Elevated prostate-specific antigen, abnormal prostate evaluation on digital rectal examination, and transrectal ultrasound and prostate biopsy.

Prostate cancer screening for the early diagnosis of organ-confined, potentially curable prostate cancer has dramatically changed the practice of urology over the past 15 years. The introduction of prostate-specific antigen (PSA) testing, increased medical and public awareness for digital rectal examination (DRE), and transrectal ultrasound-assisted needle biopsy of the prostate (TRUS/PNBX) has been instrumental in these dramatic changes.

Genetic susceptibility of benign prostatic hyperplasia.

In an effort to provide new insight into the etiology of benign prostatic hyperplasia (BPH), an evaluation of genetic factors was performed. Recognizing that early age of onset is a marker for hereditary disease, we performed a case-control study of men with early onset of significant BPH. Men in the youngest quartile (less than 64 years old) with a large prostate (greater than 37 gm. resected tissue) who underwent surgery for BPH were identified as case probands from 909 consecutive prostatectomies for BPH. Control probands, selected because of the ability to distinguish treatment for benign prostate disease from treatment for malignant prostate disease, were women whose spouses underwent radical prostatectomy during the same interval. Male relatives of men with early onset of BPH had a 66% cumulative lifetime risk of prostatectomy for BPH, compared to a 17% cumulative risk among control relatives (p = 0.001). A 4-fold increase in age-specific risk of prostatectomy for BPH was present among relatives of men who had undergone prostatectomy for BPH (p = 0.0003), while brothers of these affected cases had a 6-fold increase in risk (p = 0.0089) compared to controls. To determine the likelihood that genetic factors account for this familial aggregation of BPH, segregation analysis was done. Although the small sample size prevented rigorous exclusion of nongenetic models, direct comparison of mendelian and nongenetic models showed that mendelian transmission provided the best overall explanation of the observed familial aggregation. The optimal model suggested mendelian dominant inheritance of a gene associated with early age at onset of BPH. These findings identify family history of BPH as a risk factor for clinical BPH and suggest the presence of a predisposing gene in patients with early onset BPH. Evidence of dominant mendelian transmission of this allele provides a framework for genetic studies to characterize this gene and elucidate the development of BPH in general.

Tubularized neourethra following radical retropubic prostatectomy.

A 1.5 cm. tubularized neourethra was formed using an anterior bladder flap as part of bladder neck reconstruction after radical retropubic prostatectomy in 69 consecutive patients with clinically localized prostate cancer (study group). Postoperative continence (defined as requiring no protection for any activity) was assessed by history at 3 months (all men) and 6 months (45 of 69 men). Continence in the study group was compared to that of 45 men with 6 months of followup who underwent radical retropubic prostatectomy without tubularization of the anterior bladder (control group). At 3 months 38 of 69 men (55%) were continent in the study group and 14 of 45 (31%) were continent in the control group (p < 0.03). At 6 months 39 of 45 men (87%) were continent in the study group compared to 21 of 45 (47%) in the control group (p < 0.01). Upright cystograms performed on men with and without the tubularized neourethra after radical retropubic prostatectomy suggest that a neourethra proximal to the external sphincter may increase resistance in this area and result in early return of urinary control in men undergoing radical retropubic prostatectomy.

Extragonadal germ cell tumor originating in iliac fossa.

Extragonadal germ cell tumors usually originate in midline body structures. We describe the first case of an extragonadal germ cell tumor that arose atypically in the right iliac fossa, a nonmidline pelvic region. Based on this case report and a review of the literature, we suggest a modification of Abell's criteria for the diagnosis of retroperitoneal extragonadal germ cell tumors.

Unilateral nerve-sparing radical prostatectomy and hemicystectomy in management of prostate sarcoma.

A patient with sarcoma of the prostate was treated with radical prostatectomy including wide excision of the ipsilateral neurovascular bundle and hemicystectomy. Six years postoperatively he is free of disease, continent with a bladder capacity of 350 cc, voids to completion, and is potent.

A modified thoracoabdominal approach for retroperitoneal lymphadenectomy.

A modified thoracoabdominal approach for radical retroperitoneal lymphadenectomy is described. In addition, this same incision is ideal for surgical access to the retroperitoneal structures. The primary advantage of this approach is full exposure of the retroperitoneum with minimal retraction by assistants and without entering the chest cavity.

Leiomyoma of the kidney: presentation of 4 new cases and the role of computerized tomography.

Renal leiomyoma is a challenging diagnostic and therapeutic condition. It is clinically similar in presentation and radiographic appearance to its malignant counterpart, leiomyosarcoma. We review 30 cases of clinically diagnosed leiomyoma of the kidney from the literature, including 4 new cases with emphasis on the computerized tomography findings. Computerized tomography may locate a renal leiomyoma serendipitously in an asymptomatic patient. If the lesion is peripheral or in the parapelvic area and a plane can be seen between the tumor and kidney a capsular tumor, such as a leiomyoma of the kidney, might be considered in addition to the more common renal cell carcinoma. Renal leiomyomas have a variable radiographic pattern from that of a pure cystic to a mixed solid/cystic to an entirely solid lesion. Renal leiomyomas usually are sharply demarcated from the surroundings. Although computerized tomography cannot distinguish a renal leiomyoma from other benign or malignant renal processes the presence of invasion can virtually eliminate this benign tumor as a diagnosis. Since a preoperative diagnosis cannot be made, management involves renal exploration and radical nephrectomy in the larger lesions with a renal-sparing operation possible in selected cases. After treatment patients have a uniformly excellent prognosis.

Behavioral training for post-prostatectomy urinary incontinence.

We treated 20 men with persistent post-prostatectomy incontinence by biofeedback-assisted behavioral training procedures. Initially, scheduled 2-hour voiding resulted in a mean 33.1 per cent increase in urge incontinence, a mean 28.5 per cent decrease in stress incontinence and no change in continual leakage. Subsequently, biofeedback was used to teach selective control of the sphincter muscles and/or inhibition of detrusor contractions. Individualized home practice included a voiding schedule, sphincter exercises, active use of the sphincter to prevent urine loss and strategies to manage urgency. After 1 to 5 biofeedback sessions patients with urge incontinence demonstrated an average 80.7 per cent decrease in incontinence, while stress incontinence was decreased an average 78.3 per cent and patients with continual leakage were less successful, with a mean 17.0 per cent improvement. The findings indicate that biofeedback training is an effective intervention for episodic stress or urge incontinence after prostatectomy. However, its usefulness appears to be limited in patients with postoperative incontinence characterized by continual leakage.

External ureteroneocystostomy in renal transplantation.

The urologic complications of 184 consecutive renal transplants (68 living-related and 116 cadaveric) performed at Walter Reed Army Medical Center are reviewed. An anterior extravesical technique modified from Witzel, Sampson, and Lich was used to reimplant the ureter. Urologic complications occurred in 11 patients (6%): urine leak (4), obstruction (3), stricture (3), and total ureteral necrosis (1). These complications occurred in the first 115 patients; no complications have been documented in the last 69 patients. The several advantages of extravesical ureteroneocystostomy include: less operative time, avoidance of a separate cystotomy, virtually no hematuria, ability to use short ureters, no need for splints or stents, shortened Foley catheter drainage, and no interference with native ureteral function. Complications are few and become uncommon with practice.

Cost-effective uroflowmetry in men.

A simple method of timed urine flow measurement performed at home by the patient is compared to instrumental measurements of peak flow rate. The timed method correlates well with the peak flow rate. Timed uroflowmetry is free, can be done in the privacy of the home and provides multiple measurements. This is a valid technique to document a weak stream and is a useful screening test for patients with lower urinary tract obstruction.

Testicular cancer risk among young men: role of cryptorchidism and inguinal hernia.

The role of cryptorchidism (undescended testis) and inguinal hernia in the etiology of testicular cancer among men aged 18-42 years was evaluated in a case-control study of 271 cases and 259 controls referred to three collaborating medical centers in the Washington, DC, area. The relative risk of testicular cancer for men who reported a history of an undescended testis was 3.7 (95% confidence interval = 1.6-8.6). The risk increased with increasing age at correction; the risk was highest for those men whose cryptorchid testis was never corrected. Among unilateral cryptorchids, no increased risk of testicular cancer was observed for the normally descended testis. There was only a slight excess risk for men without cryptorchidism who had a herniorrhaphy; however, those who underwent a hernia operation after age 7 had a significantly elevated risk of testicular cancer on the same side as the hernia. This case-control study is the first one to support the clinical recommendations for early surgical correction of cryptorchidism and inguinal hernia. Data from this study suggest that the excess cancer risk associated with cryptorchidism is due to internal factors that affect the undescended testis rather than to some underlying developmental abnormality.

Localization of alpha-fetoprotein and human chorionic gonadotropin to specific histologic types of nonseminomatous testicular cancer.

We used an indirect immunoperoxidase technique to localize alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG) to specific histologic types of testicular germ cell cancers. Among 20 nonseminomatous tumors studied, yolk sac tumor reacted for AFP in 13 of 15 cases, teratoma in 3 of 11 cases, and embryonal carcinoma in 3 of 14 cases. Syncytiotrophoblasts alone reacted for HCG in 14 of 15 cases, and syncytiotrophoblasts associated with choriocarcinoma reacted for HCG in 2 of 2 cases. There was a close correlation between the tissue demonstration of AFP and HCG and elevated serum levels of AFP and HCG, respectively. We conclude that in nonseminomatous testicular cancer yolk sac tumor is the primary site of synthesis of AFP, and syncytiotrophoblasts are the only site of synthesis of HCG.

Leiomyosarcoma of the inferior vena cava presenting as a suprarenal mass.

Leiomyosarcoma of the inferior vena cava is a rare disease with protean manifestations related to the location of the tumor. Urological manifestations of the disease are rare and include renal vein thrombosis and renovascular hypertension. Approximately 63 cases have been reported in the literature, with a striking female predominance. Presentation as an isolated suprarenal mass has not been reported previously. We discuss this unusual tumor and report a case that presented as an asymptomatic suprarenal mass.

Commercial radioimmunoassay for beta subunit of human chorionic gonadotropin: falsely positive determinations due to elevated serum luteinizing hormone.

Among 17 men who had received seemingly curative treatment for unilateral non-seminomatous germ cell tumors for the testis and who had consistently normal serum human chorionic gonadotropin (HCG) levels at a reference laboratory, 7 (41%) had at least one falsely positive commercial serum HCG determination. To investigate the cause of these falsely positive determinations the authors measured the cross reactivity of luteinizing hormone (LH) and follicle stimulating hormone (FSH) standards in the commercial HCG assay, and studied the relationship between commercial HCG levels and serum LH levels, serum FSH levels and gonadal status in men with and without normal gonadal function. The falsely positive HCG determinations appeared to be due to elevated serum LH levels and cross reactivity of LH in the commercial HCG assay because: 1) there was substantial cross reactivity of the LH standards in the commercial assay, 2) the serum LH was elevated in four of six men with solitary testes, 3) there was a striking correlation between elevated serum LH levels and falsely elevated commercial HCG levels in ten men with solitary or absent testes, and 4) there were no falsely positive HCG determinations in 13 normal men but there were falsely positive HCG determinations in seven of ten anorchid men.

Radical prostatectomy with pelvic lymphadenectomy: observations on the accuracy of staging with lymph node frozen sections.

The accuracy of intraoperative frozen section examination of excised lymph nodes was analyzed in 40 consecutive patients with clinical stages A2, B1 and B2 adenocarcinoma of the prostate who underwent pelvic lymphadenectomy immediately before anticipated radical prostatectomy. Lymph node metastases were observed with frozen sections and verified with paraffin sections in 5 cases (13 per cent). Among the 35 patients with negative frozen sections lymph node metastases were found with paraffin sections in 3 cases (9 per cent). Despite the potential for false negative findings we believe that intraoperative frozen sections constitute a practical method of pathologic staging prior to radical prostatectomy.