Comparison of lower urinary tract symptoms between women with detrusor overactivity and impaired contractility, and detrusor overactivity and preserved contractility

PURPOSE

We compared symptoms in women with detrusor overactivity with impaired contractility and women with detrusor overactivity who had preserved contractility.

MATERIALS AND METHODS

The study included 359 consecutive women with detrusor overactivity who underwent multichannel urodynamics at our department between 2009 and 2011. The women were divided into 2 groups, including 151 (42%) with detrusor overactivity and impaired contractility, and 208 (58%) with detrusor overactivity and preserved contractility. We compared the 2 groups.

RESULTS

Women with detrusor overactivity and impaired contractility were older (mean ± SD age 73.2 ± 17.3 vs 54.1 ± 20.7 years) with a higher frequency of diabetes mellitus (49% vs 31%, each p <0.001). The prevalence of previous urinary retention and recurrent cystitis was significantly higher in women with impaired contractility (7% vs 1%, p <0.01 and 22% vs 7%, p <0.001, respectively). Mean post-void residual urine was greater in the group with impaired contractility (89 ± 42 vs 21 ± 18 ml) and the mean maximal flow rate was lower (11 ± 6 vs 23 ± 5 ml per second, each p <0.001). The frequency of storage symptoms was similar in the 2 groups. However, voiding symptoms were more common in women with impaired contractility, including a slow stream in 69% vs 42%, an intermittent stream in 72% vs 26%, hesitancy in 35% vs 22%, straining in 84% vs 26%, terminal dribbling in 73% vs 42% and incomplete emptying in 71% vs 49% (p <0.001).

CONCLUSIONS

Women with detrusor overactivity and impaired contractility are older than women with detrusor overactivity and preserved detrusor contractility. Urinary retention and recurrent cystitis are more frequent in women with detrusor overactivity and impaired contractility, and voiding symptoms are significantly more common.

Is transureteroureterostomy performed during multi-organ resection for non-urothelial malignancy safe and effective?

BACKGROUND

Multi-organ resection in patients with non-urothelial cancer may include segmental ureteral resection. The resulting ureteral defect can be reconstructed with a transureteroureterostomy (TUU); however, whether TUU is safe and effective in this patient group remains unclear.

OBJECTIVES

In the current retrospective analysis, we evaluated renal function before and after complex multi-organ resection that included TUU to determine whether TUU is safe and effective.

METHODS

We retrospectively reviewed the charts of patients who underwent TUU between 1995 and 2011. Renal imaging studies performed before and after TUU were used to determine whether hydronephrosis was present in either kidney. Kidney function was assessed by measuring serum creatinine levels and calculating the estimated glomerular filtration rate (eGFR) before and after TUU.

RESULTS

Twelve patients underwent TUU during multiorgan resection. Median follow-up time was 15 months. Three patients with cancer recurrence involving the TUU developed progressive hydronephrosis. Serum creatinine levels did not increase more than 0.5 mg/dl in any patient. Kidney function as assessed by eGFR was maintained in all patients (until the time of recurrence in the three patients with recurrence affecting the TUU).

CONCLUSIONS

TUU during multi-organ resection for non-urothelial malignancy is safe and effective. Long-term renal function is maintained in the majority of patients.

Autonomic response during bladder hydrodistention in patients with bladder pain syndrome

PURPOSE

We determined whether patients with bladder pain syndrome who have typical interstitial cystitis endoscopic findings, including glomerulations and/or Hunner ulcer, have a distinct autonomic response during bladder hydrodistention.

MATERIALS AND METHODS

Included in the study were 50 consecutive patients (40 females and 10 males) who met International Society for the Study of BPS recommendations. All patients underwent the same clinical evaluation, consisting of medical history, physical examination, urine and blood tests, urine cytology and culture, urinary tract ultrasound and urodynamics. Bladder hydrodistention and biopsies were performed using general anesthesia. Systolic and diastolic blood pressure, and heart rate were recorded after the induction of general anesthesia and at the end of the filling phase. Patients were divided into 2 groups, including patients with and without typical endoscopic findings, respectively. Clinical, histological and urodynamic variables, and autonomic parameters were compared between the 2 groups.

RESULTS

No significant differences in demographics, symptoms, pain severity, comorbidities, previous surgery, urodynamic variables, anesthetic bladder capacity or histological findings were found between the 2 groups. In patients with endoscopic findings average ± SD systolic and diastolic blood pressure increased by 25 ± 19 and 21 ± 12 mm Hg, respectively, and average heart rate increased by 12 ± 11 beats per minute. All hemodynamic changes were statistically significant (p <0.001). In patients without endoscopic findings a minor decrease in hemodynamic parameters was observed.

CONCLUSIONS

Patients with bladder pain syndrome who have typical interstitial cystitis findings on endoscopy show a marked autonomic response during bladder hydrodistention, consisting of an increase in heart rate, and systolic and diastolic blood pressure.

[Is the rate of medical publication from Israel similar to other countries? A comparative study of three medical specialties]

Academic careers of individual doctors are commonly evaluated by examining the number and quality of authored publications. Similarly, the extent and quality of medical research may be assessed nationwide by measuring the number of publications originating from the country of interest over time. This in turn, may indicate on the quality of medicine practiced. To evaluate the extent and quality of IsraeLi publications we measured the rate and quality of medical publications originating from Israel for two decades in the fields of urology, cardiology and orthopedics, and compared the data to those of other countries.

METHODS

Leading journals in urology, cardiology, and orthopedics were selected. A Medline search (http://www.ncbi.ntm.nih.gov/sites/entrez] was conducted for all the publications originating in Israel between the years 1990-2009 in the selected journals. Data from Israel was compared to those from Italy, France, Germany, Egypt and Turkey. The change in rate of publications was tested using Linear regression. The quality of publications was calculated by multiplying the number of publications by the relevant impact factor.

RESULTS

While the urology publications rate in Israel increased by 32.7% in the second study decade as compared with the first, the urology publication rates during the same time period from Italy, France, Germany, Egypt and Turkey were 199%, 115%, 184%, 180% and 227% respectively. The regression coefficient for the urology publication rate was 0.51 for Israel, and 0.78, 0.95, 0.78, 0.87 and 0.97 for the other countries, respectively. The regression coefficient for the change in the quality of publications from Israel was 0.31 and 0.81, 0.75, 0.92, 0.73, and 0.92 for the other countries, respectively. In cardiology, the Israeli publication rate increased by 26% during the second study decade, whereas in the other countries the increments were 46%, 35%, 76%, 80% and 309% respectively. The regression coefficient for Israeli pubLication rate was 0.45, and 0.78, 0.54, 0.62, 0.13 and 0.75 for the other countries, respectively. The regression coefficient of the quality of publications in Israel was 0.3 as opposed to 0.47, 0.36, 0.48, 0.01, and 0.78 respectively. The Israeli publications in orthopedics increased by 9.3% during the second decade compared with the first. At the same time, other countries increased the publication rate in orthopedics by 69%, 121%, 173%, 140% and 296% respectively. The regression coefficient for the publication rate in orthopedics was 0.02 for Israel, and 0.62, 0.64, 0.78, 0.34 and 0.71 for the other countries, respectively. The regression coefficient of the quality of publications in Israel was 0.05 as opposed to 0.67, 0.62, 0.75, 0.31, and 0.66 in the other countries, respectively.

CONCLUSIONS

Israel lags behind Italy, France, Germany, Egypt and Turkey with regard to the increase of both the number and the quality of medical publications in urology and orthopedics. While the rate and quality of IsraeLi publications in cardiology surpasses those from Egypt, they lag in the number of publications in this medical field behind those of all the rest of the countries examined. In a world of rapid progress and expansion of medical research, Israel has been stagnant in publications in 3 medical specialties, rendering it inferior to other nations.

The predominance of benign histology in small testicular masses

OBJECTIVES

To evaluate the concordance between testicular tumor size and benign histology in order to identify a cut-off size, below which the rate of benign lesions would be highest.

METHODS AND MATERIALS

During the years 1995-2008, we performed 131 consecutive testicular operations for testicular tumors. Ten of these were testicular preserving surgery, whereas the other 121 patients had radical orchiectomy. We searched for the rate of benign lesions in the following 3 groups of tumor diameter: 10 mm or less, 11-20 mm, and greater than 20 mm. ROC analysis was used to find the optimal size cut-off below which the rate of benign lesions would be highest.

RESULTS

Benign lesions were found in 11 patients (8%), including epidermoid cyst (n = 4), Leydig cell tumor (n = 3), fibrosis (n = 1), adenomatoid tumor (n = 2), and 1 patient with a simple cyst. Small tumor size strongly correlated with benign histology. The mean diameter of benign vs. malignant lesions was 15 mm and 41 mm, respectively (P < 0.05). The rate of benign lesions in tumors with a diameter of 10 mm or less, 11-20 mm and greater than 20 mm was 50%, 17%, and 2%, respectively. Receiver Operating characteristic (ROC) analysis with 87% sensitivity and 83% specificity revealed a cut-off value of 18.5 mm tumor diameter below which the proportion of benign lesions was 38.5% compared with 2% above it (P < 0.05).

CONCLUSIONS

While benign lesions comprise only 8% of all testicular tumors, their proportion among small lesions is much higher. With a size cut-off of 18.5 mm, 38.5% of smaller lesions are benign. These findings support consideration of testicular exploration for small testicular lesions aiming at preservation rather than predetermined radical orchiectomy.

Carbon dioxide-based nephroscopy during laparoscopic pyeloplasty provides suboptimal view when stones are located in the lower calices

Flexible nephroscopy while using carbon dioxide to insufflate the collecting system has been described as a "good trick" to remove caliceal stones during laparoscopic pyelolithotomy. We found this true only for those calices with undisturbed urine drain into the renal pelvis, while it provided suboptimal view of stones that were located in dependent lower pole calices. We describe how we dealt successfully with a group of lower pole caliceal stones during laparoscopic pyeloplasty.

Sex, age, and surgeon decision on nephron-sparing surgery are independent predictors of renal masses with benign histologic findings--a multicenter survey

OBJECTIVES

To define the preoperative independent predictors indicating that renal mass has benign histologic features.

METHODS

A total of 1664 patients with Stage T1-T2N0M0 with a unilateral renal mass underwent nephrectomy. The endpoint at multivariate analysis was benign versus malignant histologic features.

RESULTS

The surgical approach (odds ratio [OR] 2.9, P = .0001), sex (OR 1.97, P = .0001), and age (OR 1.01, P = .007) were independent predictors for the malignant-benign distinction. Malignant tumors were more likely to occur in men (878 of 1009, 87%) versus women (515 of 651, 79%; P <.001). A weak relationship was found between an increasing tumor size and malignancy risk in men only. High-grade renal cell carcinoma was more prevalent in men (31% versus 21%, P = .001). The histologic tumor types were distributed differently between the 2 sexes: 8% papillary renal cell carcinoma in women versus 16% in men, 86% and 78% clear cell renal cell carcinoma, 33% and 57% oncocytoma, and 40% versus 12% angiomyolipoma, respectively. The physician's preoperative judgment regarding tumor amenability for nephron-sparing surgery resulted in patient selection: 10% benign tumors for radical nephrectomy versus 25% for partial nephrectomy (P = .001) and 31% versus 20% high-grade tumors, respectively (P = .0001).

CONCLUSIONS

Renal tumors were consistently benign in 20% of women, regardless of size. In contrast, in men, the malignancy risk increased slightly with tumor size. The surgeons' preoperative decision regarding nephron-sparing surgery caused a selection bias in favor of benign lesions, regardless of sex. Our findings support the possibility of basing treatment decisions on the preoperative biopsy findings. Such changes could alter current practice and limit treatment of histologically proven benign lesions to surveillance or ablation only.

Testicular sparing surgery for small masses

OBJECTIVES

To determine the proportion of benign testicular lesions among candidates for testicular sparing surgery (TSS) and to assess the safety and efficacy of this procedure.

METHODS AND MATERIALS

Sixteen patients underwent surgical exploration for testicular tumors with TSS intent in our center. Surgery was performed via an inguinal approach with temporary cord occlusion and frozen section (FS) analysis of the lesions. Benign findings allowed for TSS, whereas cancer prompted total orchiectomy.

RESULTS

The lesions measured 8-25 mm in the largest diameter. Eleven of the 16 lesions were benign (69%) and TSS was accomplished in these cases. Complete concordance was observed between the results of FS and permanent sections. Of the 5 patients with cancer, 3 had pure seminoma, and embryonal carcinoma and teratoma were found in 1 patient, each. Surveillance was applied in 4 of these patients, and chemotherapy was used in the patient with embryonal carcinoma. With an average follow-up duration of 48 months, all are alive and free of disease. All 11 patients in whom TSS was accomplished had an uneventful postoperative course, and with an average follow-up duration of 28 months, 9 have normal scrotal physical examination and ultrasound, whereas 2 patients were lost to follow-up.

CONCLUSIONS

Sixty-nine percent of testicular lesions under 25 mm are benign. TSS is safe and effective in patients with small benign lesions. Cancer is reliably detected by FS, and testicular exploration is not associated with local or distant recurrence in any of our patients.

Positive surgical margins with renal cell carcinoma have a limited influence on long-term oncological outcomes of nephron sparing surgery

OBJECTIVES

To define the rate of positive surgical margins (PSMs) and analyze the outcome of patients with PSMs. The outcome and proper management of patients with positive PSMs during nephron sparing surgery (NSS) are questionable. In this study we define the clinical outcomes of PSMs at NSS and suggest management.

METHODS

Clinical records of 114 renal units who underwent open NSS for a renal mass between May 1995 and September 2005 were reviewed.

RESULTS

PSMs were suspected on frozen section in 17 of 114 renal units (15%). Tumors with suspected PSMs at frozen section were smaller (2.9 +/- 1.6) in comparison to those with negative surgical margins (3.4 +/- 1.8 cm) (P = .001). Nine of 17 (53%) cases underwent total nephrectomy (5 immediately, 4 delayed). In 4 (24%), immediate re-excision of the renal crater was performed. A total of 4 (24%) that were followed up clinically were with no evidence of disease. Therefore, in 13 of 17 (77%) cases, the presence of tumor cells at the remaining side of the kidney could be evaluated histologically. In 2 cases from the immediate response group, tumor cells were found in the side opposite to the resection. There was no residual tumor in any case subjected to delayed nephrectomy. At median follow-up of 71 months, 15 of 17 patients are alive and with no evidence of disease. Two patients died because of unrelated causes. The overall 5-year survival rate is 98.2% and there is no cancer-specific mortality.

CONCLUSIONS

The true PSM rate is in the range of 1.75%-5.26%. No disease progression or deaths attributable to renal cell carcinoma were associated with PSMs. Total nephrectomy should be avoided as a response to PSMs.

[Palliative surgery for locally advanced prostate cancer]

Local progression of prostate cancer occurs when the tumor grows beyond the prostatic capsule and invades adjacent structures such as the urinary bladder, rectum, pelvic side-wall and ureters. This is an important clinical event that can in itself cause significant morbidity, impaired quality of life and even mortality. Patients with this condition may experience urinary symptoms due to bladder outlet obstruction by the tumor mass, ureteral obstruction and renal failure, hematuria due to invasion of the tumor into the bladder, and pelvic pain, constipation or tenesmus, as a result of rectal involvement. In the absence of metastasis, some patients with Locally advanced prostate cancer (LAPC) may survive for Longer than 5 years. Therefore, effective and durable palliation is necessary to reduce morbidity and maintain patient quality of life. ALthough the majority of the patients with LAPC cannot be cured by any currently available modality, effective palliation is an independent clinical endpoint. This article presents the LAPC syndrome and treatment options.

Ductal adenocarcinoma of the prostate: clinical features and implications after local therapy

BACKGROUND

Ductal or endometrioid adenocarcinoma of the prostate may be a subtype of prostate cancer that is amenable to aggressive local therapeutic strategies. The authors of this report investigated the clinical outcome of patients who had prostate ductal adenocarcinoma after primary radical prostatectomy or radiotherapy.

METHODS

The clinical features of 108 patients with locally confined or advanced prostate ductal adenocarcinoma who had undergone primary radical prostatectomy (surgical group, n = 76 men) or no surgery (nonsurgical group, n = 32 men) were evaluated retrospectively. Clinical records were reviewed, and Gleason scores, clinical/pathologic stages, and preoperative prostate-specific antigen levels were examined. The clinical features that were assessed included local recurrence, distant metastasis, and progression-free and overall survival after primary therapy.

RESULTS

In the surgical group, patients who had pure ductal prostate cancer survived longer (median, 13.8 years; 95% confidence interval [CI], from 13.8 years to not attained) than patients who had mixed ductal prostate cancer (median, 8.9 years; 95% CI, from 7.1 years to not attained; P = .05). In addition, the median time to local progression was shorter (2.8 years vs 4.9 years) and the median time to distant metastasis was longer (3.9 years vs 2.0 years) for patients who had pure ductal adenocarcinoma than for patients who had mixed ductal adenocarcinoma of the prostate after surgery, respectively.

CONCLUSIONS

The results of this preliminary study suggested that pure ductal prostate adenocarcinoma tends to pursue an indolent clinical course and poses an increased risk for local recurrence. Local control (particularly prostatectomy) may improve the clinical outcome of patients with pure prostate ductal adenocarcinoma. These results need to be confirmed in prospective studies.

Locally recurrent prostate cancer after initial radiation therapy: a comparison of salvage radical prostatectomy versus cryotherapy

PURPOSE

We compared the treatment outcomes of salvage radical prostatectomy and salvage cryotherapy for patients with locally recurrent prostate cancer after initial radiation therapy.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of patients who underwent salvage radical prostatectomy at the Mayo Clinic between 1990 and 1999, and those who underwent salvage cryotherapy at M. D. Anderson Cancer Center between 1992 and 1995. Eligibility criteria were prostate specific antigen less than 10 ng/ml, post-radiation therapy biopsy showing Gleason score 8 or less and prior radiation therapy alone without pre-salvage or post-salvage hormonal therapy. We assessed the rates of biochemical disease-free survival, disease specific survival and overall survival in each group. Biochemical failure was assessed using the 2 definitions of 1) prostate specific antigen greater than 0.4 ng/ml and 2) 2 increases above the nadir prostate specific antigen.

RESULTS

Mean followup was 7.8 years for the salvage radical prostatectomy group and 5.5 years for the salvage cryotherapy group. Compared to salvage cryotherapy, salvage radical prostatectomy resulted in superior biochemical disease-free survival by both definitions of biochemical failure (prostate specific antigen greater than 0.4 ng/ml, salvage cryotherapy 21% vs salvage radical prostatectomy 61% at 5 years, p <0.001; 2 increases above nadir with salvage cryotherapy 42% vs salvage radical prostatectomy 66% at 5 years, p = 0.002) and in superior overall survival (at 5 years salvage cryotherapy 85% vs salvage radical prostatectomy 95%, p = 0.001). There was no significant difference in disease specific survival (at 5 years salvage cryotherapy 96% vs salvage radical prostatectomy 98%, p = 0.283). After adjusting for post-radiation therapy biopsy Gleason sum and pre-salvage treatment serum prostate specific antigen on multivariate analysis salvage radical prostatectomy remained superior to salvage cryotherapy for the end points of any increase in prostate specific antigen greater than 0.4 ng/ml (HR 0.24, p <0.0001), 2 increases in prostate specific antigen (HR 0.47, p = 0.02) and overall survival (HR 0.21, p = 0.01).

CONCLUSIONS

Young, healthy patients with recurrent prostate cancer after radiation therapy should consider salvage radical prostatectomy as it offers superior biochemical disease-free survival and may potentially offer the best chance of cure.

Association between tamsulosin and intraoperative "floppy-iris" syndrome

Intraoperative "floppy-iris" syndrome is a novel entity that was initially described in 2005 by Chang and Campbell who encountered it during cataract surgery. The manifestations include a triad of the following intraoperative findings: (a) flaccid iris stroma leading to fluttering and bellowing of the iris, (b) prolapse of the iris through the surgical incisions, and (c) progressive pupil constriction. IFIS has been associated with increased surgical difficulty and, as a result, with increased morbidity including retinal detachment and loss of vision. Since the initial publication of IFIS in 2005, there have been several reports of a possible association between the use of tamsulosin for symptomatic prostate hyperplasia and IFIS. Consequently, in 2005 the U.S. Food and Drug Administration issued an alert recommending ophthalmic examination prior to treatment with tamsulosin. In this review we present evidence of the association between tamsulosin and IFIS. We conducted a Medline search using the key words tamsulosin or alpha-blockers and retrieved English written reports and data on the prevalence of treatment with alpha-blockers in general and specifically tamsulosin among patients undergoing cataract surgery, the prevalence of IFIS among treated versus non-treated patients, and the resulting surgical complications. Of the 19 publications on this topic only 7 were patient series providing data on IFIS and treatment with tamsulosin. The prevalence of men receiving tamsulosin for BPH among the patients operated for cataract was 1-3%, the occurrence of IFIS was reported in 2-3% of the patients, and 57-100% of the patients receiving tamsulosin had at least one manifestation of IFIS. The occurrence of IFIS among men receiving other alpha-blockers or in non-treated patients was rare. An association between preoperative treatment with tamsulosin and IFIS is probable. This observation warrants further research to establish causality. Meanwhile, it seems prudent to perform an ophthalmic examination prior to prescribing tamsulosin.

Outcome of patients with bladder cancer with pN+ disease after preoperative chemotherapy and radical cystectomy

OBJECTIVES

Persistent nodal disease in the surgical specimen (pN+) after preoperative chemotherapy for urothelial carcinoma is associated with a poor prognosis. To improve our understanding regarding the outcomes of such patients, we performed a retrospective review of our experience.

METHODS

From 1993 to 2003, 857 patients underwent radical cystectomy for urothelial carcinoma of the bladder, and 150 were found to have pN+ disease. Of these 150 patients, 37 had pN+ disease despite preoperative chemotherapy and formed the basis of this report. The survival data were analyzed using the Kaplan-Meier method and Cox regression analysis.

RESULTS

The median patient age was 66 years (range 39-85), and the median follow-up was 50 months (range 13.0-58.7). The clinical stage at the initiation of preoperative chemotherapy was cT2 with lymphovascular invasion in 7, cT3b in 6, cT4a in 4, cT4b in 2, and cN+ in 18. The 2-year overall, disease-specific, and recurrence-free survival rate was 20%, 29.2%, and 13.5%, respectively. Of the 37 patients, 11 (30%) received adjuvant chemotherapy after surgery, most (73%) were platinum-based regimens. On Kaplan-Meier analysis, adjuvant chemotherapy was associated with improved recurrence-free and disease-specific survival. On multivariate analysis, surgical margin status, sex, and histologic type were significantly associated with overall survival, and the histologic type and use of adjuvant chemotherapy were significantly associated with recurrence-free survival.

CONCLUSIONS

Patients with persistent nodal disease despite preoperative chemotherapy have a poor prognosis. A cohort of such patients might do well with adjuvant chemotherapy. The lymph node density and pT category were not prognostic in patients with nodal metastasis after preoperative chemotherapy.

Saturation prostate biopsy in high risk patients after multiple previous negative biopsies

OBJECTIVES

To evaluate the diagnostic value of saturation prostate biopsy in patients with prostate-specific antigen (PSA) greater than 10 ng/mL, PSA velocity greater than 0.75 ng/mL/year, free PSA ratio less than 0.2, and at least 3 sets of negative biopsy specimens.

METHODS

Twenty-seven patients underwent the procedure with the use of a transrectal approach under general or regional anesthesia. A systematic coverage of the peripheral zone was accomplished by maintaining a fixed distance between punctures (5 mm). In addition, multiple cores were obtained from the transition zone bilaterally, bladder neck, and midline according to a strict preplanned template.

RESULTS

The mean number of cores obtained per patient was 61.7 +/- 9.5 (range 41 to 76). Average PSA was 19.4 +/- 8.5 ng/mL (range 10.1 to 49). Prostate cancer (Gleason score 3+3) was found in 3 patients (11.1%). All 3 patients who received a diagnosis of cancer had minimal disease affecting less than 1% of a single core sampled from the peripheral zone. Two patients were designated for watchful waiting and 1 patient chose radical prostatectomy. His pathologic specimen contained carcinoma of prostate (Gleason 3+3) in less than 1% of the total prostate volume. All patients were discharged within 24 hours after the procedure. Asymptomatic bacteremia was documented in 1 patient. Two patients had epididymitis develop and were treated conservatively.

CONCLUSIONS

According to our findings, saturation prostate biopsy has low diagnostic yield in patients who previously had at least 3 sets of negative traditional biopsy specimens. In all the cases, that prostate cancer was found, it had histologic features consistent with biologically insignificant disease.

Intracavernosal saline infusion decreases intraoperative blood loss during radical retropubic prostatectomy

OBJECTIVE

Radical retropubic prostatectomy (RRP) is associated with intraoperative blood loss. We studied whether regional hemodilution using intracavernosal saline infusion has an impact on blood loss during RRP.

METHODS

This is a prospective, randomized controlled study. There were 16 patients treated with intracavernosal saline infusion, and 17 did not receive infusion and served as the control group. Patients who received neoadjuvant therapy and those who underwent pelvic lymph node dissection or salvage RRP were excluded. Both corpora were infused in a pressure of 80-cm water. Clinical, pathologic, and laboratory parameters were evaluated and compared. Intraoperative actual blood loss was calculated.

RESULTS

Blood loss was significantly higher in the control group (1,036 +/- 176 vs. 482 +/- 184 ml; P < 0.001). Postoperatively, 3 control patients received 2 packed-cell units each. There were no differences between the 2 groups in regard to patient's age, comorbidities, body mass index, American Society of Anesthesiologists score, prostate-specific antigen level, clinical or pathologic stage, Gleason score, prostate specimen weight, and operating time. Localized penile edema developed in 6 patients (37.5%) that resolved spontaneously 48 hours postoperatively. None of the patients had symptoms or signs of systemic fluid overload.

CONCLUSION

Our result indicates that localized hemodilution using intracavernosal saline infusion is feasible, safe, and significantly decreases blood loss during RRP.

Does prostate biopsy Gleason score accurately express the biologic features of prostate cancer?

PURPOSE

To correlate Gleason grading in prostate biopsies with the final Gleason score in radical prostatectomy specimens, and to investigate predictors for concordance and preoperative undergrading.

MATERIALS AND METHODS

The charts of 303 patients who underwent radical retropubic prostatectomy between 1992 and 2002 were retrospectively reviewed. Prostate biopsy and surgical specimen Gleason scores and correlative clinical data were recorded, and a multivariate analysis model was applied.

RESULTS

Data were available in 293 cases (97%). The preoperative biopsy predicted the prostatectomy Gleason score accurately in 51% and undergraded them in 41% of the patients. Accuracy rates were significantly higher for Gleason scores 7-10 compared to low Gleason scores (2-4), concordance 90% and 6%, respectively (P < 0.01). Moreover, accuracy rates were higher in patients with prostate-specific antigen (PSA) higher than 10 ng/ml (85% vs. 40%; P < 0.01) and prostate glands smaller than 55 g (68% vs. 38%; P < 0.01). In 233 patients, the biopsy Gleason score did not include 4 or 5 components. Upgrading to 4 or 5 in 1 of the components was noted in 32 patients (14%). Multivariate analysis revealed that upgrading is associated with preoperative serum PSA (odds ratio 1.05; P < 0.05) and the percentage of positive cores in the biopsy (odds ratio 1.47; P < 0.001).

CONCLUSIONS

Biopsy Gleason scores of 2-4, low PSA, and a low percentage of positive cores in the biopsy can predict the biopsy driven biologically significant undergrading of 1 of the components of the Gleason score that may adversely affect therapeutic decisions.

The Prevalence of Malignancy in Satellite Renal Lesions and its Surgical Implication During Nephron Sparing Surgery

PURPOSE

We examined the prevalence of malignancy in a synchronous ipsilateral renal lesion identified during partial nephrectomy and evaluated its clinical significance.

MATERIALS AND METHODS

We retrospectively reviewed the records of 112 patients (114 renal units) who underwent nephron sparing surgery for a clinically localized sporadic renal mass between May 1995 and September 2005.

RESULTS

In 37 patients (32%) an additional lesion was diagnosed and excised intraoperatively, while in 67% these lesions were known before the operation and believed to be simple cysts. During surgery the additional mass was suspicious in 8 cases and in the remainder the mass was described as simple cysts that were excised. The mean size of the primary mass was 3.1 cm (SD 1.4). In 29 (78%) cases the primary mass was malignant, in 23 (79%) of these the second mass was benign and in the remainder renal cell carcinoma was diagnosed. In 8 cases (22%) the primary mass was benign and in 2 (25%) the secondary mass was malignant. Overall 22% of all second masses were malignant, and all were low grade and low stage. We found that 7% of second ipsilateral masses could be expected to harbor malignancy.

CONCLUSIONS

Based on our data it is questionable whether total nephrectomy is mandatory as an immediate response to an ipsilateral synchronous second renal mass. The present findings may represent an increased appreciation of ipsilateral multicentricity compared to historical data.