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Objectives: To characterize the effect of prostate-specific antigen (PSA) and transurethral resection of the prostate (TURP) on the rate of diagnosis of well-differentiated (WD) prostate cancer (PCa) and PCa mortality., Methods: All cases of PCa and rates of TURP at both Wilford Hall and Brooke Army Medical Centers between 1984 and 1995 were reviewed. Tumor grade was compared between prostate needle biopsy and TURP. The pattern of diagnosis was analyzed annually and for two time periods: pre-PSA (1984 to 1988) and post-PSA (1989 to 1995)., Results: The number of WD tumors fell by 50% over the period of study and was caused by a fall in number of TURPs as well as in WD tumors detected by TURP. PSA for early detection of PCa began in 1988, and within 5 years a more than 50% fall in the rate of metastatic disease was witnessed. These two events (PSA screening and fall in TURPs) led to an increase from 57% to 92% of tumors that were both clinically significant and potentially curable., Conclusions: These data help explain the fall in the rate of diagnosis of WD PCa. The resultant increase in the diagnosis of moderately and poorly differentiated PCa, coupled with the dramatic fall in the rate of diagnosis of metastatic PCa, may explain the reports of a fall in PCa mortality. If this observation is replicated in other populations, it may provide further impetus for a stronger recommendation for early detection with PSA and digital rectal examination.

Objectives: To determine whether the incidence of hypospadias is increasing and whether racial differences among patients are significant, we evaluated the current incidence of hypospadias and patient race in an equal-access healthcare system., Methods: We undertook a retrospective review of discharge records between 1990 and 1998 from 15 military treatment facilities to determine the total number of male live births and the number of male live births with hypospadias reported by race (categorized as white, black, Asian, Native American, and unknown)., Results: Among 99,210 male live births, 709 cases of hypospadias were identified (0.7%). Of the total male live births, 68,444 were white, 18,984 were black, 1761 were Asian, 175 were Native American, and 9846 were unknown, with an incidence of hypospadias of 0.8%, 0.6%, 0.5%, 0.6%, and 0.6%, respectively. Racial differences were not statistically significant (P = 0.2)., Conclusions: The 0.7% incidence of hypospadias detected is near the upper limit of what has been historically reported. No significant difference between races was found, but the incidence of hypospadias in minorities is higher than previously reported.

Objectives: To provide a simple and reliable clinical prediction for an individual patient's overall risk of cancer at biopsy by deriving an easily implemented test based on a generalizable model. Four variables are analyzed for inclusion in the model: prostate-specific antigen (PSA) level, digital rectal examination (DRE) results, race, and age., Methods: Two populations were used to develop and validate the test: a model (n = 633) and an independent, geographically separate, external population (n = 766). Pathology records for patients who underwent prostate biopsy between 1991 and 1995 were reviewed and screened for the presence of PSA and DRE results. Records where age and race could be determined were extracted. Multiple logistic regression was used with an iterative approach to optimize each test factor. The Wald chi-square test, receiver operating characteristic (ROC) curve, and Hosmer-Lemingshaw test were used to evaluate the model's predictive capability in the two populations., Results: The model and external populations were significantly different for racial mix, PSA level, age, and biopsy detection rate, providing diverse populations to validate the test. Within a combined model, PSA, DRE, race, and age all demonstrated independent capability to predict cancer at biopsy. Predictive power of the overall test was high within the model population (ROC 80.8%), with minimal loss of power in the external population. The test demonstrated no significant lack of fit in either population., Conclusions: Within a combined test, PSA, DRE, race, and age all contribute significantly to prediction of prostate cancer at biopsy in an individual patient. The test depicts individual risk in an easily understood, visually provocative manner and should assist the clinician and patient in reaching a decision as to whether biopsy is appropriate.

Objective: To review the data from a series of patients with localized prostate cancer managed with observation alone. When available, cancer-specific survival was analyzed. Predictive factors for disease outcome were reviewed., Methods: Series of patients with localized prostate cancer managed with observation alone were reviewed. When available, cancer-specific survival was analyzed. Predictive factors for disease outcome are reviewed., Results: In published trials of observation alone, ten-year cancer-specific survivals of 80-90 percent are realized. Adverse predictors of outcome include higher stage and grade as well as aneuploid tumors. Although tumor progression is more common in patients with adverse predictive factors, adverse outcomes can occur in the larger group of patients with intermediate grade, stage, or tumor volume., Conclusions: Based on a small number of studies of patients with localized prostate cancer managed with observation alone, it appears that this option is reasonable for patients with good predictive factors and for patients with shorter life expectancies. The principal advantage of observation is the avoidance of treatment-related morbidity, but for the patient whose disease progresses during follow-up, disease-related morbidity can occasionally occur.

Although prevalence of perioperative mortality following transurethral resection of the prostate (TURP) has steadily declined as reported in several review studies, it has been suggested that with extended follow-up after TURP, mortality exceeds that of an age-matched population. The sample selected for this study was drawn from a data base of 2,005 men who entered a urologic health-screening program. The sample included a group of 25 patients who underwent TURP and a group of 50 age-matched control patients with symptoms of prostatism. Patients were followed for six years, a total of 450 observed person-years. Multivariate analyses based on a general linear model approach for the dependent variable of survival were used to assess gains in predictive efficiency due to combinations of TURP versus control, time, and patient variables. F-ratio hypothesis tests of coefficients of multiple determination for the models indicated that TURP did account for a significant amount of the variability of survival but only after five years of follow-up. However, a far larger proportion of the variance in survival was explained by other patient variables of age, preoperative risk, comorbidity factors, and postoperative urinary disease after all effects due to TURP, follow-up years, and operation cohort years were held constant in the survival prediction equation.

Transurethral resection of the prostate (TURP) is necessary in a significant proportion of men with a diagnosis of carcinoma of the prostate. Often, "channel" TURP (resection of visually obstructing tissue without extension to the prostatic capsule in a patient with metastatic or locally advanced disease to improve voiding symptoms) is required. Although several theoretical concerns regarding the efficacy and morbidity of this procedure have been voiced, data to support these contentions are lacking. In a review of 41 patients undergoing channel TURP, all were able to void following the procedure. Two patients in whom the resection was carried through the external urinary sphincter, which had been invaded by tumor, were incontinent postoperatively. Two patients had mild stress incontinence. There were no perioperative deaths. These data suggest that incontinence is higher than expected with TURP for benign disease but that results may be acceptable to the patient with significant outlet obstructive symptoms.

As testicular ultrasound has evolved, nonpalpable masses have been detected for which an evaluation and treatment protocol has not been established. Our experience with nonpalpable testis masses detected only by ultrasound in 5 patients is presented, with all patients found to have nonmalignant lesions. We recommend that such cases with negative serum tumor markers and normal chest radiographs be followed with serial ultrasounds. Benign masses will resolve completely, while stable or enlarging masses can be locally excised and inguinal orchiectomy completed only if cancer is found by frozen section. A modified staging system to follow these patients is proposed to determine these patients' prognoses: Stage Ia for inguinally removed nonpalpable cancers, Stage Ib for excised nonpalpable cancers without orchiectomy (false-negative frozen section), and Stage Ic for inguinally removed palpable cancers.

The Duraphase Penile Prosthesis is a new, articulating type of semirigid prosthesis which appears to have several advantages over other semirigid penile prostheses. This series describes the experience with this prosthesis in 12 patients and highlights the experience in 4 patients who underwent removal of other types of prostheses due to mechanical or functional problems and replacement with the Duraphase prosthesis. The device has been mechanically reliable during short follow-up, and there has been excellent patient satisfaction.

A case of rectourethral fistula is described, occurring after radical prostatectomy and adjuvant radiotherapy for pathologic Stage C carcinoma of the prostate. Urethral instrumentation for stricture disease immediately preceded development of the stricture. Conservative management for five years has resulted in the development of osteomyelitis of the pubis, but with antibiotic suppression the patient remains active and asymptomatic. Predisposing factors for the development of rectourethral fistula following radical prostatectomy may include adjuvant radiotherapy and recurrent urethral instrumentation. Most patients will require definitive repair but occasionally a patient may be managed conservatively.

Two recent cases of bilateral ureteral obstruction secondary to benign retroperitoneal fibrosis were treated initially with Gibbons indwelling ureteral catheters. Inadequate catheter length, calyceal stone formation, catheter encrustation, and distal migration form the basis for this report.

An institutional experience with the repair of hypospadias over a fifteen-year period is reviewed. The 119 patients treated surigcally serve as the substance of this report. Recommendations concerning options in surgical treatment are predicated on this experience and the contemporary literature.

Coronal renal imaging with ultrasound has a number of advantages over other routine scanning orientations in nephrosonography. In a series of 214 patients coronal transverse but especially longitudinal orientation was found to be superior to other scanning methods. The main advantages were: differentiation between renal cysts and hydronephrosis as well as demonstration of renal lithiasis. This approach also should be used to augment the diagnostic sequence of investigating renal masses.

Thirty-one patients with intrascrotal disease process have been studied with the Doppler ultrasonic flowmeter to determine if testicular torsion can be differentiated from acute epididymitis when clinical characteristics are ambivalent. In all instances of proved torsion there was a loss of blood flow in the involved testes, whereas in acute epididymitis or other epididymal and gonadal diseases blood flow ranged from normal to hyperemic.

Oxybutynin chloride (Ditropan), a tertiary amine possessing anticholinergic and papaverine-like, direct muscular antispasmodic effects, has been used in controlled clinical studies in patients with neurovesical reflex activity, uninhibited bladders, enuresis, and primary muscle spasm. The cystometrically documented, synergistic, anticholinergic, and muscle relaxant activity of oxybutynin observed in these studies indicates that the drug can be highly effective in the management of reflex neurovesical dysfunction, enuresis, and bladder spasm.

Two cases of seeding of adenocarcinoma of the prostate to the perineum via biopsy tract are presented. Both patients had been treated previously with external beam radiotherapy. The dose of radiation to the perineum was calculated and, in both cases, was not tumoricidal. Treatment options for this uncommon site of recurrence are presented.

The prognosis and proper treatment of Stage A1 carcinoma of the prostate remain unsettled. We report on 60 patients with Stage A1 prostate cancer (less than 5 foci of well-differentiated tumor) diagnosed between 1960 and 1980. Mean duration of follow-up was 7.5 years with a range of one to twenty years. Three patients (5%) suffered disease progression at two, five, and nineteen years of follow-up, and all died of their tumor. Thirty-four patients (56%) have died of other causes. Number of tumor foci had no correlation with chance of disease progression. Extended follow-up of these patients suggests that the vast majority with Stage A1 carcinoma of the prostate will not suffer from morbidity or mortality of the disease but will more commonly succumb to other intervening disease processes.