Biomedical subjects
Publications and source records attributed to R E Donohue.
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To evaluate the effectiveness and clinical outcome of patients treated by balloon dilatation of the prostate (BDP) compared with transurethral resection of the prostate (TURP) we performed a prospective, randomized clinical trial. Fifty-one men were randomized to either BDP or TURP. Both groups demonstrated a significant decrease in symptom score from preoperative levels (TURP 13.6 to 6.0 [p < 0.05]; BDP 14.1 to 8.1 [p < 0.01] at 1 year). The TURP group improved peak urinary flows; while, after initial improvement, the balloon group returned to pre-procedure levels. At twelve months 14 of 19 BDP patients (74%) and 14 of 18 TURP patients (78%) considered themselves improved. BDP results in symptomatic improvement; however, the effect may not persist. Objective improvement after BDP does not always occur. The morbidity of BDP is low and compares favourably to that of TURP. Thus BDP does not appear to be as effective as TURP and may offer only temporary relief of symptoms.
A multicenter, randomized, open label study compared the safety and efficacy of a single dose of oral lomefloxacin, a broad-spectrum antimicrobial agent of the quinolone class, to a single parenteral dose of cefotaxime, a third generation cephalosporin, for prophylaxis in transurethral surgery. Of the 230 patients initially recruited 182 were considered evaluable: 92 in the lomefloxacin group and 90 in the cefotaxime group. Both study groups were well balanced with respect to demographics and transurethral procedures. Efficacy and safety were evaluated with urine cultures, clinical laboratory evaluations and monitoring of adverse events. The success rate among the lomefloxacin patients was 98% versus 94% in the cefotaxime patients. The difference was not statistically significant. Adverse events, regardless of attributability, were reported by 16% of the lomefloxacin patients and 17% of the cefotaxime patients, respectively. Our results indicate efficacy and safety profiles of lomefloxacin equivalent to cefotaxime. Lomefloxacin has the economic advantage of an oral route of administration compared to the parenteral route of cefotaxime for prophylaxis in transurethral genitourinary procedures.
The first reported case of bilateral renal hemangiopericytoma is presented. The 19 previous renal hemangiopericytomas that have been reported in the world literature are reviewed. This lesion has afflicted patients ranging in age from sixteen to sixty-eight years (mean 41 years) with an equal sex distribution. Mortality from hemangiopericytoma of the kidney has been 50 percent, and the primary mode of therapy remains surgical.
Clinical understaging abounds in adenocarcinoma of the prostate. The preoperative prostate-specific antigen is not useful in preoperative staging, although enzymatic acid phosphatase elevation is associated with positive nodes in two-thirds of patients. Whole mount evaluation of radical prostatectomy specimens reveals tumor multicentricity in more than half the patients and tumor extension beyond the prostatic capsule in the majority of patients. A significant number of patients have a final tumor grade higher than that initially assigned. Capsule penetration by tumor is a factor of tumor grade as is volume.
Pelvic lymphadenectomy is the final staging procedure before institution of therapy for patients with clinically locally confined adenocarcinoma of the prostate, a normal acid phosphatase, and a bone scan free of metastatic disease. The pathologic information it provides cannot be accurately acquired at the present time by any other method. Extraperitoneal lymphadenectomy is associated with some morbidity intraoperatively and in the early postoperative period. We enumerate our results with 284 extraperitoneal lymphadenectomies.
The distribution of skeletal metastases in prostatic and lung cancer was examined to test the hypothesis that prostatic carcinoma spreads by a unique hematogenous route. Abnormal technetium-99m methylene diphosphonate bone scans were retrospectively reviewed in 71 patients with prostatic carcinoma and 41 patients with lung cancer comparing patterns of osseous involvement. Differences in the distribution of lesions were not significant. It is concluded that prostatic carcinoma does not metastasize to specific skeletal sites by a singular hematogenous pathway.
Pelvic exenteration has a high complication rate due, in large part, to the extensive raw surfaces and dead space it creates. Numerous techniques have been used to control this space and line these surfaces, but none, to date, has proven to be a reliable solution. We investigated the use of continent ileocolonic urinary reservoirs as a new "flap" to fill and line the pelvis in 17 patients, and found that our historical complication rate of 44% for pelvic exenteration was reduced to 18%. These reservoirs appear to be an improved method of managing the post-exenteration pelvis.
Between 1980 and 1987, we operated on 23 patients (16 men and 7 women) with fixed rectal cancer. Two patients had primary tumours. Twenty-one patients had recurrent disease (anterior resection, 8; abdominoperineal resection, 13). Eighteen patients had prior irradiation (40 Gy to 120 Gy). Resection was possible in 20 patients (16 for cure and 4 for palliation). Operations included extended proctectomy (n = 4), standard pelvic exenteration (n = 4), and sacropelvic exenteration (n = 12). One (5%) patient died postoperatively and five (25%) others had significant postoperative complications. With a follow-up time of 1 to 48+ months (median, 18 months), nine patients are dead of disease (operative death included), four are living with disease, two are dead free of disease, and eight (50% of those undergoing curative resection) are living free of disease. The results suggest that resection of fixed rectal cancer is feasible in many patients and of potential long-term benefit to approximately 50% of those in whom curative resection is possible.
The vas deferens is infrequently palpated at the time of routine physical examination or even during examination of the scrotum. Its absence, especially unilaterally, has been associated both clinically and at the time of autopsy with ipsilateral renal anomalies, especially agenesis. Twenty-six patients with unilateral agenesis of the vas deferens were examined for the presence of an ipsilateral renal unit; 25 patients were examined by intravenous pyelography and one by bone scan. Twenty-two patients were missing the ipsilateral renal unit. Contralateral abnormalities occurred in seven (33%) of these 22 patients also. The absence of the vas deferens is a significant anomaly, and examination for the presence of the ipsilateral renal unit is mandatory.
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Postirradiation "fixed" anorectal tumors are often considered incurable. Since 1980, we have carried out 12 pelvic and seven sacropelvic exenterations for this problem (adenocarcinoma, 18; squamous cancer, one). Nine tumors were primary; ten were recurrent (five after an anterior resection and five after an abdominoperineal resection). Prior irradiation ranged from 3000 to 12,000 rad (30 to 120 Gy). Four patients had synchronous distant metastases; three died of disease (one with local recurrence), and the fourth patient has been living with disease (distant metastasis). Fifteen patients (four with B2 tumors and 11 with Astler-Coller C2 disease) had no extrapelvic disease. One patient died of postoperative complications; two others died free of disease. Three of the 15 patients died of disease (all with local recurrence), and one has been living with disease (local recurrence). Eight (53%) of 15 patients have been living free of disease 12+ to 53+ months. The results suggest that many patients with fixed postirradiation anorectal tumors may be salvaged by aggressive surgery.
The natural history of Stage D1 adenocarcinoma of the prostate remains unclear. In a series of 50 patients with positive pelvic lymph nodes at the time of staging lymphadenectomy, metastatic disease developed in 43 per cent of the patients treated for cure within the period of time of follow-up. Several series from the literature confirm those findings. Positive pelvic lymph nodes most probably represent systemic disease, and the patients are incurable by current surgical and radiotherapeutic modalities.
Of 343 patients who underwent pelvic lymph node dissection during treatment for carcinoma of the prostate 25 had persistently elevated serum enzymatic acid phosphatase levels preoperatively: 15 (60 per cent) had metastases to the pelvic lymph nodes and 10 (40 per cent) had negative nodes. Bone metastases occurred in 10 of 12 (83 per cent) and 5 of 7 patients (71 per cent), respectively, who were followed for a minimum of 2 years. Of the 318 patients with normal serum enzymatic phosphatase levels 70 (22 per cent) had positive nodes. A persistently elevated serum enzymatic acid phosphatase level in patients with proved carcinoma of the prostate, with elimination of infrequent causes of enzyme elevation, indicates metastases and has significant implications regarding staging and, thus, therapy of this disease.
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Two hundred fifteen patients have undergone pelvic node dissection in clinical Stages A1, A2, B1, and B2 adenocarcinoma of the prostate as a final staging procedure. Two hundred four patients have had the tumor grade assessed adequately and the influence of the grade on the results of the node dissection evaluated. As the grade of the primary tumor worsens in each clinical stage, the incidence of positive nodes increases.
Metastatic tumors to the stomach are distinctly unusual. Rarer still is renal cell carcinoma metastatic to the stomach following radical excision of the primary tumor several years previously. During evaluation for an upper gastrointestinal hemorrhage, a patient was found to have a large antral mass. Endoscopic biopsy revealed renal cell carcinoma. At celiotomy the tumor was found to have penetrated through to the liver capsule. An antrectomy and wedge resection of the left lobe of the liver was performed. There was no evidence of further metastatic disease. This is the first report of such a patient resected for cure, and emphasizes the unique biology of this tumor in its potential for late, solitary metastasis and surgical resectability.
The obturator nerve passes in close proximity to the inferolateral bladder wall, bladder neck and lateral prostatic urethra. During a transurethral operation resection in these areas may result in stimulation of the obturator nerve, causing violent adductor contraction and possible inadvertent bladder perforation. To block this reaction d-tubocurarine and succinylcholine can be used during general anesthesia. However, it often is preferable to use spinal anesthesia during transurethral operations. Local anesthetic blockade of the obturator nerve as it passes through the obturator canal if effective for adductor spasm during spinal anesthesia. We herein describe the anatomy, pharmacology, technique and results of local obturator nerve blockade.