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PURPOSE: Posterior urethral valves are usually detected during infancy by prenatal sonography. Rarely they may be diagnosed during later childhood, adolescence or even adulthood. Less is known about presentation and outcome in these older patients. We reviewed our experience at 4 institutions with the late presentation of posterior urethral valves. MATERIALS AND METHODS: A 13-year retrospective review revealed the late presentation of posterior urethral valves in 47 patients 5 to 35 years old (mean age 8). Data collected included presenting symptomatology, radiographic findings and renal function. Statistical analysis determined the relationships among presenting symptoms, patient age at diagnosis and renal function. RESULTS: The most common presenting symptoms were diurnal enuresis in 60% of the cases, urinary tract infection in 40% and voiding pain in 13%. Other presenting symptoms in less than 10% of the cases included poor stream, gross hematuria and proteinuria. At diagnosis hydronephrosis and vesicoureteral reflux were present in 40 and 33% of the patients, respectively, while serum creatinine was elevated in 35% and end stage renal disease had developed in 10%. The severity of presenting signs and symptoms was significantly associated with renal impairment, while patient age at diagnosis was not. CONCLUSIONS: Posterior urethral valves is not merely a disease of infancy. Voiding cystourethrography should be considered in boys older than 5 years who have voiding complaints, especially in association with diurnal enuresis or urinary tract infection. Patients who present late with posterior urethral valves are at risk for progression to end stage renal disease.

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OBJECTIVES: To assess whether a preliminary skin incision enhances diagnostic yield of percutaneous testis biopsy and to further evaluate the clinical efficacy of this procedure. METHODS: A total of 45 men (67 testes) underwent testicular biopsy with two passes of a Biopty gun spring-loaded needle. Twenty-seven biopsies were performed without a preliminary skin incision (group 1), and 40 were performed after a small scrotal incision (group 2). In 56 testes, needle biopsy histopathologic diagnosis was compared with that of open biopsy or orchiectomy specimens from the same patient. Needle and surgical specimens were fixed in Bouin's solution and sent separately for independent, blinded, histologic interpretation. RESULTS: Complications of the procedure were negligible. In all 67 needle biopsies, specimen quality was adequate for histopathologic interpretation. The mean number of seminiferous tubules obtained from needle biopsy was 28% higher among patients having a preliminary skin incision (25.9) compared with those without (18.7, P = 0.023). Correlation between needle and open histopathologic diagnosis was excellent (55 of 56, 98%). CONCLUSIONS: A preliminary skin incision made before needle biopsy increases the diagnostic yield of percutaneous testis biopsy. Percutaneous testis biopsy using the Biopty gun needle provides equal diagnostic information when compared with open testis biopsy or orchiectomy specimens. The concomitant reduction in morbidity and cost make this an attractive diagnostic procedure.

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OBJECTIVES: We sought to determine the prevalence of hot flushes after neoadjuvant hormonal therapy. METHODS: Forty-three patients who received neoadjuvant hormonal therapy before radical prostatectomy were asked to complete a questionnaire regarding hot flushes. RESULTS: Complete information was available for 35 of the 43 patients. No hot flushes were noted in 20%; in 69%, hot flushes were noted during treatment but resolved after termination of treatment; and in 11%, hot flushes continued for at least 3 months after cessation of hormonal therapy. Analyzing the data with respect to duration of hormonal therapy showed that patients receiving neoadjuvant hormonal therapy for more than 4 months had the highest incidence of persistent hot flushes. CONCLUSIONS: Hot flushes will be noted in 80% of patients who receive neoadjuvant hormonal therapy. In approximately 10%, hot flushes will continue for a significant period after hormonal therapy is terminated. Patients should be apprised of this potential side effect.

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Flutamide withdrawal syndrome is characterized by a decrease in prostate-specific antigen (PSA) after flutamide withdrawal in a subset of patients with progressing metastatic carcinoma of the prostate. It is generally hypothesized to be due to a point mutation in the androgen receptor that allows the antiandrogen to function as an agonist, leading to a dramatic and rapid PSA response. We describe a patient with androgen-independent prostate cancer in whom PSA continued to decrease for a period of 15 months after flutamide withdrawal. With continuing fall in PSA, the patient had unequivocal progression of disease seen on bone scan. This case illustrates the potential decoupling of PSA response from disease status in flutamide withdrawal. It also illustrates the need for continued clinical evaluation of patients with metastatic prostate cancer, even in the face of PSA response.

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We describe the use of a short, rigid ureteroscope to place a Foley catheter into the bladder under direct vision. The Circon ACMI MICRO-6 short ureteroscope was passed through a 22F Foley catheter modified with a catheter punch device. The catheter was placed rapidly and without difficulty in 2 patients with significant undermining of the trigone after transurethral incision of the prostate. This technique is rapid, simple, and avoids the potential complications of blind catheter placement following difficult transurethral procedures.

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A fundamental difference between the surgical techniques of radical retropubic and radical perineal prostatectomy is the method by which the vesicourethral anastomosis is accomplished. In the latter procedure, because the anastomosis is performed under direct vision, some authors have suggested that continence may be improved while reducing the risk of obstruction. The merit of this observation has not been established. To evaluate the characteristics of the vesicourethral anastomosis in retropubic and perineal prostatectomy, postoperative cystograms of 59 patients who underwent these procedures were reviewed in a blinded fashion. A normal, tapering bladder neck to the proximal urethra was noted in 80% of patients undergoing perineal prostatectomy compared with 2% of patients undergoing the retropubic approach. Various grades of diamond-shaped or bulbous irregularity of the vesicourethral anastomosis were seen in 98% of patients undergoing retropubic prostatectomy, and a system of grading of these abnormalities was established. These data suggest that a more physiologic-appearing bladder neck and proximal urethra is achieved with radical perineal prostatectomy. Further study is required to determine the impact of this radiologic finding on urinary function and continence.

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With the resurgent interest in radical perineal prostatectomy, a variety of enhancements have been made to the procedure. We describe herein the use of a retractor blade that allows full mobilization of the seminal vesicles and vasa prior to prostatic apical dissection, thus facilitating bladder neck-sparing radical prostatectomy. This retractor system dramatically improves visualization of the seminal vesicles and prostatic pedicles, allowing a single surgeon to perform this procedure easily.

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The authors report the successful delivery, preoperative management, and postoperative courses of ischiopagus tripus twin girls successfully separated at 5 months of age. Surgical objectives were predicated on survival and optimum postseparation reconstructive potential for both girls. Each twin has subsequently undergone additional procedures, and both are doing well 2 years after separation. The authors reviewed 17 known cases of ischiopagus tripus separation, comparing anatomic findings, use of the tripus limb, operative strategies, and attainment of abdominal closure. This 18th case includes the first report of splitting the tripus limb and giving each girl a femur. The authors found that detailed systemic investigation, advanced coordinated teamwork with appropriate technical support, applications of new technologies or reapplication of existing technologies, meticulous planning, and favorable anatomy were vital in yielding favorable outcomes.

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PURPOSE: We examined and characterized the histological features of remnant testicular tissue distal to the internal inguinal ring in boys who underwent exploration for a nonpalpable testis. MATERIALS AND METHODS: The medical records and histology of 48 boys (50 remnants) who underwent exploration for a nonpalpable testis during a 10-year period were reviewed in detail. RESULTS: Remnant tissue was characterized by evidence of ischemia and necrosis (scar, calcification, hemosiderin and hyalinization) suggestive of a vascular accident. Viable germ cells were identified in 5 remnants. CONCLUSIONS: A 10% incidence of viable germ cells in remnant testicular tissue warrants exploration and removal of all remnant tissue in boys who undergo exploration for a nonpalpable testis.

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OBJECTIVES: To determine the efficacy of limited use of voiding cystourethrogram (VCUG) in the evaluation of patients for renal transplantation. METHODS: A retrospective review of 439 patients who underwent renal transplantation between October 1983 and May 1995; however, since September 1993 we used VCUG selectively in the pretransplant evaluation. RESULTS: Since September 1993, only 51% of our renal transplant patients had a VCUG as part of their pretransplant evaluation . Only one urologic complication has occurred in a 68-year-old man with a history of glomerulonephritis. He had an episode of acute urinary retention, which was treated successfully with a temporary suprapubic tube followed by medical therapy. CONCLUSIONS: Our preliminary results reveal no adverse outcomes associated with the selective use of VCUG in the pretransplant evaluation, and indicate that this study is of little value in the routine evaluation of these patients.

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OBJECTIVES: This work demonstrates a simple technique utilizing a fiberoptic microtransducer that provides statistically reproducible stress leak point pressure (SLPP) results without the use of fluorourodynamics. METHODS: Nineteen stress incontinent patients with varied clinical histories underwent two SLPP measurements on 2 separate days, totaling four data points. A 14 F catheter sheath was inserted to empty the bladder. Through this sheath, a 5 F fiberoptic microtransducer was inserted into the bladder and zeroed. Then, 250 cc of indigo-carmine solution was instilled, during which a filling cystometrogram was performed. The sheath was removed, leaving only the 5 F transducer in the bladder. A 2 by 2 inch gauze was placed at the meatus. As each participant performed a slow Valsalva maneuver, an event marker was used to note the pressure at which indigo solution was first seen to stain the gauze. RESULTS: SLPPs ranged from 15 to 140 cm water (H2O). A two-tailed paired t test demonstrated no statistical difference (P < 0.6) between the two SLPPs performed on day 1, with a mean difference of 1.05 +/- 2.61 (95% confidence interval [CI]). Comparison of the two SLPPs performed on day 2 also revealed no statistical difference (P < 0.8), with a mean difference of -0.17 +/- 5.65 (95% CI). Lastly, comparison of the mean SLPPs from day 1 with the mean SLPPs from day 2 revealed no statistically significant difference (P < 0.8), with the mean difference of -0.59 +/- 1.62 (95% CI). CONCLUSIONS: This study demonstrates a simple technique that produces reproducible SLPP measurements in a wide variety of clinical settings and avoids ionizing radiation.

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Mesenteric lipodystrophy is a rare disorder not previously known to be associated with urological abnormalities. We report on a man with stage T3a renal cell carcinoma and congenital mesenteric lipodystrophy. To our knowledge our case represents the first concurrence of these entities.

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Surgical techniques and research efforts to define the pathophysiology of cryptorchid testes have progressed rapidly in recent decades. Medical and surgical treatment modalities have focused on the young patient with an undescended testis. The potential adult complications of cryptorchidism, infertility, and malignancy should not be forgotten or dismissed.

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Distal ureteral calculi are a common urological problem often requiring surgical and anesthetic intervention. In a health care system with limited resources this intervention can lead to the expenditure of significant monies. Ureteral stents are often used to stabilize symptomatic patients preoperatively. Since stent placement causes passive ureteral dilation, we hypothesized that temporary placement of a ureteral catheter would facilitate spontaneous calculus passage. We prospectively studied 27 patients who presented with distal ureteral calculi less than 10 mm. large and met criteria established for surgical intervention. Self-retaining Double-J stents were placed in 10 male and 7 female patients, and left for 2 weeks using only topical anesthesia during the procedures. In the majority of the patients (83%) the calculi passed spontaneously after stent removal, obviating surgical or anesthetic intervention.

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Bladder cancer is the most common cancer in the urinary tract, and transitional cell carcinoma (TCC) accounts for more than 90% of bladder tumors. Bladder cancer is responsible for 4.5% of all new malignant neoplasms and 1.9% of cancer deaths in the United States. According to 1993 estimates, 52,000 new cases of bladder cancer were diagnosed in the United States, and almost 10,000 deaths were caused by this disease. TCC is a heterogeneous neoplasm with a variable natural history and behavior pattern. Seventy to 80% of bladder cancers are manifested as early stage, superficial papillary lesions; 20% are initially diagnosed as invasive disease. Superficial tumors have a great propensity to recur, and 10-20% progress to invasion of the bladder wall. Patients with invasive tumors are at high risk for disease progression, and despite definitive therapy (frequently cystectomy), the overall 5-year mortality rate is almost 50%. Basic and clinical research have led to a better understanding of bladder cancer and are leading to new diagnostic and therapeutic strategies. This report summarizes new concepts in the pathophysiology of bladder cancer, focusing on TCC, the most common histologic type of bladder tumor.

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OBJECTIVE: To assess the reliability, safety and patient satisfaction of transcutaneous Biopty (Bard Urological, Covington, GA, USA) gun testis biopsies. PATIENTS AND METHODS: Nineteen young men who were referred for evaluation of azoospermia were included in the study. The procedure was performed in an outpatient setting, under local anaesthesia and without sedation. Two passes of the Biopty gun spring-loaded needle were performed unilaterally in each patient. RESULTS: An average of 38.9 seminiferous tubules were evaluable per patient. The procedure was extremely well-tolerated by all patients and most felt that the procedure was no more distressing than simple phlebotomy. CONCLUSION: Transcutaneous testis needle biopsy performed with the Biopty gun is safe, rapid and cost-effective. This technique may represent a viable alternative to the open method of testis biopsy.

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