Recto-cavernosal fistula after radiation for rectal cancer

Rectourethral fistula is a rare, but documented complication of rectal cancer. To our knowledge this is the first report of a recto- cavernosal fistula after chemo-radiotherapy for cancer of the rectum.

[Suburethral sling urethropexy: a vaginal approach]

Considering the poor long term results with the bladder neck suspensions, the poor results with the retropubic approach in obese or intrinsic sphincter deficiency and the complexity of the classical retropubic sling procedure, a simple vaginal sling urethropexy approach was developed. The vaginal mucosa is opened at 12 o'clock under the urethra. Dissection of the endopelvic fascia is undertaken. Polypropylene sutures are placed at the 4 corners of a free 2 x 4 cm rectus abdominis muscle flap which is suspended under the bladder neck transvaginally. Polypropylene sutures are tied at the rectus muscle through a 3 cm suprapubic incision. 25 patients were operated by one single surgeon. 7 had previous uretropexies. Previous hysterectomies: 8. Average age: 57. Average weight: 67.6. Severe stress incontinence was demonstrated in 23 patients. 9 patients had mixed incontinence. Average protective pads per day pre-op: 4.1. OR time: 93.8 min. Blood loss was minimal. 10 patients had transient post op retention (24 days average). 1 bladder perforation. 2 incisional hernias. 6 suprapubic wound infections. Average hospital stay: 5.95 days. The average follow up was 22 months. All patients were either cured (76%) or improved. 73% were satisfied (questionnaire). Despite a longer OR time, and the incidence of transient post op retention, this vaginal sling urethropexy approach is a simple and efficient procedure. It can be useful in previously operated or obese patients. It is easier to perform than the more conventional retropubic or combined (retropubic and vaginal) sling urethropexy.

Reassessment of nonplanimetric transrectal ultrasound prostate volume estimates

OBJECTIVES

To assess the accuracy and reproducibility of nonplanimetric transrectal ultrasound (TRUS) volume estimates because inaccurate volume estimates may potentially undermine the value of serum prostate-specific antigen density (PSAD) in early prostate cancer detection.

METHODS

We prospectively evaluated 535 consecutive male patients with two consecutive volume determinations performed by the same ultrasonographer at the time of the same visit.

RESULTS

Pearson correlation coefficients between two consecutive gland volume estimates ranged from 0.82 to 0.85 depending on the formula used; however, these correlation coefficients corresponded to an average 25% difference between the first and second gland volume estimates.

CONCLUSIONS

Although two consecutive nonplanimetric TRUS volume estimates show statistically good correlation, clinically up to a 25% volume difference should be expected between two such volume estimates. In consequence, nonplanimetric TRUS volume estimates should be interpreted with caution, especially when used for PSAD calculation, in the early detection of prostate cancer.

Value of systematic transition zone biopsies in the early detection of prostate cancer

PURPOSE

A prospective study was done to determine the value of performing 2 systematic transition zone biopsies in addition to systematic sextant peripheral zone biopsies for early detection of prostate cancer.

MATERIALS AND METHODS

From January 1 to August 31, 1994 we evaluated 847 consecutive patients referred to us for a suspicious lesion on digital rectal examination or an elevated serum prostate specific antigen level. All patients underwent 2 systematic transition zone biopsies in addition to systematic sextant biopsies of the peripheral zone.

RESULTS

Of the transition zone biopsies 68 (24.4%) contained malignancy, including only 8 (2.9%) with cancer found exclusively in the transition zone. The remaining 271 cases (97.1%) had 1 or more positive peripheral zone biopsies and would have been detected with or without additional systematic transition zone biopsies. The same analysis of 552 patients with a negative digital rectal examination yielded 6 (4.1%) exclusively transition zone tumors among 145 cancers detected in this group.

CONCLUSIONS

The low additional yield of transition zone biopsies (2.9 to 4.1%) does not warrant their systematic use for the early detection of prostate cancer.

Family history and the risk of prostatic carcinoma in a high risk group of urological patients

PURPOSE

We examine the association of family history and prostatic carcinoma.

MATERIALS AND METHODS

A total of 2,968 consecutive patients referred for prostate cancer detection responded to a questionnaire and underwent transrectal ultrasound examination with or without biopsy.

RESULTS

Of the men 329 (11.1%) had a family history of prostate cancer. No differences were observed between groups with and without a family history with respect to mean patient age, serum prostate specific antigen level or biopsy rate. Prostate cancer was detected in 133 of 329 patients (40.4%) with a family history and 769 of 2,639 (29.1) with no family history (p < 0.001, odds ratio 1.7). No significant differences were observed between cancer patients with or without a family history with respect to mean Gleason score (6.0 versus 6.2), patient age at diagnosis (65.8 versus 66.7) and prostate specific antigen level (16.8 versus 17.1).

CONCLUSIONS

Patients with a family history of prostate cancer have a greater risk of the disease. In this select group of patients a positive family history was not associated with an earlier age at cancer diagnosis or a different histological grade of tumor.

Correction of deteriorating renal function by superselective embolization of an arcuate renal artery pseudoaneurysm

We performed superselective embolization of an iatrogenic pseudoaneurysm of the right kidney that was causing hematuria and deterioration of renal function in a patient with chronic renal failure. An arcuate artery was embolized with absorbable gelatin sponge and a straight embolization wire without significant loss of renal vascularization, thus restoring baseline renal function. To our knowledge the clinical and technical aspects of our case are unique. The technique is described.

Prospective evaluation of prostate-specific antigen density and systematic biopsies for early detection of prostatic carcinoma

Significant controversies persist in regard to the need for systematic biopsies in patients with serum prostate-specific antigen (PSA) levels above 4 ng/mL (Hybritech assay), especially if they show no signs of prostatic cancer on digital rectal examination (DRE) or transrectal ultrasonography (TRUS). We evaluated 565 consecutive patients referred to us for prostatism, suspicious lesions on DRE, or an elevated serum PSA level. These patients do not represent a purely screened population. A detection rate of 38.4 percent was achieved by performing directed biopsies of suspicious lesions on DRE and/or TRUS, and systematic biopsies of all patients with serum PSA levels above 4 ng/mL. Among 142 patients with serum PSA between 4.1 and 10 ng/mL, but without suspicion for cancer on DRE and TRUS (DRE- TRUS-), a large number of patients (6.2) were subjected to systematic biopsies to detect one cancer. A receiver-operating characteristics curve for PSA density (PSAD) applied to this population confirmed that the best cut-off point for biopsies was a PSAD of 0.15, below which only two of twenty-three cancers would have been missed, sparing biopsies in 77 of 142 patients. A similar approach was applied to DRE- TRUS- patients with serum PSA levels above 10 ng/mL. The number of cancers in those with serum PSA between 10.1 and 14 ng/mL was too low to establish a PSAD cut-off point. In patients with serum PSA above 14 ng/mL, the best PSAD cut-off point for biopsies was 0.3, below which two of thirteen cancers would have been missed, sparing biopsies in 19 of 39 patients. We conclude that PSAD can safely reduce the number of patients subjected to systematic biopsies without significantly compromising cancer detection.

Laparoscopic management of the impalpable abdominal testis

Laparoscopy is useful in both diagnosis and management of impalpable testes. Intra-abdominal testicles can be removed laparoscopically if atrophic or can be partly devascularized by spermatic vessel clipping if apparently normal. Assessment of testicular revascularization would be desirable prior to subsequent orchiopexy. A second-stage vasal-based orchidopexy than can be performed once adequate testicular reperfusion via the deferential pedicle is believed to have occurred. We have used both diagnostic and therapeutic laparoscopy in the management of 103 non-palpable testes over a period of six years. Open procedures following laparoscopy included 57 orchidopexies, 11 orchiectomies, and 1 microvascular testicular autotransplant. Thirteen laparoscopic interventions were performed: 5 orchietomies for atrophic testes and 8 testicular vessel clippings followed by 6 second-stage open inguinal orchidopexies. Color Doppler duplex ultrasonography was not found to be reliable for assessment of testicular revascularization following spermatic vessel clipping. There were 3 complications which were all related to puncture with the Veress needle.

Management of an impalpable testis: the role of laparoscopy

The use of laparoscopy through a small infraumbilical incision permits noninvasive exploration of the pelvic fossae. The vas deferens as well as the spermatic vessels can be identified either with the testicle or as a blind ending. Twenty-six laparoscopies were performed on 19 patients with unilateral impalpable testis and 7 with bilateral impalpable testis. In this small series, laparoscopy was found to be the best method of locating the impalpable testis, and, depending on the laparoscopic findings, no further surgery or a simple inguinal exploration or abdominal incision is needed for the management of this condition.