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Purpose: The significance of isolated positive apical surgical margins in radical retropubic prostatectomy (RRP) specimens remains controversial. We examine the effects of margin status and location on biochemical recurrence rates in patients undergoing RRP., Materials and Methods: Of 800 patients with RRP we identified 498 without pathological evidence of lymph node, seminal vesicle or adjacent organ involvement and with at least 6 months of followup. Patients were subdivided into apex only positive (AM+), nonapical isolated positive (OM+), multiple positive (MM+) and negative (SM-) surgical margins. The rate and interval to biochemical disease recurrence were determined in each group. Univariate and multivariate analysis as well as Kaplan-Meier curves were used to test differences among these groups., Results: Of the 498 men who met our inclusion criteria 400 were SM-, 28 were AM+, 57 were OM+ and 13 were MM+ at a median followup of 49, 59, 64 and 83 months, respectively. Biochemical recurrence rates for SM-, AM+, OM+ and MM+ were 9.3%, 21.4%, 26.3% and 30.8%, respectively. Median time to biochemical failure in the SM-, AM+, OM+ and MM+ groups was 34, 19.5, 46.0 and 6.8 months, respectively. Biochemical recurrence was not statistically different among the AM+, OM+ and MM+ groups. On univariate analysis AM+, OM+ and MM+ were significant predictors of recurrence (p < 0.05, < 0.005, and <0.05, respectively). On multivariate models only pretreatment prostate specific antigen and OM+ were independent predictors of biochemical recurrence., Conclusions: A positive surgical margin conveys increased risk for biochemical recurrence. Patients with AM+ experienced biochemical recurrence more frequently and rapidly than those with SM-. AM+ conveys a similar risk of recurrence compared with OM+ and MM+. Apical margin status did not independently predict biochemical recurrence.

Purpose: Recto-urinary fistula formation is a rare occurrence, usually following surgery or another intervention for prostatic disease. Spontaneous closure is rarely successful and reconstructive procedures are usually performed. We report our experience in the last 30 years with modified York-Mason repair. To our knowledge our series of 24 patients is the largest reported using this approach., Materials and Methods: We retrospectively reviewed the medical records of all patients who underwent acquired rectourethral or rectovesical fistula repair at our institution. A total of 24 patients underwent York-Mason recto-urinary fistula repair, 18 fistulas occurred secondary to prostatic surgery and 11 patients underwent 1-stage repair without preoperative urinary or fecal diversion., Results: Overall 22 of the 24 fistulas were repaired successfully using the York-Mason approach. One patient required a repeat York-Mason procedure and another required a perineal incision to correct recurrence. All except 1 fistula were eventually surgically corrected. No fecal incontinence or anal stenosis developed. The fistula involved the bladder and urethra in 11 and 13 cases, respectively. Procedure time was less than 2 hours. Blood loss was 50 to 400 cc. No transfusions were required., Conclusions: York-Mason repair of recto-urinary fistula is an excellent approach to a rare and often confounding surgical complication. It provides nice exposure through unscarred planes and allows adequate closure. The success rate is excellent compared with that of other reported techniques. Postoperative recovery is rapid with minimal morbidity.

Purpose: 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., Materials and Methods: 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., Results: 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., Conclusions: 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 effects of matte finish and modularity on loosening of tapered stems using the same cementing technique were studied prospectively. In 80 patients, 82 cemented Exeter primary stems were implanted at total hip revision by one surgeon using the same surgical and cementing technique throughout the series. The polished stems behaved differently than the matte surfaced stems behaved. Polished stems subsided in the cement mantle an average of 1 mm at 2 years after implantation, but without subsequent loosening of stems at as long as 12 years after implantation. Matte surfaced stems with metal centralizers had a higher loosening rate, and loss of fixation at the prosthesis to cement interface was identified as an early sign of loosening of these stems. At a mean 6-year followup, there were no revisions nor was there radiographic evidence of loosening of the polished modular stems. It is concluded that matte finish results in increased loosening of tapered stems but the introduction of modularity did not.

Purpose: Although urology continues to be a male dominated field, the participation and influence of women within the specialty are growing. In the United States as of July 1995, 56 of 1,339 urology residents (4.2%) and 97 of 8,227 board certified urologists (1.2%) were women. The demographics of this group, including age, board certification, fellowship experience and practice patterns, are unknown. Mentorship and motivations leading to urology as a specialty choice for women are also unreported., Materials and Methods: We surveyed 161 female urologists by mail., Results: Of the women surveyed 80% responded. Female urologists tend to be young and board certified, 39% are fellowship trained and 22% hold full-time academic positions. Women were discouraged from selecting urology as a specialty because of gender. Many women had male (59%) or no (35%) mentors throughout the training years, 70% were married and 44% had children. Of the 25 respondents who had children during residency most (84%) felt supported by the program director and resident peers. Despite obstacles 94% of female urologists would encourage other women to enter urology., Conclusions: Female urologists are young, well educated and career oriented. Although most did not have mentors during training, there is a high level of job satisfaction and low attrition after training.

Purpose: Positive surgical margin rates after radical retropubic prostatectomy are reported to range from 25 to 50% in contemporary series. We report on 53 nonnerve sparing radical retropubic prostatectomies performed with attention paid to extending the margin of attached periprostatic tissue. This was accomplished primarily by initial perirectal release of periprostatic tissues at the level of longitudinal rectal fibers posterior and lateral to the prostate. This perirectal release ensures that maximal quantities of periprostatic tissue will remain with the prostate specimen and will not be attenuated or sheared away at subsequent stages of the procedure., Materials and Methods: Pathological material was examined for capsular penetration and surgical margins using transverse whole mount sections of the prostate at 4 to 5 mm. intervals. Patients were followed at regular intervals with physical examinations and serum prostate specific antigen (PSA) determinations., Results: The series consisted of 6, 5, 14 and 28 cases of clinical stages T1b, T1c, T2a and T2b cancer, respectively. Mean PSA was 10.0 ng./ml. and mean Gleason score was 5.9. Capsular penetration was observed in 47 of 53 cases (89%) and positive surgical margins were noted in 7 (13%). With a median followup of 3.61 years 2 patients experienced PSA defined recurrence., Conclusions: We believe that positive surgical margin rates may be decreased when technical modifications are directed at increasing the amount of periprostatic tissue excised with the surgical specimen.

Purpose: We report our experience with posterior sagittal, transanal, transrectal repair of rectourinary fistulas., Materials and Methods: A total of 16 fistula repairs was done in 15 patients., Results: Of the fistulas 13 occurred after a variety of prostatic procedures, 1 after Y-V plasty and 1 after pelvic trauma (2 repairs were attempted in the latter case). Six patients underwent repair without colostomy. No patient experienced fecal or anal complications and all repairs were successful., Conclusions: Our surgical approach for repair of rectourinary fistulas is simple, effective, associated with minimal morbidity and cost-effective.

Purpose: The American Urological Association convened the Prostate Cancer Clinical Guidelines Panel to analyze the literature regarding available methods for treating locally confined prostate cancer, and to make practice policy recommendations based on the treatment outcomes data insofar as the data permit., Materials and Methods: The panel searched the MEDLINE data base for all articles from 1966 to 1993 on stage T2 (B) prostate cancer and systematically analyzed outcomes data for radical prostatectomy, radiation therapy and surveillance as treatment alternatives. Outcomes considered most important were survival at 5, 10 and 15 years, progression at 5, 10 and 15 years, and treatment complications., Results: The panel found the outcomes data inadequate for valid comparisons of treatments. Differences were too great among treatment series with regard to such significant characteristics as age, tumor grade and pelvic lymph node status. The panel elected to display, in tabular form and graphically, the ranges in outcomes data reported for each treatment alternative., Conclusions: In making its recommendations, the panel presented treatment alternatives as options, identifying the advantages and disadvantages of each, and recommended as a standard that patients with newly diagnosed, clinically localized prostate cancer should be informed of all commonly accepted treatment options.

Medical interventions are identified to be in need of practice guidelines based on several criteria, including uncertainty of therapeutic benefit, economic impact, variation in practice patterns and lack of objective data for new developments. Treatment of localized adenocarcinoma of the prostate meets these criteria and has been identified as an issue in need of practice guideline development. The American Urological Association began working toward establishing prostate cancer treatment guidelines in 1989. An explicit method based on collection of scientific data was adopted, which requires complete review of the literature and analysis of the evidence collected. An update on the progress toward this data analysis and guideline document is presented.

Vascular aneurysms can present with signs and symptoms of urological disease. We report on a 74-year-old man who underwent urological referral because of an abnormal prostate on rectal examination. Diagnostic evaluation revealed large, abdominal aortic and iliac artery aneurysms with prostate and bladder displacement.

Infertility in patients with a history of cryptorchidism is usually the result of oligo-asthenospermia. In this study we analyzed the incidence of antisperm antibodies in infertility patients with a history of cryptorchidism, general infertility patients and donors of known fertility. Of the cryptorchid patients 66% tested positive for antisperm antibodies compared to 2.6% of the control group of infertile patients and 2.8% of the donors of known fertility. Sperm progressive motility was significantly (p < 0.05) decreased in the cryptorchid patients testing positive for antisperm antibodies compared to those testing negative for antisperm antibodies, and compared to both control groups. Of the patients treated for cryptorchidism by orchiopexy 52% were positive for antisperm antibodies, and the mean patient age at orchiopexy was significantly (p < 0.01) higher in the positive antibody group (14.2 +/- 1.2 years old) than the negative antibody group (8.6 +/- 0.8 years old). While decreased sperm concentration, motility and morphology are usually the primary causes of infertility in patients with a history of cryptorchidism, it appears that the presence of antisperm antibodies is also increased in these patients, which may contribute to reduced fertility.

Sperm morphology is a critical factor in the evaluation of infertile men. Patients often exhibit a morphology profile with consistent increases of specific abnormal categories of sperm morphology. We analyzed the functional ability of 7 categories of sperm morphology using assays that measure sperm viability longevity, deoxyribonucleic acid packing, acrosomal status, and the stimulation of the acrosome reaction with human cumulus/oocyte complexes and calcium ionophore A23187. Each morphology category was separately analyzed initially and at 3, 6, 12, 18 and 24 hours of in vitro culture. The data indicate that all categories of abnormal sperm morphology exhibit various functional debilities. However, tapered sperm most closely approached normal sperm function. All abnormal categories possessed subpopulations of sperm that functioned normally to the limits of these assays. These data indicate that increases in any of the categories of abnormal sperm morphology may lead to decreased fertility due to diminished functional ability indicated by the assays performed in this study.

We describe a 34-year-old man who survived a massive pulmonary embolus caused by renal cell cancer tumor emboli. The literature and clinical presentation are discussed.

During a 2-year period, 884 extracorporeal piezoelectric lithotripsy treatments have been performed on stones in 388 renal units (kidney and upper ureter) using a Wolf Piezolith device.* Lithotripsy routinely was performed on an outpatient basis without use of anesthesia or premedication. Often, the maximum number of pulses allowable by a Food and Drug Administration protocol (4,000) was delivered and retreatments frequently occurred on successive days. Of the patients 75% were stone-free 3 months after treatment, while another 20% had only residual small fragments. No intrarenal or perinephric hematomas were observed and only 1 patient has had hypertension requiring medication. Renal colic from passage of stone fragments occurred in only 10% of the patients. An aggressive treatment policy using repeat treatments as necessary provides for superior results with this device without an incision or complication.

Sixty-four patients with adenocarcinoma of the prostate and histologic evidence of pelvic nodal metastasis have been followed for at least 5 years after pelvic lymphadenectomy only. Forty-seven patients were treated with extended field irradiation, while 17 did not receive any irradiation. Only 17 per cent of the patients receiving irradiation survived free of disease for 5 years, while 40 per cent died of prostatic cancer, compared to 29 and 35 per cent, respectively, of those who did not receive irradiation. Symptomatic manifestations of local disease occurred within 5 years in 65 per cent of the patients not treated with irradiation, compared to 51 per cent of those who received pelvic irradiation. External radiation therapy imparted no discernible benefit in terms of survival free of disease in our patients. Furthermore, the impact of irradiation in preventing local symptoms in these patients seems to be slight.

The treatment of 2 prostato-rectal fistulas by a single stage York Mason repair and cystostomy is described. We realize that the therapy of rectourinary fistulas should be individualized and for the ill or septic patient the 3-stage treatment including colostomy is safe and conservative. However, for the patient in good condition the 1-stage repair seems to be an effective shortcut.

During a recent 8-year 4-month period 205 men underwent bilateral vasovasostomy. Of those patients for whom followup information was available 43 per cent have produced a pregnancy. Semen analyses after vasovasostomy revealed good sperm counts for the most part but generally reduced sperm motility and viability. Efforts are underway to evaluate whether the defect may be the result of abnormal epididymal function or of sperm agglutinating or immobilizing antibodies.

Previously, the psoas hitch had been advocated only for difficult cases of ureteral implantation, especially when there had been inadequate ureteral length. However, during the last 10 years the paoas hitch in association with a modified Paquin technique has been used routinely at this institution for ureteral reimplantation. The technique has been used in all unilateral cases and in most bilateral reimplants. Results have been excellent. The psoas hitch allows for a long submucosal tunnel, with a fixed relationship between the ureter and posterolateral bladder wall. Intermittent hydronephrosis is not seen with this method of reimplantation and there have been no voiding disturbances.

From 1970 to 1980, 153 patients with stages A2, B1 and B2 prostatic cancer and proved negative pelvic lymph nodes underwent radical prostatectomy (84 underwent radical perineal and 69 underwent radical retropubic prostatectomy). Seventeen patients were lost to followup. Of 136 patients who were followed for 5 years or until death 128 (94 per cent) were alive at 5 years, including 118 (87 per cent) who were without evidence of recurrence. Patients with microscopic invasion of the prostatic capsule have a better outcome at 5 years than those with microscopic involvement of the seminal vesicles. Only 46 of the patients could be assessed at 10 years or had died 6 to 10 years postoperatively. Results at 10 years are considered preliminary, since many more patients will reach the 10-year milestone within the next few years.

Pubectomy has been useful, particularly for the treatment of traumatic disruption of the deep urethra after a preliminary cystostomy. This procedure provides unparalleled exposure for mobilization of the apex of the prostate and distal urethral segment, and the accomplishment of an end-to-end anastomosis. Results have been good. Pubectomy has been helpful in selected cases of chronic osteitis pubis. Experience with the technique was helpful during radical pubectomy in 2 patients with chondrosarcoma of the pubis.

Chronic granulomatous disease of infancy is a rare hereditary disease that may have urologic manifestations. We describe 2 brothers who had intense cystitis and typical x-ray findings characteristic of this disease. The etiology, incidence and treatment of chronic granulomatous disease of infancy are discussed.

A case is presented of a 1-year-old boy with hypertension resulting from abnormal renin production by the right kidney. The kidney had undergone infarction and atrophy secondary to renal vein thrombosis. The left kidney remained normal despite inferior vena cava thrombosis because of the development of collateral venous circulation. The hypertension was cured by right nephrectomy. The child remains normotensive and with a normal serum creatinine at 1-year followup.

It has been suggested that patients with large, localized prostatic carcinomas (stage B2) may not be good candidates for radical prostatectomy. Inaccuracy of the rectal examination is a particular problem with a lesion of this type. Unrecognized extension beyond the prostatic capsule, especially into the seminal vesicles, is well known and unsuspected involvement of pelvic lymph nodes may be present. Patients with clinical stage B2 prostatic carcinoma who seemed to be potentially good candidates for radical prostatectomy have been subjected to pelvic lymphadenectomy for staging. All of these patients have a normal chest x-ray, serum acid phosphatase, excretory urogram and radioisotope bone scan. During a 101/2-year interval 87 patients with clinical stage B2 prostatic carcinoma underwent staging pelvic lymphadenectomy. Of these patients 24 (28 per cent) had positive pelvic lymph nodes and were excluded from consideration for radical prostatectomy. Fifty patients with clinical stage B2 prostatic carcinoma and proved negative pelvic lymph nodes have been subjected to radical prostatectomy: 43 (86 per cent) had tumor confined to the prostate on histologic examination of the radical prostatectomy specimen, 6 (12 per cent) had microscopic capsular invasion and 2 (4 per cent) had microscopic invasion of the seminal vesicles. Radical prostatectomy seems justified when there is a high likelihood that the tumor truly is confined to the substance of the prostate. In our experience pelvic lymphadenectomy has enabled us to select appropriate patients with stage B2 prostatic carcinoma for radical prostatectomy.

Patients with stage A2 carcinoma of the prostate are a heterogeneous population and not all of them progress to clinically manifest disease. We found a similar variability in terms of the pathological findings in a group of 34 patients with stage A2 disease undergoing pelvic lymphadenectomy and radical prostatectomy. While 8 patients (24 per cent) had metastatic disease on staging lymphadenectomy, 9 patients (27 per cent) had negative lymphadenectomy, with minimal or no residual tumor in the radical specimen. The histologic grade and extent of tumor on transurethral resection did not predict reliably patients with stage A2 disease and minimally invasive cancer at radical prostatectomy. It appears that present criteria for separating stage A tumors into focal and diffuse categories are adequate for selecting therapy for patients with incidental carcinoma of the prostate.

Staging pelvic lymphadenectomy has been done on 87 patients with clinically localized prostatic carcinoma. With this method nodal metastases can be discovered, although they are undetectable by any other means. There were 44 patients with negative pelvic lymph nodes by surgical staging subjected to radical prostatectomy. Only 6 patients (14 per cent) had microscopic invasion of the prostatic capsule and there was just 1 instance of microscopic seminal vesicle invasion in those with negative pelvic lymph nodes.

Retrograde ejaculation can be a significant problem when it interferes with fertility. Sympathomimetic drugs and sperm retrieval from the urine with insemination of the wife are the common methods of treatment. When these methods have not been successful we have used the Young-Dees type of bladder neck reconstruction to convert retrograde ejaculation into normal or antegrade ejaculation. The operation has been successful in 4 of 5 patients.

The neonatal adrenal gland is vulnerable to traumatic hemorrhage. With the correct interpretation of clinical, laboratory and radiographic data the diagnosis can be made non-operatively. We review 6 cases of acute neonatal hemorrhage. Trauma during or shortly after birth occurred in 4 cases and all 6 newborns had jaundice and anemia. Operative intervention rarely is necessary either for the diagnosis or treatment of intracapsular adrenal hemorrhage in the newborn.

The urinary tract has been used previously for shunting of cerebrospinal fluid. However, nephrectomy has always accompanied the procedure, making it less appealing despite adequate relief of hydrocephalus. By using reimplantation of the ureter and a psoas hitch we have performed the first reported ventriculoureterostomy without nephrectomy. To date the results in 3 patients have been excellent from a neurosurgical and urologic standpoint.

Necrosis with slough of skin flaps is a common and distressing complication after radical inguinal node dissection. Conventional methods to predict viability of dermal flaps are notoriously unreliable. Intravenous fluorescein has been shown to be a reliable indicator of the adequacy of blood supply to dermal flaps in experimental models and in radical mastectomies. Fluorescein has been used in 6 separate node dissections for carcinoma of the penis. In all cases fluorescein reliably delineated viable skin flaps and its use can help decrease the morbidity rate in inguinal node dissection.

Carcinosarcoma is a tumor composed of malignant epithelial and mesenchymal elements, which occurs rarely in the bladder. Although the prognosis of bladder carcinosarcoma is known to be poor the histology of metastatic lesions is not well described. We report 2 cases of bladder carcinosarcoma with pelvic lymph node involvement. Pure sarcomatous metastasis was present in 1 patient and only carcinoma in the other. The histologic composition of metastatic lesions may be of significance in treatment planning in patients with bladder carcinosarcoma.

We herein report on a patient who was subjected to bilateral nephrectomy in the course of treating unilateral renal cell carcinoma. The patient has survived for 3 1/2 years free of tumor and has had normal renal function after a 4 antigen match cadaver kidney allograft.

We divided 73 cases of pelvic nodal metastases from prostatic cancer into subgroups based upon the volume and extent of nodal disease. Of the patients with gross nodal disease 15 per cent survived 5 years without progression compared to 27 per cent of those with microscopic involvement of more than 1 node and 44 per cent with a single positive node. On the other hand, 52 per cent of the patients with gross disease died of prostatic cancer within 5 years compared to 37 per cent of those with multiple microscopic nodes and 28 per cent with a single node. Although other variables also influence prognosis, the differences in survival demonstrable within these subgroups may have important implications regarding selection of therapy and interpretation of treatment results.

We report a case in which extracorporeal circulation was used as an alternative to other forms of corpus-venous shunting and resulted in complete detumescence and maintenance of potency. The relative simplicity and the ability to repeat the procedure in cases of recurrent priapism suggest this as a reasonable form of treatment in patients who do not respond to conservative measures.

Experience with the Young-Dees procedure confirms that this is a useful operation for restoring urinary continence, particularly in selected female patients with non-neurogenic incontinence. Of 21 incontinent patients 15 have achieved good to excellent postoperative urinary control.

Pyeloplasty by a dismembered Y-V plasty technique to correct congenital ureteropelvic junction obstruction has been used for 8 years with uniform success. The routine use of a neophrostomy and splinting catheter offers many advantages and no significant disadvantages.

A 15-year followup was summarized for patients who had nonmicrosurgical vasectomy reversal. Over-all pregnancy rates were 45 per cent (43 per cent for the first 8 years and 49 per cent for the next 7 years) and 73 per cent of the pregnancies occurred within 1 year after vasectomy reversal. Patients who achieved pregnancy compared to those who did not had significantly better sperm motility and a lower incidence of antisperm antibodies. The data indicate that nonmicrosurgical techniques can be used successfully to reverse vasectomy more economically and more rapidly than the microsurgical approach, while contributing to a reasonable pregnancy rate.

During the last decade 452 patients have undergone pelvic lymphadenectomy as a staging procedure for apparently localized prostatic cancer. Of these patients 105 (23 per cent) had pelvic node metastasis. Node involvement occurred in no patient with a stage A1, 24 per cent with stage A2, 12 per cent with stage B1, 28 per cent with stage B2 and 53 per cent with stage C tumor. Correlation with tumor grade revealed nodal metastasis in 10 per cent of the patients with well differentiated tumors, 24 per cent with moderately differentiated lesions and 54 per cent with poorly differentiated tumors. The incidence of positive nodes is low enough to preclude lymphadenectomy in patients with stage A1 (0 per cent) and well differentiated stage B1 tumors (4 per cent), and high enough to assume metastatic disease without lymphadenectomy in those with poorly differentiated stage C tumors (93 per cent). All other patients with apparently localized prostatic cancer should undergo a staging pelvic node dissection before definitive treatment.