An observational urodynamic evaluation of men with lower urinary tract symptoms treated with doxazosin

OBJECTIVES

To assess the urodynamic changes in men with lower urinary tract symptoms (LUTS) suggestive of bladder outlet obstruction treated with doxazosin and to correlate these changes with voiding symptoms.

METHODS

Fifty patients with LUTS were treated with doxazosin at a dose of 4 mg/day for 3 months. All men were initially evaluated by International Prostate Symptom Score (I-PSS) questionnaires, measurements of urinary flow rate, and complex urodynamic study. Those patients completing the 3-month study underwent repeat testing.

RESULTS

Forty-four (88%) men underwent initial and follow-up urodynamic evaluation. The mean I-PSS improved from 20.6 to 10.5 (P < 0.001), mean peak urinary flow rate increased for 11.7 to 13.2 cc/s (P = 0.20), mean detrusor pressure at peak flow decreased from 9 3.6 to 83.0 cm H20 (P = 0.15), and mean cystometric bladder capacity increased from 266 to 304 cc (P = 0.07). Using the Abrams-Griffiths nomogram and number, more than 58% of patients remained obstructed after treatment with doxazosin for 3 months. Men with and without objective evidence of bladder outlet obstruction at the outset of the study had similar improvement in voiding symptoms. Most patients elected to continue treatment with doxazosin at the completion of the study (41/44, 93%).

CONCLUSIONS

The majority of patients had objective evidence of persistent bladder outlet obstruction after treatment with doxazosin for 3 months despite significant benefit. The results of complex urodynamic evaluation did not predict treatment response in men with LUTS suggestive of bladder outlet obstruction. Urodynamic study does not appear to be helpful in the evaluation of patients with uncomplicated LUTS prior to treatment with doxazosin.

Laparoscopic approach to retroperitoneal lymph node dissection

Laparoscopic retroperitoneal lymph node dissection is a new surgical procedure used to enhance staging in men with clinical stage I nonseminomatous germ cell tumors of the testis. The procedure has been performed in a limited number of patients at several centers with extensive laparoscopic experience. Laparoscopic retroperitoneal lymphadenectomy is a technically demanding procedure which can be successfully completed in the majority of patients. However, the risk of complications is greater than in patients who undergo standard open retroperitoneal lymph node dissection. The primary advantage of a laparoscopic approach is shortened hospitalization and rapid return to normal activity. The role of laparoscopy in the management of patients with testis malignancy has not been defined. The use of this staging procedure may help minimize the need for surveillance studies following surgery and may be best utilized in men with a lower likelihood of nodal metastases. Ultimately, prospective study in large groups of patients will be necessary to determine the role of laparoscopic retroperitoneal lymph node dissection in patients with testis cancer.

Applicability of Iceland spar as a stone model standard for lithotripsy devices

The identification of a universal stone model standard would enable reproducible fragmentation data useful for the design, evaluation, and comparison of various lithotripsy devices. The clinical benefits of such a stone model include the elucidation of setting parameters that would optimize fragmentation strategies. Iceland spar is a pure form of calcite (CaCO3) that was subjected to experimental disintegration by electrohydraulic lithotripsy and extracorporeal shockwave lithotripsy. Iceland spar was fragmented with both lithotripsy methods in a reproducible fashion. The degree of fragmentation was directly related to alterations in either power or shock frequency. Iceland spar is radiopaque, inexpensive, easily obtained, homogenous in composition, and sizable. Iceland spar meets a variety of stone model criteria, warranting its continued investigation as a potential stone model standard.

Ureteroscopic endopyelotomy in an ectopic kidney

A patient with an ectopic, pelvic kidney with congenital ureteropelvic junction obstruction was treated by retrograde, ureteroscopic endopyelotomy without percutaneous access. Preoperative ureteral stent placement and angiography facilitated the procedure. The patient had an uneventful recovery with improved drainage from the involved collecting system demonstrated by renal scintigraphy 6 months postoperatively. Ureteroscopic endopyelotomy avoids the need for percutaneous access, which may be difficult in patients with ectopic, malrotated kidneys and appears particularly well suited to the treatment of ureteropelvic junction obstruction in such cases.

Treatment of ureteropelvic junction obstruction by endopyelotomy

Endoscopically controlled incision of the ureteropelvic junction (UPJ) (endopyelotomy) has become an accepted form of treatment for both primary and secondary obstruction. The procedure may be performed using either an antegrade, percutaneous technique or via a retrograde approach. Success rates range from 61 to 86% in large series, which is slightly inferior to results of open pyeloplasty. However, the length of hospitalization and recovery period are significantly lessened with an endoscopic approach, and it appears that endopyelotomy should be the initial procedure of choice for most adults with UPJ obstruction.

Lasers in the treatment of benign prostatic hyperplasia

Laser treatment of men with BPH remains in its infancy. To date, a large number of techniques and devices have been developed and investigated to varying degrees. Each laser system that is utilized in a unique fashion must be evaluated individually, since tissue effects may vary significantly with minor changes in technique or technology. Overall, it appears that the majority of men treated by laser prostatectomy experience objective and subjective improvement with short-term follow-up. In most cases, further direct comparisons with TURP with longer follow-up are needed to assess adequately the relative efficacy and morbidity of laser therapy. Although early results are promising and technologic advances are likely to improve further the results seen with laser treatment of men with BPH, it may be premature to relegate TURP to the history books.

Combined laparoscopic and transurethral neodymium: yttrium-aluminum-garnet laser treatment of invasive bladder cancer

OBJECTIVES

The feasibility and efficacy of combined cystoscopic and laparoscopic neodymium: yttrium-aluminum-garnet (Nd:YAG) laser coagulation of invasive bladder cancer were investigated.

METHODS

Five patients with extensive Stage T2-T3a bladder cancer who were not candidates for radical cystectomy were treated by Nd:YAG laser irradiation. All patients also underwent transperitoneal laparoscopic mobilization of the intestine away from the bladder with continuous monitoring of the laser treatment. In 2 cases, laser therapy of the serosal surface of the bladder at the site of tumor was also administered.

RESULTS

The procedure was completed without complications in all 5 patients. A mean of 58,607 joules (J) of energy was delivered transurethrally with an additional 8000 to 10,000 J utilized via laparoscopy in 2 cases. Local disease recurrence was noted within 1 to 4 months in 4 of the 5 patients. Distant metastases were detected within 1 to 9 months postoperatively in 3 of 5 patients. No perioperative bowel or bladder perforation occurred.

CONCLUSIONS

The use of laparoscopy allows for the safe delivery of large amounts of laser energy to the bladder. However, in this small group of patients with extensive bladder tumors, effective palliation of local disease could not be reliably achieved. Further study is necessary to determine whether treatment modifications or selection of patients with less extensive tumors will lead to better results with combined laparoscopic and cystoscopic laser therapy.

Fournier's gangrene secondary to intra-abdominal processes

We report 2 cases of necrotizing fasciitis of the perineum, perianal area, and male genitalia (Fournier's gangrene) that arose secondary to intra-abdominal infectious processes (ruptured appendicitis and diverticulitis). Management consisted of immediate debridement of necrotic tissue, exploratory laparotomy, and diverting colostomy. The presence of an acute abdominal process was not immediately evident on initial evaluation of either patient. This demonstrates the critical importance of considering intra-abdominal infection in patients with Fournier's gangrene when the more commonly seen urinary tract, perirectal, and traumatic causes are not readily apparent.

Laparoscopic retroperitoneal lymphadenectomy: multi-institutional analysis

Modified unilateral laparoscopic retroperitoneal lymph node dissection was attempted in 20 patients with nonseminomatous testicular cancer. The procedure was completed in 18 men at a median operative length of 6 hours. Median estimated blood loss was 250 cc and median number of lymph nodes removed was 14.5. Nodal disease spread was noted in 3 of 18 patients (17%). Most patients were hospitalized for 3 days or less and had returned to normal activity levels within 2 to 3 weeks. Antegrade ejaculation was preserved in all 20 patients. Significant complications occurred in 6 of 20 patients (30%), with bleeding being the most common adverse event encountered. In 2 patients an abdominal incision and completion of the procedure by open retroperitoneal lymph node dissection were required due to significant bleeding following injury to the gonadal vessels. With a median followup of 10 months (range 2 to 25), 2 men had pulmonary disease recurrence and none had abdominal recurrence. Laparoscopic retroperitoneal lymph node dissection can be completed successfully in patients with stage I testicular cancer and may be most appropriate in those with limited risk of metastatic disease spread. The morbidity may be largely attributed to a steep learning curve. The efficacy of laparoscopic retroperitoneal lymph node dissection compared with standard techniques and determination of its role in patients with testicular cancer will require longer followup in larger groups of patients.

Carcinoma in situ of the penis

Bowen's disease, erythroplasia of Queyrat and bowenoid papulosis are uncommon disorders of the anogenital skin that may be confused with a variety of other lesions. While all appear histologically as carcinoma in situ and are strongly associated with human papillomavirus infection, only Bowen's disease and erythroplasia of Queyrat have been demonstrated to lead to the development of invasive squamous cell carcinoma. In contrast, bowenoid papulosis has a completely benign course with no present evidence suggesting the potential for malignant degeneration. The standard treatment for all 3 lesions in surgical excision, although use of the carbon dioxide or neodymium:YAG laser appears to be effective at obtaining local control of disease while achieving an excellent cosmetic result. Alternative treatments with micrographic surgery, topical 5-fluorouracil or radiotherapy have a more limited role. It is important to remember that adequate biopsies are always necessary to ensure a complete and accurate diagnosis, and allow for proper treatment and followup, as well as appropriate counseling of sexual partners.

Laparoscopic pelvic lymph node dissection: a review of 103 consecutive cases

Laparoscopic pelvic lymph node dissection is a recently introduced technique for the surgical evaluation of the regional pelvic lymph nodes in genitourinary malignancies. We report the results of a laparoscopic pelvic lymph node dissection performed on 103 consecutive patients for staging of clinically localized prostatic, bladder and penile carcinomas. In 20 patients (group 1) the adequacy of the laparoscopic pelvic lymph node dissection was evaluated with a subsequent open dissection. In this group 87 to 95% of the lymph nodes within a modified template could be reliably removed laparoscopically. In 73 patients (group 2) laparoscopic pelvic lymph node dissection was performed as a solitary operation. Mean hospitalization was 1.6 +/- 2.4 days, while postoperative narcotic requirements were minimal. Mean operative time for bilateral laparoscopic pelvic lymph node dissection was 156 +/- 41.2 minutes. The overall complication rate in these 2 groups was 13.5%. Group 3 includes 10 patients (9.7% of the total) in whom laparoscopic pelvic lymph node dissection was unsuccessful. The minimally invasive surgical techniques of laparoscopic pelvic lymph node dissection seem to provide adequate staging accuracy in patients with genitourinary neoplasms. The complication rate and recovery period appear to be decreased relative to those for open surgical lymphadenectomy.

Results of conservative management of clinically localized prostate cancer

BACKGROUND

The selection of treatment for patients with localized prostate cancer requires reliable information about the outcome of conservative management. Previous studies of this question are generally considered unreliable because they were uncontrolled and nonrandomized.

METHODS

We performed a pooled analysis of 828 case records from six nonrandomized studies, published since 1985, of men treated conservatively (with observation and delayed hormone therapy but no radical surgery or irradiation) for clinically localized prostate cancer. A Cox regression analysis was performed to determine which factors influenced survival among patients who did not die of causes other than prostate cancer (disease-specific survival). Kaplan-Meier curves for overall and metastasis-free survival among such patients were compared with use of the log-rank method and the Mantel-Haenszel test.

RESULTS

Factors that had a significant effect on disease-specific survival were grade 3 tumors (risk ratio, 10.04), residence in Israel (risk ratio, 2.48) or New York (risk ratio, 0.37), and age under 61 years (risk ratio, 0.32). Ten years after diagnosis, disease-specific survival (with data on men who died from causes other than prostate cancer censored) was 87 percent for men with grade 1 or 2 tumors and 34 percent for those with grade 3 tumors; metastasis-free survival among men who had not died of other causes was 81 percent for grade 1, 58 percent for grade 2, and 26 percent for grade 3 disease. These findings were not affected by the inclusion of men who had early-stage cancer, were older, had worse-than-average health, or underwent delayed radiation therapy or radical prostatectomy.

CONCLUSIONS

The strategy of initial conservative management and delayed hormone therapy is a reasonable choice for some men with grade 1 or 2 clinically localized prostate cancer, particularly for those who have an average life expectancy of 10 years or less. New treatment strategies are needed for men with grade 3 prostate cancer.

Conservative approach to the management of prostate cancer. A critical review

Conservative management of patients with early prostate cancer has received increased attention in recent years. While this approach allows patients to avoid the potential side effects associated with radiation therapy and radical prostatectomy, many men who live 10 years or longer will develop advanced disease with watchful waiting. These patients are likely to suffer significant morbidity due to local or distant cancer progression. Conversely, some patients who receive aggressive initial treatment for localized prostate cancer will also experience morbidity secondary to recurrent or progressive disease despite early attempts at curative therapy. Therefore, the need for further prospective study to evaluate the relative effectiveness and morbidity of conservative management in comparison with radiation therapy and radical prostatectomy is evident.

Endopyelotomy: patient selection, results, and complications

The popularity of minimally invasive surgical techniques, such as endopyelotomy, has increased markedly among urologists in recent years. While it was initially thought that this procedure was best utilized in patients with secondary UPJ obstruction, recent evidence suggests that endopyelotomy should be considered in the majority of cases. The primary contraindication to endoscopic incision of the UPJ is a long stricture, although a large redundant renal pelvis and the presence of crossing lower pole vessels are considered by some to be relative contraindications as well. Although the majority of surgeons have used a percutaneous, antegrade approach to endopyelotomy, successful results also have been reported with a ureteroscopic, retrograde technique. With the development of modified ureterotomes and balloon-cutting devices, the retrograde approach eventually may become the preferred method since no skin incision or external drainage are needed. The role of endopyelotomy in children remains undefined. While successful results have been reported in infants, the relative morbidity and long-term success of open pyeloplasty in this age group are excellent, thus limiting the relative advantage of an endoscopic approach. However, there may be a role for endopyelotomy in older children and in those patients with secondary obstruction who have failed open surgery. From a technical standpoint, there are several minor variations in surgical technique and postoperative management that are important. The success rate of endopyelotomy using a cold knife or small electrocautery probe appears to be comparable, and the use of cautery may allow for precise control of minor bleeding thus decreasing the risk of complications. However, larger electrodes may induce greater tissue reaction leading to fibrosis and should be avoided. Postoperatively, most authors prefer a tapered double-pigtail stent which allows for adequate internal drainage while avoiding excessive pressure within the distal ureter. While successful results have been reported with stenting intervals of only four days, it is generally recommended that the stent be left in place for a minimum of six weeks following endoscopic incision of the UPJ. Overall, endopyelotomy is associated with shortened hospitalization, more rapid return to normal activity levels, and decreased morbidity compared with open pyeloplasty. The success rates reported with endopyelotomy approach those achieved with open surgery, and it is likely that an endoscopic approach to UPJ obstruction will assume an increasingly greater role in the future.

Buschke-Lowenstein tumor: therapeutic options including systemic chemotherapy

Verrucous carcinoma of the penis (Buschke-Lowenstein tumor) is a rare variant of squamous cell carcinoma which has been reported to have limited potential for metastatic disease. We report on 2 patients who presented with locally advanced disease after prolonged intervals of neglect. In both cases, the disease was locally aggressive with extensive tissue destruction. In 1 patient, after failure to achieve tumor control with repeated aggressive surgical excision, systemic chemotherapy using bleomycin, cisplatin, methotrexate, and leucovorin led to a complete pathologic response. We believe this is the first reported case in which systemic chemotherapy has been used to successfully treat verrucous carcinoma of the penis. Surgical excision alone was successful in achieving local disease control in the second patient.

The application of laparoscopy to retroperitoneal surgery in urology

The application of minimally invasive laparoscopic surgical techniques has provided the urologist with access to retroperitoneal structures previously available only through an abdominal incision. The enhanced visualization provided by video-imaging as well as the ease of access to the retroperitoneum through an incision in the posterior peritoneal envelope has facilitated the manipulation of many retroperitoneal organs. In particular these techniques have been applied to the clinical management of several urologic malignancies, such as adenocarcinoma of the prostate, transitional cell carcinoma of the bladder, and squamous cell carcinoma of the penis. A transperitoneal laparoscopic pelvic lymphadenectomy appears to provide adequate surgical staging of regional pelvic lymph nodes in these malignancies, while providing the patients with reduced morbidity. Additionally, transperitoneal access may be accomplished for an internal spermatic vein ligation, as well as approaches to the kidney, ureter and retroperitoneal lymph nodes. The surgical options are limited only by the availability of the instrumentation and the creativity of the surgeon. However, the indications for these procedures remain unclear and must await further information regarding actual benefits in the form of reduced patient morbidity and cost. The challenge for the future is to more completely define the indications and selection criteria for laparoscopic surgery.

Management of acute ureteral obstruction in pregnancy utilizing ultrasound-guided placement of ureteral stents

Of 6,275 pregnancies seen at our institution over a two-year period, 5 patients required operative intervention for acute urinary obstruction unresponsive to medical management. Ultrasonography was able to definitively diagnose the presence of an obstructing calculus in 4 of 5 patients. Using ultrasound guidance, 7 indwelling ureteral stents were successfully placed with local anesthesia supplemented by intravenous sedation. Complications consisted of distal stent migration in 1 patient. This method of management was successful for symptomatic nephrolithiasis in a pregnant renal transplant patient. Endoscopic placement of ureteral stents under ultrasound guidance is an effective, safe method of urinary decompression, with no radiation risks imparted to the mother or fetus. Definitive therapy then can be safely deferred to the post-partum period.

Endourological management of upper tract urothelial tumors

Advances in ureteroscopic and percutaneous techniques have made it possible to treat many upper tract malignancies by conservative, parenchyma sparing surgery. Percutaneous techniques generally allow for easier and better access to the renal pelvis and improved tumor resection. However, concerns for tumor spillage and nephrostomy tract seeding make the ureteroscopic approach best for initial management of accessible renal pelvic lesions, particularly when the diagnosis is unclear. Ureteral tumors, especially those arising in the lower third of the ureter, are technically easier to treat endoscopically than are renal pelvic tumors. Fulguration or laser photocoagulation may be used to ablate the tumor following cold-cup biopsy for histological diagnosis. Supplemental therapy using laser treatment of the tumor base, and postoperative instillation of BCG and mitomycin C offer great potential benefit in terms of improved tumor control. Confirmation of such benefit awaits the results of larger trials. Presently, standard nephroureterectomy remains the procedure of choice for most transitional cell carcinomas of the upper urinary tract in patients with a normal contralateral kidney. For those with a solitary kidney, renal insufficiency, bilateral tumors or severe intercurrent disease preventing a major open operation conservative management using endoscopic techniques is a viable alternative. Overall, it appears that grade and stage are far more important determinants of long-term out-come than the type of operation in those with transitional cell carcinoma of the upper urinary tract. For this reason, some physicians have recommended conservative management of low grade, noninvasive lesions even in the face of a normal opposite kidney. However, the majority of patients with upper tract urothelial tumors are best treated by nephroureterectomy, which leads to a low risk of local recurrence and obviates the need for rigorous postoperative upper tract surveillance.

The role of laparoscopic lymphadenectomy in staging and treatment of urological tumours

Laparoscopic lymphadenectomy for managing a variety of urological malignancies is likely to continue to increase in popularity. It is essential that the role of these procedures be critically evaluated to ensure that they offer significant benefit without added morbidity as compared with standard techniques. The challenge for the future is to better define selection criteria for laparoscopic surgery, particularly in men with clinically localized prostate cancer, so that both staging methods and therapy can be tailored to the individual patient.

Female urinary tract fistulas

Urinary tract fistulas in women are an uncommon complication of a variety of surgical procedures. However, such fistulas lead to significant patient and physician distress, and have important medicolegal implications. Successful repair of urinary tract fistulas requires careful preoperative evaluation and adherence to basic surgical principles. A variety of approaches and techniques may be used, and the choice of procedure is less important than achieving adequate resection of fibrosis with watertight, tension-free closure of well vascularized tissues in layers. Interposition grafts of omentum, muscle, peritoneum and labial fat may be used in recurrent, complicated or radiated fistulas, and add significantly to the rate of success. Overall, successful repair of urinary tract fistulas can be achieved in the majority of cases.

Disease-specific survival following routine prostate cancer screening by digital rectal examination

OBJECTIVE

To assess prostate cancer mortality in men undergoing routine screening by routine digital rectal examination.

DESIGN

Cohort study with a median follow-up period of 75 months.

SETTING

Population consisted of volunteers at a university clinic and men in an institutional health maintenance clinic.

PATIENTS

Fifty-six men with a mean age of 65 years (range, 52 to 79 years) diagnosed with prostate cancer.

INTERVENTIONS

Patients treated initially by observation, external or interstitial radiotherapy, radical prostatectomy, hormone therapy, or combination.

MAIN OUTCOME MEASURES

Kaplan-Meier analysis of time to local progression, distant metastases, death from all causes, and death from prostate cancer. Mantel-Haenszel log-rank statistic was used to compare outcome in men diagnosed on initial examination with those diagnosed on subsequent examinations.

RESULTS

Clinically localized prostate cancer was diagnosed in 73% during an initial examination and 83% on subsequent examinations and (P.35). Grade distribution of tumors was similar in both groups. Overall 5 and 10 year survival of all cancer patients was 85% and 67%, respectively. Death from prostate cancer was 8% (3/38) in men diagnosed on initial examination and 33% (6/18) during subsequent examinations. Five- and 10-year disease-specific survival was 97% and 86%, respectively, for men diagnosed during the first rectal examination compared with only 81% and 57%, respectively, for men diagnosed on subsequent rectal examinations (P = .02).

CONCLUSION

Routine screening for prostate cancer by annual digital rectal examination alone may be insufficiently frequent and/or sensitive to prevent significant mortality from this disease [corrected].

Current and future roles of laparoscopic surgery in urology

There is little doubt that laparoscopy will gain an increasing role in urologic surgery. Pelvic node dissection, varicocelectomy, and evaluation of nonpalpable undescended testes are already widely performed. As improved instrumentation is developed expressly designed for urologic applications, there will be even greater interest and wider applicability of laparoscopic techniques. However, as this occurs, it is essential that each new procedure be critically evaluated to be certain that it offers significant benefit without added morbidity as compared with standard techniques.

Value of prostate cancer screening

The challenge for the future is to establish whether screening will lead to a decrease in prostate cancer mortality. This issue can only be settled by the performance of a properly controlled, randomized, prospective study. Due to the generally slow progression rate of prostate cancer, such a study will require an at least 15-year follow-up of a large number of men. Because of the increasing widespread use of prostate-specific antigen in the United States, finding a large control population who will not be screened for an extended period of time may no longer be possible. Nevertheless, such a study is clearly needed and is being undertaken by the National Institutes of Health. In the meantime, it is important that physicians counsel patients regarding the relative benefits and risks of screening so that they can make their own judgments regarding the aggressiveness with which the diagnosis of prostate cancer should be pursued.

Local staging of prostate cancer by tumor volume, prostate-specific antigen, and transrectal ultrasound

Conventional methods of staging prostate tumors are highly inaccurate. To improve clinical staging, prostate-specific antigen (PSA) levels (> 10 ng/mL), sonographic tumor volume (> 3 cc), maximum tumor diameter, length of capsular tumor abutment, and overall impression of capsular irregularity suggesting periprostatic tumor spread were assessed in 29 men prior to undergoing radical prostatectomy for clinically localized tumor. After surgery, 18 men had tumor confined to the prostate, while 11 men had histologic evidence of extracapsular disease. Analysis of the parameters measured showed these were the most helpful factors in predicting the presence of extracapsular disease. However, the positive and negative predictive values were only 70 to 90 percent. Therefore, the clinical usefulness of any one measurement alone in determining treatment for the individual patient is limited. However, combining these parameters yields an improved prediction of extracapsular disease. All 6 patients with PSA < 10 ng/mL, tumor volume < 3 cc, and no capsular irregularity on ultrasound had localized disease (neg. predictive value = 100%), while all 7 patients who had more than one of these parameters had extracapsular disease (pos. predictive value = 100%). Thus, using the factors in combination may provide more accurate staging and thereby help in counseling patients regarding therapy.