Priapism caused by infection and an inflammatory process in the pelvic region

Priapism caused by an inflammatory process is rare. We report on a 25-year-old man with priapism due to an infiltration in the pelvic region, enclosing the right sacral plexus. Blood cultures revealed Staphylococcus aureus to be the causal organism. Treatment consisted of parenteral antibiotics, aspiration of the corpora cavernosa and injection of epinephrine, resulting in a flaccid penis and full recovery of potency after 3 weeks. A literature review was conducted for infection and inflammatory processes as a cause for priapism.

Eosinophilic cystitis presenting as urinary retention

OBJECTIVE

To evaluate the incidence, etiology, diagnosis, therapy and results in patients with eosinophilic cystitis (EC), with special attention to patients with urinary retention as presenting symptom.

PATIENTS AND METHODS

Between 1988 and 1999, 3 patients with EC were diagnosed. One patient presented with urinary retention, without other symptoms. All patients were evaluated for symptoms, urine culture, hematology including cell differentiation, blood chemistry, cystoscopy and intravenous urography. The international literature was reviewed for incidence, etiological factors, diagnostic procedures, therapies and outcome of EC presenting with urinary retention.

RESULTS

Two male patients presented with pain, frequency of micturition and nocturia. One female patient presented with urinary retention. One patient had an urinary tract infection. One patient showed eosinophilia of the peripheral blood. Intravenous urography revealed hydroureteronephrosis in 2 patients (1 unilateral and 1 bilateral). Cystoscopy showed tumor-like lesions in 2 patients. Therapy consisted of oral or intravesical corticosteroids or transurethral resection of the lesions. All patients were cured. A review of the literature revealed that 14 patients with EC (10%) presented with urinary retention; the majority (79%) being children and women. All patients returned to normal miction following therapy.

CONCLUSIONS

The clinical presentation of EC is varied. When the lesion is located at or near the bladder neck, it may present as urinary retention. In children and women with urinary retention, EC must be considered in the differential diagnosis. Corticosteroids are the mainstay of efficient therapy.

Microvascular invasion in prostate cancer: prognostic significance in patients treated by radical prostatectomy for clinically localized carcinoma

OBJECTIVE

To investigate the clinical significance of vascular invasion in prostate cancer patients treated by radical prostatectomy for clinically localized and locally advanced disease.

MATERIALS AND METHODS

Vascular invasion was determined during a routine work-up of radical prostatectomy specimens of 273 patients who underwent surgery for prostatic carcinoma. The correlation with other pathological variables was investigated. The prognostic influence for clinical progression, local recurrence, distant metastases, biochemical progression, overall survival and cancer-specific survival was determined.

RESULTS

Vascular invasion was present in 33 patients (12%). Vascular invasion correlated significantly with capsular perforation, seminal vesicle invasion, positive margins of resection, perineural invasion, high grade, and pathological stage. Vascular invasion was a significant prognostic factor for clinical progression (p < 0.001), local recurrence (p = 0.007), distant metastases (p < 0.001), biochemical progression (p < 0.001), overall survival (p = 0.02), and cancer-specific survival (p < 0.001). Multivariate analysis, adjusting for capsular perforation, high grade, and positive margins of resection, showed that vascular invasion was associated with a 2.5-fold increased risk for clinical progression. This relative risk was 2.3 for biochemical progression, and 2.7 for cancer-specific survival.

CONCLUSION

Vascular invasion is a very important pathological variable for progression and survival, and must be evaluated on a routine basis during the work-up of radical prostatectomy specimens.

Diagnosis and management of seminal vesicle cysts associated with ipsilateral renal agenesis: a pooled analysis of 52 cases

OBJECTIVE

Seminal vesicle cysts combined with ipsilateral renal agenesis represent a rare urological anomaly. We searched the literature to review the clinical presentation, diagnosis and therapeutic treatment options of this anomaly.

METHODS

A pooled analysis was performed of 52 cases of seminal vesicle cysts combined with ipsilateral renal agenesis, including our own observation. The evaluation included: patient age at diagnosis, race, laterality (R/L), presence of ureteral remnant in the cyst, presenting symptoms, diagnostic examinations, treatment and outcome.

RESULTS

The mean age at diagnosis was 30.2 years. The majority presented in the 2nd, 3rd and 4th decade of their lives. Only 2 patients (4%) were of African origin, all others were Caucasians. The distribution R:L was 2:1. Ureteral remnants were present in 14 patients (27%). The most common symptoms were: dysuria (37%), frequency (33%), perineal pain (29%), epididymitis (27%), pain following ejaculation (21%) and scrotal pain (13%). Infertility was found in 9 patients (17%). The cyst was palpable by digital rectal examination in 79%. All patients underwent intravenous urography, and 88% underwent cystoscopy. Other frequently performed investigations are: ultrasonography (27%), CT scanning (27%), vasovesiculography (46%) and urethrocystography (23%). The final treatment was open surgery in 74%, aspiration in 6%, transurethral deroofing of the cyst in 6% and spontaneous rupture in 4%. In 6% no treatment was given and in 4% the treatment is unknown. All patients were free of symptoms after open exploration. The success rates after transurethral deroofing and aspiration were 75 and 30% respectively.

CONCLUSION

Seminal vesicle cysts combined with ipsilateral renal agenesis are a rare urological anomaly, occurring in men in the 2nd to 4th decade of their life. They present with symptoms of bladder irritation and obstruction and with pain in the perineum and scrotum. Epididymitis is frequently found. The diagnostic work-up consists of a digital rectal examination, transrectal and abdominal ultrasonography, CT scan and a cystoscopy. Open surgery and transurethral deroofing of the cyst give excellent results (100 and 75% cure respectively). Aspiration of the cyst should only be used for diagnostic purposes.

Management of locally advanced prostate cancer. 1. Staging, natural history, and results of radical surgery

Prostate cancer presents clinically as T3 disease in about 20-25% of cases. With repeated screening of large parts of the male population, this proportion may drop in the future. Correct staging of T3 prostate cancer is difficult to achieve. Rectal examination and ultrasonography produce similar results. Overstaging in the presence of pT2 disease and understaging (pT4 or pN+ disease) are common and present a dilemma for proper treatment decisions. The optimal management of T3 prostate cancer is not known at this time. Radical prostatectomy for locally advanced disease can be carried out with acceptable morbidity and mortality and is especially beneficial in patients who have been downstaged to pT2 (17-30%) and in those with moderately or well-differentiated disease. In this group of men, historical comparison suggests that radiotherapy alone is inferior to surgery. These comparisons, however, are heavily biased by differences in the distribution of prognostic factors for which a correction is impossible. Surgery alone is clearly not useful in patients presenting with poorly differentiated disease or with prostate-specific antigen (PSA) values exceeding 10-20 microg/ml. Adjuvant treatment is desirable. Considering the high prevalence of lymph node metastases in this group of patients (25-50%), lymphadenectomy is mandatory prior to surgery, radiotherapy, or any type of combination treatment.

Management of locally advanced prostate cancer. 2. Radiotherapy, neoadjuvant endocrine treatment, update 1997-1999

Part 2 of this review identifies the need for effective adjuvant treatment in patients with T3 disease and poor prognostic factors identifiable after surgery. A large volume of information has become available from randomized neoadjuvant and adjuvant studies using endocrine treatment in association with either surgery or radiotherapy. It is well documented that such therapy delays progression in prostate cancer of any stage. This must be taken into account in the interpretation of adjuvant studies of endocrine treatment. Unfortunately, although it leads to volume reduction and downstaging of the primary tumor, neoadjuvant endocrine treatment prior to surgery has not been shown to improve rates of biochemical or clinical progression and/or survival. Neoadjuvant and adjuvant approaches combined with external beam radiotherapy seem to be more effective. Recent data show significant improvements in the time to progression as well as in disease-specific and overall survival following radiotherapy alone as compared with neoadjuvant and/or adjuvant endocrine treatment in addition to radiotherapy. At this time, however, it remains unclear whether endocrine treatment alone might not produce a similar effect. Studies confirming the value of adding radiotherapy to endocrine treatment for T3 disease are urgently needed.

Diagnosis and management of eosinophilic cystitis: a pooled analysis of 135 cases

OBJECTIVE

Eosinophilic cystitis is a rare disease. We reviewed the literature for clinical presentation, diagnosis and therapeutic options to establish recommendations for diagnostic and therapeutic management.

METHODS

A pooled analysis was performed of 135 patients with eosinophilic cystitis presented in the literature. The evaluation included patient age, sex and race, presenting symptoms, diagnostic examinations, treatment and results, and complications.

RESULTS

The mean age at diagnosis was 41.6 years (range 5 days to 87 years). An equal distribution existed between males (44%) and females (35%), but in children (21%) boys were more often affected (14%) than girls (7%). The most common presenting symptoms were frequency (67%), dysuria (62%), gross/microscopic hematuria (68%), suprapubic pain (49%) and urinary retention (10%). All patients had a cystoscopy and biopsy; a biopsy is mandatory to establish the diagnosis. Positive urine cultures were found in 26% of the patients. Periferal eosinophilia was present in 43%. An intravenous urography was performed in 66%, ultrasonography in 15%, cystography in 23% and a CT scan in 10%. The majority of patients was treated with combinations of corticosteroids, antihistaminics and antibiotics (45%), avoiding of the suspected antigen (17%), transurethral resection of the lesions (9%), partial cystectomy (4%) or total cystectomy (4%). The success rates for the different treatments were variable: transurethral resection combined with corticosteroids, antihistaminics or antibiotics seemed most successful, while total cystectomy is reserved for patients with unresponsive disease and hematuria. The most common complications were dilation of the upper urinary tract (27%) and eosinophilic gastroenteritis (4.5%); all other complications occurred in less than 3% of the patients.

CONCLUSION

Eosinophilic cystitis is equally distributed among the sexes, but in children boys are affected more often than girls. The presenting symptoms are frequency, dysuria, hematuria, suprapubic pain and urinary retention. The treatment of choice is (radical) transurethral resection of the lesions in the bladder and a combination of corticosteroids and antihistaminics. Antibiotics are given when a urinary tract infection is present, or when dilation of the upper urinary tract exists. Most patients are cured but recurrence is a frequent finding.

Progression in and survival of patients with locally advanced prostate cancer (T3) treated with radical prostatectomy as monotherapy

PURPOSE

We determine the progression and survival rates in patients with locally advanced prostate cancer treated with radical prostatectomy without adjuvant treatment, and investigate subgroups of patients who may not benefit from this treatment.

MATERIALS AND METHODS

Radical prostatectomy was performed in 83 patients with T3 prostate cancer. The patients were divided in subgroups with T3G1 to 2 and T3G3 tumors, which were evaluated for clinical progression, local recurrence, distant metastases, biochemical progression, and overall and cancer specific survival at 5 and 10 years by Kaplan-Meier curves. The results were compared to those of 190 patients with locally confined tumors.

RESULTS

At 5 and 10 years overall survival was 75 and 60%, and cancer specific survival was 85 and 72%, respectively. At 5 and 10 years clinical progression was 41 and 69%, local recurrence 18 and 44%, and distant metastases 31 and 50%, respectively. Biochemical progression at 5 years was 71%. Patients with poorly differentiated tumors showed significantly lower survival and higher progression rates compared to those with well or moderately differentiated tumors. Progression and survival in patients with T3G1-2 tumor were not significantly different from those for patients with locally confined tumors.

CONCLUSIONS

Radical prostatectomy as monotherapy in patients with locally advanced nonmetastatic prostate cancer (T3) produces acceptable results in those with well or moderately differentiated tumors. The results of progression and survival are not significantly different from those in patients with locally confined prostate cancer. However, patients with poorly differentiated tumors (T3G3) have early progression and need adjuvant treatment following surgery.

[The treatment of locally advanced (T3) prostatic carcinoma using radical prostatectomy or radiotherapy. A review]

In the Netherlands 16% of all newly diagnosed prostatic carcinomas are already locally advanced (TNM-system: T3), which means that the tumor spreads beyond the prostatic capsule, or grows into the seminal vesicles. The pre-operative clinical staging is not very reliable when local tumor extension is concerned: the sensitivity for detecting extracapsular extension is 67% for digital rectal examination and 58% for transrectal ultrasonography of the prostate. In 50% of clinically locally confined tumors spread outside the prostate is found; and in 18% of the T3 tumors the tumor is confined to the prostate. In most clinics patients with locally advanced tumors are not considered to be candidates for radical prostatectomy, because the margins are small, due to anatomical factors. Progression and survival reported in the research literature for patients treated by radical prostatectomy for T3 prostate cancer are, however, at least equal to those treated with radiotherapy, which is considered the standard treatment for this stage. The average 10-year percentages for progression and survival of T3 prostate cancer patients treated by radical prostatectomy (or radiotherapy) are: clinical progression: 40% (radiotherapy: 61%); local recurrence 18% (35%); biochemical progression: 60% (93%); survival: 63% (39%); and prostate cancer specific survival: 78% (44%). These success-rates can not be compared directly, because of differences in physical condition and staging between the groups, which favor the radical prostatectomy group. There is, however, a subgroup of patients with undifferentiated carcinoma which shows high progression rates following radical prostatectomy; these patients need adjuvant hormonal treatment, or should be given a different therapy. The role of adjuvant radiotherapy following radical prostatectomy is still a matter of debate, as is the administration of neoadjuvant hormonal therapy. For the moment these therapies should only be given in clinical trials.

Tumour control according to pathological variables in patients treated by radical prostatectomy for clinically localized carcinoma of the prostate

OBJECTIVE

To evaluate the diagnosis, outcome and final pathology of radical prostatectomy for prostate cancer performed by urologists in a clinic where six urologists perform a total of 50 radical prostatectomies a year, using radical prostatectomy specimens processed routinely.

PATIENTS AND METHODS

Radical prostatectomy was performed in 273 patients who were followed prospectively. The radical prostatectomy specimens were evaluated for pathological stage, histological grade, capsular perforation, positive and apical margins of resection, seminal vesicle invasion, perineural invasion and vascular invasion; the lymph node status was also determined. The relationship between these variables and clinical progression, local recurrence, distant metastases, biochemical progression, overall survival and cancer-specific survival was assessed.

RESULTS

All evaluated variables were significantly predictive for clinical and biochemical progression in the univariate analyses, and all but perineural invasion and lymph node status for cancer-specific survival. Multivariate analysis showed vascular invasion to be the most important prognostic variable, followed by capsular perforation, positive margins of resection and poorly differentiated carcinoma. The overall results for the evaluated variables were comparable to the results from centres with greater experience.

CONCLUSIONS

The outcome of treatment in this small clinic was similar to that from larger clinics with more experience. The routine evaluation of the radical prostatectomy specimens identified pathological variables which were important prognostic factors, with vascular invasion, capsular perforation, positive margins of resection and poorly differentiated carcinoma being the most significant. The extent of vascular invasion should be part of the routine evaluation of radical prostatectomy specimens.

Radical prostatectomy as a monotherapy for locally advanced (stage T3) prostate cancer

Within a prospective protocol initiated in 1977, 100 patients with locally extensive prostate cancer (stage T3, 1982 tumor, nodes and metastasis classification) were treated by pelvic node dissection and radical prostatectomy as monotherapy. Adjuvant treatment was not given until disease progression. Radical prostatectomy, except for 3 young patients with a single micrometastasis, was not done if positive lymph nodes were found at frozen section. Six patients had positive lymph nodes at permanent sections but not at frozen section. Average followup was 43.9 months (range 1 to 155 months). Histological grade was determined according to the Mostofi system. Progression was determined biochemically (prostate specific antigen elevation) and clinically by evidence of metastatic disease, either histologically proved or evidenced as new hot spots on bone scan or chest x-rays. Of the 100 patients 41 did not undergo radical prostatectomy: 39 because of positive lymph nodes and 2 because of evidence of a stage pT4 tumor at surgical exploration. Of those 59 patients who underwent radical prostatectomy 9 had positive lymph nodes, while 2 had stage pT4, 39 stage pT3 and 9 stage pT2 tumors. Only 1 of the 9 patients with lymph node metastases is free of biochemical or clinical progression. Disease also progressed in both stage pT4, 27 of 39 stage pT3 and none of the 9 stage pT2 cases. A total of 22 patients was free of clinical or biochemical progression. Clinical progression was evidenced in approximately half of the cases as distant and local progression. Data on stage T3 disease were compared to those of 129 patients with stages T0 to T2 disease. There was a significant difference in interval to clinical progression for these 2 groups (p = 0.001). However, if grade 3 cases were excluded from the stage T3 group, this difference disappeared. Prognostic factors analyzed were pretreatment and posttreatment grade, pretreatment prostate specific antigen and prostatic acid phosphatase levels, positive margins, seminal vesicle invasion and nodal status. The analysis allows one to identify groups of patients who may benefit and others who certainly do not benefit from radical prostatectomy in this disease category. In the latter group effective adjuvant treatment is urgently indicated.

Positive margins after radical prostatectomy: correlation with local recurrence and distant progression

The impact of positive and negative surgical margins of resection on the interval to and incidence of progression was analysed in 172 patients after radical retropubic prostatectomy combined with lymphadenectomy; 56 had positive margins. Lateral and apical positive margins were evaluated separately. The status of surgical margins was correlated with other prognostic factors, such as the T category, the presence or absence of seminal vesicle invasion and the G category. This analysis showed that positive and negative margins significantly influenced time to progression independently of the other prognostic factors. Positive margins at the apex contrary to lateral margins did not significantly influence time to progression. This may be due to the definition of the status of apical margins used in this analysis. A total of 108 patients underwent a nerve-sparing radical prostatectomy, which did not lead to a higher incidence of positive margins than the standard procedure. Prostate specific antigen accurately predicted tumour recurrence after radical prostatectomy. A rise of > or = 1.0 ng/ml preceded other evidence of recurrence by a mean of 11 months.

Deoxyribonucleic acid ploidy of core biopsies and metastatic lymph nodes of prostate cancer patients: impact on time to progression. The European Organization for Research and Treatment of Cancer Genitourinary Group

We studied 98 patients with locally confined but lymph node positive prostatic cancer (1 stage T1, 29 stage T2, 55 stage T3 and 2 stage T4) who were not treated by radical prostatectomy. A retrospective analysis was done of deoxyribonucleic acid (DNA) ploidy of pretreatment core biopsies of the primary tumor and lymph node metastases. While DNA ploidy has been shown to be an important prognostic factor if applied to radical prostatectomy specimens, core biopsy specimens and nodal metastases have rarely been studied. Of the 98 patients 87 were evaluable for DNA ploidy: 45 (52%) had diploid, 13 (15%) had tetraploid and 29 (33%) had aneuploid tumors. The ploidy of the primary tumor and of the lymph node metastases correlated significantly with the rate of progression and interval to progression. Also, significant correlations were noted between the percentages of cells in the S phase or S plus G2 phases of the cell cycle and interval to progression. Most patients in this study are part of the European Organization for Research and Treatment of Cancer protocol 30846, a prospective randomized study of early versus delayed treatment in lymph node positive, otherwise locally confined prostate cancer. This study is ongoing. Early endocrine treatment was associated with a significantly longer interval to progression. In a Cox regression analysis of the prognostic factors involved in this study, early endocrine treatment was more important than ploidy or proliferation patterns. Stage (T category) and histopathological grade did not show a correlation with progression. Followup is still too short and the numbers of patients are too small for relevant subgroup analysis. DNA ploidy measurement by flow cytometry on archival (paraffin embedded) core biopsy and lymph node material is possible, and produces meaningful results in predicting the prognosis of prostatic cancer. Since this information can be made available before treatment decisions, its exact value in the management of locally confined prostate cancer can be determined.

Prostate specific antigen in screening for recurrence following radical prostatectomy for localised prostatic cancer

Eighty-five patients treated by radical prostatectomy for clinically localised prostatic cancer were followed up for 1 to 4 years with measurement of prostate specific antigen (PSA). Six patients with recurrences had elevated levels (cut-off level was 1.0 ng/ml). PSA is therefore considered an excellent tool for monitoring treatment failures. Levels exceeding 1.0 ng/ml preceded evidence of tumour recurrence by a mean interval of 11 months. PSA offers the possibility of detecting residual prostatic cancer after surgery. It is not known, however, whether these patients would have benefited from adjuvant endocrine or early radiotherapy.

DNA ploidy in cell nuclei from paraffin-embedded material--comparison of results from two laboratories

In 49 pairs of contiguous sections from paraffin-embedded prostatic cancer tissue, the DNA indices (DIs) were determined by flow cytometry (FCM) at 2 different laboratories. In 3 of 45 pairs of evaluable nuclear suspensions, DIs of 1.1 (DNA aneuploid) were found at Laboratory 1, whereas all 3 tumours were classified as DNA diploid at Laboratory 2. In the remaining 42 specimens, the correlation between the DIs was excellent, though the application of strictly defined DNA ploidy ranges led to different DNA ploidy allocation in 3 cases. It is concluded that in 85-90% of the cases, reliable DIs can be obtained by FCM done in paraffin-embedded material at different laboratories. Slight technical variations and interpretation differences may lead to different ploidy allocation in 10-15% of the cases.