Incidence of cholelithiasis in 125 continent urinary diversions.

PURPOSE: Several studies in animals and humans have demonstrated that ileal resection has an increased association with gallstone formation. However, little reported data exist in regard to continent diversion, and the incidence and relative risk of gallstones. We describe a single institution, single surgeon (J. W. W.) experience with 125 modified Indiana pouch continent urinary diversions constructed in a 14-year period and the subsequent association with gallstones. MATERIALS AND METHODS: We retrospectively reviewed the charts of 129 patients who underwent continent urinary diversion from March 1985 to August 1998 at our institution to assess postoperative cholelithiasis. Complete information was available in 125 of the 129 charts. All patients were followed yearly with ultrasound combined with telephone followup to ensure complete data. RESULTS: Cholelithiasis was present in 32 of the 125 reviewable patients (25.6%), including 53 men and 72 women. Three men and 8 women who underwent previous or concomitant cholecystectomy for gallstones were excluded from study. Therefore, cholelithiasis developed in 21 of the 114 remaining patients (18.4%), including 5 males (4.3%) and 16 females (14%). Five of the 50 remaining men (10%) and 16 of the remaining 64 women (25%) had gallstones. Mean age at surgery was 43.5 years (range 19 to 73) and mean age at gallstone development was 45 years (range 23 to 77). Mean time from surgery to gallstone development was 3 years (range 1.1 to 5.5). Mean followup via chart review was 41 months (range 1 to 127). The recent telephone followup reached 83 of the 125 patients (66.4%). However, 20 of the 42 patients who were not reached by the telephone followup had had clinic appointments at our institution in the last 11/2 years for an overall 82.4% followup rate (103 of 125 patients). Of the 21 patients with cholelithiasis 17 were identified by chart review and 4 were identified by telephone followup. CONCLUSIONS: The recent literature indicates a 10% and 20% incidence of gallstones in American men and women, respectively. Previous reports support a potential increase in cholelithiasis in patients who undergo ileal resection. Our data indicate no increased risk of gallstones in patients who undergo modified Indiana pouch urinary diversion. However, longer followup is required to verify these findings.

Erectile dysfunction.

Erectile dysfunction affects millions of men in this country. Impairment of neurologic, hormonal and vascular function can inhibit the corporal smooth muscle relaxation necessary for erectile function. Physicians should employ a diagnostic work-up that proceeds from a history and physical examination to laboratory studies and physiologic testing. Treatment, which should be prescribed with constant patient input, is successful in a high percentage of cases. For erectile dysfunction with psychogenic or hormonal etiologies, treatments target the specific underlying problem. For dysfunction caused by nonspecific vascular and neurogenic problems, useful treatments include medication, vacuum devices, intracavernosal injections and penile implants.

Comparison of patient-controlled analgesia versus intramuscular narcotics in resolution of postoperative ileus after radical retropubic prostatectomy.

Patient-controlled analgesia has become standard practice after major abdominal operations. The benefits of patient-controlled analgesia have been well documented. However, its possible effect of prolonging postoperative ileus has not been well examined. To determine if patient-controlled analgesia prolongs postoperative ileus when compared to conventional intramuscular narcotics, a retrospective review of length of postoperative ileus in 98 consecutive patients (62 using patient-controlled analgesia and 36 using intramuscular narcotics) undergoing bilateral pelvic lymphadenectomy and radical retropubic prostatectomy was done. The patients receiving patient-controlled analgesia resolved the postoperative ileus an average of 1.0 day later than the intramuscular injection group (5.2 days versus 4.2 days p < 0.0001). Overall hospital stay was not significantly affected. Our results show that patient-controlled analgesia use prolongs postoperative ileus.

Combined cholecystectomy and radical genitourinary cancer surgery.

We have routinely performed simultaneous cholecystectomy in patients with cholelithiasis undergoing selected radical genitourinary cancer surgery. A total of 31 patients have undergone cholecystectomy at the time of radical nephrectomy (25), radical cystectomy (5), and radical prostatectomy (1). Operative time was increased twenty-five to forty-five minutes. There was no significant increase in blood loss, postoperative total bilirubin, or number of complications. No complications were directly attributable to the cholecystectomy except for 1 patient who had prolonged drainage from a closed suction drain in the gallbladder fossa. We conclude that concomitant cholecystectomy at the time of radical genitourinary cancer surgery does not significantly increase morbidity and recommend that it be performed in the presence of cholelithiasis.

Prostate cancer: results of external irradiation.

From 1975 to 1982, 205 patients with local prostate cancer were treated at the radiation oncology department, the University of Kansas Medical Center, Kansas City, Kansas. Patients' median age was 73 years. All of the patients were staged according to American Urologic staging criteria. Twenty-eight patients had stage A2 cancer, 91 patients had stage B cancer, and 86 patients had stage C cancer. All patients were treated using megavoltage radiation (dosage range: 6000 cGy to 7100 cGy). The follow-up period ranged from a minimum of 8 years to a maximum of 15 years (median: 9.4 years). The clinical local control was 96% for stage A2, 94% for stage B, and 90% for stage C disease. The overall and disease-free survival rates were 71% and 60%, respectively. Fourteen patients developed moderate complications with one patient (0.5%) requiring surgical intervention. The local control and survival rates reported in this study are comparable with surgical results, suggesting that external beam irradiation in prostate cancer is safe and effective.

Management of preexisting inflatable penile prosthesis during radical retropubic prostatectomy.

A potentially difficult technical situation exists when a man with a functioning inflatable penile prosthesis elects radical prostatectomy as treatment for localized prostate cancer. Between February 1988 and June 1991 we encountered 8 men with a preexisting inflatable penile prosthesis who subsequently underwent radical retropubic prostatectomy. In 2 patients the reservoir portion of the prosthesis was in the perivesical space such that radical prostatectomy could be performed without difficulty. However, in 6 patients removal of the reservoir was necessary to complete the prostatectomy. In 3 of these 6 patients the reservoir was replaced at 3 to 6 months after radical prostatectomy and all 3 systems function well. The remaining 3 patients have not yet elected replacement of the reservoir. Only 1 patient had an infection and a complication attributable to the prosthesis. We believe that a preexisting inflatable penile prosthesis should not preclude successful radical retropubic prostatectomy, although temporary removal of the reservoir may be required.

Correlation of ultrasound guided and digitally directed transrectal biopsies of palpable prostatic abnormalities.

The authors evaluated 51 patients with palpable prostatic abnormalities detected during digital rectal examination. These findings consisted of a nodule or an area of induration. Each palpable abnormality was confined to 1 prostatic lobe and there was no suggestion of extracapsular extension of neoplasm or systemic metastatic disease. All patients underwent 7.0 MHz. sagittal ultrasound guided transrectal biopsy followed by digitally directed transrectal biopsy. Biopsies were obtained only from the area of interest. The procedure was performed in the outpatient clinic without use of sedation or anesthesia. Digitally directed biopsies were positive for adenocarcinoma in 9 lesions. Ultrasound guided biopsies detected adenocarcinoma in 23 lesions, including all those detected by the blind digitally directed technique. This study demonstrates greater diagnostic accuracy using 7.0 MHz. ultrasound guided techniques and its routine use is warranted in the evaluation of palpable prostatic abnormalities.

Adenocarcinoma of the prostate discovered in 2 young patients following total prostatovesiculectomy for refractory prostatitis.

Adenocarcinoma of the prostate gland is the most common cancer in men in the United States but it occurs rarely in men younger than 40 years. Incidental prostate cancer has been shown to exist in a significant number of patients older than 50 years, found either at autopsy or after cystoprostatectomy for a pathological condition of the bladder. We report 2 cases of unsuspected adenocarcinoma of the prostate gland discovered after total prostatovesiculectomy for refractory prostatitis in men 25 and 36 years old, respectively.

Analysis and management of chronic testicular pain.

A total of 45 patients was seen in consultation between May 1980 and April 1989 for chronic unilateral or bilateral orchialgia, defined as intermittent or constant testicular pain 3 months or longer in duration that significantly interferes with the daily activities of the patient so as to prompt him to seek medical attention. We analyzed 34 patients available for followup in terms of socioeconomic parameters, etiology and duration of pain, associated urological symptomatology, specific treatment and results of therapy. Of the patients 31 underwent surgical treatment after failing medical management (24 orchiectomies, 10 epididymectomies, 5 orchiopexies and 1 hydrocelectomy). Of 10 patients who underwent epididymectomy 9 underwent subsequent orchiectomy as definitive treatment. Of 15 patients who underwent inguinal orchiectomy 11 (73%) reported complete relief of pain, while 4 had partial relief. Of the 9 patients who underwent scrotal orchiectomy 5 (55%) reported complete relief of pain, 3 had partial relief and 1 denied improvement. On the basis of these results we recommend inguinal orchiectomy as the procedure of choice for the management of chronic testicular pain when conservative measures are unsuccessful.

Papaverine-induced priapism: 2 case reports.

Intracorporeal papaverine injection therapy for impotence has been reported recently as a therapeutic option with low morbidity. We report 2 cases of papaverine-induced priapism that required surgical intervention.

Testicular self-examination: validation of a training strategy for early cancer detection.

Testicular self-examination (TSE) can lead to early diagnosis and treatment of testicular cancer, the third leading cause of death in young men. We evaluated the effectiveness of a brief and specific checklist for teaching TSE skills. Ten men were videotaped while performing testicular self-examinations before and after training. The TSE training resulted in large and significant increases in the number of TSE steps completed and duration of the TSE. Two urological validation measures supported the improvements observed in the mens' self-examinations. Subjects reported continued performance of TSE during a follow-up telephone interview. This pilot study indicates that a brief and specific checklist is an effective strategy for teaching early cancer detection skills.

In vitro peripheral monocyte culture: possible use as a prognostic indicator for renal cell carcinoma patients.

An in vitro assay was applied to follow 39 patients with renal cell carcinoma. A mononuclear cell-rich fraction was cultured from peripheral blood of patients over a period of 7 days. The number of adherent matured monocytes (macrophages) was analyzed and quantitated at the end of the culture period. Functional activities were analyzed by antibody-coated sheep red blood cells and nonspecific esterase staining techniques. Macrophage yield in patients with detectable tumor burden was 2.06 +/- 2.81 X 10(4) cells/ml blood, and mean values at 3, 6, and 9 months post nephrectomy were 3.67 (n = 21), 6.73 (n = 12), and 9.41 (n = 10) X 10(4) cells/ml blood, respectively. Some of the patients were followed over 30 months. The improvement was significant, and macrophage yield was close to normal values (8.24 +/- 3.14 X 10(4) cells/ml). In the absence of other reliable in vitro assays for these patients, this assay appears to be highly useful in following these patients during the postsurgical period.

Treatment of renal cell carcinoma with renal infarction, delayed nephrectomy, medroxyprogesterone, and xenogeneic immune RNA.

The authors have used xenogeneic immune ribonucleic acid (RNA) in the treatment of patients with renal cell carcinoma. This has been used in conjunction with renal artery embolization, delayed nephrectomy, and progestational therapy, using immune RNA derived from sheep cell lymphocytes immunized with patient's tumor. Four of 5 patients with Stage I disease had extremely large primary tumors. This group is alive with no evidence of disease at twelve to twenty-four months. There are no Stage II tumors in this group. One patient with Stage III tumor is alive at twenty-two months without evidence of disease. Three patients with metastases are stable at five to twenty-two months. Two patients have progressive disease at three and six months. This treatment has not been effective in patients with massive tumor burden. The results in the other groups are encouraging.

Inferior vena caval replacement after resection of left renal tumor in canine model.

An animal model simulating the necessity of replacing the inferior vena cava (IVC) with a prosthetic graft is described. Six dogs underwent replacement of the IVC with an expanded polytetrafluoroethylene (E-PTFE) graft using an interrupted-suture technique. Three dogs served as controls, undergoing resection and autograft of the native IVC. Distal side-to-side femoral arteriovenous fistulas were constructed in each case and allowed to remain for six weeks. Subcutaneous heparin and prophylactic antibiotics were administered in the early postoperative period. All grafts were patent at six months, indicating a potentially successful technique for reconstruction of the IVC involved in disease or trauma.

Incidence of lymph node involvement in localized carcinoma of the prostate.

Bilateral pelvic lymphadenectomy was performed in 100 patients as a staging procedure. Sixty-one patients received iodine 125 radioisotope implant and 39 patients received external radiation therapy. The overall incidence of lymph node metastases was 27 percent. The incidence of lymph node involvement was 14 percent with clinical stage A2 disease, 3 percent with stage B1, 44 percent with stage B2, and 40 percent with stage C disease. The grade of the tumor influenced the incidence of lymph node metastases. Only 6 percent of grade I tumors had lymph node metastases, whereas 26 percent of grade II tumors and 71 percent of grade III tumors showed lymph node metastases.

Renal cell carcinoma--angioinfarction.

In our experience the mortality rate in 46 patients who underwent angioinfarction for renal cell carcinoma was 4 per cent. Fever, ileus and leukocytosis were noted in 86 to 90 per cent of our patients. The use of absolute ethanol as a medium for renal infarction was associated with a significant incidence of damage to other organs. A 30 per cent decrease in tumor volume following angioinfarction using absorbable gelatin sponge and Gianturco coils was noted in 75 per cent of the patients. There was no evidence of metastatic tumor reduction and we could not document any significant decrease in operative time or blood loss. It would appear that there is some increased survival rate in patients with metastasis who are given adjuvant immune ribonucleic acid therapy. However, the numbers in our series are not significant to draw any definite conclusion. It is apparent that patients treated with infarction, delayed nephrectomy and medroxyprogesterone acetate did not have any significant survival over those treated with palliative nephrectomy or chemotherapy. The macrophage maturation assay may be useful during clinical followup.

Culture of peripheral monocytes in vitro in patients with renal cell carcinoma: a possible prognostic indicator.

An in vitro assay has been applied in 23 patients with renal cell carcinoma. A mononuclear cell-rich fraction was cultured from peripheral blood of patients with renal cell carcinoma. The number of monocytes maturing into macrophages was quantitated over a period of 7 days. Monocyte maturation was significantly lower in patients with renal cell carcinoma than in normal individuals. Of 10 patients tested both pre- and post-nephrectomy, 8 patients showed clinical improvement after surgery. In all 8, the posttreatment macrophage yield improved significantly from the pretreatment values to approach normal values. In 2 patients found to have metastasis postoperatively, the macrophage yield continued below normal levels. Our results suggest that the in vitro maturation of macrophages from mononuclear cells may parallel clinical events.