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ABSTRACT: Although technically challenging, salvage prostatectomy for radiorecurrent prostate cancer is an effective option in carefully selected patients and offers the best chance for cure and long-term survival. Alternatively, cystoprostatectomy may be indicated in some patients who have a small capacity fibrotic bladder or intractable voiding symptoms related to radiation cystitis. Good long-term results can be expected in this patient group; however, exenterative surgery in patients with locally advanced disease is associated with comparably inferior results and should not be advocated. If cystectomy is necessary, orthotopic urinary diversion can be performed safely in young motivated patients who wish to maintain a better quality of life with associated morbidity. Although the higher rate of incontinence and impotence after salvage procedures may detract from the quality of life, the impact of these long-term complications on the patient's overall well-being is less than previously believed, and most patients are satisfied with their treatment outcome and adjust well to the circumstances, accepting some increased degree of morbidity. This observation emphasizes the value of careful preoperative counseling and the discussion of treatment options and outcomes, which also should incorporate quality of life issues.
Urologic Clinics of North America 09/2001; 28(3):545-53. · 1.82 Impact Factor
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ABSTRACT: With improved surgical technique and perioperative care, the intraoperative and early postoperative complications of radical prostatectomy have decreased over the last 2 decades. Incontinence and impotence are two of the most significant long-term complications related to this procedure. Although the wide range of incontinence and impotence rates reported has been attributed to multiple factors, including the method of data collection and patient selection, it is apparent that the surgeon's experience is a significant factor, and that lower long-term morbidity can be expected from centers with more experience with radical prostatectomies. The impact of long-term complications, including urinary and sexual dysfunction, on the quality of life may be less than previously reported and should be discussed with patients.
Urologic Clinics of North America 09/2001; 28(3):639-53. · 1.82 Impact Factor
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ABSTRACT: To determine the impact of various preoperative serum prostate specific antigen (PSA) levels in the range from 0.1 to 10 ng/ml on pathological stage and disease-free survival after radical prostatectomy.
We selected a cohort of 585 patients who underwent radical prostatectomy between 1991-1996 for clinically localized prostate cancer and presented with preoperative serum PSA levels from 0.1 to 10 ng/ml.
Pathological organ-confined disease was present in 57.6% of patients. The rate of organ-confined disease decreased from an average of 85% for patients with a PSA value < 2 ng/ml, to 46.8% for patients with a PSA value > 7 ng/ml. We found statistically significant correlations between preoperative serum PSA level and overall pathological stage (P = 0.001), pathologically organ-confined disease (P = 0.001), margin positive rates (P = 0.001), extra prostatic extension (P = 0.001), and seminal vesicle invasion (P = 0.001). The overall disease-free survival rate was 87%, with a median follow up of 42.4 months. Disease free survival was significantly better for patients with PSA up to 4 ng/ml (P = 0.005).
Our data suggests that PSA detection programs should strive to detect prostate cancer in men before the PSA level rises above 7 ng/ml. In addition, since patients with a PSA level < 4 ng/ml had better disease-free survival rates than those with a PSA level between 4.1-10 ng/ml, eliminating an arbitrary cutoff of 4 ng/ml, may lead to improved disease-free survival.
The Prostate 08/2001; 48(3):136-43. · 3.48 Impact Factor
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ABSTRACT: We compared testicular position with genital phenotype in a clinical series and a literature review of androgen receptor mutations to assess the role of androgens in testicular descent.
Our clinical reports, the androgen receptor mutations database and selected literature were reviewed. Subjects with a proved androgen receptor mutation were included in our study when a female or ambiguous phenotype was present (Quigley grade 3 to 7) and testicular position was documented. Comparison among groups was done by Fisher's exact or chi-square test.
Of the 7 patients with detailed clinical records 5 had abdominal (bilateral in 4) and 2 had bilateral inguinal testes. Four patients with abdominal testes also had aberrant pelvic ligaments extending medially from the gonads. Including an additional 102 cases identified in the literature, abdominal testes were present in 52% and 3% of those with complete and partial androgen insensitivity, respectively. The incidence of abdominal testes was highest (86%) in patients with a complete female phenotype and no pubic hair (grade 7). It decreased significantly with increasing masculinization and was higher in phenotypic females diagnosed at or after (67%) than in those identified before (22%) puberty. Hernia was associated with inguinal and abdominal testes.
Testicular position correlates with genital phenotype in patients with androgen receptor mutations, supporting a major role for androgens in testicular descent. Inguinal hernia and abnormal pelvic ligaments in these individuals may partially determine testicular position but to our knowledge the role of androgen receptors, if any, in their development is unknown.
The Journal of Urology 09/2000; 164(2):497-501. · 3.75 Impact Factor
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ABSTRACT: Although the rate of positive surgical margins is higher in African-American men (AAM) than in white men (WM), the impact of this difference on survival is not clear. Furthermore, it is unknown whether there are racial differences in the distribution of the positive surgical margins after radical retropubic prostatectomy (RRP). We investigated the differences between AAM and WM in terms of the site and multifocality of the positive surgical margins and their effect on disease-free survival (DFS) following RRP.
Between January 1991 and December 1995, 493 patients (288 WM and 205 AAM) were treated with RRP as monotherapy. Positive surgical margins were observed in 179 patients (86 WM and 93 AAM). Patients were divided in two groups: group 1 = WM and group 2 = AAM. The incidence and location of the positive surgical margins and their correlation with DFS were determined and compared.
Overall, AAM had a higher rate of positive surgical margins than WM (48% versus 33%, respectively, P = 0.001). There was no significant difference in the frequency of multifocality of the positive margins (P = 0.4). Positive surgical margins were located significantly more often at the base in AAM (P = 0.015); however, the location of the positive surgical margins did not impact on DFS between groups. In those with multifocal positive surgical margins, AAM had a worse DFS compared with WM (P = 0.03).
Race is an independent prognostic factor for DFS in patients with positive surgical margins. There were no differences in DFS between WM and AAM based on the margin location. In WM, prognostic factors for DFS in those with positive surgical margins were preoperative serum prostate-specific antigen, Gleason score, and pathologic stage. Conversely, in AAM none of these parameters were significant predictors of failure.
Urology 07/2000; 55(6):899-903. · 2.43 Impact Factor
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ABSTRACT: Hemostasis represents a challenge when performing laparoscopic partial nephrectomy. Hydro-Jet cutting is an advanced technology that has been used to create an ultra-coherent water force that functions like a sharp knife. In the surgical field, it has mainly been used for liver surgery and initial clinical experience with laparoscopic cholecystectomies has been favorable. This technique allowed selective parenchymal cutting with preservation of vessels and bile ducts. We describe a novel Hydro-Jet assisted dissection technique for laparoscopic partial nephrectomy in a porcine model.
Ten partial nephrectomies were performed in 5 pigs using a Muritz 1000 (Euromed Medizintechnik, A. Pein, Schwerin, Germany) Hydro-Jet generator. A thin stream of ultra coherent fluid is forced at a high velocity through a small nozzle. A modified probe allows both blunt dissection concomitantly with high-pressure water application. Coagulation can be applied via a bipolar thermoapplicator as needed.
Laparoscopic partial nephrectomy was successful in all animals. Water-jet cutting through the parenchyma was virtually bloodless and preserved the vasculature and the collecting system. The vessels were then ligated or coagulated under direct vision. The continuous water flow established a bloodless operating field and a clear view for the surgeon. The mean dissection time and warm ischemia time were 45+/-9 and 17+/-3 minutes, respectively.
This preliminary study supports the suitability of this technique for laparoscopic partial nephrectomy to improve hemostasis. The improved anatomical dissection and hemostasis may further decrease morbidity and operative time. Further studies are underway to compare this technique with laser coagulation for laparoscopic partial nephrectomy.
The Journal of Urology 04/2000; 163(3):1005-8. · 3.75 Impact Factor
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ABSTRACT: Although hematuria has been reported in children with Klippel-Trenaunay syndrome, it is a rare presentation in the adult population. Two cases of massive hematuria in adults with Klippel-Trenaunay syndrome are reported here. A unique feature was venous malformations of the bladder which were responsible for massive recurrent bleeding in 1 patient. The clinical presentation and management are discussed. Conservative endoscopic and arteriographic control seems to be appropriate as initial management in these patients.
Urologia Internationalis 02/2000; 64(4):226-8. · 0.99 Impact Factor
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ABSTRACT: Ileal and sigmoid augmentation are equally effective at increasing bladder capacity and compliance. Therefore, knowledge of the incidence of major complications, including perforation, small bowel obstruction (SBO), anastomotic complications, calculus formation, and indications for revision may be useful in choosing the ideal segment. We compared the complications of ileocystoplasty and two types of sigmoidocystoplasty that required reoperative surgery.
Between 1981 and 1997, 158 patients with a mean age of 11 years (range 2 to 25) underwent augmentation cystoplasty. Ileum or sigmoid colon was used in 133 patients, who were the subjects of this study. The mean follow-up was 64 months (range 6 to 185). Indications included neurogenic bladder (n = 100), bladder exstrophy (n = 12), cloacal exstrophy (n = 6), posterior urethral valves (n = 3), and miscellaneous (n = 12). Ileum was used in 65 patients and sigmoid colon in 68. Of these, 48 underwent conventional colocystoplasty and 20 seromuscular colocystoplasty lined with urothelium (SCLU). Seventy-nine percent required additional procedures to achieve continence or facilitate catheterization, which included bladder neck procedures in 56% or continent stomas alone in 23%.
There were no deaths or complications of bowel anastomosis. Overall, continence was achieved in 95%. Spontaneous bladder perforation was highest in patients with neurogenic bladder. Calculi developed more frequently in patients with continent stomas (P = 0.04) and in patients with bladder/cloacal exstrophy (32%) than in patients with neurogenic bladder (P = 0.01). Additional procedures and route of catheterization did not increase the risk of perforation. One patient with SCLU with known hypercalciuria developed bladder calculi.
Sigmoid colon showed a trend of a lower rate of SBO with no difference in perforation or stone formation compared with ileum. Primary diagnoses of bladder or cloacal exstrophy and continent stomas are risk factors for the development of calculi. SCLU has a low rate of surgical complications and no incidence of perforation or SBO thus far; therefore, we advocate the use of SCLU when feasible, and sigmoid as the preferred bowel segment for augmentation cystoplasty.
Urology 02/2000; 55(1):123-8. · 2.43 Impact Factor
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ABSTRACT: The Hydro-Jet technique has been used to cut various industrial materials. In the medical field, this technique has been successfully used for selective dissection of the parenchyma of organs such as the liver. Recently, this technique was successfully used for laparoscopic cholecystectomy in humans. We developed a new Hydro-Jet probe and a technique of Hydro-Jet dissection during laparoscopic nephrectomy (LN) in a porcine model and compared the results with those of conventional laparoscopy.
Fourteen pigs underwent unilateral LN using the Hydro-Jet and a conventional LN on the contralateral side. A Muritz 1000 Hydro-Jet generator was used. An adjustable water pressure gauge allowed manual control up to a maximum of 30 atm, and coagulation was applied by way of a bipolar thermoapplicator. The bent end of the probe allowed both blunt dissection and concomitant high-pressure water application. Results were compared with regard to ease of anatomic dissection, complications, and operative time between the two techniques.
LN was successful in all animals with no conversion to open surgery. The dissector allowed anatomic planes to be created in a relatively bloodless field, and continuous water flow allowed a clear view for the operator. The high-pressure stream resulted in excellent dissection of adventitial and soft tissue adjacent to vascular structures, with complete preservation of vessels and ureter for selective ligation. The dissection time was shortened (mean 27 minutes for the Hydro-Jet versus 40 minutes for the conventional technique).
To our knowledge, we describe the first report of Hydro-Jet dissection for LN as an alternative to the conventional technique. The improved anatomic dissection may decrease complications. Moreover, shorter operating times were achieved, which may result in cost savings. Further studies in humans are necessary to investigate this technique.
Urology 01/2000; 54(6):964-7. · 2.43 Impact Factor
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ABSTRACT: Membrane type 1-matrix metalloproteinase (MT1-MMP) is a known activator of latent MMP-2 (pro-MMP-2), and increased MMP-2 expression has been associated with tumor aggressiveness in prostate cancer. However, expression of MT1-MMP in human prostate tissue has not been described. We investigated the expression and immunolocalization of MT1-MMP and MMP-2 in the epithelial components of benign prostate epithelium, high-grade prostatic intraepithelial neoplasia (HGPIN), and prostate cancer. Tissue sections from the peripheral zone of 50 prostates (radical prostatectomy specimens) were chosen based on their containing benign glands, HGPIN, and prostate cancer glands. All 50 sections were immunostained for MT1-MMP and MMP-2 and were evaluated for staining pattern, uniformity, and intensity. Western blotting and gelatin zymography were done to confirm expression of MT1-MMP and activity of MMP-2, respectively. Comparisons were made between benign epithelium, HGPIN, and cancer. In benign glands, basal cells (BCs) uniformly stained intensely for MT1-MMP, whereas secretory cells (SCs) were rarely positive (P < 0.0001). Conversely in HGPIN, SCs showed consistent cytoplasmic staining (P < 0.0001). In cancer cells, staining was heterogeneous and varied from no staining to very intense staining in select glands. MMP-2 in normal tissue stained both BCs and the apical region of SCs, whereas in HGPIN, staining was observed in the SC in a predominantly cytoplasmic pattern. Similar to MT1-MMP, staining in cancer tissue for MMP-2 was heterogeneous; however, there was a significant association between the pattern of MMP-2 and MT1-MMP staining within the epithelial components of the cancer glands in individual specimens (P < 0.001). Finally, MMP-2 and MT1-MMP were confirmed to be expressed in the prostate tissues by gelatin zymography and Western blotting. In conclusion, we found that consistent changes in localization and intracellular distribution of MMP-2 and MT1-MMP were associated with the transition from benign prostate epithelium to HGPIN, suggesting that regulation of these enzymes is altered during the earliest stages of prostate cancer.
Clinical Cancer Research 01/2000; 5(12):4105-10. · 7.74 Impact Factor
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ABSTRACT: To assess the role of clinical parameters and pathologic stage in predicting a positive vesicourethral anastomosis (VUA) biopsy in patients with a rising prostate-specific antigen (PSA) level after radical prostatectomy.
Forty-five patients were referred for a rising PSA level after radical prostatectomy. Transrectal ultrasound evaluation included visualization of the VUA and VUA quadrant biopsies. The rate of positive biopsies (per core and per patient) was correlated with race, PSA level, and the radical prostatectomy pathologic stage.
Overall, 53% of patients had a positive biopsy. In multivariate analysis, the dominant independent and synergistic clinical parameters determining positive biopsy rates were a PSA greater than 1 ng/mL at the time of biopsy and the pathologic stage (P = 0.04 and P = 0.02, respectively). Using a PSA cutoff point of 1.0 ng/mL, those patients with organ-confined disease and a PSA of 1.0 ng/mL or less showed no positive cancer cores (low-risk group). Conversely, 89% of patients with extraprostatic extension and a PSA greater than 1.0 ng/mL had a positive biopsy (P <0.01) (high-risk group). Patients with organ-confined disease and a PSA greater than 1.0 ng/mL or extraprostatic extension and a PSA 1.0 ng/mL or less (intermediate-risk group) had a significantly higher chance of having residual cancer than the low-risk group (P <0.025).
The PSA level at the time of biopsy and the pathologic stage of the radical prostatectomy specimen were the strongest determinants of a positive biopsy. A combination of PSA and pathologic stage is useful for decisions regarding VUA biopsy. Patients with organ-confined disease and a PSA of 1.0 ng/mL or less do not appear to benefit from a VUA biopsy, and patients with extraprostatic extension and a PSA greater than 1.0 ng/mL have such a high probability (89%) of local recurrence at the VUA that biopsy may be unnecessary. It appears that VUA biopsy can be restricted to those patients with an intermediate risk (organ-confined disease with PSA greater than 1 ng/mL or extraprostatic extension with a PSA less than 1 ng/mL).
Urology 12/1999; 54(6):1044-8. · 2.43 Impact Factor
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ABSTRACT: The management of extravesical ureterocele is controversial. Heminephrectomy and recently recommended primary incision or puncture have high reoperation rates. We reviewed and compared the long-term results of these procedures with those of primary lower tract reconstruction for ureterocele.
We reviewed the records of 106 children with ureterocele treated between 1979 and 1997. Followup was available in 99 patients, including 72 with extravesical and 27 with intravesical ureterocele. Patients with extravesical ureterocele were divided based on initial management into group 1-13 who underwent transurethral incision or puncture, group 2-41 who underwent an upper tract approach, including partial or complete nephrectomy with partial ureterectomy or ureteroureterostomy and group 3-18 who underwent complete reconstruction, including ureterocelectomy and ureteral reconstruction with or without upper tract surgery.
Overall the reoperation rate in patients with intravesical ureterocele was 22% and 23% in those treated with initial endoscopic incision or puncture. In patients with extravesical ureterocele the reoperation rate was 100, 41 and 0% in groups 1 to 3, respectively. Differences in followup (overall mean 6 years) and the incidence of preoperative reflux in the 3 groups were not statistically significant. In group 2, the reoperation rate in patients with versus without preoperative reflux was 57 versus 20% (p = 0.08). Of the 25 prenatally diagnosed patients urinary tract infection developed preoperatively in 3 (12%) at ages 2, 3, and 6 months, respectively. Mean age at the time of the initial operation in all prenatally diagnosed patients was 3.1 months (range 5 days to 11 months).
Complete reconstruction appears to be safe and highly effective even in infancy for treating extravesical ureterocele. Although the primary upper tract approach is associated with a significantly higher reoperation rate, it is a favorable alternative in patients with no preoperative reflux. However, while transurethral decompression is effective in the majority of patients with intravesical ureterocele, it is not definitive therapy for extravesical ureterocele and it should have a limited role in initial management.
The Journal of Urology 10/1999; 162(3 Pt 2):1072-6. · 3.75 Impact Factor
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ABSTRACT: The advisability of early ureteral reimplantation in neonates and infants is controversial and to our knowledge long-term results are not available. We evaluated long-term voiding function after ureteral reimplantation in infancy.
Between 1984 and 1993, 32 children underwent ureteral reimplantation in year 1 of life at our institution. Long-term results were evaluated in regard to surgical outcome, voiding function, urinary tract infection and the need for prophylaxis. Analysis of voiding function included family interviews, uroflowmetry and post-void residual urine measurement.
Complete long-term data were available in 14 girls and 7 boys. The diagnosis was primary bilateral and unilateral vesicoureteral reflux, and ureterovesical junction obstruction in 11, 4 and 6 cases, respectively. Of the 26 refluxing renal units overall disease was grade II in 3, III in 6 and IV to V in 17. Patient age at surgery was 0.6 to 12 months (mean 5.4) and followup was 5 to 13 years (mean 9.5). Tapered reimplantation was performed in 8 renal units using excisional or infolding in 5 and 3, respectively. There were no complications in 19 patients (94%), while 2 had postoperative reflux for which 1 underwent reoperation. In 13 patients voiding habits were normal, while 8 reported infrequent voiding (3 or fewer voids daily). In 19 of the 20 patients tested voided volume was appropriate, and the flow rate of 10.8 to 52.7 cc per second (mean 20.9) and post-void residual urine volume of 0 to 40 cc (mean 11) were considered normal. One patient with normal uroflowmetry had incomplete vesical emptying.
Early reimplantation may result in a high technical success rate and low postoperative morbidity in infants. After long-term followup infrequent voiding was common but noninvasive assessment of bladder function revealed no significant abnormality in the majority of patients.
The Journal of Urology 10/1999; 162(3 Pt 2):1209-12. · 3.75 Impact Factor
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ABSTRACT: Patients on clean intermittent catheterization (CIC) have a high rate of asymptomatic bacteriuria. Although prophylactic antibiotics for routine surgical procedures in patients with bacteriuria is common practice, the role of prophylaxis for invasive diagnostic procedures remains unclear. The aim of this study was to investigate the morbidity associated with urodynamic evaluation in patients with asymptomatic bacteriuria.
Routine urodynamic evaluation was performed in 69 pediatric patients (mean age 10 years). Ninety-six percent had a neurogenic bladder, and most were on CIC. Routine urine cultures were obtained at the time of the cystometrogram. Forty-six patients had positive urine cultures, and 23 patients with sterile urine served as a comparison. Patients were evaluated subjectively for symptoms of a urinary tract infection (UTI) within 1 week of the procedure. The results of the cystometrograms were compared between the patients with and without bacteriuria.
No patient developed symptomatic UTI after the urodynamic studies. Overall, 65% of the patients with and 52% of the patients without bacteriuria had adequate capacity and compliance, and there was no difference in the urodynamic findings between the patients with and without bacteriuria (P = 0.4).
Urodynamic studies were performed safely in the presence of asymptomatic bacteriuria in the present study. Therefore, routine use of urine cultures or prophylactic antibiotics before urodynamic studies in pediatric patients with a neurogenic bladder does not appear to be indicated.
Urology 09/1999; 54(2):359-61; discussion 362. · 2.43 Impact Factor
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ABSTRACT: It is unclear whether palliative endourologic or percutaneous urinary diversion in the treatment of advanced cancer provides significant improvement in quality or duration of life. The purpose of this study was to evaluate survival and performance status after endourologic palliative urinary diversion in patients with advanced malignancy and to compare the results for different malignancies.
One hundred three patients with advanced malignancies underwent palliative urinary diversion (stent or nephrostomy) between 1986 and 1997. Ninety-two patients and 11 patients had bilateral and unilateral obstruction, respectively. Indications, complications, performance status after diversion, and survival for patients with different malignancies were identified and compared. A modified Karnofsky performance scale (KPS) was used for assessment of physical performance. A scale of 0-4 was used: 0) hospitalized until death; 1) bedridden at home, severe pain despite analgesia; 2) moderate disability, moderate pain despite analgesia; 3) mild disability, pain free with medication; and 4) normal.
The mean age of patients was 68 years. The mean pre- and postoperative creatinine levels were 6 mg/dL and 3.3 mg/dL, respectively (P < 0.0001). The median survival and days of hospitalization were 112 and 45, respectively. The median postdiversion KPS score was 2 (range, 0-4), and 15% of patients never left the hospital. Overall, 51% required secondary percutaneous procedures, and 68.4% had complications (minor, 63%; major, 5.4%).
Most patients with advanced cancers had poor performance status and survival after diversion. Eighty six percent had cancer-related symptoms despite the diversion. The average survival was 5 months, 50% of which was spent in the hospital. Primary endourologic procedures had a high failure rate, and additional procedures were required.
Cancer 03/1999; 85(4):998-1003. · 4.77 Impact Factor
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The Journal of Urology 10/1998; 160(3 Pt 1):842-3. · 3.75 Impact Factor
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ABSTRACT: Penile prosthesis malfunction is associated with mechanical failure as well as with infection requiring removal of the prosthesis. We report on the 2 first cases in the literature of inflatable penile prostheses in the presence of inguinal hernia. We advocate early hernia repair in patients with inflatable penile prostheses to avoid malfunction related to hernia.
Urologia Internationalis 09/1998; 60(4):262-3. · 0.99 Impact Factor
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ABSTRACT: Intractable, therapy-resistant priapism in a patient with sickle cell disease is presented. The patient was managed with insertion of an inflatable penile prosthesis. He consequently maintained potency and remains free of priapitic episodes. To our knowledge, immediate penile prosthesis insertion for management of priapism has not been reported. We discuss the indications and advantages of this approach and review the current literature.
Urology 05/1998; 51(4):638-9. · 2.43 Impact Factor
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ABSTRACT: Children with sickle cell priapism have traditionally been treated conservatively with surgery done as a last resort. Only sparse subjective data are available on the long-term assessment of potency in these patients.
We retrospectively reviewed the charts of all pediatric patients with sickle cell priapism who presented to Children's Hospital of Michigan between 1972 and 1992, and subsequently assessed erectile capabilities subjectively by questionnaire and objectively by RigiScan.
Of the 15 patients interviewed 5 had undergone shunt procedures. The return of potency tended to vary inversely with patient age at onset and duration of priapism.
Shunts performed within 48 hours, especially in postpubertal children, seemed more likely to preserve potency.
The Journal of Urology 05/1996; 155(4):1419-23. · 3.75 Impact Factor
