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Severe hemorrhage from cyclophosphamide-induced cystitis sometimes requires aggressive open management when conventional endoscopic and intravesical therapies have failed. We present 2 patients with intractable hematuria who were managed by open cystotomy, temporary urinary diversion via external ureteral stents, and continuous postoperative bladder packing with gauze and hemostatic agents. Both patients had a dramatic improvement in the hematuria immediately postoperatively and 1 with prolonged followup has no urological disability. We suggest that this procedure be considered for management of severe hemorrhagic cystitis as an alternative to more aggressive surgical therapies, such as formal urinary diversion with cystectomy.

The mechanism of the calcium and phosphorus abnormalities associated with metastatic prostate carcinoma (CaP) is not yet understood. A tumor model was recently established in which 9479, a human CaP from a patient with prostate carcinoma-induced osteomalacia, was heterotransplanted into athymic nude mice (ANM). In the present study the effect of 9479 on ANM was evaluated. Serum calcium (Ca), phosphorus (P), parathyroid hormone (PTH), 1,25-dihydroxyvitamin D3(1,25-(OH)2D3) and urinary cAMP were measured. Ca was markedly elevated in ANM bearing 9479 vs. age-matched controls (C); the increased Ca returned to control level after tumor removal. Serum PTH was lower in 9479-bearing ANM vs. C while urinary cAMP and serum 1,25-(OH)2D3 levels were elevated. In the ANM bearing 9479, there was a decrease in serum P vs. C which returned to normal after tumor removal. Fractional P excretion was greater in 9479 animals than C. Extracts of 9479 were examined for the presence of parathyroid hormone-like bioactivity by measuring stimulation of intracellular cAMP in ROS 17/2.8 cells. Cyclic AMP stimulation which was found was shown to be inhibited by the competitive PTH antagonist [8Nle, 18Nle, 34Tyr]bPTH-(3-34) amide. These data suggest tumor induction of parathyroid hormone-like humoral modulation of calcium, phosphate and vitamin D metabolism in vivo associated with a parathyroid hormone-like prostate carcinoma product.

Transrectal prostatic ultrasonography is a potentially valuable means to evaluate the prostate of men with suspected carcinoma. We studied 118 patients with this modality before histological evaluation of the prostate (20 underwent radical prostatectomy, 75 core needle biopsy and aspiration cytology, and 23 transurethral resection of the prostate). Transrectal ultrasonography was more efficient than digital rectal examination in the staging of carcinoma of the prostate before radical prostatectomy. The value of transrectal ultrasonography in the diagnosis of prostatic cancer in men with an abnormal-feeling prostate on digital rectal examination is less certain, since 10 of 75 patients (13 per cent) in this group had a falsely positive scan. The predictive value of a scan positive for malignancy was 37 per cent. Further refinements in the technique of transrectal prostatic ultrasonography are needed to realize fully the diagnostic potential of this imaging modality.

A case report of low-grade, low-stage transitional cell cancer of the bladder with isolated metastases to the uterus, fallopian tube, and ovary is presented. The pathogenesis of such unusual behavior for a local bladder malignancy is discussed along with a review of similar cases from the literature.

Approximately 50 per cent of patients with carcinoma of the prostate have either advanced local disease or metastases at the time of diagnosis. To achieve earlier diagnosis of prostate cancer in its localized, most treatable stages, it will be necessary to develop safe, cost-effective screening tests with sufficiently high sensitivity and specificity rates. To date, no single test fulfills these criteria, although advances in the measurement of serologic markers of prostate cancer such as prostate-specific antigen, fine-needle aspiration cytology of the prostate, and transrectal prostatic ultrasonography are being widely investigated as potential screening tests.

An actuarial analysis of the risks and benefits of repeated courses of intravesical bacillus Calmette-Guerin therapy for superficial bladder cancer was performed for 100 consecutive patients treated for carcinoma in situ (29), prophylaxis against recurrent tumor (51) or residual superficial papillary tumor (21). The risk-to-benefit ratio at entry into bacillus Calmette-Guerin therapy (7 per cent risk of invasive cancer developing, 5 per cent risk of metastases and 77 per cent prospect for status free of tumor) and in patients who had failed only 1 course of bacillus Calmette-Guerin therapy (11 per cent invasive cancer, 14 per cent metastases and 58 per cent free of tumor) were highly favorable. However, among patients who had failed 2 or more courses of bacillus Calmette-Guerin therapy the risks of invasive (30 per cent) or metastatic (50 per cent) cancer developing exceeded the prospects for eradicating the superficial tumor present (20 per cent) with further therapy. The results suggest that patients who have failed 2 courses of bacillus Calmette-Guerin therapy (as given in our treatment protocol) should be considered for alternative treatment.

The effect of low osmolar, ionic and nonionic, contrast media on the cytologic features of exfoliated urothelial cells were measured in vitro and compared to those induced by standard, high osmolar radiographic contrast media. The low osmolar agents were found to induce no significant adverse effects on the cytologic features of the urothelial cells, whereas the ionic agents clearly distorted certain cytoplasmic and nuclear features. These findings may support the use of low osmolar nonionic agents for retrograde urography if posturographic cytologic studies are contemplated.

Management of vesicourethral dysfunction after a major extirpative pelvic visceral operation could be complex and difficult owing to the variety of partial and complete functional and anatomical derangements produced by the primary operation. We report our experience with 22 patients who suffered various types of vesicourethral dysfunctions after extirpative pelvic visceral surgery, 5 of whom had preoperative studies. The surgical procedures were abdominoperineal resection in 9 patients, proctocolectomy in 3, anterior resection of the rectum in 2 and radical hysterectomy in 8. All 22 patients underwent urodynamic evaluations. The abnormalities noted on the preoperative urodynamic evaluations in patients about to undergo extirpative pelvic visceral surgery suggest the need for routine preoperative assessment of the lower urinary tract for an accurate understanding of the postoperative changes.

Renal arteriovenous fistulas may be treated with radiological embolization or surgical ablation. Although recent reports in the literature have proposed embolization as the treatment of choice for renal arteriovenous fistulas, this form of therapy can be associated with significant morbidity in large arteriovenous communications. We report 3 cases of a large intrarenal arteriovenous fistula treated by transparenchymal repair. This technique offers an excellent method of obliterating the fistula without sacrificing the renal parenchyma.

Abdominoperineal resection with pelvic sidewall dissection is not uncommonly performed for treatment of bulky primary or locally recurrent rectal neoplasms. Usually, the internal iliac arteries and veins are ligated bilaterally early in the course of the procedure to reduce intraoperative blood loss and to facilitate subsequent dissection of the pelvic sidewalls. No complications related to bilateral internal iliac artery ligation in this setting have been described previously. In this report, profound vesical and perineal necrosis after bilateral internal iliac artery ligation occurred in a female patient operated on for recurrent rectal cancer. If the internal iliac artery is ligated below the take-off of the gluteal vessels, perineal necrosis can be prevented.

Intravesical alum irrigation is reported to be an effective and relatively safe means of controlling severe urinary hemorrhage. We describe a patient who experienced severe encephalopathy, metabolic acidosis and unexplained coagulopathy while receiving continuous intravesical alum irrigation. The serum aluminum level was elevated. The probable role of alum absorption from the bladder as the etiology of the encephalopathy and metabolic abnormalities, as well as the pathophysiology of aluminum metabolism are discussed. Guidelines for the use of intravesical alum irrigation in patients at high risk for the development of these abnormalities are proposed.

We evaluated 64 patients with clinically localized prostate cancer (on the basis of rectal examination, serum acid phosphatase, bone scan and pelvic computerized tomography scan) by transrectal sonography before radical prostatectomy. Of the 48 patients with histologically proved localized prostate cancer sonography overstaged the disease in 5 (10%) and correctly staged it in 43 (90%). All overstaged cancer patients were scanned after either prostatic biopsy (4) or transurethral prostatectomy (1) established the diagnosis of prostate cancer. Of the 16 patients with histologically proved, locally advanced prostate cancer (that is extracapsular extension and/or seminal vesicle invasion) sonography understaged the disease in 10 (62%) and correctly staged the disease in 6 (38%). These data suggest that sonography is associated with considerable staging errors when used to evaluate men with clinically localized prostate cancer.

Indwelling ureteral stents are a useful addition to the urologic armamentarium. The current double-J ureteral stent offers the advantages of ease of endoscopic insertion, exceptional patient tolerance and improved resistance to incrustation. We used these stents in 87 patients: to bypass obstruction in 57, as an adjunct to complicated upper tract surgery in 15, as initial treatment of upper urinary fistulas in 10 and for miscellaneous reasons in 5. The majority of the stents were placed endoscopically (58 per cent) and under local anesthesia (54 per cent). Half of the urinary fistulas healed without an operation and none of the patients treated with stents for malignant obstruction was hospitalized for more than 4 days. The stents were changed easily on an outpatient basis under local anesthesia and patient tolerance was excellent. When used as adjuncts to open procedures the stents frequently allowed for shorter hospital stay, since postoperative urinary drainage was decreased markedly. Of the 136 stents used in our series 13 became obstructed, usually after they were indwelling for more than 8 weeks. Irritative symptoms were noted in only 6 patients and responded well to pharmacologic therapy. We have found the double-J ureteral stent useful and reliable in patients with ureteral obstruction, as adjuncts to genitourinary surgery in selected instances and as internal diversion for upper urinary tract fistulas.

From 1975 through 1983, 69 patients with hereditary angioneurotic edema were treated with danazol, a semisynthetic anabolic steroid. Hematuria developed in 13 of these patients (19 per cent). Careful evaluation of the genitourinary tract showed the presence of a distinct form of hemorrhagic cystitis in 10 patients. Clinically, 9 patients presented with microscopic and 1 with intermittent gross hematuria. Irritative bladder symptoms were reported by 2 patients. Neither the dose nor duration of danazol therapy correlated with the severity of the cystoscopic or pathological findings. Cystoscopically, a rather nonspecific pattern of erythema, submucosal telangiectasia and neovascularity was observed. Histopathologically, bladder biopsy typically showed numerous dilated submucosal vessels with hemorrhage, mucosal ulceration and occasional inflammatory cells. These changes regressed in all but 1 patient when danazol therapy was discontinued. Further studies are needed to elucidate the role of danazol itself or of the danazol-hereditary angioneurotic edema interaction in the pathogenesis of these abnormalities.

The five alpha-reductase inhibitors are a newly developed family of compounds that block the intracellular conversion of testosterone (T) to dihydrotestosterone (DHT). 17-beta-N, N-Diethylcarbamoyl-4-methyl-4-aza-5-alpha-androstan-3-one (4MA), the most widely studied of these compounds, has been shown to inhibit the androgen-dependent growth of both normal animal tissues and of the Noble tumor, an experimental, hormone-responsive rat neoplasm. 4MA has been found to inhibit androgen-dependent growth without altering plasma levels of T or DHT. In the present study, we assessed the efficacy of 4MA in inhibiting the growth of PC-82 and R198, human androgen-responsive genitourinary malignancies. In the first experiment, 4MA was administered subcutaneously at a dose of 6 mg/kg/day to castrated and hormonally replaced groups of PC-82-bearing male athymic nude mice. 4MA therapy when compared to control therapy caused significant PC-82 growth inhibition in three different groups of hormonally replaced castrated mice: physiologic T-replaced (P less than .001), supraphysiologic T replaced (P less than .001), and supraphysiologic T and DHT replaced (P less than .001). There was no difference between the post therapy plasma levels of T or DHT in the control-treated and 4MA-treated mice. In the second experiment, the effect of 4MA (6 mg/kg/day S.Q.) was compared to that of castration and control therapy on the growth of R198. Both castration and 4MA therapy effectively inhibited R198 growth when compared to control therapy (P = .01 and .02, respectively), but there was no difference in the degree of growth inhibition seen with 4MA or castration (P = .45). Castration and 4MA-therapy significantly lowered plasma T levels when compared to control therapy; castration also significantly lowered plasma DHT levels, while 4MA and control therapy did not. These studies suggest that 4MA is effective in inhibiting the growth of human androgen-responsive tumors grown in athymic nude mice and that further studies with other 5 alpha-reductase inhibitors are indicated.

Computed tomographic imaging was utilized to diagnose ureteral obstruction caused by a sloughed papilla in a patient with renal papillary necrosis and distal renal tubular acidosis.

Review of the postoperative course of seven patients who underwent retroperitoneal lymph node dissection (RPLND) for staging of testicular carcinoma revealed an unexplained tachycardia that was persistent for several days. Postoperative catecholamine determinations from three subsequent patients subjected to RPLND revealed dramatic increases in epinephrine, norepinephrine, dopamine, and total catecholamines. Since cardiac acceleration is mediated almost exclusively by sympathetic stimulation, this finding may explain the postoperative tachycardia observed in these patients.