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Purpose: We evaluate the usefulness of pretreatment 111Indium capromab pendetide (ProstaScint™) planar imaging (immunoscintigraphy) plus single photon emission tomography co-registration with computerized tomography scans to detect occult metastatic disease and predict for biochemical failure, in a cohort of patients with a clinical diagnosis of localized adenocarcinoma of the prostate referred for primary radiotherapy.Materials and Methods: Patients were followed after radiotherapy for evidence of biochemical failure using 2 criteria of prostate specific antigen clinical nadir +2 ng/ml and American Society for Therapeutic Radiology and Oncology Consensus definitions. Median followup was 58.8 months (mean 64.8). Clinical risk factors defined 3 risk groups of high (51), intermediate (72) and low (116).Results: Overall biochemical failure was 18.3% vs 11.8% by the 2-BFC at 8-year actuarial analysis with 58.8 months median followup. By the CN +2 definition the control date for the cohort is 34.8 months. Pret...

We identified time to the development of hormone refractory prostate cancer (HRPC) and survival in men with advanced prostate cancer and examined any association with cigarette smoking history.The study design was retrospective. A complete tobacco history was obtained in 222 patients with advanced prostate cancer. HRPC was diagnosed in 133 of these 222 patients and death occurred in 77. Standard statistical methods and software were used to analyze these data.Median time to HRPC was 11, 23 and 35 months in patients with a current, former or never smoked tobacco history (p = 0.00001). Median overall survival time on androgen ablative therapy was 38, 47 and 60 months in patients with a current, former or never smoked tobacco history, respectively (p = 0.00001).Tobacco use independently correlates with time to HRPC and survival in a dose dependent manner in patients with advanced prostate cancer on androgen deprivation therapy.

Purpose: Urologists are often referred patients who initially present with an extremely high serum prostate specific antigen (PSA) level. Despite a presumptive diagnosis of prostate cancer, many of these men undergo biopsy to obtain a tissue diagnosis before treatment with androgen ablative therapy. We examined a data base of men undergoing prostate biopsy to determine the accuracy of high PSA levels (greater than or equal to 20 ng./ml.) in predicting prostate cancer.Materials and Methods: We reviewed the records of 1,250 consecutive patients undergoing transrectal ultrasound guided prostate biopsy at 1 institution. From this data base we identified all patients with PSA greater than or equal to 20 ng./ml. at the time of prostate biopsy. The accuracy of PSA in predicting cancer was determined by calculating positive predictive values for PSA ranges and PSA cutoffs.Results: We identified 187 men (15%) presenting with PSA greater than or equal to 20 ng./ml. Of these 187 men 157 (84.0%) were diagnose...

Purpose: Bilateral sex cord stromal testicular tumors are common in the syndrome of myxoma, spotty pigmentation and endocrine overactivity (Carney’s complex). Large cell calcifying Sertoli cell tumor is the particular testicular tumor found in Carney’s complex. A clinicopathological review of 26 patients is presented.Materials and Methods: We report 2 cases of Carney’s complex with testicular tumors. An additional 24 patients with Carney’s complex and testicular tumors were identified by MEDLINE search and review of the literature.Results: Bilateral testicular tumors were found in 16 patients (61%) with a familial occurrence in 10 (38%). A testicular mass was the most common presentation. The associated findings of Carney’s complex included cardiac myxoma in 16 patients, skin myxoma in 16, skin pigmentation in 15, Cushing’s syndrome in 8, acromegaly in 3 and schwannoma in 3. Excisional biopsy, surveillance, bilateral orchiectomy and unilateral orchiectomy were performed in 7, 4, 7 and 8 patients, respecti...

Purpose: Like all other medical and surgical practitioners, urologists are occasionally confronted with the unpleasant realization that they are being sued for medical malpractice. These suits are generated through any number of acts or failures to act during innumerable circumstances. We reviewed all urological claims presented to 1 representative insurance company and delineated the types of acts, settings, expenses and disposition of these claims. This review was performed to understand better the claims confronting urologists and provide future guidance to urologists in the medical malpractice setting.Methods and Materials: Working with The St. Paul Companies 259 medical malpractice claims against urologists consecutively closed from 1995 to 1999 were reviewed. Claims were defined as urological malpractice when the insured-defendant in a malpractice claim was a urologist. Each claim was reviewed in terms of disposition, patient age, geographic location, office-hospital setting, purported negligent act...

Purpose:: The Internet is changing the way medicine is being practiced and challenging our notions of the doctor-patient relationship. We analyze the development of online prescriptions and propose guidelines for the sale of sildenafil over the Internet.Materials and Methods:: Using MEDLINE, Medscape and Lexis-Nexis search engines we reviewed pertinent materials from January 1996 to July 1999 focusing on the keywords Viagra, † †Pfizer, New York, New York. prescription and Internet. The review included press releases, law review articles, case law, medical literature, pending litigation, proposed legislation, and federal and state statutes.Results:: Online prescriptions are an outgrowth of the mail order drug business. This development continues the historic innovations in communications and transportation that have enabled physicians to practice medicine over long distances while maintaining ties to hospitals and other specialists. While the sale of sildenafil over the Internet may be profitable and conve...

Purpose: We analyze patterns of prostate growth in men diagnosed with benign prostatic hyperplasia (BPH) and treated with placebo during 4 years, and determine which baseline parameters were the st...

The American Urological Association Prostate Cancer Clinical Guidelines Panel reviewed 12,501 publications on prostate cancer from 1955 to 1992 to determine whether the complication rates of external beam radiation therapy, interstitial radiotherapy and radical prostatectomy have decreased.Complications reported in at least 6 series, study duration and sample sizes were extracted. Year specific study weighted mean patient ages and complication rates were computed. Regression analysis was performed of the study year on weighted mean patient age and complication rate.Study year had a significant effect on mean patient age and rate of the majority of complications examined. Data indicated a gradual increase in study patient age and a simultaneous decrease in complications from 1960 to 1990.Complication rates in the treatment of localized prostate cancer have decreased during the last 20 to 40 years. This decrease occurred despite evidence that the average age of treated patients had increased during the same period.

The development and advances in extracorporeal shock wave lithotripsy and endourological procedures have greatly diminished the need for open surgery in the treatment of renal and ureteral stones. We reviewed our experience with open stone surgery to determine the current indications and efficacy of this treatment modality.Hospital and office charts, operative notes and records, and pertinent radiographic studies of all patients undergoing open stone surgery from January 1991 through December 1995 at 3 university affiliated hospitals were reviewed. Patient characteristics, stone burden, indications, surgical factors and outcomes were reviewed for each patient.Of 780 procedures performed for stone removal, 42 were open surgical procedures (5.4%) including pyelolithotomy in 15 (extended pyelolithotomy or pyelonephrolithotomy in 7), anatrophic nephrolithotomy in 14, ureterolithotomy in 7 and radial nephrolithotomy in 6. There were 24 men and 18 women ranging in age from 1 to 90 years (mean age 51.5). The most common indications for open surgery were complex stone burden (55%); failure of extracorporeal shock wave lithotripsy or endourological treatment (29%); anatomic abnormalities such as ureteropelvic junction obstruction, infundibular stenosis and/or renal caliceal diverticulum (24%); morbid obesity (10%) and co-morbid medical disease (7%). Mean estimated blood loss was 428 cc. Average hospital stay was 6.4 days. The stone-free rate after surgery was 93%. Five patients had minor postoperative complications that resolved with appropriate therapy.While most patients with renal and ureteral stones can be treated with less invasive techniques, open stone surgery continues to represent a reasonable alternative for a small segment of the urinary stone population.

We reviewed 50 patients with genitourinary fungal infections between 1982 and 1992. Infections were classified as simple--localized to the bladder and complex--demonstrated evidence of upper tract and/or systemic infection. Predisposing factors of fungal infections, including diabetes mellitus, prolonged Foley catheter drainage and corticosteroid use, were not significantly different. The incidences of obstructive uropathy (88 percent and 20 percent), malnutrition (88 percent versus 48 percent), neoplasia (56 percent versus 16 percent), renal failure (24 percent versus 8 percent) and prolonged antibiotic use (60 percent versus 32 percent) were significantly greater in patients with complex infections. The incidence of fungemia in patients with complex infections was 81 percent with an associated mortality rate of 36 percent. Of the patients with complex infections 56 percent required urological intervention. Given the high incidence of obstructive uropathy with complex fungal infections, upper tra...

Two-thirds of matrix of all urinary stones consists of proteins. Despite intense research, their relationship to calculogenesis remains controversial. In an attempt to study excretion of proteins in stone formers, their urinary profiles were analyzed and compared with those of healthy subjects. Two-dimensional gel electrophoresis was employed to obtain high resolution separation of proteins.The urine of patients with histories of idiopathic calcium oxalate (CaOx) calculi contained 7 unique proteins, and 2 others that appeared to be overexpressed. Except for alpha1 -acid glycoprotein, the remaining 8 proteins are previously unknown constituents of urine with molecular weights of approximately 43, 39.5, 29, 26, 25.5, 26.5, 27 and 18.5 kD. Their isoelectric points range from 5.5 to 8.0. Coelectrophoresis of pooled urinary proteins of male and female stone formers disclosed that all 9 proteins had identical charges and molecular weights, regardless of the donors' sex. Analyses of urines of idiopathic ...

Many facts and statistics regarding urolithiasis are well known. Approximately two-thirds of patients with urolithiasis have calcium oxalatekalcium phosphate stones, and these calculi occur more commonly in men and white patients. The lifetime chance of an individual having a stone is approximately 10 to 15% and if that individual is untreated the chance of recurrence is nearly 60% within approximately 10 years. Many treatment programs include the use of various medications that have been effective in either eliminating or decreasing the incidence of stone recurrence. Recent treatment developments in percutaneous techniques and extracorporeal shock wave lithotripsy (ESWLP) have lessened the morbidity associated with open stone surgery and represent a major advance in management of this common problem. We also know that many stone patients exhibit low urinary volumes and/or hypercalciuria. Other metabolic disorders are also well recognized, including hyperuricosuria, hyperoxaluria and hypocitraturia. Identification of these disorders is relatively easy and treatment programs, including dietary modification in addition to pharmacological agents, have been shown to be effective. Prevention is recognized as being preferable to treatment (for example ESWL) and recurrence. With this background, why was another conference on urolithiasis needed? A National Institutes of Health (NIH) sponsored consensus conference on prevention and treatment of kidney stones was held March 28 to 30,1988 and many of these points were emphasized. Additionally, stone disease is not fatal, most patients eventually do well, incapacitation is usually short-lived and most return to their normal lifestyles. Although most individuals with kidney calculi pass the stone, often hospitalization is required. For individuals requiring intervention various procedures are performed, most in the operating room and most requiring anesthesia with use of ancillary medical personnel. Although patients as a group do well, there is significant expense associated with this treatment, time lost from work, need for recuperation and attendant morbidity. Additionally, after appropriate treatment most of these patients are not evaluated and resume their previous life-style, and many may have a recurrent stone. Another problem in the clinical arena relates to medical management itself. Although various pharmacological agents are available and many have been proved to be efficacious, treatment failures occur. Long-term followup is required to determine that preexisting stones do not grow and that new stones do not form. Efforts are needed to assess medical therapy better and also to develop new agents that can be used either alone or in combination to prevent stone formation more effectively in those so predisposed. Many investigations in the past have attempted to identify

Human urine contains a spectrum of proteins derived from various organs in the body. This investigation was undertaken to identify a group of proteins secreted primarily by bladder urothelium. Saline bladder washouts were collected from 9 male and 4 female patients undergoing routine cystoscopic examination. Each sample was sieved, desalted, freeze-dried and solubilized in urea mix. identical amounts of proteins were pooled according to donor sex. All individual and pooled samples were then subjected to 2-dimensional gel analysis using the ISO-DALT system. Profiles of both groups of subjects were highly reproducible, comparable and resembled those of urine and plasma. Several hundred spots were visualized although most of them as yet remain unrecognized. The proteins identified in bladder washouts include albumin, transferrin, IgG gamma-heavy chain, Gc-globulin, alpha 1-antichymotrypsin, alpha 1-antitrypsin, alpha 1-acid glycoprotein, G4, IgG light chains, alpha 1-microglobulin, and low and high density lipoproteins. Most importantly, while some abundant urinary macromolecules such as Tamm-Horsfall mucoprotein and most acidic urinary proteins were undetectable, albumin and transferrin were relatively less expressed. The 2-dimensional profiles we developed can be used as a data base to study urothelium derived proteins in various disease conditions such as bladder cancer.

Laparoscopic pelvic lymphadenectomy and radical perineal prostatectomy performed under the same anesthetic provide accurate surgical resection of localized carcinoma of the prostate with reduced intraoperative blood loss, minimal postoperative discomfort, short hospital stay (mean 4.1 days), high level of postoperative continence (81% completely dry after 4 months postoperatively) and low morbidity (4 complications). The clinical records of 37 patients undergoing this combined procedure during the last 22 months were reviewed retrospectively and the efficacy of the procedure was evaluated. This combined treatment modality avoids an abdominal incision and pelvic drains, and is associated with minimal postoperative discomfort and a short hospital stay. Laparoscopic pelvic lymphadenectomy combined with radical perineal prostatectomy is an alternative to open pelvic lymph node dissection and radical retropubic prostatectomy.

Of 35 patients with prostate carcinoma and suspected spinal cord compression 26 (74%) had myelograms and/or magnetic resonance imaging studies demonstrating epidural spinal cord compression. In 5 of 26 patients (19%) spinal cord compression was the first indication of prostate cancer. All patients were initially treated with radiation, steroids and androgen deprivation therapy. Three patients underwent laminectomy. Of 12 patients (100%) ambulatory at presentation 12 remained ambulatory. Of 12 patients (83%) who were paraparetic at presentation 10 were ambulatory after treatment. However, 2 of these patients subsequently had recurrent compression and became paraplegic. Overall, 7 of 26 patients (27%) had recurrent compression. Of 5 patients who either presented with paraplegia or in whom paraplegia developed secondary to recurrent spinal cord compression 4 remained paraplegic despite treatment. The average survival of these 5 patients after treatment was 3.9 months versus 18 months for the group as a whole. In ambulatory or paraparetic patients radiation, androgen deprivation therapy and steroids are effective palliative therapy. However, patients who present with paraplegia or in whom paraplegia developed secondary to recurrent compression are often not palliated by this combination therapy. Prophylactic radiation of vertebral metastases discovered concurrently with compressive metastases may be valuable in preventing paraplegia.

We examined 13 cases of small cell carcinoma of the genitourinary tract to evaluate and compare the immunocytochemical and ultrastructural features as well as the clinicopathological behavior. Immunohistochemical stains revealed that neuron specific enolase and chromogranin showed differences in staining between the bladder and prostate, as well as between the small cell and adenocarcinomatous components of the prostate. Also, synaptophysin was negative over-all in 12 of 13 cases. Epithelial membrane antigen, carcinoembryonic antigen and keratin showed strong focal positivity within the small cell component. Electron microscopy was performed in 4 cases, with 3 demonstrating neurosecretory granules. Clinically, 6 of the 7 patients with adenocarcinoma/small cell carcinoma of the prostate did poorly, all with a survival of 15 months or less. Of 5 patients with transitional cell/small cell carcinoma of the bladder 2 fared better (both had no evidence of disease at 12 months and 11 years, respectively). Based upon the immunostaining and electron microscopic findings, small cell carcinoma of the genitourinary tract is heterogeneous in appearance and, therefore, may arise from a multipotential cell of origin. This cell of origin may be organ-specific, as demonstrated by the variability in staining characteristics among the prostate, bladder and kidney, as well as by the differences in the clinical behavior of these malignancies. Small cell carcinoma of the prostate has a poor prognosis, while small cell carcinoma of the bladder may portend a better prognosis if diagnosed at an early stage.

The exact role of urinary proteins in kidney stone formation remains an area of controversy. Some investigators believe that urinary proteins are selectively incorporated within urinary calculi and as such have an active role in stone formation. Other investigators believe that urinary proteins are nonspecifically adsorbed into urinary crystals and thus have only a passive role in stone formation. In the current investigation a previously described stone-forming animal model (hyperoxaluric rat) was utilized along with an animal model for renal tubular injury (gentamicin nephrotoxicity) in an effort to clarify the role of urinary proteins in kidney stone formation. Urine specimens were collected before and after the induction of stone formation and after the induction of renal tubular injury. The purified proteins from each urine specimen were separated in two dimensions by electrophoresis resulting in a characteristic "map" of protein spots for each urine specimen. All animals in the stone-forming group had pathologic evidence of early stone formation (diffuse intranephronic calculosis). Early stone formation was consistently associated with a reduction in the excretion of low molecular weight urinary proteins (30,000 dalton and less than 20,000 dalton ranges). Alcian blue staining confirmed the presence of matrix within clumps of intranephronic calcium oxalate crystals. Renal tubular injury was associated with an increase in the excretion of low molecular weight proteins (approximate 20,000 dalton range) consistent with classical tubular proteinuria. These results suggest that low molecular weight urinary proteins are selectively incorporated within the crystalline structure of the stone early during its formation.

Relative degrees (25%, 50% or 75%) of constriction of the entire cauda equina at the seventh lumbar level were performed on eighteen pure bred female beagle hounds by surgically implanting a circular polyethylene loop with an imbedded stainless steel wire. The wire was mechanically constricted by external control and the degree of compression was confirmed by pre- and postoperative magnetic resonance imaging or computed tomography scanning. A control group of two dogs had laminectomy only. Neurologic function was evaluated daily. Cystometrics were performed on each dog after constriction had been present for three months. Cortical evoked potentials (CEPs) were obtained on all dogs preoperatively, immediately following constriction and at monthly intervals for three months. Dogs were sacrificed at three months and the cauda equina and spinal cord were examined histopathologically. Cystometric tracings were noted to become a flat line with 75% compression of the cord. Less compression had minimal effect on the cystometric curves. The mean latency, determined by cortical evoked potentials, was noted to increase by 3.2%, 7.8%, and 17.2% immediately after 25%, 50% and 75% constriction, respectively. Histologic changes ranged from occasional enlargement of the axons on the periphery of the cauda equina with 25% constriction to severe loss of all axons and atrophic roots at the level of the constricting band with 75% constriction.

Purpose: We discuss the specific urological abnormalities associated with protease inhibitor therapy.Materials and Methods: We report on a human immunodeficiency virus positive patient who was on protease inhibitor therapy and presented with renal colic.Results: The stone passed spontaneously. Stone analysis was not consistent with any known composition of urinary calculus.Conclusions: The positive effects of protease inhibitors in human immunodeficiency virus positive patients mandate that the urological community become familiar with these drugs and the specific urological complications as the use of these drugs becomes widespread.

Inflammation of the penile corpus cavernosum is an unusual condition most often associated with an infectious process. We report on a diabetic man with localized inflammation of the corpus cavernosum resulting from acute occlusion of the cavernous artery. Diagnosis was made by exclusion and ultimately confirmed by penile angiography. Conservative measures led to resolution of this process.

Delayed adverse reactions to ionic and nonionic intravenous contrast media have been reported previously. We report a case in which delayed hypersensitivity to iohexol, a nonionic intravenous contrast agent commonly used in excretory urography, resulted in a bi-phasic allergic response. This reaction consisted of a mild post-infusion episode of urticaria, which preceded and was clinically distinct from a moderately severe dermatological eruption. The episode of urticaria was self-limited. The dermatological reaction was treated successfully with antihistamine therapy.