when specialty support is not immediately available, but even if this technique is apparently successful, the patient should be transferred to specialty care without delay.

5-year experience with intravesical therapy of carcinoma in situ: an inquiry into the risks of "conservative" management.

Recent reports of disease progression in patients being treated with intravesical agents for carcinoma in situ of the bladder led us to examine our 5-year experience with 26 consecutive patients with carcinoma in situ treated with intravesical therapy for this lesion. Nine patients with isolated carcinoma in situ and 17 with carcinoma in situ associated with papillary lesions were treated intravesically with a variety of agents in a closely monitored program for a mean of 22 months. All patients wished to exhaust conservative options before accepting cystectomy. Of 26 patients treated 9 (35 per cent) have no evidence of disease with a functional bladder after 27 months, 13 (50 per cent) are treatment failures and 4 (15 per cent) maintain an equivocal status to date. Successful treatment results with each drug were 6 of 24 thiotepa, 0 of 7 mitomycin, 0 of 6 doxorubicin and 3 of 8 bacillus Calmette-Guerin. Treatment failure was associated with disease progression to muscle invasion, adjacent organ invasion or metastases in 7 patients (27 per cent). Significant reduction in bladder capacity after prolonged therapy occurred in 3 patients. Our results suggest that persistent, intensive, "conservative" intravesical therapy in the face of recurrent or persistent disease is associated with substantial patient risk.

Cranial metastases from prostate cancer simulating meningioma: report of two cases and review of the literature.

Two cases of prostatic carcinoma metastatic to the cranium that presented with clinical and radiographic features simulating meningioma are described. The literature was reviewed, and 13 similar cases were identified. From the data gathered, we conclude that metastatic prostate cancer should be considered in the differential diagnosis of elderly males who present with characteristic clinical and radiological features of meningioma and that the classical description of meningioma is not specific.

Prolactin secreting renal cell carcinoma.

We report a case of hyperprolactinemia and long-standing gynecomastia associated with a hypernephroma. After radical nephrectomy serum prolactin returned to normal and remained so for 4 years without evidence of tumor recurrence. Potential explanations for the observed concurrent findings and the literature are discussed.

Intravesical bacillus Calmette-Guerin therapy and associated granulomatous renal masses.

We report a case of clinically symptomatic renal granulomas occurring during intravesical and intracutaneous bacillus Calmette-Guerin therapy for bladder cancer. The patient responded to antituberculous triple therapy. We emphasize the rarity of such extravesical infectious complications and discuss the possible routes of renal inoculation.

Diagnosis of intraperitoneal extravasation of urine by peritoneal lavage.

The diagnosis of intraperitoneal extravasation of urine in the multiple trauma patient is often delayed, resulting in increased morbidity and mortality. To determine if intraperitoneal extravasation of urine can be detected by peritoneal lavage, an animal study was designed to investigate whether urea nitrogen and creatinine levels in the urine, serum, and lavage fluid would be predictive of urinary extravasation. Seventeen adult mongrel dogs, weighing 21 to 30 kg, were divided into two groups. The six dogs in Group 1 were utilized as controls, and had peritoneal lavage (15 mL normal saline/kg) performed using the open technique (direct visualization of the peritoneum). Blood, urine and lavage urea nitrogen and creatinine and lavage red cell count were measured. Group 2 (11 dogs) had varying amounts of urine (5 mL to 330 mL) instilled into the peritoneal cavity. Diagnostic peritoneal lavage was performed 30 to 45 minutes after the instillation of urine in all Group 2 animals. Group 2A (nine dogs) had urine instilled under direct visualization through a peritoneal lavage catheter. As bladder dome rupture is the most common cause of intraperitoneal urine extravasation, Group 2B (two dogs) had bladder dome ruptures performed by cystoscopic approach using the resectoscope. Cystograms were obtained in the bladder-ruptured dogs after completion of the peritoneal lavage to confirm intraperitoneal extravasation of bladder contents. In these animals, urine was instilled back into the bladder following bladder rupture. Results demonstrate that urea nitrogen and creatinine can be measured in peritoneal lavage fluid when extravasation of urine is in amounts of 15 mL or greater, and not measurable in amounts of 5 mL or less.(ABSTRACT TRUNCATED AT 250 WORDS)

Congenital ureteral valves: report of 2 patients, including one with a solitary kidney and associated hypertension.

We report 2 cases of congenital ureteral valves treated successfully by excision of the involved segment and ureteroureterostomy. Hypertension in 1 patient and recurrent urinary tract infection in the other prompted initial evaluation. In the hypertensive patient renin collections from the vena cava and the renal vein of the solitary kidney were normal. Nevertheless, relief of obstruction has resolved the hypertension for 3 years. We review the literature regarding ureteral valves and discuss the mechanism by which unilateral hydronephrosis probably produces hypertension.

Use of clonal assay in determination of urothelial drug sensitivity in carcinoma in situ of the bladder: clinical correlations in 5 patients.

Five patients with carcinoma in situ of the bladder, including 4 with associated grossly apparent tumors, were followed for 2 years or until invasive disease appeared while receiving intravesical chemotherapy. In vitro drug sensitivity determinations were made using the clonal assay. Of 9 retrospective and prospective in vitro/in vivo drug sensitivity correlations 7 proved correct. However, in vitro growth occurred in only 50 per cent of the urothelial samplings in which adequate cells were present. The assay has some potential use in selecting agents for intravesical chemotherapy but the problem of unpredictable and limited in vitro growth must be overcome.