The Buschke-Lowenstein tumor (BLT) is a slow-growing, locally destructive verrucous plaque that typically appears on the penis but may occur elsewhere in the anogenital region. It most commonly is considered to be a regional variant of verrucous carcinoma. It is rare but accounts for 5-24% of all penile cancers. It can also affect the perineum and other portions of the genitalia. It was first described by Buschke and Löwenstein in 1925, and is also known as giant condyloma acuminatum (GCA). Regardless of the treatment modality, careful follow-up is recommended because of the high risk of recurrence and the possibility for malignant transformation in 30-56% of patients. We present a case of a 47-year-old Hispanic female that presented to the urology clinic for dysuria and upon work-up was found to have a GCA. GCA typically affects the penis, although the perianal region, vulva, vagina, rectum, scrotum, perineum and bladder may be involved. To date, we believe this is the only reported case of GCA in the urethra of a female patient with sparing of the bladder. This lesion was successfully removed with wide local excision. We believe that further studies are needed to define this disease, identify its pathogenesis, and the most successful treatment protocol.
387 Background: To compare overall survival (OS) in patients undergoing radical cystectomy (RC) and bladder preservation therapy (BPT) for muscle invasive urothelial carcinoma of the bladder. Methods: We conducted a retrospective, observational cohort study in which we reviewed the National Cancer Database (NCDB) to identify patients with analytic stage II-III (N0M0) urothelial carcinoma of the bladder from 2003-2011. BPT patients were stratified as any external beam radiotherapy (EBRT), definitive radiotherapy (RT) [50-80Gy], and definitive RT + chemotherapy. Treatment trends were evaluated using Pearson Chi-square tests. OS was compared between RC and BPT using unadjusted Kaplan Meier curves and Cox regression models adjusted for year of treatment, hospital volume, and patient/tumor characteristics using increasingly stringent selection criteria to identify those undergoing BPT. Results: Of the 603,298 patients with bladder cancer captured in the NCDB from 2003-2011, 9% (n = 54,518) had analytic stage II-III with urothelial histology. 51.1% (n = 27,843) of these patients were treated with RC (70.9%, n = 19,745) or BPT (29.1%, n = 8,098). Of the patients undergoing BPT, stratified by selection criteria, 26.9% (n = 2,176) and 15.0% (n = 1,215) were treated with definitive RT and definitive RT + chemotherapy, respectively. Following adjustment, improved survival in patients undergoing RC was noted regardless of BPT definition employed in multivariate analysis. However, we noted attenuated differences in OS using increasingly stringent definitions for BPT (EBRT: HR 2.2 [CI 2.15-2.29]; definitive RT: HR 1.94 [CI 1.74-2.14]; definitive RT + chemotherapy: HR 1.56 [CI 1.45-1.68]). Conclusions: In the NCDB, receipt of BPT was associated with decreased OS compared to RC in all patients with stage II-III urothelial carcinoma, in part due to selection biases. However, the use of increasingly stringent definitions of BPT attenuated the observed survival differences. Further randomized prospective controlled trials are needed to compare trimodal BPT to RC to identify optimal candidates for bladder preservation.
ANOVA and chi-square. Multiple significant associations were compared by logistic regression.RESULTS: Median Age, PSA and PSAD were 65 years, 5.5 mg/ml and 0.159. 218/366 (59.7%) were diagnosed with prostate cancer by TPMB with a median of 7.0 cores positive. 11/258 (4.3%) of the men who had TRUS biopsy developed urinary tract infections compared 3/336 (0.89%) of those with mapping biopsy. Age, number of TRUS biopsies (mean 1.5, range 1-9), or PV were not associated with TRUS infections. None of the 11 men with TRUS infections developed an infection after TPMB. Neither the number of cores taken by TPMB or a larger PV was associated with infection. 2 of the 3 men who developed infection after mapping also had post-TPMB urinary retention (OR 27.0, 95% CI 2.4-308.6, p<0.001). No TRUS biopsy men developed retention while 27/336 (7.4%) did following TPMB. Mean age, PV and core number was higher in retention patients (69.5 vs 64 years, p¼0.001, 62.6 vs 46 cc, p<0.001 and 62.6 and 56.9 cores, p¼0.011). PSA, PSAD, prior TRUS biopsy, number of prior TRUS biopsies and diagnosis of cancer was not associated with retention. Linear regression revealed age (p¼0.001), PV (p¼0.010) and number of cores (0.061) as significant.CONCLUSIONS: Urinary tract infections are 5x more common in TRUS biopsy compared to TPMB. A TRUS biopsy followed by a mapping biopsy does not increase the risk of a urinary tract infection. Men who develop retention after TPMB are much more likely to develop an infection (7.4% vs 0.3%). Urinary retention occurred in 7.4% and was associated with older age and increased prostate size. These data should be helpful in counseling men who desire prostate biopsy by TPM.
Gross hematuria has several different etiologies, and as such, the process of working up a patient presenting with bleeding follows an outlined algorithm. The instillation of formalin, a caustic substance that hydrolyzes proteins and coagulates tissues, is a possible treatment option only when patients have failed previous preceding therapeutic steps. In our case, a 69-year-old African-American male presented with an acute episode of gross hematuria that did not resolve following several diagnostic and therapeutic steps. His hospital course was complicated by a steadily dropping hemoglobin, requiring many blood transfusions throughout his care. He was successfully treated with intravesical instillation of formalin following cystoscopy, transurethral resection of the prostate, and cystogram in the operating room. Thoughtful discussion regarding a treatment course in a patient with refractory gross hematuria deserves consideration.
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