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Introduction:We evaluated the necessity of obtaining routine postoperative laboratory studies, such as complete blood count and basic metabolic panel, after robotic assisted radical prostat...

Introduction: Robotic surgery has transformed the standard treatment for localized prostate cancer. Oncologic control is at the foremost concern when treating prostate cancer. Previous studies have detailed the use of a periurethral suspension stitch during robotic assisted radical prostatectomy (RARP), but none have demonstrated significant improvement in surgical margins. Objective: The purpose of this study is to illustrate the use of a periurethral suspension stitch during RARP and its impact on apical surgical margin status. Methods: This study retrospectively analysed 97 patients who underwent RARP by a single high-volume robotic surgeon (TJM) between November 2011 and February 2014. The patients were split into two cohorts with one group (Suspended Stitch) having the dorsal venous complex (DVC) ligation stitch suspended while the second group having the DVC ligation stitch unsuspended (Unsuspended Stitch). Results: Positive margins were seen in 39.6% of patients in the Unsuspended Stitch group and 20.4% of patients in the Suspended Stitch group (p=0.04). Patients in the Unsuspended Stitch group had a Gleason score > 7 in 33.3% of cases, where patients in the Suspended Stitch group had a Gleason score > 7 in 57.1% of cases. Conclusion: Localized prostate cancer treatment has significantly changed with RARP. This study provides an additional technique for achieving improved oncologic control.

To identify trends in complications following robot-assisted radical cystectomy (RARC) using a multi-institutional database, the International Robotic Cystectomy Consortium (IRCC).A retrospective review of the IRCC database was performed (2976 patients, 26 institutions from 11 countries). Postoperative complications were categorized as overall or high grade (≥ Clavien Dindo III) and were further categorized based on type/organ site. Descriptive statistics was used to summarize the data. Multivariate analysis (MVA) was used to identify variables associated with overall and high-grade complications. Cochran-Armitage trend test was used to describe the trend of complications over time.1777 (60%) patients developed postoperative complications following RARC, 51% of complications occurred within 30 days of RARC, 19% between 30-90 days, and 30% after 90 days. 835 patients (28%) experienced high-grade complications. Infectious complications (25%) were the most prevalent, while bleeding (1%) was the least. The incidence of complications was stable between 2002-2021. Gastrointestinal and neurologic postoperative complications increased significantly (P.01, for both) between 2005 and 2020 while thromboembolic (P = .03) and wound complications (P.01) decreased. On MVA, BMI (OR 1.03, 95%CI 1.01-1.05, P.01), prior abdominal surgery (OR 1.26, 95%CI 1.03-1.56, P = .03), receipt of neobladder (OR 1.52, 95%CI 1.17-1.99, P.01), positive nodal disease (OR 1.33, 95%CI 1.05-1.70, P = .02), length of inpatient stay (OR 1.04, 95%CI 1.02-1.05, P.01) and ICU admission (OR 1.67, 95%CI 1.36-2.06, P.01) were associated with high-grade complications.Overall and high-grade complications after RARC remained stable between 2002-2021. GI and neurologic complications increased, while thromboembolic and wound complications decreased.

Robotic surgery has revolutionized postoperative outcomes across surgical specialties. However, the use of pneumoperitoneum comes with known risks given the change in physiological parameters that accompany its utilization. A recent internal review found a 7% decrease in postoperative ileus rates when utilizing a pneumoperitoneum of 12 mmHg over the standard 15 mmHg in robotic assisted radical prostatectomies (RARP). The purpose of this study is to prospectively evaluate the utility of lower pressure pneumoperitoneum by comparing 8 mmHg and 12 mmHg during RARP. Patients were randomly assigned to undergo robotic assisted radical prostatectomy at a pneumoperitoneum pressure of 12 mmHg or 8 mmHg. The primary outcome was development of postoperative ileus and secondary outcomes were length of operation, estimated blood loss and positive surgical margin status. A total of 201 patients were analyzed; 96 patients at 8 mmHg and 105 patients at 12 mmHg. The groups were adequately matched as there were no differences between demographic parameters or medical comorbidities. There was a decrease in postoperative ileus rates with lower pneumoperitoneum pressures; 2% at 8 mmHg and 4.8% at 12 mmHg. There were no clinically significant differences in estimated blood loss, total length of operative time and positive margin status. Lower pressure pneumoperitoneum during robotic assisted radical prostatectomy is non-inferior to higher pressure pneumoperitoneum levels and the experienced surgeon may safely perform this operation at 8 mmHg to take advantage of the proposed benefits.

The gold standard for urologic management of large stone disease traditionally has been percutaneous nephrolithotomy (PCNL). An alternative to PCNL is robotic pyelolithotomy (RP), which continues to gain traction. This study is a retrospective review of ten cases performed over a 2 year period presenting operative outcomes for large stone disease treated with RP. The mean and standard deviation were calculated for age, body mass index, stone volume, stone diameter, pre-operative creatinine, operative time, robot-docked time, length of stay, post-operative creatinine, and estimated blood loss. In addition, results were collected for post-operative complications and secondary procedure requirements. Complete stone clearance was successful in 9 of 10 cases. The average renal function remained stable from a pre-operative creatinine of 0.917 mg/dL to a post-operative creatinine level of 0.943 mg/dL. This case series demonstrates that robotic assisted surgery has practical application when managing large stone disease.

INTRODUCTION AND OBJECTIVE:The objective is to determine opportunities for improvement in patient selection for radical nephrectomy (RN) in and identify appropriate criteria for RN in cT1 renal mas...

Robotic-assisted radical prostatectomy (RARP) is the most commonly performed surgery for prostate cancer. This is a study comparing differences in postoperative outcomes between pneumoperitoneum pressures of 15 mmHg and 12 mmHg. Retrospective chart review was performed on 400 patients undergoing RARP over a 5 year period. A combination of Fisher’s exact test and ANOVA were utilized for statistical analysis. Age, BMI, Gleason score, positive margin rate, complication rates, blood loss, and operative times were similar in both groups. Length of stay and postoperative ileus rates were significantly less in the 12 mmHg group (p

Objective To compare the perioperative outcomes of intracorporeal (ICUD) vs extracorporeal urinary diversion (ECUD) after robot-assisted radical cystectomy (RARC). Patients and methods We retrospectively reviewed the prospectively maintained International Robotic Cystectomy Consortium (IRCC) database. A total of 972 patients from 28 institutions who underwent RARC were included. Propensity score matching was used to match patients based on age, gender, body mass index (BMI), American Society of Anesthesiologists Score (ASA) score, Charlson Comorbidity Index (CCI) score, prior radiation and abdominal surgery, receipt of neoadjuvant chemotherapy, and clinical staging. Matched cohorts were compared. Multivariate stepwise logistic and linear regression models were fit to evaluate variables associated with receiving ICUD, operating time, 90-day high-grade complications (Clavien-Dindo Classification Grade ≥III), and 90-day readmissions after RARC. Results Utilisation of ICUD increased from 0% in 2005 to 95% in 2018. The ICUD patients had more overall complications (66% vs 58%, P = 0.01) and readmissions (27% vs 17%, P = 0.01), but not high-grade complications (21% vs 24%, P = 0.22). A more recent RC era and ileal conduit diversion were associated with receiving an ICUD. Higher BMI, ASA score ≥3, and receiving a neobladder were associated with longer operating times. Shorter operating time was associated with male gender, older age, ICUD, and centres with a larger annual average RC volume. Longer intensive care unit stay was associated with 90-day high-grade complications. Higher CCI score, prior radiation therapy, neoadjuvant chemotherapy, and ICUD were associated with a higher risk of 90-day readmissions. Conclusions Utilisation of ICUD has increased over the past decade. ICUD was associated with more overall complications and readmissions compared to ECUD, but not high-grade complications.

INTRODUCTION AND OBJECTIVES:The Decipher assay is a tissue-based genomic classifier (GC) developed and validated in the post-radical prostatectomy (RP) setting as a predictor of metastasis. Retrosp...

The objective of the study was to assess the safety and clinical outcomes of performing RARP utilizing LPP 12 mmHg with locally confined adenocarcinoma of the prostate. Utilizing the Metro Health RALP database registry and the Michigan Urological Clinic records, we retrospectively reviewed the records of consecutive RALPs performed between December 2012 and March 2015 by a single robotic surgeon. 100 patients underwent RARP utilizing 15 mmHg of standard pressure pneumoperitoneum (SPP) and 100 patients underwent RALP utilizing 12 mmHg lower pressure pneumoperitoneum (LPP). Intraoperative parameters reviewed included operative time (OT) and blood loss (BL). Postoperative parameters reviewed included length of hospital stay (LOS), postoperative ileus, fistulas, urinary retention and hematoma formation. Surgical outcomes reviewed included pathological stage and combined Gleason score. Patient age, BMI, mean combined Gleason score and pathological stage were similar in both groups. Mean OT for the LPP group was 105.49 (66-166) and for the standard pressure pneumoperitoneum (SPP) group 111.31 (61-231) min. The length of stay in both groups was similar, averaging 1.53 (1-6) days for the LPP group and 1.57 (1-6) days for the SPP group. The LPP group had a lower postop ileus rate of 4 vs 8 % in the SPP group, but they were not statistically different. Likewise, the positive margin rate, readmission rate, hematoma rate, retention rate and urinary fistula rate were similar and not statistically different for both groups. Pneumoperitoneum of 12 mmHg is noninferior to 15 mmHg during RARP and does not alter the clinical outcomes.

INTRODUCTION AND OBJECTIVE:Laparoscopic and robotic surgery have revolutionized post-operative outcomes across surgical specialties. However, the use of pneumoperitoneum comes with known risks give...

Objective To characterise the surgical feasibility and outcomes of robot-assisted radical cystectomy (RARC) for pathological T4 bladder cancer. Patients and Methods Retrospective evaluation of a prospectively maintained International Radical Cystectomy Consortium database was conducted for 1118 patients who underwent RARC between 2003 and 2012. We dichotomised patients based on pathological stage (≤pT3 vs pT4) and evaluated demographic, operative and pathological variables in relation to morbidity and mortality. Results In all, 1000 ≤pT3 and 118 pT4 patients were evaluated. The pT4 patients were older than the ≤pT3 patients (P = 0.001). The median operating time and blood loss were 386 min and 350 mL vs 396 min and 350 mL for p T4 and ≤pT3, respectively. The complication rate was similar (54% vs 58%; P = 0.64) among ≤pT3 and pT4 patients, respectively. The overall 30- and 90-day mortality rate was 0.4% and 1.8% vs 4.2% and 8.5% for ≤pT3 vs pT4 patients (P < 0.001), respectively. The body mass index (BMI), American Society of Anesthesiology score, length of hospital stay (LOS) >10 days, and 90-day readmission were significantly associated with complications in pT4 patients. Meanwhile, BMI, LOS >10 days, grade 3–5 complications, 90-day readmission, smoking, previous abdominal surgery and neoadjuvant chemotherapy were significantly associated with mortality in pT4 patients. On multivariate analysis, BMI was an independent predictor of complications in pT4 patients, but not for mortality. Conclusions RARC for pT4 bladder cancer is surgically feasible but entails significant morbidity and mortality. BMI was independent predictor of complications in pT4 patients.

We report a postoperative hemorrhage of the dorsal vein complex after transperitoneal robotic-assisted laparoscopic prostatectomy managed with external penile compression. Control of the dorsal vein required two sutures, and the estimated blood loss due to the procedure was 400 ml. Severe gross hematuria developed on postoperative day 2, but this quickly subsided with external compression at the base of the penis. Transfusions were required, but the patient refused re-exploration. A self-adherent bandage was applied circumferentially to the entire penis for 48 h. During this time there was no further hematuria, and the patient recovered uneventfully.

One hundred consecutive men with adenocarcinoma of the prostate, treated by modified pelvic lymphadenectomy and radical retropubic prostatectomy, were evaluated, comparing DNA ploidy as determined by flow cytometry to surgical tumor stage (pT), preoperative prostatic specific antigen (PSA), Gleason grade, and age at presentation, in an effort to assess the prognostic ability of DNA ploidy. There were 71 (71%) men found to have diploid tumors and 29 (29%) with nondiploid tumors. There was no statistical difference in surgical pathologic stage between these two groups (P = 0.2369). There was no statistical difference when comparing preoperative PSA between these two groups (P = 0.0925). There was no statistical difference when comparing Gleason grade between these two groups (P = 0.5807). Age at presentation was similar in both groups. Based on these findings, it is apparent that longitudinal studies of patient outcome will be necessary to fully assess the prognostic ability of DNA ploidy determined by flow cytometry in men undergoing radical prostatectomy for treatment of adenocarcinoma of the prostate gland.

Although DNA ploidy analysis of prostate cancer is generally associated with grade, stage, clinical outcome, and responsiveness to androgen therapy, one possible reason cited for contrary reports may be tumor heterogeneity. A preliminary report using flow cytometric analysis of punch biopsies demonstrated DNA heterogeneity in five of nine patients. We evaluated 75 patients by cutting whole mounts of formalin fixed prostatectomy tissue every 0.6 cm. All malignant areas and a selected normal area were circumscribed, excised, remounted, and 1–3 50 μ thick sections removed. The nuclei were extracted by a Hedley technique and the DNA stained with propidium iodide. Each whole mount had an average of 1 distinct malignant area (range of 1–6 areas per whole mount block). Nuclei were analyzed on a Becton Dickinson (San Jose, CA) FACScan flow cytometer equipped with RFIT DNA software program. After excluding histograms with CVs > 8.0% and/or “suspicious” diploid histograms having a right “shoulder,” 75 or 87 patients still had ≥2 malignant sites available for analysis (average 4, range 2–9 malignant sites/patient). The 322 histograms had an average CV of 4.4%. Thirty of 75 patients (40%) showed DNA heterogeneity in multiple samples taken from the same prostate. There were 37 prostates with only diploid (D), 1 with only tetraploid (T), 7 with only aneuploid (A), 20 with D plus A, 7 with D plus T, 2 with D plus T plus A, and 1 with a D plus suspected hypodiploid DNA content. Exclusion of the tetraploid and “near diploid aneuploid” cases still resulted in 16% (12/75) of the patients having a diploid versus aneuploid DNA content heterogeneity. Because 40% of the prostates contained a different ploidy depending on which area was sampled, this report suggests multiple sites of malignancy must be analyzed to more accurately assess the ploidy status of prostatic adenocarcinoma. © 1995 Wiley-Liss, Inc.

We examined the safety and feasibility of transitioning from open radical cystectomies to robotic-assisted laparoscopic cystectomies in a community-based, non-tertiary health care setting. A retrospective review and analysis of our most recent 14 unselected consecutive patients who underwent open cystectomy was compared to our first 14 unselected consecutive patients who underwent robotic-assisted laparoscopic cystectomy. Perioperative and pathologic outcomes were reviewed to determine the safety and oncologic equivalence of the two procedures. From 2003 to 2010, 14 consecutive patients underwent an open cystectomy and from 2010 to 2012 another 14 consecutive patients underwent a robotic-assisted laparoscopic cystectomy. The operative time was significantly longer in the robotic group (6 h 23 min vs. 4 h 28 min; p

Serial serum prostate tumor markers (acid phosphatase, prostate-specific antigen-Yang, prostate-specific antigen-Hybritech, lipid-associated sialic acid in plasma, and tissue polypeptide antigen) were obtained every four hours during a twenty-four-hour interval from men with Stage D adenocarcinoma of the prostate. No therapeutic or diagnostic manipulations occurred during sample procurement, so that the amount of fluctuation in these serum prostate cancer markers could be determined. The average co-efficient of variation for acid phosphatase 28.8, prostate-specific antigen-Yang 8.85, prostate-specific antigen-Hybritech 7.2, lipid-associated sialic acid in plasma (LASA-P) 6.19, and tissue polypeptide antigen (TPA) 14.75 indicate that prostate-specific antigen determined by either method fluctuates minimally, indicating stability and, because it is prostate-cancer specific, is the most useful tumor marker tested.

Surgical simulation technology may efficiently train and accurately assess the acquisition of many skills. Surgical simulators often lack realism and can be expensive at $3,000 to more than $60,000. We assessed the face, content and construct validity of a newly developed, anatomically accurate, reasonably priced high fidelity ureteroscopy and renoscopy trainer.A total of 46 participants, including attending urologists, urology residents, medical students and industry representatives, assessed the face and content validity of the simulator using a standard questionnaire. Ten experienced ureteroscopists with greater than 30 procedures per year and 10 novice ureteroscopists with 0 were assessed on the ability to perform flexible ureteroscopy, renoscopy and intrarenal basket extraction of a lower pole calculus using the adult ureteroscopy trainer (Ideal Anatomic Modeling, Holt, Michigan). Subject performance was assessed by an experienced ureteroscopist using a checklist, global rating scale and time to task completion.Of participants 100% rated the trainer as realistic and easy to use, and thought it was a good training tool, 98% thought that it would serve as a good training format and 96% would recommend it to urology trainees. All participants recommended it for use in residency programs and 96% would or would have used it during residency. Only 37.5% vs 100% of experienced vs novice ureteroscopists would use it to practice. Of participants 9% foresaw a problem with the trainer. On the trainer experienced ureteroscopists scored significantly higher on the global rating scale (mean +/- SD 33.1 +/- 1.3 vs 15.0 +/- 2.7, p0.0001) and checklist (4.1 +/- 1.0 vs 2.4 +/- 1.1, p = 0.004), and required less time to complete the task (141.2 +/- 40.1 vs 447.2 +/- 301.7 seconds, p = 0.01).Our preliminary study suggests the face, content and construct validity of the adult ureteroscopy trainer as a high fidelity ureteroscopy and renoscopy trainer.

Twenty Sprague Dawley rats were administered various doses of 1.5% amino acetic acid (glycine), lactated Ringer's, and water, both intravenously and retroperitoneally, in an attempt to recreate the post-transurethral resection syndrome in a rat model. The kidneys, liver, and pancreas were harvested 6 hours after exposure and examined pathologically. Water and lactated Ringer's had no histologic effect on these organs. Glycine was found to have a toxic effect on the kidneys and liver and this effect was dose related. Based on these results, it is postulated that glycine toxicity may play a significant role as a causative factor in producing the post-transurethral resection syndrome.

OBJECTIVES To compare the incidence of positive surgical margins obtained with robotic-assisted laparoscopic prostatectomy (RALP), during the initiation of a robotics program, with that from a similarly matched cohort of open radical retropubic prostatectomy (RRP) cases as performed by a single surgeon. METHODS From December 2005 to March 2008, 63 patients underwent RRP and another 50 underwent RALP by a single urologist. The records were retrospectively reviewed, and 50 RRP patients were selected from the RRP group whose records were similar to the records of the 50 patients who had undergone RALP. We compared the incidence of positive surgical margins and the location of positive margins among the 2 groups. Additional variables evaluated included the preoperative prostate-specific antigen level, preoperative Gleason score, clinical stage, postoperative Gleason score, tumor volume, and pathologic stage. RESULTS The positive margin rate for the RRP group was 36% compared with 22% for the RALP group (P = .007). The incidence of positive margins for pathologic Stage pT2c disease in the RALP group was 22.8% compared with 42.8% in the RRP group, a statistically significant difference (P = .006). Fewer positive margins were found in the RALP Gleason score 7 group than in the RRP group, 29% vs 60%, again a statistically significant difference (P = .003). CONCLUSIONS We present our series comparing a single urologist's positive margin rates during the learning curve of a robotics program with his experience of a similarly matched cohort of RRP patients. A statistically significant lower positive margin rate can be achieved in RALP patients even during the learning period.

To compare the effectiveness of two local anesthetic techniques in men undergoing no-scalpel vasectomy.Before undergoing no-scalpel vasectomy, 50 men underwent separate forms of anesthesia to each side of their scrotum. One vas deferens was anesthetized with a high-pressure spray of 0.3 mL 2% lidocaine using the MadaJet Medical Injector, and the other vas deferens was anesthetized using the traditional vasal block performed with three 1.7-mL ampules of mepivacaine using a 27-gauge needle. The pain of the initial delivery of anesthesia and the pain with the subsequent vasectomy were recorded.Fifty men underwent no-scalpel vasectomy with a different anesthetic delivery system to each vas deferens separately. A statistically significant reduction was noted in the visual analog pain scores in favor of no-needle administration of anesthesia, 1.56 of 10 versus 2.12 of 10 (P0.029). A reduction was noted in the visual analog pain score for the subsequent vasectomy after administration of anesthesia using the no-needle method, but this was not statistically significant (1.68 of 10 versus 1.86 of 10; P0.66).No-needle anesthesia with jet injection reduced the pain associated with traditional delivery of anesthesia to the skin and vas deferens before no-scalpel vasectomy. Additional studies are needed with more subjects to evaluate whether the decrease in procedural pain is statistically significant when comparing the two types of anesthetics.

Renal cell carcinoma (RCC) is a histologically diverse disease, with variable and often unpredictable clinical behavior. The prognosis worsens dramatically with the onset of clinical metastasis, and current regimens of systemic therapy yield only modest benefits for metastatic RCC. Gene expression profiling is a promising technique for refining the diagnosis and staging of RCC, as well as for highlighting potential therapeutic targets. We review the recent advances in expression profiling of RCC and discuss the clinical and biological insights obtained from these studies.

Objectives. To compare the effectiveness of periprostatic nerve blockade versus intrarectal lidocaine during transrectal ultrasound-guided biopsies. Methods. A prospective randomized study was performed on 150 men requiring biopsy of the prostate. Patients were assigned to three groups: group 1 received no anesthetic, group 2 received 10 mL of 2% lidocaine gel intrarectally, and group 3 received a periprostatic injection of 5 mL of 1% lidocaine solution before undergoing prostate biopsy. Patients were asked to respond to a preprocedural and postprocedural questionnaire that consisted of four questions designed to evaluate pain perception and pain experienced, respectively, during the entire procedure. Results. The mean pain scores, comparing responses from groups 2 (topical lidocaine) and 3 (periprostatic) individually with those from group 1 (control), were not statistically different for any of the preprocedural questions. The postprocedural pain scores were significantly lower in groups 2 and 3 compared with those from group 1 (control) for overall procedure impression (3.1 ± 1.7 and 2.6 ± 1.8 versus 3.8 ± 1.8, respectively; P

With the increasing incidence of prostatic intraepithelial neoplasia being found at the time of prostate biopsy and the association of prostatic intraepithelial neoplasia to coexisting prostate cancer and/or the future development of prostate cancer, patient compliance in following post-biopsy follow-up instructions for re-biopsy is becoming more significant in the detection of prostate cancer at an earlier and, therefore, potentially curable stage. During a 3-y period, we reviewed the charts of 130 patients who received an initial diagnosis of prostatic intraepithelial neoplasia after undergoing transrectal ultrasound of the prostate with biopsy. It is our policy to inform the patient of their diagnosis of prostatic intraepithelial neoplasia at the time of the initial biopsy and to recommend a repeat biopsy in 6-12 months. Patients are informed of the diagnosis of prostatic intraepithelial neoplasia verbally and in writing. In addition, a letter is sent to their referring physician with the re-biopsy recommendation. Thirty-nine of 130 patients (30%) were seen for re-biopsy within the specified time. An additional 36 patients (27.69%) were re-biopsied between 12 and 18 months after the initial diagnosis of prostatic intraepithelial neoplasia. An additional 11 patients (7%) were re-biopsied more than 18 months after their initial diagnosis. Forty-four patients failed to return for re-biopsy. Overall, patient follow-up within the desired protocol was poor and must be improved upon to prevent any delays in the diagnosis of prostate cancer. Prostate Cancer and Prostatic Diseases (2001) 4, 63-66

To determine the postoperative instruction compliance rate in men undergoing bilateral vasectomy.Retrospective chart review.Private practice urological office.The records of all patients undergoing vasectomy were reviewed to determine the rate of compliance with postvasectomy follow-up instructions. It is our policy to have the patient continue to use some form of birth control until he achieves two consecutive negative semen analyses 1 month apart. In addition, we recommend a yearly semen analysis after achieving sterility to screen for the rare patient who recanalizes. Postvasectomy follow-up instructions are given to the patient both verbally and in writing.None.The records of 1,892 consecutive patients undergoing vasectomy were reviewed, and the results of semen analyses were noted to determine the rate of compliance with postvasectomy follow-up instructions.Six hundred forty-four men (34%) never returned after vasectomy and, therefore, no semen analyses were available for examination. Six hundred nineteen men (33%) returned for a single semen analysis. Six hundred twenty-nine men (33%) returned for a second negative semen analysis. Only 60 men (3%) completed postvasectomy follow-up instructions and returned for a yearly semen analysis.The rate of compliance with postvasectomy follow-up instructions for determining sterility is poor.To determine the rate of patient compliance with post-vasectomy instructions for verifying sterility, the records of all 1892 men undergoing bilateral vasectomy in a private urological practice in Grand Rapids, Michigan, during 1985-95 were reviewed. Vasectomy acceptors at this practice are instructed to use some form of birth control until 2 consecutive negative semen analyses 1 month apart have been recorded. In addition, a yearly semen analysis is recommended to screen for recanalization. These post-vasectomy instructions are delivered verbally on 1 occasion and 3 times in writing. 644 men (34%) never returned after vasectomy. Another 619 men (33%) returned only for a single semen analysis, even though 36 had a positive test result. 629 men (33%) with an initial negative result returned for a second semen analysis; in 65 cases, the second analysis failed to document azoospermia. A total of 157 men with positive first or second semen analyses never were cleared. Only 60 men (3%) returned for the yearly semen analysis. 8 pregnancies (0.4%) were reported in this series, all of which involved men who had not followed the post-vasectomy protocol. These findings underscore the need for thorough patient education on the importance of the post-vasectomy follow-up.

The majority of literature concerning DNA analysis of prostate cancer involves testing formalin-fixed prostatectomy tissue, fresh or formalin-fixed transurethral resections of the prostate (TURP), or fresh core biopsies. We were interested if flow cytometry could analyze the DNA of formalin-fixed, paraffin-embedded, core biopsies separated into normal versus malignant segments. Of the 50 potentially available samples for analysis representing 11 controls of normal core tissue and 39 core biopsies from the 11 patients, one patient had no normal tissue, one core had no malignancy, and three cores had no tissue visibly remaining in the paraffin blocks for analysis. Therefore, of 45 actual samples available for processing, sometimes representing segments as small as 0.2 cm, separate segments containing malignant glands or normal glands were excised from the blocks, and processed separately by the Hedley technique. Forty-four of the 45 available samples produced interpretable DNA histograms as defined by discernible G0/G1 peaks, a calculable cell cycle analysis, and the qualitative appearance of a “smooth” histogram appearance, reflecting sufficient nuclei were analyzed. This is the first report to our knowledge where flow cytometry has successfully been used to analyze paraffin blocks of core biopsies which were, in addition, separated into malignant versus normal enriched segments. © 1994 Wiley-Liss, Inc.

From 1974 to 1989, 18 patients underwent surgical treatment for isolated dissection of the renal artery causing high grade stenosis, including 2 patients with bilateral renal involvement. The causes of renal artery dissection were blunt trauma (1 patient), unsuccessful percutaneous transluminal angioplasty (5) and atherosclerosis (5) or intimal fibroplasia (7) of the renal artery. The most common presenting signs or symptoms of a dissection were hypertension (94%), an abdominal bruit (44%), headache (44%), minimal proteinuria (44%), microscopic hematuria (38%) and flank pain (38%). Renal artery dissection led to segmental or total renal infarction in 8 of 20 involved kidneys (40%). Seventeen patients underwent unilateral surgical revascularization with amelioration of hypertension and preservation of renal function. Three kidneys were lost due to irreversible ischemic damage from an occlusive dissection. Isolated renal artery dissection is an uncommon lesion that can cause hypertension and threaten renal function.

Transrectal ultrasound-guided biopsy of the prostate is a common urologic procedure associated with low morbidity and mortality. On occasion, rectal bleeding occurs and can be effectively managed by temporarily inserting a tampon into the rectum.

During a fourteen-month period, 497 men were evaluated for a primary complaint of erectile dysfunction. The initial evaluation consisted of a history taken in a conventional manner and supplemented by a patient-completed sexual function questionnaire, a physical examination, and serum testosterone, serum prolactin, and nocturnal penile tumescence studies. When appropriate, additional evaluations, including penile vascular studies, two-hour oral glucose tolerance tests, and psychiatric consultation were obtained. Abnormal glucose metabolism was present in 161 men (32%). Five men (1%) had insulin-dependent diabetes mellitus (IDDM), 80 men (16%) had noninsulin-dependent diabetes mellitus (NIDDM), 55 men (11.1%) had newly diagnosed noninsulin-dependent diabetes mellitus, and 21 men (4.2%) had impaired glucose tolerance tests. One hundred forty-seven of these men (91.3%) had organic pattern impotence, and 14 (8.7%) had psychogenic pattern impotence.

Intrarenal masses in children are uncommon, with Wilms’ tumor the most prevalent of these. Two cases are presented in which the preoperative evaluation of renal masses was highly suggestive of benign disease, renal abscess, and multilocular cyst. Surgical exploration was performed in both patients, and Wilms’ tumor was found and treated successfully with radical nephrectomy. These two cases emphasize the need for surgical exploration to accurately diagnose intrarenal masses in children even when all diagnostic modalities are suggestive, but not confirmatory, of benign disease.

From 1968 to 1983, 254 patients underwent an operation for presumed renal cell carcinoma. In this retrospective review the pathological diagnosis was renal oncocytoma in 11 patients (4 per cent). Renal oncocytomas were present bilaterally in 2 patients, including 1 with a coexisting renal cell carcinoma. In 2 other patients the oncocytomas were multicentric. The angiographic, computerized tomographic and sonographic findings in these patients typified renal cell carcinoma. Surgical treatment comprised radical or partial nephrectomy for unilateral and bilateral lesions, respectively. Because of the benign nature, multicentricity, possible bilaterality and absence of pathognomonic radiographic features, renal oncocytomas should be considered in the differential diagnosis of solid renal masses.

Three patients (aged 56, 40, and 38 years, respectively) presenting with large retroperitoneal masses 10 to 18 years after prior orchiectomy for testicular neoplasms (seminoma and embryonal carcinoma) are presented. Despite aggressive chemotherapy in all three patients and surgical excision of the tumor in two, two of the men subsequently died 11 to 16 months after initial diagnosis of the retroperitoneal tumors, and one is living with the disease. Theoretic etiologic mechanisms for the development of late retroperitoneal tumors in these men are discussed, including (1) metastatic disease from a second primary tumor in the remaining testicle, (2) a primary extragonadal retroperitoneal tumor, and (3) delayed transformation of metastatic teratomatous retroperitoneal tumor from the original primary into malignant neoplasm.

Serial serum prostatic acid phosphatase levels were obtained every 4 hours during a 48-hour interval from 10 men with stage D adenocarcinoma of the prostate. No therapeutic or diagnostic manipulations occurred during sample procurement, so that the amount of fluctuation of serum prostatic acid phosphatase levels that can be expected in these patients could be determined. The coefficient of variation for each man ranged from 16.67 to 43.68 per cent, which was significantly higher than the expected 8 per cent coefficient of variation determined with a control sample. The maximum percentage variations above and below the mean were 79 and 50 per cent, respectively. The average percentage variation in all patients was within 50 per cent greater than and 50 per cent less than the mean value of prostatic acid phosphatase. Thus, the usefulness of serum acid phosphatase by radioimmunoassay as a clinical tumor marker is limited by the number of serial assays needed to establish a mean. Based on these findings, certain guidelines are suggested.

Two hundred consecutive men presenting with a chief complaint of impotence have been evaluated with a protocol involving one or two outpatient visits. The initial evaluation for all patients consisted of a history taken in a conventional manner and supplemented by a patient-completed sexual function questionnaire, physical examination, serum testosterone and prolactin, and two-night nocturnal penile tumescence studies. Following the initial evaluation the patients were placed in one of three categories: (1) organic impotence, (2) functional impotence, (3) ambiguous impotence (mixed functional and organic impotence or organic impotence of undetermined etiology). Patients in the latter group underwent additional testing including penile vascular studies, two-hour oral glucose tolerance test, and psychiatric consultation. With this protocol, patients can be efficiently and effectively evaluated as outpatients with costs ranging from $250 to $450.

Regional chemotherapy with intra-arterial cis-platinum and doxorubicin as an adjuvant to total cystectomy and urinary diversion has been evaluated in a phase I to II study. In the first 17 patients chemotherapy consisted of 40 to 75 mg. per m. cis-platinum intra-arterially during 30 minutes, 30 to 40 mg. per m. doxorubicin intra-arterially during 60 minutes (11 patients) or 12 hours (6 patients) and 400 to 500 mg. per m. cyclophosphamide intravenously. The remaining 8 patients received 70 to 100 mg. per m. cis-platinum intra-arterially during 30 minutes. Intra-arterial chemotherapy was administered through a percutaneous catheter placed in the hypogastric artery before each course. Courses were repeated at 4-week intervals. A total of 25 patients received 58 courses (median 2 per patient). Clinical stages of disease in the patients entering the protocol were T3aNxMo (8), T3bNx-2Mo (12) and T4a-bNxMx-1 (5). Clinical response was assessed in 24 of 25 patients: 6 achieved a complete clinical response, 12 had a partial response and 7 had no response. Of 25 patients 16 underwent total cystectomy and urinary diversion with pathological staging as follows: ToNoMo in 3, T1NoMo in 1, T3aNoMo in 5, T3bNo-2Mo in 6 and T4NoMo in 1. Intra-arterial chemotherapy can produce a complete pathological response in patients with locally advanced bladder cancer and is tolerated well by most patients.