Biomedical subjects
Publications and source records attributed to R G Rowland.
A modification of the Gilchrist procedure is used to create a continent urinary reservoir that provides reliable continence and antireflux mechanisms. The tubular form of the cecum is altered by a patch or reconfiguration to prevent bolus contractions of the reservoir. The procedure offers a choice of locations of the reservoir and stoma in most patients. Each step of the procedure uses techniques already familiar to urologists.
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.
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.
A case of a yolk-sac tumor associated with an intra-abdominal testis in a patient with persistent müllerian duct syndrome is presented.
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.
Advanced testicular cancer is best treated with combination platinum based chemotherapy as primary therapy. If there is only moderate tumor bulk at presentation, many patients will achieve a complete remission and have no evidence of disease thereafter. Those with more bulky tumor who obtain a partial remission should then have residual tumor completely resected by surgery. This effectively re-stages the patient, provides therapeutic benefit to many and determines the need for additional chemotherapy. If carcinoma is found in the resected specimen, further "salvage" chemotherapy is required. If the resection is grossly complete even this group can obtain survival in the majority of cases.
Advanced testicular cancer is best treated with combination platinum-based chemotherapy as primary therapy. If there is only moderate tumor bulk at presentation, many patients will achieve a complete remission and have no evidence of disease thereafter. Those with more bulky tumor who obtain a partial remission should then have residual tumor completely resected by surgery. This effectively restages the patient, provides therapeutic benefit to many, and determines the need for additional chemotherapy. If carcinoma is found in the resected specimen, further "salvage" chemotherapy is required. If the resection is grossly complete, even this group can obtain survival in the majority of cases.
Twenty-five patients with nonseminomatous germ cell carcinoma of the testis underwent CT and nuclear magnetic resonance (NMR) of the retroperitoneum followed by radical retroperitoneal lymph node dissection for surgical proof of metastatic disease. Computed tomography correctly predicted the presence or absence of adenopathy in 88% and assigned the correct stage in 84%. Nuclear magnetic resonance had comparable figures of 84 and 80%. Computed tomography appeared superior to NMR in detecting other abdominal abnormalities, although these were few in number. Nuclear magnetic resonance is nearly equivalent to CT in staging retroperitoneal lymphadenopathy from testicular cancer and may surpass CT following technical advances and the introduction of oral contrast agents.
Patients with testicular cancer who have disseminated disease at presentation do not always undergo orchiectomy for diagnosis of staging before initiation of chemotherapy. Between October 1978 and November 1982 orchiectomy was performed following cisplatin combination chemotherapy in 20 patients with disseminated germ cell tumors. There were three patients with residual carcinoma in the removed testis and six patients with teratoma. Therefore, in patients with evidence of a primary testicular neoplasm that was not resected initially, orchiectomy should be performed after chemotherapy. Furthermore, the testis may be a sanctuary site for germ cell malignancies during systemic treatment.
More than 350 patients with testicular germ cell cancer have been treated with cisplatin combination chemotherapy. Seventy-two with metastases to the thorax who had operation are discussed here. In a subgroup of 24 patients with additional retroperitoneal disease, a one-stage median sternotomy was performed in 18 patients, and a thoracotomy in 6, with retroperitoneal node dissection. Seventeen patients had similar pathological lesions in the thorax and retroperitoneum; in 7, the lesions differed. There was no operative mortality in the entire group. Overall, chemotherapy altered the metastases to mature teratoma in 28 patients, and 27 are long-term survivors. Among 22 patients with fibrotic, necrotic masses, 19 are long-term survivors; 6 of the 22 with persistent carcinoma had chemotherapy postoperatively and are long-term survivors. The overall cure rate for patients with disseminated testicular cancer is approximately 80%. Among those who had a one-stage thoracoretroperitoneal procedure, long-term survival is 83%; for the entire thoracic surgical group, it is 74%.
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.
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.
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.
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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.
We gave 102 male Fischer 344 rats (100 to 200 g) 0.2 per cent nitrofurylthiazolyl formamide (FANFT) diet for 14 weeks. Half of the animals underwent urinary diversion and half, sham operation. All animals resumed the FANFT diet. Half of each of the groups received four weekly i.p. injections of cyclophosphamide and the remainder received saline injections. The animals were sacrificed 12 weeks after diversion or sham operation. The incidences of tumor and tumor invasion were tabulated. Urinary diversion produced a greater effect in reducing progression of early neoplastic lesions to gross or microscopically invasive tumor than did systemic cyclophosphamide; however, an additive effect was noted when diversion and cyclophosphamide therapy were combined.