Does prostate transitional cell carcinoma preclude orthotopic bladder reconstruction after radical cystoprostatectomy for bladder cancer?

PURPOSE: We determined if urethral preservation and orthotopic bladder replacement in patients with transitional cell carcinoma within the prostatic urethra or prostate placed these patients at risk for urethral recurrence or death. MATERIALS AND METHODS: The clinical course of all patients undergoing urethral preservation and orthotopic bladder replacement was reviewed. The urethra was sacrificed only if the distal prostatic urethral margin was positive for transitional cell carcinoma. The pathological T stage and the grade of the primary malignancy, local recurrence, site of recurrence (urethral, pelvic, distant) and death were documented. RESULTS: Of 81 patients 70 were evaluable (June 1996) with a mean followup of 35 months. Of the 70 patients 48 were alive without evidence of disease for a mean of 38 months (range 8 to 107) and 5 died without evidence of disease. Eight of these 53 patients (15%) had prostatic involvement (carcinoma in situ in 6, intraductal carcinoma in 1 and stromal invasive transitional cell carcinoma in 1). Of the 70 patients 17 had disease recurrence (13 died of disease and 4 are alive, 1 of whom had urethral recurrence without initial prostatic transitional cell carcinoma). Of the 17 patients (35%) 6 had transitional cell carcinoma prostatic involvement (carcinoma in situ in 4 and stromal invasion in 2), and 5 of these 6 died, none with or of urethral recurrence but of the primary bladder pathology. Of these 5 patients 1 had stromal invasive transitional cell carcinoma of the prostate and experienced a bulbar urethra recurrence at 1 month and a pelvic recurrence at 3 months, and died at 5 months. Death was not secondary to the urethral recurrence. Thus, of the 14 patients who had prostatic transitional cell carcinoma, only 1 had urethral recurrence (7%), and this recurrence did not present as the cause of death. CONCLUSIONS: The guidelines for urethral resection can be relaxed, increasing the opportunities for orthotopic reconstruction, without placing the patients at increased risk for death of transitional cell carcinoma.     

Conservative surgical therapy for penile and urethral carcinoma

OBJECTIVES: Invasive penile and urethral tumors are traditionally treated with aggressive excision that requires involved organ and adjacent organ sacrifice. An alternative approach seeks to completely excise the tumor with adequate margins while preserving form and function of the organ. We present 6 patients who underwent such organ-sparing surgery. METHODS: Six selected cases (4 penile and 2 urethral) are presented with operative photographs and pertinent data. RESULTS: Three distal tumors of the penis were treated with excision limited to the glans with histopathologic findings of verrucous carcinoma, melanoma, and angiosarcoma. One patient with squamous cell carcinoma of the distal shaft refused partial penectomy and underwent a local wedge resection. A patient with locally advanced bulbourethral transitional cell carcinoma (TCC) refused cystourethrectomy and underwent an anterior urethrectomy and perineal urethrostomy. A 48-year-old woman with an adenocarcinoma contained in a very distal urethral diverticulum underwent simple diverticulectomy and excision of distal urethra. Postoperative voiding and sexual function were well preserved. Follow-up was 12 to 48 months. The patient with angiosarcoma died of lung metastases at 48 months with no local disease, and the patient with bulbourethral TCC developed pelvic disease at 12 months with no local recurrence and died of metastases at 25 months. CONCLUSIONS: Organ-sparing surgery is appropriate in selected patients on the basis of stage and location, high risk of distant failure, and patient disposition. Close follow-up is necessary. Comanagement with reconstructive and oncologic specialists optimizes results and outcomes.     

Membrano-bulbo-urethral junction stenosis. Posterior urethra obstruction due to extreme caliber disproportion in the male urethra

OBJECTIVE: Based on 4 cases of infravesical obstruction due to extreme caliber disproportion between the posterior urethra and the penile urethra, a pathophysiological mechanism for this dynamic obstruction is given and endoscopic treatment is described. SUBJECTS: Four cases of membrano-bulbo-urethral junction (MBUJ) stenosis, seen between September 1995 and April 1996, are described. Two boys had previous successful valve resection but still showed extreme ballooning of the posterior urethra. The other 2 boys showed bladder instability on urodynamics and the male variant of the spinning top urethra on voiding cystourethrography (VCUG). RESULTS: All cases were successfully treated by endoscopic incision at the 12 o'clock position of the kink between the posterior and the penile urethra which is seen when the full bladder is expressed. Disproportion in the posterior urethra, seen on VCUG, together with bad urinary flow measured on uroflowmetry raise the suspicion of MBUJ stenosis. CONCLUSION: Although rarely seen, extreme caliber disproportion in the male urethra can cause obstruction. Ballooning of the posterior urethra, caused by urethral valves, bladder instability resisted by voluntary sphincter contraction or congenital posterior urethral dilatation, creates an obstructive kink in the urethra comparable to some obstructions in ureteropelvic junction stenosis. If suspicion of such a form of obstruction arises, cystoscopy during pressure on the full bladder is mandatory in order to see the obstruction, descending as a membrane from the vault of the urethra.     

Bladder distention and pyelectasis in the male fetus: causes, comparisons, and contrasts

The objective of this paper was to determine if prenatal sonographic findings can accurately differentiate between the causes of bladder distention and pyelectasis in the male fetus. Twenty-one cases were evaluated for the presence of oligohydramnios, posterior urethral dilation, bladder wall thickening, urachal patency, cortical thinning, cortical cysts, and increased renal echogenicity. Postnatal diagnosis included posterior urethral valves (10 cases), prune belly syndrome (four cases), vesicoureteral reflux (four cases), left ureterovesical junction obstruction (one case), and nonrefluxing, nonobstructive megacystis-megaureter (two cases). Oligohydramnios was present in eight of 10 cases of posterior urethral valves and in one of four cases of prune belly syndrome. A dilated posterior urethra was noted in seven of 10 cases of posterior urethral valves and transiently in two of four cases of prune belly syndrome. Bladder wall thickening developed in all cases of posterior urethral valves and was noted in two of four patients with prune belly syndrome. A patent urachus likewise was identified in two of four cases of prune belly syndrome. The presence of oligohydramnios, progressive bladder wall thickening, and dilated posterior urethra was most suggestive of posterior urethral valves, whereas the presence of a patent urachus was most suggestive of prune belly syndrome. The presence of pyelectasis and megacystis without additional amniotic fluid, bladder, urethral, or renal abnormalities was most suggestive of vesicoureteral reflux, ureterovesical junction obstruction, or nonrefluxing, nonobstructive megacystis-megaureter. Owing to the overlap and evolution of these findings, close follow-up evaluation is recommended.     

Modified ileocolonic bladder: 5 years of experience

A total of 25 patients 17 to 78 years old (mean age 61 years) underwent bladder replacement with a modified ileocolonic bladder: 20 underwent construction of the neobladder following cystoprostatectomy for invasive bladder tumor, 4 after cystectomy for severe interstitial cystitis and 1 for undiversion. There were 21 men and 4 women. Followup ranged from 3 to 66 months. There were no perioperative deaths. The early complication (perioperative 3 months) and late complication rates were 18% and 16%, respectively. Complications included ureterocolonic anastomotic strictures in 4 ureters (3 were treated via endoscopic retrograde balloon dilation and 1 with endourological antegrade dilation), urethral strictures in 2 patients, treated by urethral dilation, pancreatitis 2 weeks postoperatively in 1 and mild hypercholoremia without concomitant acidosis in 2. One patient presented 3 years postoperatively with a left mid ureteral stone that was managed by ureteroscopic extraction. Three patients died of recurrent carcinoma (none with urethral recurrence). The daytime continence rate was 100% and the nighttime continence rate was 92%. The ureters in this modified ileocolonic bladder were placed in an anatomically correct position to resemble a trigone near the mouth of the neobladder with the left ureter uncrossed. This placement provided easy visualization and instrumentation of the upper urinary tract. No patient had vesicoureteral reflux.     

Permanent endoprostatic prostheses in patient with obstruction caused by benign hyperplasia of the prostate

Presentation of the results obtained using the intraprostatic prosthesis UroLume in 78 patients wit BPH obstruction, 69 of which presented high surgical risk (ASA IV). Mean age was 79.8 years (r: 62-93). All patients carried urethral catheters, except 4 (5.1%) who had a provisional metal coil that required replacement. Prosthesis were implanted successfully in 72 cases (93.3%). The most significant exclusion criterion was an excessive length of prostate urethra. Mean follow-up was 15.3 months (r: 3-38). Mean maximum flow at 1 year after implant was 12.7 mL/sec; mean symptoms score (I-PSS score) was 6.2 points and in most prosthesis, epithelization had taken place. Three patients required implant of another prosthesis, either during the same surgical procedure (1 case) or later due to retention or dysuria (2 cases). Due to acute urine retention (AUR) during the immediate postoperative, resection of the middle lobe was performed in one case while a second case required late resection of intraluminal hyperplastic tissue. Three patients (4.1%) had haematuria that forced hospital admission some months after the implant, and three cases (4.1%) required removal of the prosthesis; at patient's request (1 case), due to calcification (1 case) and for stress incontinence (1 case). After a follow-up of over three years, it can be concluded that the UroLume prosthesis is an effective alternative to TUR in patients at high surgical risk.     

Preservation of the anterior urethral ligamentous attachments in maintaining post-prostatectomy urinary continence: a comparative study

PURPOSE: The impact was determined on post-prostatectomy urinary incontinence of a technique preserving the anterior attachments of the proximal urethra to the posterior pubis by comparison to the results of other surgical methods. MATERIALS AND METHODS: Urinary continence in 51 patients undergoing preservation of the anterior urethral attachments was compared to that of 70 patients undergoing an anatomical prostatectomy with resection of the bladder neck, 55 patients with preservation of the bladder neck and 14 patients undergoing a dorsal vein gathering procedure. Comparisons were made for rate of total continence, time to return of continence, incidence of extra organ disease and operative blood loss. RESULTS: Total continence at 1 year was 84.3%, 89.1%, 85.7% and 100% respectively. Immediate total continence after catheter removal was seen in 25.5% after preservation of the anterior urethral attachments, 80.4% at 3 months compared to 41.4%, 50.9% and 50% at 3 months for anatomical prostatectomy with bladder neck resection, preservation and dorsal vein gathering. Clinical staging with the incidence of specimen confined disease was similar in all groups. Mean operative blood loss was 1,031 ml. for those patients undergoing anatomical prostatectomy compared to 681 ml. for those with preservation of the anterior urethral attachments. CONCLUSIONS: Preservation of the anterior urethral attachments results in improved urinary continence and lower operative blood loss without an increase in positive surgical margins.     

The natural history of condyloma in children

OBJECTIVES: To prospectively evaluate our previously established pathologic risk factors in women undergoing cystectomy for bladder cancer and to determine if these criteria identify appropriate female candidates for orthotopic diversion. METHODS: Prospective pathologic evaluation was performed on 71 consecutive female cystectomy specimens removed for primary transitional cell carcinoma of the bladder. The histologic grade, pathologic stage, presence of carcinoma in situ, number, and location of tumors were determined. In addition, final pathologic analysis of the bladder neck and proximal urethra was performed and compared with the intraoperative frozen-section analysis of the distal margin (proximal urethra). RESULTS: Tumor at the bladder neck and proximal urethra was seen in 14 (19%) and 5 (7%) cystectomy specimens, respectively. Bladder neck tumor involvement was found to be the most significant risk factor for tumor involving the urethra (P <0.001). All patients with urethral tumors demonstrated concomitant bladder neck tumors. However, more than 60% of patients with bladder neck tumors had a normal (tumor-free) proximal urethra. Furthermore, no patient with a normal bladder neck demonstrated tumor involvement of the urethra. Intraoperative frozen-section analysis of the distal surgical margin was performed on 47 patients: 45 without evidence of tumor and 2 patients with urethral tumor involvement. In all cases, the intraoperative frozen-section analysis was correctly confirmed by final permanent section. CONCLUSIONS: We prospectively demonstrate that bladder neck tumor involvement is a significant risk factor for urethral tumor involvement in women. However, despite bladder neck tumor involvement, a number of women undergoing cystectomy for bladder cancer have a normal urethra and may be candidates for orthotopic diversion. Furthermore, our data demonstrate that intraoperative frozen-section analysis of the distal surgical margin accurately and reliably evaluates the proximal urethra and currently determines which patients undergo orthotopic diversion at our institution.     

Decreased sensitivity in the membranous urethra after orthotopic ileal bladder substitute

PURPOSE: The effect of cystoprostatectomy with orthotopic substitution on membranous urethral sensation and subsequent urinary continence is unknown. We determined the sensory threshold for electrical stimulation of the membranous urethra and correlated it with continence, nerve sparing surgical technique and potency. MATERIALS AND METHODS: The sensory threshold was measured in a control group of 35 men before radical prostatectomy or cystoprostatectomy and in 47 men after cystoprostatectomy and ileal bladder substitution. RESULTS: The sensory threshold of the membranous urethra was 9+/-2 in the control group compared to 27+/-11 mA. in the postoperative group (p<0.001). Patients with daytime continence had a threshold of 24+/-9 compared to 39+/-10 mA. in incontinent patients (p<0.001). We were unable to show any correlation between the sensory threshold in patients with (25+/-10 mA.) and without (31+/-11 mA.) attempted nerve sparing surgery (p = 0.1) nor between potent (25+/-12 mA.) and impotent (27+/-11 mA.) patients (p = 0.4). CONCLUSIONS: Sensitivity in the membranous urethra decreased in patients after cystoprostatectomy and ileal bladder substitution. Urethral sensitivity in the sphincter area was better in continent than incontinent patients. Since we were unable to find any correlation between the sensory threshold and nerve sparing surgery or potency, it may be assumed that at least part of the sensory fibers to the membranous urethra pass through the pudendal nerve and/or the intrapelvic extrapudendal nerve fibers.     

Diverticula of the female urethra

OBJECTIVES: The contribution of ultrasonography to pretreatment morphological assessment of strictures of the anterior urethra and assessment of the risk of recurrence after internal urethrotomy. MATERIAL AND METHODS: 33 patients (16-89 years) operated by internal urethrotomy for stricture of the anterior urethra and followed for at least 6 months. Preoperative urethral ultrasonography, recording the number, length and degree of strictures and echostructure of the peristenotic fibrosis of the corpus spongiosium. RESULTS: Ultrasound visualization of all urethral strictures, with no false-positives and no false-negatives. 11 patients relapsed after a mean interval of 5.7 months (1-16 months), 22 patients did not present recurrence: mean interval: 15.5 months (6-36 months). Corpus spongiosum fibrosis associated with urethral stricture is isoechoic to the corpus spongiosum (19 cases) or hyperechoic to the corpus spongiosum (14 cases). No statistical correlation was observed between the echostructure of the fibrous tissue and the risk of recurrence after internal urethrotomy. CONCLUSION: Ultrasonography allows excellent analysis of the morphological characteristics of a stricture of the male anterior urethra. In our experience, and in contrast with the limited data of the literature, no correlation was observed between the echostructure of the peristenotic fibrosis and the risk of recurrence after internal urethrotomy.     

Anatomical anterior exenteration with urethral and vaginal preservation: illustrated surgical method

PURPOSE: We describe in detail a method for urethral and vaginal preservation in women considering orthotopic urinary tract reconstruction after bladder removal. MATERIALS AND METHODS: We retrospectively reviewed the pathological reports of patients treated with anterior exenteration at our hospital between 1984 and 1997 for specific evidence of urethral, vaginal, cervical or uterine involvement by the primary bladder tumor. Based on our findings we describe our approach to anterior exenteration in 6 patients. RESULTS: A total of 46 patients were treated at our center with en bloc anterior exenteration and pelvic lymphadenectomy for primary bladder cancer between 1984 and 1997. In 7 patients (15%) pathological review of the surgical specimen documented urethral involvement by the primary tumor. In 1 patient (2%) microscopic evidence of tumor was identified in the cervix and 1 (2%) had tumor extension to the vagina documented in the final pathology report. CONCLUSIONS: The observed rates of vaginal and urethral involvement agree with those reported by others, and suggest that in the majority of women treated with anterior exenteration sacrifice of the urethra and vagina is usually not necessary from an oncological perspective. This procedure is particularly appropriate in women concerned with postoperative sexual function and those considering orthotopic reconstruction of the lower urinary tract after exenterative bladder cancer surgery.     

Trace elements in egg contents and egg shells of slider turtles (Trachemys scripta) from the Savannah River Site

OBJECTIVES: Stricture of the vesico-urethral anastomosis is a well-known complication after radical prostatectomy. Dilatation, stricture incision or resection have been proposed for endoscopic treatment. METHODS: In a retrospective study of 340 patients with prostatic cancer who underwent a radical retropubic prostatectomy from 1988 until 1996, we looked at the incidence of anastomotic strictures. RESULTS: An anastomotic stricture was found in 24 cases (7%) requiring endoscopic treatment. Based on prospective X-ray studies, we were able to show that the site of stricture is located below the bladder neck musculature in most cases well above the distal urethral sphincter and pelvic floor. No continence problems were encountered following structure resection in a follow-up of 12-72 months determined by a questionnaire and pad test. CONCLUSION: The transurethral resection of anastomotic stricture allows for a rather generous tissue resection, which is preferable to incision or dilatation in our hands.     

Transitional carcinomas of the urinary tract: synchronous and metachronous lesions

OBJECTIVE: The urothelium is a pseudostratified cylindrical epithelium that lines the calices, renal pelvis, urethers, bladder, part of the urethra and part of the prostate ducts. Transitional cell carcinoma (TCC) is a malignant neoplasia that can appear in any site where urothelium is present, being the bladder the most frequently affected organ. We performed an analysis of our experience and conducted a literature-based metanalysis to evaluate the coexistence of tumoral lesions at different locations in the urinary tract. MATERIAL AND METHODS: Between 1983 and 1993, 397 patients with TCC lesions involving the upper urinary tract (UUT), bladder, urethra or prostate, were diagnosed and treated. Coexistence, either synchronic or metachronic, of several lesions in different sites of the urinary tract was considered as a multiple tumor. RESULTS: Overall, 440 tumors were diagnosed in 397 patients. A single lesion appeared in 360 patients, while 37 presented multiple locations with a total of 79 tumors. The lesions were located at the following levels: 17 renal, 21 uretheral, 372 vesical, 13 in the urethra and 17 in the prostate ducts. According to the location, the frequency of single lesions was: UUT 58%, bladder 91%, urethra 8% and prostate ducts 35%. Synchronic UUT and intravesical tract tumors develops in 1% and 4% of patients with bladder TCC, respectively. Two percent of vesical tumors showed metachronic relationship with UUT tumors and the same rate was seen for intravesical lesions. CONCLUSIONS: Urothelial UUT tumors have a typical nosologic entity with specific features. Their coexistence with vesical tumors is frequent. When tumors of the bladder occur after a UUT tumor the interval of highest incidence between diagnoses is 2-3 years, and there are no histological risk factors among them for prognosis. Transitional cell prostatic urethral tumors are most often secondary to histologically similar, poor prognosis, bladder tumors, and usually synchronic.     

NonHodgkin's lymphoma of the male urethra

Ten cases of malignant lymphoma of the female urethra have been reported. To our knowledge we report the first such case in a man who presented in acute urinary retention with a mass protruding from the urethral meatus. Multiple subcutaneous nodules developed over the anterior abdominal wall and a 3 x 3 cm. mass developed above the umbilicus. Wedge resection of this mass was consistent with large cell lymphoma. Treatment consisted of 2 courses of arabinoside C, doxorubicin and prednisone. Followup 6 months later showed no urethral or other recurrence. Local excision, radical excision, radiotherapy (external beam and intracavitary) and chemotherapy have been used with success in other cases.     

Urethral reconstruction by pedicled labial flap in the treatment of extensive urethral lesions after obstetrical injury. Apropos of 34 cases

Reported here is our experience with a new procedure using a pedicled labial flap for urethral reconstruction in patients treated for extensive urethral damage after obstetrical injury. From January 1992 to January 1996, 31 cases of urethral damage in African female patients, with an average age of 18-years-old were treated by pedicled labial urethroplasty. This procedure was done by using a pedicled flap obtained from the major labia. The flap was then introduced as in a tunnel beneath the vaginal epithelium reaching the damaged urethra. A variety of techniques were used: the patch to lengthen sufficiency (13 cases), or the tubularized flap following complete reconstruction of the urethra (21 cases). Good quality urine continence was obtained by using the suburethral Martius' sling procedure. In 6 cases, we combined the treatment with a colposuspension procedure. The average follow-up is 14 months (ranging from 6 to 37 months). Recovery of normal micturition with absence of urinary leak was obtained in 21/30 cases (70%). While 5 moderate failures occurred, 4 cases were considered complete failures. In view of the high success rate, the authors consider that the one-stage procedure by the use of a pedicled labial flap is a choice treatment and highly suitable procedure for the management of extensive urethral cervical damage after obstetrical injury.     

The fate of patients with locally advanced bladder cancer treated conservatively with neoadjuvant chemotherapy, extensive transurethral resection and radiotherapy: 10-year experience

PURPOSE: We assess the results of bladder preservation for infiltrating bladder cancer. The potential for neoadjuvant chemotherapy followed by extensive transurethral resection and radiotherapy was evaluated in 40 patients with T2-T4a G2-G3 bladder carcinoma. MATERIALS AND METHODS: From 1983 to 1995, 40 patients with bladder cancer underwent bladder sparing treatment, consisting of neoadjuvant chemotherapy, extensive transurethral resection and radiotherapy. Most patients had T3G3 cancer. A deep transurethral resection biopsy was performed before and after chemotherapy, and an extensive transurethral resection was repeated at the end of radiotherapy. Of the patients 30 received cisplatin and methotrexate and 10 also received vinblastine. Total dose of radiotherapy was 60 to 65 Gy. Recurrent superficial tumors were treated transurethrally. Radical cystectomy was considered for persistent or recurrent invasive disease. RESULTS: Complete response occurred in 19 patients (47.5%) after chemotherapy, and in 8 patients after transurethral resection and radiotherapy (67.5%). Within 10 years 8 responding patients (30%) had local recurrences and 3 underwent cystectomy. Of the patients 14 (35%) are alive, including 13 with no evidence of disease (mean survival 65 months), 5 died of unrelated disease and 21 (52.5%) died of distant metastases (mean survival 28 months). Of the 21 patients 14 had residual tumor after radiotherapy, 3 presented with distant metastases after vesical infiltrating recurrence and 4 had distant metastases in the absence of locoregional recurrence. In 22 patients (55%) the bladder was salvaged. Patients with complete response to chemotherapy had a low risk for recurrent infiltrating tumors and metastases. CONCLUSIONS: Complete tumor control was maintained at 5 years in more than 50% of the patients treated conservatively. Bladder salvage is feasible in select patients.     

Response to recombinant human erythropoietin in patients with myelodysplastic syndromes

OBJECTIVES: The impact of a positive surgical margin in otherwise confined prostate cancer after radical prostatectomy remains unclear. We analyzed the outcome of a large number of patients with organ-confined prostate cancer according to the presence and anatomic site of margin positivity. METHODS: We evaluated 2712 prostatectomy patients with Stage pT2N0 cancer (ie, no evidence of extra-prostatic disease, seminal vesicle or regional node involvement) and no prior therapy who were treated by radical prostatectomy between 1987 and 1995 at Mayo Clinic. A total of 697 patients (26%) had positive margins. To assess the effect of margin status in the absence of treatment, 378 patients with postoperative adjuvant therapy were not considered for the study group: the final group consisted of 2334 patients. RESULTS: Overall, 253 (58%) tumors were positive at the apex and/or urethra, 85 (19%) at the prostate base, 11 (2.5%) at the anterior prostate, and 174 (40%) at the posterior prostate; 89 (20%) had at least two margins involved and 21 (8.3%) had more than two involved. The apex/urethra was the only positive anatomic site in 183 (42%). Five-year survival free of clinical recurrence or prostate-specific antigen (PSA) biochemical failure (postoperative serum PSA of 0.2 ng/mL or more) for patients with a single positive margin was 79% for apex or urethra, 78% for anterior/posterior, and 56% for prostate base. Five-year survival free of clinical recurrence or PSA (biochemical) failure was slightly higher for those with one versus two margin-positive regions (77% versus 68%, respectively). Multivariate analysis revealed that positive surgical margins were a significant predictor of clinical recurrence and PSA (biochemical) failure (relative risk [95% confidence interval]: 1.65 [1.24, 2.18]) after controlling for Gleason grade, preoperative PSA, and deoxyribonucleic acid (DNA) ploidy. The effect of margin positivity on recurrence at a specific anatomic site (versus negative margins or positive at a different anatomic site) revealed the prostate base to be the only significant anatomic site when adjusted for grade, PSA, and ploidy. Five-year survival free of the combined clinical or PSA failure end point for those with versus those without positive margins at the prostate base was 56% versus 85%, respectively (P < 0.0001). CONCLUSIONS: Positive surgical margins are a significant predictor of recurrence in Stage pT2N0 cancer, which is independent of grade, PSA, and DNA ploidy. The impact of positive margin status on recurrence-free survival appears to be anatomic and site-specific, with prostate base positivity significantly associated with poor outcome. The benefit of adjuvant therapy based on anatomic site-specific margin positivity remains to be tested in order to optimize recurrence-free survival.     

Urethral duplication in children: surgical treatment and results

PURPOSE: Urethral duplication is a rare congenital anomaly. We report the clinical presentation, imaging findings and surgical treatment in 7 boys with incomplete sagittal duplication of the urethra. MATERIALS AND METHODS: Duplication involved hypospadias in 5 cases (group 1) and a bifid urethra with an accessory preanal tract (Y duplication) in 2 (group 2). Group 1 was treated with 1-stage urethroplasty, including marsupialization of the dorsal orthotopic urethra, ventral-to-dorsal urethrourethrostomy and penile island flap onlay repair to cover the open dorsal urethra. In contrast, group 2 was treated with 2-stage urethral reconstruction with detachment and mobilization of the accessory preanal branch in association with a scrotal tubed neourethra followed by urethroplasty, as in group 1. In all cases the dorsal penile urethra was located between the corpora cavernosa and surrounded by the tunica albuginea. RESULTS: A urethrocutaneous fistula developed in 1 of the 5 group 1 patients. In group 2, 1 patient had recurrent penoscrotal meatal stenosis after the 1-stage procedure and 1 had a urethral diverticulum with calculi at the scrotal tubed neourethra 7 years after urethral reconstruction. Six of the 7 patients now void spontaneously through a meatus located normally at the tip of the glans. The remaining patient with a neurogenic bladder is on intermittent catheterization via appendicovesicostomy due to difficult catheterization of the irregular and sensitive neourethra. CONCLUSIONS: While the ideal surgical management of urethral duplication anomalies remains uncertain, we used a combination of surgical techniques to correct this severe malformation.     

An open study on the efficacy and safety of transurethral needle ablation of the prostate in treating symptomatic benign prostatic hyperplasia: the University of Florida experience

PURPOSE: We determine the safety and efficacy of transurethral needle ablation of the prostate in patients with moderate to severe symptoms of benign prostatic hyperplasia. MATERIALS AND METHODS: Transurethral needle ablation of the prostate was performed on 45 consecutive patients. For an average prostate of 2.5 to 3 cm. long treatments were performed in 2 separate planes at 4 quadrants (2, 4, 8 and 10 o'clock positions) each. The 2 planes were 1 cm. below the bladder neck and 1 cm. proximal to the verumontanum. For prostatic urethral lengths longer than 3 cm. a treatment plane was added for each additional centimeter of prostatic urethra. The procedure was performed in 26 patients under local anesthesia using 20 cc 2% intraurethral lidocaine gel (11) or supplemented with intravenous 1.25 to 5 mg. midozolam (15). Of these patients 2 had a supplemental perineal block using a mixture of equal amounts of 15 cc 2% lidocaine without epinephrine and 0.25% bripivacaine, 10 underwent the procedure under general anesthesia, 2 had epidural and 4 had spinal anesthesia, and 3 had managed anesthesia care. Mean length of each procedure was 79 minutes (range 50 to 240). All procedures were done on an outpatient basis and patients were released on the same operative day. RESULTS: Mean prostatic volume on transrectal ultrasound was estimated at 48.1 cc (range 20 to 185). Following treatment the International Prostate Symptom Score decreased from a mean of 20.9 at baseline to 15.4 at 1 month, 16.1 at 3 months, 10.7 at 6 months and 9.9 at 1 year. The peak flow rate improved from a baseline mean of 8.3 to 13.4 at 3 months, 13.1 at 6 months and 14.9 at 1 year. The quality of life score improved from a baseline of 4.8 to 3.5, 2.2, 2.5 and 1.03 at 1, 3, 6 and 12 months, respectively. Of the 2 patients in whom the procedure failed; 1 required a bladder neck incision at 3 months and the other transurethral resection of the prostate. Foley catheters were left in place in all patients for an average of 4.85 days. CONCLUSIONS: After a followup of up to 12 months we conclude that transurethral needle ablation of the prostate is an effective treatment for symptomatic benign prostatic hyperplasia. This procedure has minimal morbidity, is less costly than conventional transurethral resection of the prostate and can be performed as an outpatient office procedure under local anesthesia in a significant number of patients.     

Changes in prostatic thickness and the location of ejaculatory ducts in autopsy prostates

OBJECTIVE: To measure prostatic thickness and the depth of ejaculatory ducts from the urethral surface to prevent ejaculatory duct damage during transurethral balloon laser thermotherapy. MATERIALS AND METHODS: In 47 prostates obtained at autopsy, the prostatic thickness and the depth of ejaculatory ducts from the urethral surface were measured in eight directions from the centre of the urethra. RESULTS: The depth of ejaculatory ducts was approximately 6 mm from the urethral surface regardless of prostatic weight. Increase in prostatic weight was associated with increase in the thickness in all directions except the posterior one; the thickness ranged from 9 to 20 mm. The posterior thickness at the level of the transition zone was 10 mm regardless of prostatic weight. CONCLUSION: When benign prostatic hypertrophy is treated transurethrally, using laser or microwave equipment, care should be taken to avoid heating the posterior region of the prostate.