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Purpose: Several reports have documented that the MB isoenzyme of creatine kinase is present in prostatic tissue. However, since it has been shown that lower urinary tract manipulations, including transurethral prostatectomy, do not significantly increase serum creatine kinase isoenzyme MB levels, such elevations, which are found in patients after prostatic surgery, are believed to be specific for myocardial infarction. We examined whether cryosurgical ablation of the prostate altered serum creatine kinase or isoenzyme MB levels.Materials and Methods: In 81 consecutive patients undergoing routine cryosurgical ablation of the prostate serum levels of creatine kinase and creatine kinase isoenzyme MB were measured from peripheral blood specimens drawn preoperatively, in the recovery room and at 8 and 24 hours postoperatively. Postoperative electrocardiograms were compared to the preoperative study.Results: In 72 of 81 patients (89%) significant elevations in creatine kinase and creatine kinase isoenz...

A case of collecting-duct carcinoma associated with abnormal urine cytology is described. The finding of an abnormal cytologic examination, yet not typical of transitional-cell carcinoma (TCC), suggests that a close relationship between the cytology and histology of this uncommon malignancy may be demonstrated.

Purpose: We prospectively examined the effect of varicocelectomy on standard semen parameters and Kruger strict morphology, including site of specific sperm defect.Materials and Methods: Kruger strict morphology and routine semen analysis were performed in a blinded fashion before and a minimum of 4 months after varicocelectomy in 61 subfertile men with a primary diagnosis of varicocele.Results: Sperm motility, total number of motile sperm, and percentage and total number of sperm with normal strict morphology were significantly increased after varicocele repair. Average density was also increased, while volume and forward progression were unchanged. The percentage of normal head strict morphology was significantly improved, whereas tail and neck morphology did not reflect similar changes.Conclusions: Varicocele repair in subfertile men improves Kruger strict morphology. In addition, motility and total motile sperm are significantly improved after repair. Since the stoichiometry of the sperm head ...

Cryosurgical ablation of the prostate is a novel therapeutic modality that induces cell lysis in the prostate by direct application of low temperatures. We have been conducting an ongoing prospective pilot study of the use of cryosurgical prostate ablation in treating patients with nonmetastatic prostate adenocarcinoma since January 1993. Results in 145 consecutive patients with mean 36 months and minimum 12 months of followup are presented.Accrual was open to patients with clinical stages T1a to T3c prostate adenocarcinoma. Pelvic lymph node dissections were recommended but not required for patients with prostate specific antigen (PSA) greater than 15 ng./ml. before study entry. PSA changes, random prostate biopsy findings and morbidities after cryosurgical prostate ablation were recorded for each patient.Overall actuarial rates at 42 months for maintaining PSA less than 0.3 and less than 1.0 were 59% and 66%, respectively. The overall actuarial progression-free rate at 60 months was 56%. Among 160 biopsies performed 16% showed some evidence of residual carcinoma. Overall crude rates of maintaining either a negative biopsy or PSA less than 0.3 at 6 and 24 months after cryosurgical prostate ablation were 87% and 73%, respectively. Significantly higher morbidities were seen in previously radiated patients undergoing cryosurgical prostate ablation compared to those with no prior radiation. Among nonradiated patients 85% experienced no significant morbidity after cryosurgical prostate ablation.Although preliminary, short-term outcomes after cryosurgical prostate ablation appear to be comparable to identical outcomes reported for external beam radiotherapy. Based on these results cryosurgical prostate ablation appears to be an effective therapeutic alternative for treating patients with localized prostate adenocarcinoma.

The management of metastatic renal cell carcinoma remains challenging and controversial. There is some evidence of improved response to interleukin-2 (IL-2) based immunotherapy in patients who undergo nephrectomy before systemic treatment. However, recent reports have suggested that surgery prior to immunotherapy may not be an efficient strategy, since many patients will not be able to receive systemic treatment after nephrectomy. We describe our criteria for determining which patients are candidates for nephrectomy before immunotherapy and present our series of patients treated with this approach.Based on our initial experience with IL-2 based immunotherapy we developed certain inclusion criteria for treatment with initial nephrectomy followed by systemic immunotherapy, including greater than 75% debulking of tumor burden possible, no central nervous system, bone or liver metastases, adequate pulmonary and cardiac function, and Eastern Cooperative Oncology Group performance status of 0 or 1. In addition, patients in whom biopsies show other than predominantly clear cell type histology are excluded. From 1991 through 1996, 28 patients met these criteria and were treated with this approach. Patients were followed to determine the number receiving immunotherapy as well as overall response and survival rates.Radical nephrectomy was performed in all patients. One patient died of respiratory failure from disease progression 1 month after nephrectomy. Another patient had poor pulmonary function and, therefore, was treated with an alternative cytokine therapy. The remaining 26 patients (93%) received at least 1 course of IL-2. Median interval between nephrectomy and initiation of immunotherapy was 1.5 months (range 1 to 3). Overall response rate was 39% with 5 complete (18%) and 6 partial (21%) responses. Actuarial median survival of the entire group was 20.5 months (range 1 to 66) from the initiation of treatment. Currently 13 patients are alive, including 8 who are disease and/or progression-free.Using these strict criteria nephrectomy can be effectively performed before immunotherapy without compromising the likelihood that patients will receive systemic treatment. The activity of IL-2 in patients treated with this approach is encouraging and justifies its consideration in properly selected patients.

Since the birth in 1978 of the first child conceived by in vitro fertilization and embryo transfer (IVF/ET),1 the technologies that may be used to treat infertility have expanded rapidly. Each new procedure has been developed as a more efficient treatment for specific disorders.2 The classic gamete intrafallopian tube transfer (GIFT) procedure was seen as an advantage over IVF, as it provided a more natural and physiologic environment for fertilization. However, GIFT did require laparoscopy and general anesthesia, which were neither natural nor physiologic. In contrast to the classic GIFT procedure, transcervical tubal canalization is one of the latest developments in the continuing refinement and simplification of assisted reproductive technology (ART).

Leydig cell tumors of the testis are rare, comprising 1 to 3% of all testicular neoplasms.l.2 Approximately 10% of these tumors are malignant. They most commonly present as a testicular mass or with endocrine abnormalities, such as gynecomastia and loss of libido. We report on 2 patients with Leydig cell tumors who presented with the unusual symptoms of infertility and azoospermia. CASE REPORTS Case 1. A 33-year-old man presented for evaluation of primary infertility 3 to 4 years in duration. History included a left maldescended testicle which spontaneously descended at age 2 years and prepubertal mumps without orchitis. Laboratory tests included 3 semen analyses showing azoospermia and pellet analysis confirming absence of sperm. Serum testosterone was 386 ng./dl. (normal 270 to 1,070), and serum a-fetoprotein, p-human chorionic gonadotropin and lactic dehydrogenase were normal. Physical examination revealed a left testis measuring approximately 25 cc with a large mass in the upper portion. The right testis was approximately 10 cc and soft. Ultrasonography confirmed a hyperechoic mass in the upper two-thirds of the left testis. Given the appearance of the mass, left radical orchiectomy was performed. Pathological examination revealed a Leydig cell tumor (figs. 1 and 2). Metastatic evaluation with abdominal and pelvic computerized tomography was negative. Case 2. A 32-year-old man presented for evaluation of 2.5 years of primary infertility. History included bilateral inguinal hernia repairs. Physical examination revealed bilateral severe testicular atrophy. Two semen analyses showed fructose positive azoospermia. Serum testosterone was normal but follicle-stimulating hormone (1,567 mlU/ml., normal 4 to 10) and luteinizing hormone (156 mlU/ml., normal 2 to 10) were elevated. Diagnostic biopsy of the right testis revealed late maturation arrest. The patient returned for additional evaluation 5 years later and a nodule was palpated in the left testis, which was confirmed to be solid on ultrasound. Serum hormones were without significant change from previous levels and serum tumor markers were negative. Left radical orchiectomy was performed, and pathological evaluation revealed Leydig cell tumor. Metastatic evaluation was negative. The patient was lost to followup for 9 years, when he returned for additional infertility treatment. At that time, an 8 mm. mass was palpated in the solitary right testis. Despite ultrasound confirmation of the mass, the patient has refused any intervention.

Metastasis of renal cell carcinoma (RCC) to the penis or spermatic cord is rare. We present an unusual case of initial metastasis to the cord with delayed involvement of the penis. This is the first report of metachronous involvement of the genitalia from RCC metastases.

The authors describe what appears to be the first case of transperitoneal marsupialization of a lymphocele following laparoscopic pelvic lymph node dissection. The 9.7 x 5.6 x 6-cm collection was opened, its edges were cauterized, and the internal membranes were resected with an operative time of 90 minutes and a blood loss of less than 30 mL. A multicenter trial may be useful to determine whether excision of a portion of the peritoneum or an inverted-V rather than a linear incision would decrease the incidence of lymphoceles after laparoscopic pelvic lymphadenectomy.