Renal cell carcinoma with vena caval extension: operative management.
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Adult↗
Biomedical subjects
S D Boyd
Publications and source records attributed to S D Boyd.
Ectopic ureter presenting in midline urethral diverticulum.
A rare case of an ectopic ureter terminating in a urethral diverticulum is presented. While numerous cases of extravesical ectopic ureters draining directly into the urethra or uterovaginal canal have been reported, the termination of a ureter as a diverticular sac is extremely unusual. Moreover, only rarely has a urethral diverticulum been documented to arise congenitally due to any cause. The history and management of this new case are detailed, and the general subjects of ectopic ureter and urethral diverticulum are discussed with particular reference to etiology and continence.
Adult↗
Squamous cell carcinoma of the bladder associated with cyclophosphamide therapy for Wegener's granulomatosis: a report of 2 cases.
Cyclophosphamide has been used to treat a variety of malignant and nonmalignant diseases. The association of this agent with the development of urothelial tumors has been well documented. Although most bladder cancers associated with prior cyclophosphamide therapy are transitional cell carcinoma, to our knowledge there have been 6 reports of cyclophosphamide-induced squamous cell carcinoma of the bladder. We report 2 additional cases of squamous cell carcinoma of the bladder that occurred in patients after cyclophosphamide treatment for Wegener's granulomatosis. Any patient with a history of prolonged cyclophosphamide ingestion needs careful long-term monitoring of the lower urinary tract, since there is at least a 9-fold increase in the incidence of lower urinary tract malignancy in such patients.
Adult↗
The rationale for en bloc pelvic lymph node dissection for bladder cancer patients with nodal metastases: long-term results.
From August 1971 through June 1989, 591 consecutive patients underwent curative pelvic lymphadenectomy with en bloc radical cystectomy for bladder cancer. Of these patients 132 (22%) had pathologically proved nodal metastases. The incidence of positive nodes increased with increasing pathological stage of the primary tumor: stage PIS (0.75%), stage P1 (13%), stage P2 (20%), stage P3a (24%), stage P3b (42%) and stage P4 (45%). The median followup for the 31 patients still alive was 5.5 years (range 2.6 to 18.8). Recurrent bladder cancer was documented in 89 patients (67%) with a median interval to progression of 1.5 years. Pelvic recurrence as the first site of progression was uncommon, occurring in 15 patients (11%). The actuarial 2, 3, 5 and 10-year survival rates were 55%, 38%, 29% and 20%, respectively. Increased risk of progression and death was associated with advanced pathological tumor stage (stage P3b or greater, p < 0.001 and p < 0.001, respectively) and 6 or more positive nodes (p < 0.001 and p = 0.012, respectively). There was no significant difference in survival and interval to progression among patients who received preoperative irradiation or adjuvant chemotherapy compared to those treated with surgery alone. This retrospective analysis further substantiates the philosophy that single stage pelvic lymphadenectomy with en bloc radical cystectomy can provide long-term progression-free survival, particularly for patients with localized primary tumors and minimal metastatic nodal disease.
Aged↗
New trends in the treatment of benign prostatic hyperplasia and carcinoma of the prostate.
Benign prostatic hyperplasia (BPH) is a very common condition affecting over 800,000 American males each year. A standard, effective, and well-proven therapy is prostatectomy. This surgical procedure is used to treat, in the United States, approximately 400,000 BPH patients annually. Major treatment benefit is expected in 70% to 80% of patients. Complications are seen in 20% of the surgically treated patients. Due to the advanced age of BPH patients and the presence of other serious coexisting medical problems, surgical therapy may be difficult to utilize. These patients, who present a high risk for surgery, are in need of alternative treatments. Alternative therapy in BPH patients with clinically important symptoms and signs of urinary outflow obstruction include treatment with pharmacological agents, balloon dilatation, laser beam therapy, transurethral thermal therapy, transrectal microwave hyperthermia, and transurethral microwave hyperthermia. These alternative treatment modalities are currently under intensive study. These new treatment modalities ultimately must be compared with the standard treatment, which is prostatectomy. Due to the unpredictable natural history of BPH, it is desirable that each Phase III study should contain a no-treatment observation-only arm. Adenocarcinoma of the prostate (CaP) has become a tumor, which first in frequency, and second in importance in cancer mortality statistics of American males. Local tumor control rates and long-term survivals, with radical prostatectomy or radiation therapy, have been excellent. There was, however, recent concern regarding a high incidence of microscopic local tumor recurrence following a definitive course of irradiation. Deep regional or intracavitary hyperthermia (HT) with phase steering may be of value as an adjuvant treatment to radiotherapy. This HT may increase the incidence of local tumor control obtained with radiotherapy. Phase I-II clinical studies are currently underway.
Adrenergic alpha-Antagonists↗
Study of antireflux nipple valves of Kock ileal urinary reservoir. Experimental investigation in dogs.
To better assess the construction, maintenance, and function of the Kock ileal urinary reservoir with its continent antirefluxing nipple valves, laboratory investigations in dogs were done simultaneously with clinical trials in humans in 1983. Fifteen dogs underwent creation of hemi-Kock ileal reservoirs (without the efferent valve and limb) that were anastomosed to their bladders as enterocystoplasties. The afferent antirefluxing nipple valves were intussuscepted after 7 cm of underlying mesentery had been removed. The nipples were further stabilized with metal and absorbable (Polysorb) staples and Marlex collars. The right ureters were anastomosed to the afferent limb of the reservoirs with the contralateral systems left intact as controls. Ten dogs were able to be followed at the vivaria for twelve to thirty-six months and then studied. All nipple valves remained intact, viable, and nonrefluxing without revision. All kidneys remained histologically normal except those in dogs with dilated ureters secondary to ureteroileal stenosis with concurrent calculi formation. Calculi formed on exposed metal staples and Marlex. The absorbable staples were found to promote appropriate healing and were never the nidus for stone formation. It appears that the intussuscepted nipple valve (with its mesentery removed) is reproducible and functionally reliable in preventing reflux. It also appears these valves can histologically preserve diverted kidneys if the upper urinary tract drainage is normal and calculi are minimized. The proper placement of staples and the elimination of Marlex-anchoring collars are indicated to minimize calculi.
Anastomosis, Surgical↗
Lower urinary tract reconstruction following cystectomy: experience and results in 126 patients using the Kock ileal reservoir with bilateral ureteroileal urethrostomy.
Between May 1986 and February 1990, 126 consecutive men underwent lower urinary tract reconstruction by means of bilateral ureteroileal urethrostomy using a Kock ileal reservoir. The early complication rate was 11.1%. Late complications requiring rehospitalization or reoperation have been surprisingly few: 1 for prolapse of the afferent antirefluxing nipple valve, 1 for calculi and 4 for artificial urinary sphincter placement due to unsatisfactory continence. Good continence has been achieved in 94% of the patients during the day and in 84% at night. Tumor recurred in the pelvis in 5 patients, with 4 requiring cutaneous urinary diversion. All patients had progression or died of metastatic disease. Our experience has yielded extraordinary results in terms of patient acceptance with few late complications or need for reoperation.
Adult↗
The role of adjuvant chemotherapy following cystectomy for invasive bladder cancer: a prospective comparative trial.
We assigned 91 patients with deeply invasive, pathological stage P3, P4 or N+ and Mo transitional cell carcinoma of the bladder (with or without squamous or glandular differentiation) to adjuvant chemotherapy or to observation after radical cystectomy and pelvic lymph node dissection. For most patients chemotherapy was planned as 4 courses at 28-day intervals of 100 mg./M.2 cisplatin, 60 mg./M.2 doxorubicin and 600 mg./M.2 cyclophosphamide. A significant delay was shown in the time to progression (p = 0.0010) with 70% of the patients assigned to chemotherapy free of disease at 3 years compared to 46% in the observation group. Median survival time for patients in the chemotherapy group was 4.3 years compared to 2.4 years in the observation group (p = 0.0062). In addition to treatment groups, important prognostic factors included age, gender and lymph node status. The number of involved lymph nodes was the single most important variable. We recommend adjuvant chemotherapy for patients with invasive transitional cell carcinoma after definitive surgical resection.
Antineoplastic Combined Chemotherapy Protocols↗
Kock pouch bladder replacement.
Between May 1986 and February 1990, 126 consecutive male patients have undergone lower urinary-tract reconstruction by means of Kock bladder replacement at our institution. The early and late complication rates have been minimal. Good continence has been achieved in 94% of patients during the day and in 84% at night. Our experience with bladder replacement has yielded extraordinary results in terms of patients acceptance. It is anticipated that our experience as well as the experience of others with this surgery will encourage patients afflicted with high-grade bladder cancer and their physicians toward an earlier decision for aggressive therapy by cystectomy while cure is still possible.
Adult↗
The role of radical cystectomy in the management of high grade superficial bladder cancer (PA, P1, PIS and P2)
Between January 1979 and 1987, 411 consecutive patients were considered candidates for bilateral pelvic iliac lymph node dissection and radical cystectomy for the management of bladder cancer. From this group 160 were identified as having pathological stage P2 or less disease, including 11 who also had positive nodes. The 5-year actuarial survival rate for the respective stages at 95% confidence limits was 100% for stage P0/A, 80% for stage P1, 78% for stage P1 with stage PIS, 85% for pure stage PIS, 76% for stage P2 and 87% for stage P2 with stage PIS. Additionally, we identified a group of patients with stage P2 transitional cell carcinoma who were at significant risk for development of metastatic disease. Of 46 patients with stage P2 transitional cell carcinoma 18 had vascular space invasion resulting in 6 of 18 cancer-related deaths (33%). Our study demonstrates that radical cystectomy has been highly effective in curing patients with high grade superficial disease, including those with superficially invasive disease associated with nodal metastases.
Carcinoma, Transitional Cell↗
Technique of left adrenalectomy for autotransplantation to the caudate nucleus in Parkinson's disease.
Autotransplantation of the adrenal medulla to the caudate nucleus is a new neurosurgical treatment under investigation for severe Parkinson's disease. The success of the procedure is reliant partly on the ability of the urologist to remove the adrenal gland safely and atraumatically with minimal morbidity. We describe our technique using a posterior 12th rib approach, which is extrapleural and extraperitoneal. In the initial 10 patients there was no significant morbidity from the operation and all patients were discharged from the hospital within 3 to 7 days postoperatively. The importance of using a no touch technique in mobilizing the gland is emphasized, since any hemorrhage within the adrenal medulla may make it impossible to recover the tissue for stereotactic implantation. Hemorrhage occurred in 1 of our patients, who was elderly and obese. The technique described allows for adequate exposure while maintaining acceptably low morbidity from the procedure.
Adrenal Medulla↗
Transurethral hyperthermia for benign prostatic hyperplasia: preliminary clinical results.
A total of 21 patients with biopsy proved benign prostatic hyperplasia underwent treatment on a pilot protocol involving intracavitary transurethral radiating microwave (630 or 915 MHz.) antenna hyperthermia. Acute and subacute toxicity was mild and consisted primarily of bladder spasm (26% of the patients), hematuria (23%) and dysuria (9%), none of which significantly limited the achievement of desired temperatures during the treatment sessions. No chronic treatment-related morbidity or mortality was observed. Detailed thermal mapping, performed along the course of the prostatic urethra, recorded temperatures of 43C or more at greater than 75% of the loci. Highly significant increases in urine flow rate, decrease in post-void residual urine capacity and decrease in frequency of nocturia were observed. A marginally significant decrease in prostate volume was noted and, with a median followup of 12.5 months, only 3 patients have required subsequent prostatic resection. Transurethral hyperthermia represents a safe and promising outpatient approach to treatment of benign prostatic hyperplasia, particularly for patients who are not candidates for conventional surgical approaches because of medical or personal reasons. Further studies with the goal of optimizing the technique appear to be warranted, although long-term results would be best evaluated with prospective phase 3 trials.
Aged↗
Utilization of unilateral and bilateral stereotactically placed adrenomedullary-striatal autografts in parkinsonian humans: rationale, techniques, and observations.
A limited clinical pilot study involving an amalgam of specialized disciplines including neurology, neuropharmacology, neuropsychology, neurosurgery, neuroanesthesia, neuroradiology, surgical pathology, neuropathology, and urological surgery was organized to clarify issues related to patient selection, optimization of grafting materials, design of a safe, effective, standardized, and reproducible surgical technique, and possible modification of clinical patterns. After initial assessment of 82 Parkinsonian patients for periods of 6 to 20 months, 10 (age, 39-68 years) were selected for unilateral or bilateral adrenomedullary autografts to the caudate nucleus with ependymal and cerebrospinal fluid contact, employing image-directed stereotactic methods. Selection was made only after clear definition of clinical pattern and optimization of medication responses. Adrenal glands were harvested by a retroperitoneal approach (mean estimated blood loss less than 75 ml). Care was taken to maximize the graft content of medullary tissue. Stereotactic methods afforded standardized, reproducible, precise targeting and transit trajectory with unilateral or bilateral placement of materials within the striatum (tissue volume, 80 mm3) with access to the ventricular fluid of the frontal horn. Considerable variability in satisfactory donor medullary tissue was encountered. One patient did not undergo grafting because of unsatisfactory medullary tissue. No significant surgical complications were noted and all patients were ready for discharge 7 days after surgery. One patient who manifested no apparent clinical change died 6 weeks after bilateral grafting of unrelated causes during a lithotripsy procedure. Postmortem examination disclosed precise graft placement with a paucity of structurally preserved medullary cells. Postoperative observations, including parameters of clinical observation, medication schedules and records, patient and family commentaries, and imaging studies (computed tomograms and single photon emission computed tomograms), have been made for periods from 16 to 20 months. Sustained improvement in preexisting clinical patterns and reduction in drug requirements were observed in 4 of 8 patients. No increased benefit could be ascribed to bilateral graft placement. These observations would indicate a safe, and reproducible surgical method. In addition, the clinical observations indicate favorable alterations in the established pattern of the disorder, which would justify further cautious exploration of alternate donor sources or refinements of biological graft site manipulations.
Adrenal Medulla↗
Adjuvant chemotherapy following cystectomy benefits patients with deeply invasive bladder cancer.
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Carcinoma, Transitional Cell↗
Prospective study of metabolic abnormalities in patient with continent Kock pouch urinary diversion.
Metabolic alterations as a result of bowel being employed in the urinary tract are well documented. To investigate this phenomenon in the continent ileal reservoir urinary diversion, 106 patients who had undergone Kock pouch surgery were followed in a prospective study at the University of Southern California between 1985 and 1987. Serum chemistries and urine osmolality determinations were performed approximately every three months for a year. Mean patient values for each time period were then compiled and compared with the norms and with the preoperative values. The mean serum electrolyte values were found to be within normal limits during all follow-up periods. Fourteen patients were identified, however, as having values falling intermittently outside of the normal range. These patients were investigated and found to be abnormal during episodes of acute renal failure usually secondary to dehydration or obstruction at which time they usually became acidotic and occasionally hyperchloremic. These problems disappeared when the renal failure was corrected. This study corroborated our previously reported findings that hyperchloremic acidosis or other metabolic alterations requiring replacement therapy do not routinely occur in this population.
Acute Kidney Injury↗
Successful use of transureteroureterostomy to salvage ureterosigmoidostomy after anastomotic failure.
Four cases are presented of patients who had undergone ureterosigmoidostomy and in whom a unilateral ureteral anastomotic complication developed that was salvaged subsequently by a transureteroureterostomy. Although other forms of urinary diversion are now being utilized routinely in many centers, the ureterosigmoidostomy is still being employed worldwide, and urologic surgeons need to be versed in its potential problems and how to correct them.
Adult↗
Inflatable penile prostheses in patients undergoing cystoprostatectomy with urethrectomy.
When urethrectomy is indicated in the male patient in combination with cystoprostatectomy for diffuse transitional cell carcinoma, an additional challenge to reconstruction and sexual rehabilitation will be encountered. Inflatable penile prostheses were implanted in 19 patients who had undergone cystoprostatectomy with prophylactic urethrectomy. Of the patients 13 underwent cystoprostatectomy with en bloc urethrectomy and delayed placement of an inflatable penile prosthesis. The remaining 6 patients required urethrectomy and simultaneous implantation of an inflatable penile prosthesis 6 to 12 weeks after radical cystectomy. All 19 patients healed appropriately and had an adequate functioning prosthesis. However, results in patients in whom the glandular urethra could be preserved safely were far superior to those in patients requiring total urethrectomy. This was so because of easier and improved cylinder placement with better support to the glans, increased glandular sensation and a more acceptable penile appearance. The inflatable penile prosthesis can be used successfully in the cystourethrectomy patient with gratifying results, especially when the glandular urethra remains intact.
Adult↗
Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival.
In 1972 we first reported that vena caval extension by tumor thrombus was a potentially curable lesion provided that complete removal could be achieved. We have developed a technique for safe removal of extensive vena caval thrombi extending up to the right atrium without the need for cardiopulmonary bypass or hypothermic cardioplegia. Cardiopulmonary bypass, however, is advocated for some type III thrombi, but the addition of the pump and heparinization compounds the magnitude of the procedure. We use a right thoracoabdominal approach for tumors arising from either kidney with vascular isolation of the vena cava from its insertion into the right atrium to the iliac bifurcation. From 1972 to 1988, 56 patients ranging in age from 31 to 76 years were evaluated and 53 underwent radical nephrectomy with en bloc vena caval tumor thrombectomy. Of these patients, 21 had subhepatic caval thrombus extension (level 1); 24 had extension into the intrahepatic vena cava (level 2), and 8 had thrombi extending into the heart (level 3). Overall 1-, 3-, and 5-year survival was 56%, 34%, and 25%, respectively. Crucial to survival was complete surgical excision. Successful extirpation of all apparent tumor was possible in 75% of the patients in this series. With an expected 5-year survival rate of 57% for those without metastatic disease to other organs, we continue to advocate an aggressive optimistic approach for patients if there is no preoperative evidence of metastatic disease.
Actuarial Analysis↗