Variable definitions influence the reporting of biochemical failure rates

The purpose of this study was to assess how the reporting of biochemical failure (BF) rates would be affected by the application of three different definitions. Three hundred and fifteen men with localized prostate cancer underwent I-125 brachytherapy (n=109), conformal three-dimensional radiation therapy (n=99), or radical prostatectomy (n=107). No patient received adjuvant or neoadjuvant hormone therapy in this study. BF rates at 12, 24 and 36 months were assessed using three definitions: (1) prostate-specific antigen (PSA) nadir >0.5 ng/ml; (2) PSA rise by 0.5 ng/ml; and (3) three consecutive PSA rises. Median follow-up for the brachytherapy group, external beam radiotherapy group, and the radical prostatectomy group was 27, 30 and 36 months respectively. The applied definition influenced reporting of failure rates in two of the three groups. I-125 brachytherapy group: BF rates at 24 months: 46%-definition 1, 35%-definition 2, and 4%-definition 3 (P<0.05). Radiation therapy group: BF rates at 24 months: 39%-definition 1, 17%-definition 2 and 3%-definition 3 (P<0.05). No patient in the radical prostatectomy group had a BF by any applied definition. A more universal definition of BF is needed to compare the efficacy of treatments for localized prostate cancer.

Laparoscopic cross-trigonal Cohen ureteroneocystostomy: novel technique

PURPOSE

We describe a novel technique of laparoscopic transvesical cross-trigonal Cohen anti-reflux ureteroneocystostomy.

MATERIALS AND METHODS

A 10, an 11 and a 32-year-old patient with symptomatic unilateral vesicoureteral reflux underwent laparoscopic cross-trigonal ureteral reimplantation. Two 5 mm. balloon tip ports were suprapubically inserted into the bladder. Using a transurethral resectoscope with a Collins knife a 4 to 5 cm. cross-trigonal submucosal trough was created from the refluxing ureteral orifice to the contralateral side of the bladder. The refluxing ureteral orifice and intramural ureter were completely mobilized intravesically, advanced transtrigonally and secured to the detrusor muscle at the apex of the trough with 3 deep interrupted sutures. The elevated mucosal flaps of the trough were suture approximated over the ureter to create a submucosal tunnel. All suturing was performed by freehand laparoscopic technique.

RESULTS

Operative time was between 2.5 and 4.5 hours and blood loss was 10 to 50 cc. Adequate submucosal trough creation, ureteral extravesical mobilization and intravesical advancement, and bladder mucosal flap reapproximation were done to create a submucosal tunnel in all cases. Satisfactory transtrigonal anchoring of the neoureteral orifice to the detrusor muscle and mucosa was achieved with 3 stitches. Hospital stay was 2, 2 and 1 days in the 3 cases, and the Foley catheter remained in place for 3, 1 and 1 week, respectively. At 6 months reflux had resolved in 2 patients, while in 1 grade II reflux persisted, which was improved from grade IV preoperatively. All patients have remained infection-free without antibiotics.

CONCLUSIONS

Laparoscopic transvesical cross-trigonal antireflux ureteral reimplantation is technically feasible. Intravesical laparoscopic suturing is possible. Potential advantages include a decreased hospital stay, decreased narcotic requirement and better cosmesis. Further experience is necessary to refine the technical nuances and evaluate outcomes compared to the open technique.

Screening and monitoring for bladder cancer: refining the use of NMP22

PURPOSE

While detecting bladder cancer, bladder tumor markers demonstrate improved sensitivity compared with urinary cytology but the current limitation is the low specificity and positive predictive value, that is high false-positive rate. We examined the clinical categories of the false-positive results, established relative exclusion criteria, and recalculated the specificity and positive predictive value of this assay with these criteria.

MATERIALS AND METHODS

A total of 608 patients considered at risk for bladder cancer presented to a urology clinic and submitted a single urine sample. Of the 608 patients 529 (87%) presented with de novo hematuria or chronic voiding symptoms without a diagnosis of bladder cancer. There were 79 (13.0%) patients being monitored with a known history of bladder cancer. Each urine sample was examined via cytology, urinalysis, culture and NMP22 protein assay. All patients underwent office cystoscopy, and transurethral resection and/or biopsy if a bladder tumor was suspected.

RESULTS

Of the 608 patients 226 (37.2%) presented with microscopic hematuria, 143 (23.5%) with gross hematuria and 239 (39.3%) had chronic symptoms of urinary frequency or dysuria. There were 52 (8.6%) patients who had histologically confirmed bladder cancer. Of these 52 cancers NMP22 detected 46 (88.5%), whereas cytology identified only 16 (30.8%). When atypical cytology was considered positive, cytology detected 32 (61.5%) cases. In the 135 patients with increased NMP22 values the 46 identified tumors were accompanied by 89 false-positive values yielding a specificity of 83.9% and a positive predictive value of 34.1%. These false-positive results were divided into 6 clinical categories. Exclusion of these categories improved the specificity and positive predictive value of NMP22 to 99.2% and 92.0%, respectively, yielding results similar to urinary cytology (99.8% and 94.1%).

CONCLUSIONS

Awareness and exclusion of the categories of false-positive results can increase the specificity and positive predictive value of NMP22, enhancing the clinical use of this urinary tumor marker.

Contemporary "urologic" intervention in the pancreaticobiliary tree

OBJECTIVES

To evaluate the role of minimally invasive "urologic" interventional techniques for the treatment of pancreaticobiliary calculi in contemporary practice.

METHODS

Fourteen patients with retained cystic duct (n = 2), hepatic duct (n = 5), common duct (n = 2), pancreatic duct (n = 4), or gallbladder (n = 1) calculi were treated with 19 procedures, including shock wave lithotripsy (n = 9) and percutaneous flexible endoscopy with electrohydraulic or holmium laser lithotripsy (n = 10). Previous attempts using standard gastroenterologic or radiologic interventions before the urologic referral had failed in all 14 patients.

RESULTS

A successful result, defined by the resolution of stones and symptoms, was achieved in 12 patients (86%); 2 patients (14%) had residual calculi that ultimately required an open operative procedure. The hospital stay for each intervention was 0 to 2 nights, and no patients had any significant complications.

CONCLUSIONS

Even in this age of advanced gastroenterologic technology, including laparoscopic cholecystectomy, endoscopic retrograde cholangiopancreatoscopy, and percutaneous transhepatic cholangiography, the urologist can play a significant role in the minimally invasive treatment of patients with complicated biliary disease such that the need for open operative "salvage" procedures will be further minimized.

Penile adhesions after neonatal circumcision

PURPOSE

The appropriate management of penile adhesions in circumcised boys is unclear. An important consideration is whether adhesions resolve spontaneously. We studied the incidence of penile adhesions as a function of patient age to assess the natural history.

MATERIALS AND METHODS

We evaluated all circumcised boys presenting to our pediatric urology clinic. A standard form was used to classify adhesions as grade 0-no adhesions, 1-fine adhesions to the corona, 2-adhesions covering less than 50% of the glans and 3-adhesions covering greater than 50% of the glans. All boys were evaluated by 1 of 2 pediatric urologists. Previous treatment of adhesions was assessed and skin bridges were also noted.

RESULTS

We enrolled in our study 254 boys 1 month to 19 years 8 months old. Only 7 patients had a history of treatment of adhesion, of whom 3 had recurrent adhesions at evaluation. Patients were divided into groups based on age, including younger than 12 months (61), 13 to 60 (78), 61 to 108 (51) and 109 months old or older (64). In these groups we noted an adhesion rate of 71%, 28%, 8% and 2%, respectively. The rate of adhesions more severe than grade 1 was 30%, 10% and 0% in boys 12 months old or younger, 13 to 60 and 61 months old or older, respectively. The oldest patient with grade 3 adhesions was 31 months old. Skin bridges in 6 cases involved the circumcision line in 4.

CONCLUSIONS

Penile adhesions develop after circumcision and the incidence decreases with patient age. Although there is debate on whether to lyse these adhesions manually, our findings suggest that adhesions resolve without treatment. Based on our results we do not recommend lysing penile adhesions, except perhaps those involving the circumcision line.