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Upon physical examination, tenderness in the suprapubic arera was present. Upon cytoscopy, as the bladder was filled with saline the patient experienced increasing suprpubic pain with as little as 90 ml of fluid.
The patient was treated with oral sodium pentosan-polysulfate 50 mg q 4 days. This resulted in relief from urgency frequncy and nocturia.
PHYSICAL EXAMINATION: The patient was a well-developed male with a temperature of 37.1 oC, pulse of 88 beats per minute, and blood pressure of 148/90 mm Hg. Examination of the central nervous system, cardiopulmonary system, a gastrointestinal system was unremarkable. Rectal examination showed no evidence of external hemorrhoids. Sphincter tone was normal and no rectal masses were palpated. Examination of the prostate demonstrated a 1.5 x 1.0 cm raised and indurated lesion on the rightlateral portion of the posterior lobe. Seminal vesicles were unremarkable and the prostate and adnexa were freely movable. Elevated blood levels of prostate specific antigen, was detected.
HOSPITAL COURSE: The patient was admitted to the hospital urology service the next morning with the diagnosis of probable prostatic carcinoma. Trans-rectal needle biopsy of the prostate was performed and showed a well-differentiated adenocarcinoma. The patient underwent a radical perineal prostatectomy and bilateral orchidectomy during his third hospital day. PATHOLOGIC EXAMINATION: The specimen weighed 42 grams and was grossly identifiable as prostate with attached seminal vesicles. The immediate right lateral portion of the posterior lobe contained a 1.5 x 1.3 cm firm nodule. Serial sections of the gland in the transverse plane demonstrated a subcapsular focus of bright yellow tissue in the aforementioned nodule . The periurethral tissue was spongy and nodular. Microscopic examination of the indurated subcapsular nodule showed the presence of well-differentiated glandular structures formed by a single layer of well-oriented tall columnar cells with abundant vacuolated cytoplasm, enlarged nuclei, and prominent nucleoli. These glands could be found within perineural spaces; no extension outside the capsule or into the seminal vesicles was present. The peri-urethral tissue contained numerous adenomatous nodules. Final anatomic diagnosis was well-differentiated prostatic adenocarcinoma and benign prostatic hyperplasia. FOLLOWUP: The patient was discharged from the hospital during the second postoperative week. Postoperative complications have included only impotence without incontinence; no evidence of metastatic spread has appeared during the ensuing six months.
HOSPITAL COURSE: The patient was admitted to the urology service of the local hospital three days later where he underwent a right inguinal orchiectomy with complete removal of the spermatic cord, contents of the inguinal canal, and intact testicle. While under anesthesia, the general surgeons performed a left scalene fat pad biopsy.
PATHOLOGIC EXAMINATION: The tunica albuginea of the moderately enlarged testicle contained numerous dilated venous channels. The sectioned testicle demonstrated the presence of a homogeneous grayish white lobular mass which bulged above the cut surface and had a soft consistency. No foci of hemorrhage, necrosis, or extension beyond the tunica albuginea or into the cord could be shown. Microscopic examination revealed the tumor to be composed of lobules and sheets of large polyhedral cells with clear cytoplasm, centrally located hyperchromatic nuclei, and distinct basophilic nucleoli. The stroma subdividing the tumor was composed of fine strands of connective tissue containing moderate numbers of mature lymphocytes. The biopsied supraclavicular fat pad demonstrated only scattered aggregates of lymphoid tissue and few lymph nodes without significant histopathologic change.