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Purpose: The American Urological Association convened the Bladder Cancer Clinical Guidelines Panel to analyze the literature regarding available methods of treating nonmuscle invasive bladder cancer, and to make practice policy recommendations based primarily on treatment outcomes data., Materials and Methods: The panel searched the MEDLINE database for all articles related to nonmuscle invasive bladder cancer published from 1966 to January 1998. Outcomes data were extracted from articles accepted after panel review and meta-analyzed to produce comparative probability estimates for alternative treatments., Results: All of the intravesical agents (thiotepa, bacillus Calmette-Guerin, mitomycin C and doxorubicin) when used as adjuvant therapy after transurethral resection resulted in a lower probability of recurrence compared to resection alone. However, there is no evidence that intravesical therapy affects long-term progression., Conclusions: For patients with no prior intravesical therapy adjuvant intravesical chemotherapy or immunotherapy is a treatment option after endoscopic removal of low grade Ta bladder cancers. Intravesical instillation of bacillus Calmette-Guerin or mitomycin C is recommended for carcinoma in situ, and after endoscopic removal of T1 and high grade Ta tumors.

Purpose: We determine if post-chemotherapy resection of residual retroperitoneal and chest tumor under the same anesthetic is reasonable based on tumor pathology and morbidity, and if the finding of necrosis in the abdomen allows observation of chest tumor., Materials and Methods: We retrospectively reviewed 143 post-chemotherapy patients who underwent resection of residual retroperitoneal and chest disease under the same anesthetic., Results: Retroperitoneal pathology was generally predictive of chest pathology. Concordance existed in 77.5% of patients with necrosis, 70% with teratoma and 69% with cancer of the abdomen. However, the correlation was much stronger (86%) in predicting necrosis/fibrosis if cases were categorized as uncomplicated by Indiana University criteria. Although the morbidity of the combined approach is higher than that of standard post-chemotherapy retroperitoneal lymph node dissection, it was acceptable., Conclusions: The morbidity of post-chemotherapy retroperitoneal lymph node dissection and resection of chest disease under the same anesthetic is acceptable. Retroperitoneal pathology generally predicts chest pathology but this correlation is much stronger if the case is uncomplicated based on our criteria. In an uncomplicated case the discovery of necrosis of the abdomen allows observation of chest tumor.

Purpose: We review the indications for nephrectomy at post-chemotherapy retroperitoneal lymph node dissection, identify patients at risk for nephrectomy and assess the impact of nephrectomy on outcome., Materials and Methods: Using a computerized data base and chart review we retrospectively reviewed the records of 848 patients who underwent retroperitoneal lymph node dissection after chemotherapy., Results: En bloc nephrectomy was performed at retroperitoneal lymph node dissection after chemotherapy in 162 of the 848 patients (19%). The indications for nephrectomy included contiguous involvement of perirenal structures in 73% of the cases, renal vein thrombosis in 6%, a poorly functioning or nonfunctioning renal unit in 5% and a combination of these conditions in 16%. Pathological studies of the hilum revealed cancer in 20% of the cases, teratoma in 49% and fibrosis in 31%. Patients requiring nephrectomy had significantly more advanced disease and larger disease volume at presentation and after chemotherapy. There were no significant differences in perioperative morbidity or mortality compared with patients who did not undergo nephrectomy. Only 3 patients required perioperative dialysis and none required long-term renal support., Conclusions: These findings support en bloc nephrectomy at post-chemotherapy retroperitoneal lymph node dissection in select patients with large volume perihilar retroperitoneal disease.

Purpose: Nerve sparing techniques are used routinely during retroperitoneal lymph node dissection in patients with low stage testis cancer in an attempt to preserve postoperative ejaculation. Preservation of ejaculation without an increased retroperitoneal recurrence rate in such patients prompted us to reevaluate the role of nerve sparing techniques in select patients undergoing post-chemotherapy retroperitoneal lymph node dissection., Materials and Methods: Of 472 patients who underwent post-chemotherapy retroperitoneal lymph node dissection between March 1988 and January 1995, 93 (19.7%) underwent a nerve sparing procedure. Two patients died of disseminated cancer within 6 months after post-chemotherapy retroperitoneal lymph node dissection. In 10 patients the ejaculatory status could not be established from the clinical notes and the patient was lost to followup. The remaining 81 patients form the basis of this report. Disease status, complications and ejaculatory status were evaluated. Mean followup was 35.5 months., Results: Of the patients 76.5% reported normal ejaculation after post-chemotherapy retroperitoneal lymph node dissection. Testis cancer recurred after nerve sparing surgery in 6 patients but no tumor was retroperitoneal. Ten pregnancies have been reported to date with uneventful term deliveries in 7., Conclusions: Select patients are candidates for nerve sparing post-chemotherapy retroperitoneal lymph node dissection. Although indications for nerve sparing techniques in the post-chemotherapy population have expanded, the local recurrence rate has not increased. Nerve sparing post-chemotherapy retroperitoneal lymph node dissection can preserve the inherent fertility potential of the patient without increasing retroperitoneal relapse rates.

Purpose: We determined if the behavior of germ cell tumors metastatic to the mediastinum is different from that of primary mediastinal germ cell tumors, a group known to have distinct clinical features., Materials and Methods: A search of the computerized data base for germ cell tumors metastatic to the mediastinum at our university revealed 80 patients, 65 of whom underwent concomitant retroperitoneal lymph node dissection at mediastinal surgery., Results: Of the patients 60 (75%) are free of disease, 14 (18%) died of cancer and 6 (8%) are living with disease. Mediastinal pathology included teratoma in 65% of the patients, cancer in 26% and fibrosis in 9%. Of the 65 patients who underwent retroperitoneal lymph node dissection 75% had teratoma, 15% had fibrosis and 10% had cancer. Mediastinal relapses after dissection were rare (4 of 80 patients)., Conclusions: Germ cell tumors metastatic to the mediastinum appear to behave similarly to those metastatic to the retroperitoneum. Primary mediastinal germ cell tumors have an entirely different clinical course. Teratoma is the predominant pathological type of post-chemotherapy germ cell cancer metastatic to the mediastinum.

Purpose: We determined whether teratomatous elements in the orchiectomy specimen predict for teratoma in the retroperitoneum in patients who have not received chemotherapy., Materials and Methods: We retrospectively reviewed the records of patients with clinical stages A, B and B2 nonseminoma who underwent retroperitoneal lymph node dissection., Results: Teratomatous elements in the orchiectomy specimen predict for retroperitoneal teratoma., Conclusions: When deciding on treatment for low stage nonseminoma, the presence or absence of teratoma in the orchiectomy specimen should be considered to minimize double therapy.

Purpose: Testicular cancers were studied in patients on immunosuppression., Materials and Methods: A retrospective analysis was done of testicular cancer in patients on immunosuppression reported on between 1975 and 1995., Results: The management schemes adopted in the immunosuppressed population followed the generally accepted management concepts. No patient with low stage (A to B1) disease died of testis cancer. Only 4 of 66 patients (6.1%) with the acquired immunodeficiency syndrome died of testis cancer compared to 5 of 20 (25%) after transplantation, implying significantly higher cause specific mortality in post-transplant patients (Fisher's exact test, p < 0.01). The incidence of adverse effect of therapy did not differ from the expected incidence in other patients., Conclusions: Patients on immunosuppression with testicular neoplasms should be treated in the standard fashion as indicated by tumor histology and stage of disease, since most will tolerate therapy and benefit from the standard treatment protocols.

Purpose: We reviewed current experience at our university with delayed orchiectomy after chemotherapy in patients with metastatic nonseminomatous germ cell tumors., Materials and Methods: We retrospectively analyzed the records of 160 patients with metastatic germ cell cancer who were given systemic chemotherapy, and subsequently underwent orchiectomy and retroperitoneal lymph node dissection., Results: Analysis of 160 testicular specimens revealed necrosis or scar in 70 (43.7%), pure teratoma in 50 (31.2%) and persistent germ cell cancer in 40 (25%). Corresponding incidences of histopathological findings in the post-chemotherapy retroperitoneal lymph node dissection specimens were significantly different, correlating with less than half of the cases (chi-square, p = 0.002)., Conclusions: Our study confirms the need for delayed orchiectomy after systemic chemotherapy even when there seems to be a partial or complete clinical response at other sites.

Purpose: Postoperative hyperamylasemia was evaluated in patients undergoing post-chemotherapy retroperitoneal lymph node dissection for testis cancer., Materials and Methods: Serum levels of amylase, lipase and bilirubin were evaluated prospectively in the immediate postoperative period in 39 consecutive patients who underwent post-chemotherapy retroperitoneal lymph node dissection., Results: Hyperamylasemia was found in 16 patients (41%), hyperlipasemia in 17 (43%) and hyperbilirubinemia in 9 (23%). Peak elevations were observed at 24 hours postoperatively and most returned to normal at 1 week. Elevation of these parameters was significantly associated with length and difficulty of the procedure. No patient demonstrated clinical acute pancreatitis., Conclusions: Extended retraction of the pancreas during post-chemotherapy retroperitoneal lymph node dissection may cause a minor reversible injury to the pancreas expressed as hyperamylasemia, hyperlipasemia and, rarely, jaundice. These findings are important to consider in the differential diagnosis of hyperamylasemia following post-chemotherapy retroperitoneal lymph node dissection.

Purpose: To investigate the issue of incidental appendectomy during urological surgery we retrospectively studied its consequences in 2 groups of urological patients., Materials and Methods: We studied 147 patients undergoing cystectomy and urinary diversion (group 1) and 200 undergoing primary retroperitoneal lymphadenectomy (group 2). Incidental appendectomy was performed in 122 (83%) and 114 (57%) patients, respectively., Results: The incidence of infectious complications in group 2 was significantly higher among patients who underwent incidental appendectomy compared to those without appendectomy (9.6% and 2.3%, respectively, p = 0.032). No difference was noted among the patients in group 1 (10.6% and 12.0%, respectively, p = 0.51)., Conclusions: When evaluating the prophylactic merits, incidental appendectomy can be performed safely during radical cystectomy and urinary diversion. It is probably contraindicated in patients undergoing retroperitoneal lymphadenectomy for testis cancer due to the apparent added risk of infectious complications.

Patients undergoing pelvic lymphadenectomy and radical retropubic prostatectomy are traditionally considered to be at high risk for postoperative venous thromboembolic complications. A prospective deep venous thrombosis screening regimen was initiated at our medical center in 1990 following 2 cases of fatal pulmonary embolism that occurred after hospital discharge. During a 3-year period 245 consecutive patients undergoing radical retropubic prostatectomy for prostate cancer were screened postoperatively for lower extremity deep venous thrombosis using ultrasound duplex scanning with color Doppler flow imaging. The results were correlated only with the development of clinical deep venous thrombosis. No additional diagnostic modalities were used to confirm a normal venous system in asymptomatic patients. Venous thromboembolic complications were encountered in 9 of the 245 patients (3.6%). In 2 patients deep venous thrombosis was associated with nonfatal pulmonary embolism. Only 2 of the 9 cases of deep venous thrombosis were detected by color Doppler flow imaging screening. The striking decrease in the incidence of deep venous thrombosis following radical prostatectomy in the last decade and the low yield of screening at a single point in time may warrant reconsideration of the need for deep venous thrombosis screening among patients undergoing pelvic lymphadenectomy and radical retropubic prostatectomy for prostate cancer.

The surgical morbidity rate of 603 patients who underwent lymphadenectomy after primary chemotherapy for clinical stages II and III testis cancer from 1982 to 1992 was reviewed. There were 144 complications in 125 patients (20.7%). The majority of patients (93%) had a tumor volume of greater than 5 cm. Five patients died 3 to 47 days postoperatively, for an operative mortality rate of 0.8%. Pulmonary complications were the most frequent cause of severe morbidity: 6 patients had the adult respiratory distress syndrome and 5 needed prolonged ventilation. The underlying cause was a combination of bleomycin induced pulmonary toxicity, and large volume retroperitoneal and pulmonary disease resected in these patients. Limiting inspired oxygen concentration and perioperative volume replacement are imperative to minimize bleomycin related pulmonary morbidity. Additional procedures, such as nephrectomy and colectomy, did not add to the morbidity rate. Among patients undergoing concomitant venacavectomy there was a higher occurrence of postoperative chylous ascites. Most of the other complications (gastrointestinal, lymphatic, neurological and renal) were temporary and treated conservatively. Perioperative management of the post-chemotherapy testis cancer patient is different from that of the patient undergoing primary retroperitoneal lymphadenectomy. The latter operation is usually performed in physically fit patients and the surgical template of dissection is of a smaller scale. Thus, the complications in this group are minor and without mortality. Specific technical considerations and difficulties are common to post-chemotherapy patients. Factors, such as large volume of disease, post-chemotherapy desmoplastic reaction and extensive retroperitoneal dissection, make these patients more prone to have complications. Decreased pulmonary, renal and nutritional reserves add to the surgical morbidity. Knowledge of possible pitfalls and their causes can avoid unnecessary operative complications.

Between 1965 and 1989, 1,180 patients underwent retroperitoneal lymph node dissection for nonseminomatous germ cell testis cancer (638 underwent primary dissection). Of these patients, 174 were considered to have clinical stage B disease preoperatively (suspected retroperitoneal node metastases by clinical staging). Surgery revealed that 41 patients (23%) actually had pathological stage A disease (no cancerous nodes). This nonspecificity in clinical staging remains consistent despite advance in clinical staging methods during this 25-year period. Of the pathological stage B cancer patients 65% were cured by retroperitoneal lymph node dissection alone. These long-term data indicate that primary retroperitoneal lymph node dissection for low stage metastatic nonseminomatous germ cell testis cancer (pathological stage B) not only had diagnostic but also therapeutic impact. Furthermore, this cure rate with long-term followup is equivalent to that of current series of primary chemotherapy alone for stage B disease, which are still relatively early reports. This cure rate with single modality therapy (retroperitoneal lymph node dissection alone) was accomplished within an average of 4 hours and, therefore, should be more time and cost-effective than prior reports of 3 and 4 courses of primary chemotherapy. In the post-cisplatin era (1979 to 1989), 140 patients with clinical stage B disease were treated with primary retroperitoneal lymph node dissection: 32 (23%) had pathological stage A cancer and 2 of them (6%) had relapse. Both patients are currently disease-free with subsequent chemotherapy. Of the remaining 108 patients with pathological stage B disease 49 received no adjuvant chemotherapy and 59 received cisplatin-based adjuvant chemotherapy. Among the former 49 patients 18 (37%) had relapse and 2 died. No patient receiving postoperative cisplatin-based adjuvant chemotherapy had relapse. The overall survival rate in these 140 clinical stage B cancer patients was 98%. There were 3 deaths, only 1 from cancer. The addition of cisplatin-based adjuvant chemotherapy postoperatively has rendered pathological stage B nonseminomatous germ cell testis cancer entirely free of subsequent relapse. Therefore, retroperitoneal lymph node dissection as monotherapy is curative in two-thirds of the patients with stage II disease, while the remaining one-third with progression to clinical relapse can be reliably saved by chemotherapy. Future considerations in selecting therapy for clinical stage II nonseminomatous germ cell testis cancer will be risk-benefit, cost-benefit and quality of life issues. Several cooperative studies will examine these issues, involving European and United States groups.

The Indiana continent urinary diversion evolved from the Gilchrist procedure. Full detubularization of the reservoir segment, tapering of the efferent limb with staples, plication of the ileocecal valve, and tunneled tenial implants have resulted in a reliable and reproducible continent cutaneous urinary reservoir. In this report the first 69 patients treated with these techniques are reviewed after a minimum 2-year followup. Overall day and night continence rates were 97% by 1 year after surgery. More than 80% of all patients are able to sleep a normal nighttime interval without catheterizing or leaking. Early plus late reoperation rates for problems related to the pouch were 17%. This rate compares favorably to other series of continent cutaneous reservoirs and even to series of ileal conduits.

Nerve sparing retroperitoneal lymph node dissection reliably preserves emission and ejaculation in patients with clinical stage I nonseminoma. The fertility of 51 patients who underwent nerve sparing retroperitoneal lymph node dissection was assessed by 3 different methods: standard semen analysis, analysis of chromatin content by deoxyribonucleic acid histogram and assessment of ultimate fertility status by a questionnaire. Approximately 75% of these patients have semen analyses generally considered to be in the normal range. Virtually all patients who underwent deoxyribonucleic acid histogram analysis had histograms similar to controls. A retrospective analysis of fertility was performed in 201 patients who had previously undergone nerve sparing retroperitoneal lymph node dissection. Of these patients who attempted pregnancy after nerve sparing retroperitoneal lymph node dissection 76% have been successful. Approximately 75% of patients who present with clinical stage I nonseminoma are potentially fertile. Nerve sparing retroperitoneal lymph node dissection is capable of preserving this potential in allowing these patients to father children.

The surgical morbidity in 478 patients who underwent primary retroperitoneal lymphadenectomy for clinical stages I and II nonseminomatous testicular cancer from 1982 to 1992 was reviewed. There were 54 complications in 51 patients (10.6%) and no operative related mortality. Superficial wound infection was the most frequent complication, comprising 45% of the total number of complications. Most major complications were related to small bowel obstruction and atelectasis. No complications caused permanent disability. The complication rate was less in patients who underwent a modified unilateral procedure (9.4%) than in those who underwent bilateral dissection (19.3%). Complications were significantly less with procedures done during the latter 6 years of the study (1987 to 1992). The ejaculation rate of patients undergoing a nerve sparing procedure was 98%, which reflects the increase in experience gained with the technique of nerve sparing modified unilateral dissection for early stage testicular cancer. This study reinforces the view that primary retroperitoneal lymph node dissection is an operation with minimal morbidity and no long-term effects. Furthermore, this study serves as the basis for cost-benefit and risk-benefit analyses of primary retroperitoneal lymph node dissection in low stage testicular cancer, which can be set against surveillance and primary chemotherapy programs.

Initial success with nerve sparing retroperitoneal lymph node dissections in patients with low stage nonseminomatous germ cell tumors of the testis has led to the application of these techniques to a select group of 40 patients treated after chemotherapy at our institution between March 1988 and November 1991. A minimum 1-year followup was available for 38 patients. There have been no abdominal relapses, and 34 of the 38 patients report normal ejaculation postoperatively. Nerve sparing techniques are applicable to select patients undergoing retroperitoneal lymph node dissection after primary chemotherapy for metastatic disease without increasing the chance of local recurrence. Emission and ejaculation are preserved in the majority of patients.

Iatrogenic ascites is an uncommon complication of surgery of the retroperitoneum, the base of the mesentery or mediastinum. We treated 18 patients with chylous ascites occurring after retroperitoneal dissection for testicular cancer. Patients were diagnosed by paracentesis or on clinical grounds (increasing abdominal girth). Of interest, 6 patients underwent resection of the inferior vena cava as part of the procedure, and this appears to be a high risk group for this complication. Management options include dietary restriction of fat, administration of medium chain triglycerides and diuretics, hyperalimentation, peritoneovenous shunt or surgery. The majority of patients were managed successfully by dietary treatment.

Results with primary retroperitoneal lymphadenectomy in 464 patients with clinical stage A nonseminomatous germ cell testis cancer (1965 to 1989) were reviewed. The false-negative staging error by clinical methods remains at 30%. The relapse rate in pathological stage A cancer patients was 11% (37 of 323), with 2 deaths. For pathological stage B disease 64% of the patients were cured by retroperitoneal lymphadenectomy alone. With modern adjuvant chemotherapy no stage B tumor relapsed since 1979 and the survival rate was 100%. For all 25 years (464 patients) the relapse rate was 14% and the survival rate was 98.9% (3 cancer and 2 noncancer deaths). Because these results are based on preoperative clinical staging, they are directly comparable with series using radiotherapy or surveillance.

A total of 42 patients underwent inferior vena caval resection (40) or intraluminal tumor thrombectomy (2) during retroperitoneal lymph node dissection for bulky abdominal metastatic nonseminomatous germ cell cancer (7% of all post-chemotherapy retroperitoneal lymph node dissection cases). The 3 indications for vena caval resection included tumor clearance (38%), vena caval scar occlusion (14%) and vena caval tumor thrombus (48%). En bloc vena caval resection to achieve tumor clearance was justified by subsequent nodal pathology (cancer in 63% of the specimens and teratoma in 31%). Vena caval resection in the presence of scar occlusion was de facto required by virtue of its incorporation in the specimen. Vena caval resection or thrombectomy is indicated for intraluminal tumor thrombus because thrombus pathology (cancer 35%, teratoma 45% and fibrosis 20%) reflected nodal pathology in 71% of the patients with cancer, 78% with teratoma and 100% with fibrosis. The complications of vena caval resection were generally transitory. The 71% survival rate justifies this intensive surgical approach because these patients had exhausted all chemotherapy options.

The feasibility of sparing postganglionic fibers of lumbar sympathetic nerves during the course of retroperitoneal lymphadenectomy has been investigated at our university medical center beginning in 1978. We selected 75 patients for nerve-sparing retroperitoneal lymphadenectomy in an effort to preserve ejaculatory function postoperatively. This cohort of patients was selected on the basis of clinical stage. Of the 75 patients 73 had clinical stage I disease. However, 14 of these 73 patients had pathological stage II cancer. No patient was treated with adjuvant chemotherapy after nerve-sparing retroperitoneal lymphadenectomy. Of these 14 patients with pathological stage II disease 4 had relapse: 1 with proved retroperitoneal recurrence, and 3 with serological elevations of tumor markers and questionable clinical findings as to anatomical site of relapse. All 4 patients are free of disease after chemotherapy and/or surgical (1) rescue. There were no local recurrences in the 61 patients with negative nodes. All 75 patients ejaculate and had no evidence of disease more than 2 years after nerve-sparing retroperitoneal lymphadenectomy. It is clear that nerve-sparing retroperitoneal lymphadenectomy is a feasible technique. As noted, it can even be applied to selected patients with low volume positive nodes, yet maintaining relapse and survival figures that are acceptable. Ejaculation is reliably preserved when this nerve-sparing technique is applied accurately in retroperitoneal lymphadenectomy.

A total of 80 patients with stage B3 or B2/C germ cell testis tumors underwent computerized tomography before and after chemotherapy. The volume and computerized tomographic density of metastatic retroperitoneal tumor were measured on all scans. The patients then underwent full bilateral retroperitoneal lymphadenectomy. The change in volume and density of retroperitoneal disease was correlated with the histological type of the primary testis tumor and with the histological findings at retroperitoneal lymphadenectomy. In all 15 patients (100 per cent) without teratomatous elements in the original tumor and who had a greater than 90 per cent decrease in the volume of retroperitoneal masses as a response to systemic chemotherapy no teratoma or active cancer was found in the surgical specimen. In contrast, 7 of 9 patients (78 per cent) with teratomatous elements in the original specimen had either teratoma or carcinoma in the retroperitoneal lymphadenectomy specimens despite having a greater than 90 per cent decrease in tumor volume. This difference was significant (p less than 0.05). These data suggest that patients with no teratomatous elements in the original specimen and a greater than 90 per cent decrease in the volume of retroperitoneal masses in response to chemotherapy can be observed carefully for signs of recurrence rather than undergoing post-chemotherapy retroperitoneal lymphadenectomy.

We report a case of leiomyosarcoma in the bladder 8 years after completion of 45 months of cyclophosphamide chemotherapy for Hodgkin's disease. One year after cystoprostatectomy a large fibroblastic tumor arose in the soft tissues of the pelvis.

We report a case of spontaneous intraperitoneal rupture of the bladder in an elderly man with severe atherosclerotic vascular disease who had widespread systemic evidence of an arterial embolic phenomenon after elective abdominal aortic aneurysm repair. Atherosclerotic plaques were identified in the vesical arteries and were believed to be the primary event responsible for spontaneous vesical perforation. The clinical presentation, diagnosis and principles of management of vesical rupture are discussed.

Immunohistochemical staining for the A, B and H blood group antigens was studied in 61 normal human ureters using monoclonal antibodies with avidin-biotin complex application. Thirty-seven of these were archival material, and 24 were processed prospectively. In 100 per cent of the prospectively processed ureters, A, B and H antigens were demonstrated corresponding to the blood type of the source. Archival material stained for A, B and H 65 per cent, 50 per cent and 100 per cent of the time, respectively. Serial sampling of prospectively processed ureters showed diminution of staining with prolongation of immersion in formalin. A characteristic staining pattern was found in ureters from patients with type B blood.

Of 8 patients who underwent delayed orchiectomy after adequate chemotherapy for metastatic testicular cancer 7 had no evidence of disease at the time of orchiectomy but 3 had residual cancer in the testis removed. The testis may be a privileged sanctuary for malignancy even during treatment with appropriate chemotherapy. Therefore, the primary tumor should be removed in patients presenting initially with metastatic disease, even if the metastases clear with treatment.

After 2 years of mucusuria a villous adenoma of the urachus was resected from a woman by partial cystectomy and excision of the entire urachus. Convalescence was uneventful and the patient was well 12 months later. Urachal adenomas are rare, this being the sixteenth case reported. Generally, they are multilocular cystic tumors lined by columnar epithelium with a population of mucous goblet cells. Often, there is a striking resemblance to gut epithelium. Ultrastructurally, by transmission and scanning electron microscopy, the tissue resembles gut mucosa. Urinary mucus is a common and relatively specific symptom for adenomas of the lower urachus, occurring in 7 of 11 cases. Resection alone is effective therapy but care must be exercised to avoid spilling adenoma cells in the peritoneum.

We reviewed the surgical morbidity in 235 patients who underwent retroperitoneal dissection for testis cancer. Of these patients 95 had stage I, 91 had stage II and 49 had stage III disease, and underwent a secondary or primary cytoreductive operation. In the early postoperative period there were 19 major complications in 13 patients (5.5 per cent) and 19 minor complications in 15 patients (6 per cent). There also were 3 late postoperative complications, 2 of which required re-hospitalization. Therefore, the over-all rate of 38 early major and minor complications in 28 patients (11.9 per cent) compares favorably to other reports. These complications generally are treated easily an successfully. However, there is a striking increase in the incidence of operative difficulties and postoperative complications in patients with advanced disease (stage III). Of 49 such patients there were 13 complications. One patient had multiple complications. Also, all patients who had an extensive primary cytoreductive operation suffered either intraoperative or postoperative complications. It is concluded that the complication rate is related directly to the extent of the disease. Factors contributing to this rate are increased operative time, added technical demands, diminished reserve and nutritional status of these patients, and the effects of prior chemotherapy. Therefore, a new population is emerging in cases of testis cancer, namely patients with extensive disease who have had prolonged intensive chemotherapy that alters the pulmonary, hematologic an nutritional status. Specific difficulties are noted and suggestions for management are reviewed.

An infectious complication involving placement of a penile prosthesis is a disastrous event. A review of more than 300 devices placed between 1979 and 1984 at this center reveals an infectious complication rate of 8.3 per cent. Perioperative risk factors predisposing to infection included reoperation for technical failures, inadequate antibiotic coverage (specifically for Staphylococcus epidermidis), failure to perform a circumcision at the time of placement in uncircumcised patients and simultaneous placement with an artificial urinary sphincter device. No group of patients nor type of prosthesis was more susceptible to the development of a postoperative infection.

From April 1975 through May 1981, 51 patients had teratoma resected from residual disease following cisplatin-based combination chemotherapy. All patients had normal serum markers before resection of abdominal (25), lung (12), mediastinal (5), thoracoabdominal (8) or other (1) disease. Teratoma was classified as mature in 29 cases, immature in 15 or immature with nongerm cell elements in 7. Of the 51 patients 31 (61 per cent) remain free of recurrent disease, while 20 either had recurrent carcinoma (10) or teratoma (10) requiring further therapy. Nine patients died, including 1 in whom angiosarcoma developed, which was thought to be secondary to previous radiation therapy. In 4 patients the initial relapse of carcinoma developed beyond 2 years after resection. Univariate factors predicting for relapse include tumor burden, immature teratoma with nongerm cell elements and site (mediastinum), while only immature teratoma with nongerm cell elements and site predicted for survival. Patients with immature teratoma had a comparable relapse-free and over-all survival as those with mature teratoma. Using a multivariate analysis, primary tumor site at the mediastinum was the most significant adverse factor predictive for relapse and survival. This study appears to support the various pre-clinical models that demonstrate multipotential capabilities of teratoma. Complete surgical excision of teratoma remains the most effective treatment with continued close followup recommended for high risk patients (immature teratoma with nongerm cell elements, large tumor burden and primary mediastinal tumors) with resected teratoma.

Routine retroperitoneal lymph node dissection is generally not required after a complete remission is achieved by chemotherapy in initially disseminated nonseminomatous testis cancer. However, in patients with multiple relapses retroperitoneal lymph node dissection should be considered even if the retroperitoneum is unremarkable by radiographic staging. We report on a patient with initial stage III disease in whom a complete clinical response to chemotherapy was achieved multiple times but there was repeatedly re-seeding of the lungs from an undetected focus of nodal cancer later proved by retroperitoneal lymph node dissection. Controversies in management as well as potential mechanisms of drug resistance are discussed.

Cecoileal reservoirs were created in 29 patients. Tunneled ureteral implantations along the tenia of the cecum provided the antireflux mechanism. Plication or tapering of the terminal ileal segment along with the ileocecal valve provided the continence mechanism. The tubular configuration of the cecum was disrupted with either an ileal or sigmoid patch, or it was re-configured in a Heineke-Mikulicz type of closure to avoid bolus (unit) contractions. Short-term followup examination with excretory urography showed no upper tract obstruction. X-rays of the pouch showed no reflux and interviews revealed satisfactory continence in 93 per cent of the patients.

We encountered 7 cases of significant penile curvature after placement of an inflatable penile prosthesis. In 3 cases curvature was present preoperatively owing to Peyronie's disease and penile trauma, while in 4 it developed postoperatively owing to improper penile positioning. Curvature was straightened successfully by removal of small elliptical wedges of tunica albuginea of the corpus cavernosum from the convex surface of the curve and closing the defects created with 3-zero polydioxanone sutures. A subjectively gratifying result was achieved in each instance.