Search

Purpose: We determined the sensitivity and specificity of detecting flat bladder carcinoma in situ through fluorescent detection after intravesical hypericin instillations., Materials and Methods: The study included 40 patients, of whom 26 presented with macroscopic visible tumor, 9 had a positive cytology without visible tumor and 5 underwent cystoscopy after bacillus Calmette-Guerin instillations (4) or radiotherapy (1). We instilled 40 ml. of a 8 microM. solution of hypericin intravesically for at least 2 hours. Fluorescence excitation with blue light was effective up to 16 hours after termination of the instillation., Results: All visible papillary tumors showed red fluorescence. In addition, 134 flat fluorescent areas were detected. Analysis of 281 biopsies from flat bladder wall indicated 93% sensitivity and 98.5% specificity for detecting carcinoma in situ. Visible lesions resulting from radiotherapy, chemotherapy or immunotherapy did not show any fluorescent signs and, therefore, did not induce false-positive readings. There were no signs of photobleaching during inspection and resection., Conclusions: We report a simple yet comprehensive endoscopic method for early detection of bladder cancer, including carcinoma in situ. Hypericin induced fluorescence has a high sensitivity and specificity for detection of bladder transitional cell carcinoma, papillary and flat carcinoma in situ. When carcinoma in situ is suspected, this technique is highly recommended.

Purpose: Partial nephrectomy is becoming more widely accepted as alternative treatment for small renal cell carcinoma. To analyze its value in tumor control and its complication rate a retrospective study was done., Materials and Methods: A total of 76 patients underwent kidney sparing surgery, which was required in 25 and in the presence of a normal contralateral kidney in 51. Tumor size varied between 0.9 and 15 cm. Simple enucleation was done in 4 and partial nephrectomy in all other cases. The patients were followed every 3 months during year 1, every 4 months during years 2 and 3, and every 6 months during years 4 and 5 postoperatively. Mean followup is 75 months., Results: Eight patients had postoperative complications, most often hemorrhage. None of the patients had local recurrence, although in 3 systemic disease developed., Conclusions: Nephron sparing surgery is more challenging than radical nephrectomy and, therefore, can be more complicated. The selection of suitable candidates is the key to success. Many patients can benefit from nephron sparing surgery for small easily resectable renal cell carcinoma even in presence of a normal contralateral kidney. Randomized trials are needed to establish the definitive role of this approach in kidney cancer treatment.

Purpose: We described the long-term outcome of intravesical capsaicin instillations in patients with urinary incontinence and compared its efficacy in 2 similar populations of patients with multiple sclerosis in a dual center study., Materials and Methods: During 5 years 79 patients with intractable urinary incontinence have been treated with intravesical capsaicin. The majority of patients had spinal cord disease due to multiple sclerosis but 4 were neurologically normal. Cystometry was performed before and 4 to 6 weeks after intravesical instillation of 1 to 2 mmol./l. of capsaicin in 30% ethanol in saline. Instillations of vehicle (30% ethanol in saline) alone were carried out in 5 patients., Results: In patients with phasic detrusor hyperreflexia complete continence was achieved in 44%, satisfactory improvement occurred in 36% and treatment failed in 20%. Clinical benefit from a single instillation lasted 3 to 6 months and was repeated in some patients with similar improvement. Capsaicin was ineffective in patients with poor bladder compliance and in neurologically normal patients with sensory urgency and detrusor instability. There was no clinical or urodynamic improvement in patients treated with vehicle alone. There have been no long-term complications., Conclusions: Our study shows that repeated instillations of intravesical capsaicin are effective in treatment of patients with detrusor hyperreflexia due to spinal cord disease and that effectiveness of the treatment persists at least 3 to 5 years.

Purpose: Although many factors have been considered to predict the outcome after radical nephrectomy, renal cell carcinoma continues to behave unpredictably. In a retrospective study the correlation between microvascular tumor invasion and disease-free survival after surgery for renal cell carcinoma was analyzed., Materials and Methods: Between 1980 and 1993, 180 patients (mean age 60 years) were followed for a mean of 52 months after radical or partial nephrectomy for clinically localized renal cell carcinoma. The relevance of microscopic vascular invasion was compared to classical tumor staging, grade and tumor diameter., Results: Microscopic vascular invasion was found in 51 patients (28.3%), including 20 (39.2%) with progression (mean interval to progression 72 months). Of 129 patients with no pathological evidence of microscopic vascular invasion only 8 (6.2%) showed progression at a mean interval of more than 160 months. The difference in disease-free survival as a function of microvascular invasion was statistically highly significant (log rank p < 0.00001) and on multivariate analysis this parameter was by far the most relevant predictor of progression., Conclusions: In patients who underwent radical nephrectomy for clinically nonmetastatic renal cell carcinoma with microvascular invasion but without lymph node involvement or macroscopic vascular invasion the chance of disease progression is estimated at 45% within 1 year. Microvascular invasion is the single most relevant prognosticator after presumed curative radical nephrectomy for renal cell carcinoma.

Purpose: We analyzed 100 consecutive radical prostatectomy specimens to evaluate the extent and clinical relevance of the stage T1c cancers discovered., Materials and Methods: All cases were diagnosed by systematic prostatic puncture biopsies because of abnormal prostate specific antigen (PSA) or PSA density. Surgical specimens were examined with the whole organ multiple step-section technique (4 mm.) to identify primary tumor location (peripheral or transition zone cancer), tumor volume, tumor volume divided by prostate volume (percent tumor volume), Gleason score, pathological T stage and positive surgical margins. Tumors smaller than 0.5 cm.3 and without unfavorable pathology (Gleason score 7 or more, or positive surgical margins) were considered insignificant., Results: Median patient age, PSA, tumor volume and Gleason score were 64 years, 8.8 micrograms./l., 1.6 cm.3 and 6, respectively. Of the specimens 46 (46%) had transition zone cancer that was clinically undetectable due to anterior location, while peripheral zone cancers were small, diffuse, anterolateral or in large glands with low percent tumor volume. Transition zone cancer showed greater PSA, PSA density, tumor volume and percent tumor volume than peripheral zone cancer (p = 0.08, 0.03, 0.0002 and 0.0004, respectively), yet with similar Gleason score (p = 0.4). Of the tumors 34 (34%) were locally advanced (stage pT3 and/or positive surgical margins, mostly anterior in 16 transition zone cancers, and apical or posterolateral in 18 peripheral zone cancers), whereas 22 were insignificant (6 transition and 16 peripheral zone cancers). Prostatic puncture biopsies with a core cancer length of less than 3 mm. could have predicted 18 of 19 insignificant tumors but underestimated 13 (33%) and 6 (17%) significant transition and peripheral zone cancers., Conclusions: The majority of our stage T1c tumors were significant with a distinguished high incidence of transition zone cancer. Therefore, they were large but occult. Transition zone cancer behaved differently than peripheral zone cancer, and warranted considerations during treatment of stage T1c prostate carcinoma.

Purpose: We investigated whether impalpable, invisible (stage T1c) but significant prostate cancer can be detected better by determining the free-to-total prostate specific antigen (PSA) ratio of equivocal PSA serum levels., Materials and Methods: The specificity of free-to-total PSA ratio using research monoclonal enzyme immunoassays was compared to that of PSA greater than 4.0 ng./ml. in 117 consecutive patients with PSA 3 to 15 ng./ml. (Hybritech Tandem-R assay) due to untreated benign prostatic hypertrophy or prostate cancer. Of the patients 77% underwent adenectomy or radical prostatectomy with thorough pathological evaluation of surgical specimens., Results: Benign prostatic hypertrophy had a greater median free-to-total PSA ratio than stages T1c and T2 or greater prostate cancer (0.16 versus 0.09 and 0.11 ng./ml., p = 0.0001 and p = 0.0268, respectively). In stage T1c prostate cancer, areas under receiver operating characteristic curves were 0.58 and 0.84 for PSA and free-to-toal PSA ratio, and free-to-total PSA ratio correlated with prostate volume (r = 0.49, p = 0.005) and Gleason score (r = -0.37, p = 0.036). Pathologically, 84% of stage T1c cancers were significant and comparable to stage T2 or greater cancers., Conclusions: Free-to-total PSA ratio enhances the efficacy of PSA measurement by improving specificity for detecting impalpable, invisible but significant stage T1c prostate cancer.

Purpose: We explored the immunohistochemical expression of prostate specific antigen (PSA) in pancreas and salivary glands., Materials and Methods: We investigated 62 specimens from male and female subjects, representing normal cases and several pathological conditions of pancreas and salivary glands. Two commercially available monoclonal antisera for PSA and 1 for prostatic acid phosphatase were used., Results: A consistently positive reaction for PSA and prostatic acid phosphatase, independent of patient sex, was noted in ductal cells of normal pancreas and normal salivary glands, as well as pleomorphic adenoma, adenocarcinoma and all oncocytic epithelial cells of Warthin's tumor. Reaction was absent in normal stromal and acinar cells, and squamous carcinoma., Conclusions: PSA is detectable in normal and cancer tissues far from the prostate. Therefore, we may not entirely rely on specificity of PSA alone to diagnose metastatic prostate cancer.

Purpose: We analyzed the value of the Bard bladder tumor antigen (BTA*) test for the diagnosis of stage Ta superficial bladder cancer and carcinoma in situ, and compared it to the highly sensitive bladder washing cytology., Materials and Methods: The BTA test is a latex agglutination test that qualitatively detects the presence of basement membrane complexes in the urine. A total of 60 patients with superficial bladder cancer underwent voided urine BTA analysis and bladder washing cytologies., Results: Of the patients 65% were correctly diagnosed with the BTA test compared to 32% with bladder washings, which is statistically significant (p < 0.001)., Conclusions: The BTA test is a noninvasive diagnostic tool that is superior to bladder washing cytology for diagnosing superficial bladder cancer.

Purpose: We investigated the effect of neoadjuvant treatment before radical prostatectomy for clinically localized prostate cancer., Materials and Methods: A total of 130 patients with stages T2b and T3 prostate cancer was randomized in a multicenter study: 62 underwent immediate radical prostatectomy and 65 received 560 mg. estramustine phosphate daily for 6 weeks preoperatively., Results: For clinical stage T2b tumors the neoadjuvant treatment resulted in a significant decrease in positive surgical margins compared to the nonpretreated group. This difference was not found for clinical stage T3 tumors. The impact on progression and survival still must be analyzed., Conclusions: Neoadjuvant treatment can be beneficial for clinical stage T2 prostate cancer. Optimal treatment for stage T3 tumors remains controversial.

A 53-year-old woman presented with a renal angiomyolipoma extending as a thrombus into the renal vein and vena cava. This case is most unusual and we are unaware of any report of a benign angiomyolipoma that has presented as a tumor thrombus. The intravascular growth of a benign angiomyolipoma has previously been described.

The sensitivity and accuracy rate of computerized tomography (CT) in lymph node staging of localized prostatic carcinoma is commonly considered to be low. Fine needle aspiration cytology of pathological lymph nodes seen on radiological staging can enhance this low accuracy rate. We prospectively investigated the accuracy of CT and fine needle aspiration cytology in lymph node evaluation of 285 patients with clinically locally confined prostatic carcinoma. The sensitivity, specificity and accuracy rates of this combined method were 77.8%, 100% and 96.5%, respectively. False-negative staging results were found in only 10 patients with minimal nodal disease. Although in contrast with previous reports, combined CT and fine needle aspiration cytology in our hands seems to be a highly efficient staging method for lymph node involvement. This method could be considered as an alternative to surgical lymphadenectomy in the preoperative evaluation of the nodal status of patients with localized prostatic carcinoma who are scheduled for radical prostatectomy or curative radiotherapy.

The preliminary results of a randomized trial comparing orchiectomy versus orchiectomy and mitomycin C in 119 newly diagnosed metastatic prostate cancer patients are presented. Of 109 evaluable patients 57 were treated with orchiectomy alone and 52 received adjuvant intravenous mitomycin C. Mean interval to progression was 13 months in the orchiectomy group versus 11 months in the mitomycin C group. Preliminary analysis did not demonstrate a favorable effect of the combination with this chemotherapeutic agent compared to orchiectomy alone (p = 0.3).

We report on the preliminary results of 12 patients with multifocal carcinoma in situ of the bladder treated with whole bladder wall photodynamic therapy. The total light dose (scattered plus nonscattered light) measured in situ was 100 joules per cm.2 in the first 6 patients (group 1) and 75 joules per cm.2 in the remaining 6 (group 2). These light doses correspond on the average to 27 joules per cm.2 and 15.5 joules per cm.2 nonscattered light as reported by other investigators. Followup ranged from 6 to 22 months (average 11.5). In group 1, 2 tumors recurred after 6 and 9 months, respectively, and 2 other patients had a permanently shrunken bladder without evidence of disease. In group 2, 1 tumor recurred 5 months after photodynamic therapy. In this group the bladder capacity increased on the average to 135% of the pretreatment value 3 months after photodynamic therapy. All recurrences were in patients with a history of invasive bladder cancer (stages T1 and T2). These preliminary results demonstrate the importance of in situ scattered light dosimetry for minimizing local side effects of whole bladder photodynamic therapy.

High energy pulsed dye laser lithotripsy (Candela MDL-2000), with energy output upgraded to a maximum of 140 mJ. at the laser fiber tip using the 320 mu core fiber, was compared to the initially commercialized device, with the energy output fixed at 60 mJ. using the 200 mu core fiber (Candela MDL-1). A total of 31 treatments in 28 patients was performed with the Candela MDL-1 device. Complete disintegration or at least fragmentation to spontaneously passable fragments occurred in 18 of 31 cases (58%). Only in 11 of the 24 calcium oxalate monohydrate calculi (46%) was fragmentation achieved. Another 73 laser lithotripsies in 72 patients were performed with the Candela MDL-2000 device. Complete disintegration or at least fragmentation to spontaneously passable fragments was achieved in 67 of 73 treatments (92%). Calcium oxalate monohydrate calculi were successfully treated in 41 of 45 procedures (91%). There was no response to the laser treatment in the only cystine calculus.

Extracorporeal shock wave lithotripsy (ESWL) was performed for the treatment of urinary tract calculi in 28 children. All treatments were done with the standard Siemens Lithostar device in situ: no special adaptations for adequate positioning of children are required to target the stone precisely. A total of 42 calculi in 30 renal units was treated, requiring 50 ESWL sessions. The mean energy used was 16.4 kv. and the number of shock waves averaged 3,188. Mean fluoroscopy time per session was 1.5 minutes. In 26 of 50 sessions (52%) general anesthesia was needed for the child to remain perfectly still. A complete stone-free rate was achieved in 38 of 42 calculi (90.5%): after 1 session in 30 (71.4%), after 2 sessions in 6 (13.7%) and after 3 sessions in 2 (4.8%). Five staghorn calculi were treated with ESWL monotherapy. A complete stone-free result was obtained after 3 treatments in 2 patients, while 2 had residual fragments in the lower pole (5 mm. after 6 sessions and 11 months of followup in 1, and 7 mm. after 3 sessions and 3 months of followup in 1). A cystine staghorn stone necessitated open nephrolithotomy after 3 sessions without any fragmentation. One impacted sacroiliac ureteral stone required endoscopic laser lithotripsy. Except for these 2 failures no adjuvant procedures were needed. There were no intraoperative or postoperative complications and minor skin bruising at the coupling site after 3 treatments did not require any therapy. We conclude that electromagnetic ESWL with the standard Lithostar unit is a safe and effective method to treat calculi throughout the urinary tract in children.

When postoperative gastric decompression is necessary a percutaneous gastrostomy tube is an alternative to nasogastric intubation. The percutaneous insertion of a suprapubic bladder catheter is an easy procedure without notable complications that increases the comfort of the patient in the immediate postoperative period. We advocate its use in all major urological abdominal operations.

We reviewed 50 patients with staghorn stones to determine whether extracorporeal shock wave lithotripsy monotherapy is a successful alternative to the classical approaches (open operation versus percutaneous lithotripsy alone or with extracorporeal shock wave lithotripsy). Results free of stones at long-term followup (greater than 3 months) were obtained in 28 of 50 patients (56%) and when we included residual fragments with a diameter of less than 4 mm. (9 patients, or 18%) an over-all success rate of 74% (37 patients) was achieved. Of the patients 41 had a Double-J stent to improve fragment evacuation (5 experienced obstructive elimination), while uncomplicated evacuation was noted in the remaining 9 without a stent. No case of septicemia after extracorporeal shock wave lithotripsy was observed but all patients had received strict antimicrobial prophylaxis.

Between June 1987 and April 1989 a total of 4,500 extracorporeal shock wave lithotripsy treatments was performed in our department with the Siemens Lithostar lithotriptor. Renal (pelvic, caliceal and staghorn stones), ureteral and even bladder calculi can be treated by means of a system of fluoroscopic detection and electromagnetic shock wave generation. The treatments are performed without the use of anesthesia and on an outpatient basis. Hospitalization is indicated whenever underlying infectious stone disorders are suspected (associated urinary tract infection or infected calculi). Initial experience in the first 10 patients with bladder stones treated by electromagnetic extracorporeal shock wave lithotripsy monotherapy is reported. All stones disintegrated after 1 treatment, except in a patient with 2 bladder stones who required 2 sessions. Mean treatment duration was 53 minutes. Mean number of shock waves was 3,600 and electrical discharge averaged 20.2 kv. per shock wave. Minute fragmentation was obtained and uncomplicated evacuation occurred without the need for adjuvant procedures, even in the presence of prostatic hypertrophy (2 patients) or neurogenic bladder dysfunction (3). No morbidity during or after treatment was encountered in these 10 patients.

Direct transperineal infiltration of the prostate with antibiotics was performed in 24 selected patients with refractory chronic bacterial prostatitis. Diagnosis had been made following a modification of the classical lower tract localization studies. Remission periods of at least 6 months were obtained in 71 per cent of these patients after 1 or 2 infiltrations, while 6 of 24 (25 per cent) required several procedures to assume a long-term remission state and 1 (4 per cent) failed therapy (patient 24490). Seven patients had relapse after remission periods ranging from 13 months to 7 years. The last culture in 3 patients was positive. The value of the method compared to other therapeutic alternatives in the management of chronic bacterial prostatitis is discussed.

A total of 15 patients with proved chronic bacterial prostatitis underwent bilateral seminal vesiculography to determine the morphological appearance of the seminal vesicles and the ampulla ducti deferentis in this condition. A pathological condition, such as segmental stenosis or complete shriveling of the seminal vesicles, was obvious in 21 of 24 vesiculograms (87.5 per cent), while malformations of the ampulla were seen in 7 (29.1 per cent). The role of chronic bacterial prostatitis as an important pathogenetic factor in the history of epididymo-orchitis is discussed.