Biochemical course after radical retropubic prostatectomy: preliminary results

OBJECTIVE

To investigate prognostic factors in localized and lymphatically spread prostate cancer.

METHODS

The biochemical course after radical retropubic prostatectomy in 306 patients was subject to a retrospective analysis.

RESULTS

Prostate-specific antigen (PSA), Gleason score (prostatectomy specimen) and pathological stage proved to be prognostically relevant (p < 0.0001). PSA, Gleason score and tumor stage also were to be considered as (independent) prognostic factors by means of a multivariate analysis (p < 0.001), whereas perineural invasion (prostatectomy specimen) and preoperative bone marrow findings (CK 2) had no impact on the course of the disease. After a median follow-up of 1,307 days (3.6 years), a biochemical relapse occurred in 41.8%.

CONCLUSION

High preoperative PSA values and the resulting high portion of advanced tumor stages are a possible basis for the high biochemical relapse rate in our collective. The learning curves of several surgeons and the previously more restrictive pelvic lymphadenectomy (surgical understaging) may also be considered causes.

Unenhanced helical computed tomography in the evaluation of acute flank pain

OBJECTIVE

The diagnostic value of unenhanced helical computed tomography (CT) for the evaluation of acute flank pain is investigated in a prospective study.

PATIENTS AND METHODS

In 125 patients aged 18-86 years, we performed unenhanced helical CT in addition to abdominal plain film, abdominal ultrasound and urinalysis as a diagnostic measure for acute flank pain. Ureteral calculi were confirmed or, respectively, excluded by retrograde ureteropyelography in 80 cases. In the other cases, diagnosis was verified by clinical course and/or stone asservation.

RESULTS

In 91 of 125 patients the flank pain was caused by a ureteral calculus. In 67 of 91 patients with urolithiasis, stones could be collected for analysis. Helical CT was able to precisely identify 90 ureteral calculi. Abdominal plain films led to 8 false-positive and 48 false-negative findings. Thus, sensitivity of plain radiography, ultrasound and urinalysis was 47, 11 and 84% with a specificity 76, 97 and 32%, respectively.

CONCLUSIONS

Unenhanced helical CT reaches a distinctively increased diagnostic value (sensitivity 99%, specificity 97%) in the evaluation of acute flank pain as compared to plain radiography, ultrasound and urinalysis.

[A young man with adynamia, subepicardial ischemia and sleep apnea]

HISTORY AND CLINICAL FINDINGS

A 44-year-old manager presented himself for the assessment of nocturnal apnoea. He reported increasing lack of drive and nightly angina pectoris.

INVESTIGATIONS

Polysomnography indicated obstructive apnoea and hypopnoea with a respiratory disturbance index of 29.1, while the ECG showed T wave inversion in all leads. There was severe hypothyroidism with atrophic thyroid tissue.

DIAGNOSIS, TREATMENT AND COURSE

The patient had an obstructive sleep apnoea syndrome (OSAS), hypothyroidism with myxoedema, hypopnoea and myocardial ischaemia. He was treated with negative peak airway pressure (nCPAP) ventilation, administration of L-thyroxine and initiation of anti-anginal medication, which relieved his symptoms. The severe hypothyroidism was thought to be the most important cause of his respiratory disorder and angina.

CONCLUSION

This case illustrates the connection between hypothyroidism and OSAS. Hypothyroidism must be excluded in patients with OSAS, regardless of the patient's age.

[Long-term treatment of primary pulmonary hypertension with inhaled iloprost]

BACKGROUND

Continuous intravenous infusion of prostacyclin is an effective treatment for primary pulmonary hypertension. This approach, however, requires the insertion of a permanent central venous catheter with the potential risk of serious complications. Recently, administration of aerosolized iloprost, a stable prostacyclin analogue, has been introduced as an alternative therapy for severe pulmonary hypertension.

METHODS

We evaluated the effects of treatment with aerosolized iloprost over a one-year period on exercise capacity and hemodynamic variables in patients with primary pulmonary hypertension.

RESULTS

Twenty-four patients with primary pulmonary hypertension received aerosolized iloprost at a cumulative daily dose of 100 to 150 micrograms for at least one year. The mean (+/- SD) walking distance in the 6-min-walk test increased from 278 +/- 96 meters at base line to 363 +/- 135 meters after 12 months (P < 0.0001). During the same period, the mean pulmonary artery pressure declined from 59 +/- 10 mmHg to 52 +/- 15 mmHg (P = 0.006), the cardiac output increased from 3.8 +/- 1.4 l/min to 4.4 +/- 1.3 l/min (P = 0.02), and the pulmonary vascular resistance declined from 1.205 +/- 467 dynes.s.cm-5 to 925 +/- 469 dynes.s.cm-5 (P = 0.0003). Treatment was generally well tolerated and except for mild coughing, minor headache and jaw pain in some patients, no side effects occurred.

CONCLUSIONS

Long-term treatment with aerosolized iloprost is safe and has sustained effects on exercise capacity and pulmonary hemodynamics in patients with primary pulmonary hypertension.

Radical prostatectomy: survival outcome and correlation to prostate-specific antigen levels

BACKGROUND

This paper reviews a 10-year experience with radical retropubic prostatectomy (RP) focussing on survival outcome related to pre- and postoperative levels of prostate-specific antigen (PSA).

PATIENTS AND METHODS

739 patients who underwent RP between 1987 and 1998 were prospectively investigated. Kaplan-Meier analyses were performed and correlated to pre- and postoperative PSA concentrations.

RESULTS

In a follow up period of 11 years duration, (mean 3 yrs.) 57 of 739 patients died (20 from prostate disease progression, 37 from other causes). Correlation between low pre-operative PSA and pathological organ-confinement was significant (p < 0.001). Of 175 patients with PSA progression, 53 (30%) had never reached undetectable levels of PSA. 57% of PSA relapses were detected during the first year, and 3% later than 5 years post-operatively. Kaplan-Meier analysis yielded an average 3 years advantage in estimated prostate-cancer-specific survival when pre-operative PSA levels were below 50 ng/ml. Overall, prostate-cancer-specific and PSA-free 5-year survival-rates were 88%, 96% and 67% respectively.

CONCLUSIONS

Survival-rates after RP are high even in conjunction with unfavourable PSA outcome. Merely one third of deaths resulted from prostate cancer, since men at risk frequently suffer from concomitant diseases that affect survival.

First experience with gamma probe guided sentinel lymph node surgery in penile cancer

Because of the curative approach, the detection of lymph node metastases in squamous cell carcinoma (SCC) of the penis is of significant clinical relevance. Sentinel lymph node (SLN) identification by means of lymphangiography has been proven to be insufficiently safe. However, the high morbidity of inguinal lymphadenectomy and the considerable individual variability regarding the location of lymph node metastases justify the necessity of a technique that enables the identification of SLNs. Since 1998, SLNs have been intraoperatively identified and selectively dissected, after peritumoral injection of technetium-99m nanocolloid and using lymphoscintigraphy, in three patients (one with malignant melanoma and two with SCC). At least one SLN could be detected in each patient. The maximum surgical time was 30 min. There were no severe complications. Lymph node metastases did not occur in any patient. Upon a mean follow-up of 10 months, all patients are currently free of tumor. Owing to the long-term results of sentinel lymphadenectomy in malignant melanoma of other locations and our preliminary results with respect to penile carcinoma. we consider the current method appropriate as the only primary operation for lymph node staging in early stages and, in combination with modified inguinal lymphadenectomy, in locally advanced stages.

Long-term treatment of primary pulmonary hypertension with aerosolized iloprost, a prostacyclin analogue

BACKGROUND

Continuous intravenous infusion of epoprostenol (prostacyclin) is an effective treatment for primary pulmonary hypertension. This approach requires the insertion of a permanent central venous catheter, with the associated risk of serious complications. Recently, aerosolized iloprost, a stable prostacyclin analogue, has been introduced as an alternative therapy for severe pulmonary hypertension.

METHODS

We evaluated the effects of aerosolized iloprost on exercise capacity and hemodynamic variables over a one-year period in patients with primary pulmonary hypertension.

RESULTS

Twenty-four patients with primary pulmonary hypertension received aerosolized iloprost at a daily dose of 100 or 150 microg for at least one year. The mean (+/-SD) distance covered in the six-minute walk test increased from 278+/-96 m at base line to 363+/-135 m after 12 months (P<0.001). During the same period, the mean pulmonary arterial pressure before the inhalation of iloprost declined from 59+/-10 mm Hg to 52+/-15 mm Hg (P=0.006), cardiac output increased from 3.8+/-1.4 liters per minute to 4.4+/-1.3 liters per minute (P=0.02), and pulmonary vascular resistance declined from 1205+/-467 dyn x sec x cm(-5) to 925+/-469 dyn x sec x cm(-5) (P<0.001). The treatment was generally well tolerated, except for mild coughing, minor headache, and jaw pain in some patients.

CONCLUSIONS

Long-term treatment with aerosolized iloprost is safe and has sustained effects on exercise capacity and pulmonary hemodynamics in patients with primary pulmonary hypertension.

[Noninvasive ventilation]

Die nicht-invasive Beatmung (NIV) über eine Maske ermöglicht bei vielen Patienten eine effiziente Beatmung unter Vermeidung der Risiken und Nebenwirkungen der endotrachealen Intubation. Für die chronisch-obstruktive Lungenerkrankung (COPD) sind die Vorteile der Maskenbeatmung im Hinblick auf Beatmungsdauer, Dauer der Intensivbehandlung, Prognose und Behandlungskosten inzwischen relativ gut durch Studien belegt. Bei anderen Indikationen –“Nicht-COPD-Patienten”– erlauben die verfügbaren Daten noch kein gesichertes Urteil, rechtfertigen aber einen Behandlungsversuch auch außerhalb von Studien in klinischer Routine. Nachteilig sind der initial höhere personelle Betreuungsaufwand bei NIV sowie die stark von der Erfahrung abhängige Erfolgsrate.

Die wichtigste Voraussetzung für eine erfolgreiche nicht-invasive Beatmung in der Intensivmedizin ist die Bereitschaft von Ärzten und Pflegepersonal, eine ungewohnte Beatmungsphilosophie zu akzeptieren und die relativ einfache Technik der Maskenbeatmung zu erlernen. Bei Beherrschung der Technik kann die NIV aber eine wertvolle Hilfe vom Notarztwagen bis zur Intensivstation sein.

Determination of cardiac output by the Fick method, thermodilution, and acetylene rebreathing in pulmonary hypertension

Assessment of cardiac output is an important part of the management of patients with pulmonary hypertension. The accuracy of the thermodilution technique in patients with low cardiac output or severe tricuspid regurgitation has been questioned. To address this issue, we simultaneously compared 105 cardiac output measurements by the Fick method and thermodilution in 35 patients with pulmonary hypertension. Moreover, we evaluated the acetylene rebreathing technique, a noninvasive method of determining cardiac output. The mean difference +/- 95% limit of agreement between thermodilution and the Fick method was +0.01 +/- 1.1 L/min. The mean difference +/- 95% limit of agreement between acetylene rebreathing and the Fick method was -0.23 +/- 1.14 L/min. Neither the mean agreement nor the 95% limits of agreement of both thermodilution and acetylene rebreathing with the Fick method were affected by the presence of low cardiac output or severe tricuspid regurgitation. We conclude that thermodilution and acetylene rebreathing are useful tools for assessing cardiac output in patients with pulmonary hypertension, even in the presence of low cardiac output or severe tricuspid regurgitation.

[The role of non-invasive positive pressure ventilation in lung volume reduction surgery of pulmonary emphysema--a survey of German hospitals]

BACKGROUND

Since the first publication by Cooper et. al. in 1994 of lung volume reduction surgery (LVRS) of emphysema a marked respiratory failure with hyperkapnia (PaCO2 > 55 Torr) has been regarded as an exclusion criterion for LVRS.

PATIENTS AND METHOD

In a survey in German hospitals the question was asked whether non-invasive nasal ventilation (NIPPV) has a role in the management of LVRS. Of 12 hospitals 6 had experience with NIPPV and LVRS in a total of 19 patients with a mean FEV1 of 0.64 +/- 0.101.

RESULTS

LVRS improved FEV1 by 0.20 +/- 0.181. Preoperative NIPPV was short (< 6 months) in 8 patients and resulted in improvement of physical condition and getting the patient used to NIPPV for better perioperative management. In 5 cases NIPPV was used on a long-term basis in order to allow the patient to be included in the LVRS program. In fact 7 of these 13 patients needed ventilation perioperatively, and 4 had to continue long-term NIPPV after surgery. In further 3 patients NIPPV was applied only perioperatively. One patient had to resume NIPPV after 15 months. Two patients started NIPPV 1 resp. 12 months after surgery. Two patients had bronchial cancer which was resected. Four patients died: 1 perioperatively after intubation, 2 after 3 resp. 13 months due to respiratory failure, 1 for cancer relapse after 20 months.

CONCLUSION

NIPPV may be helpful in the planning and management of LVRS in patients with ventilatory failure with hypercarbia.

[Malignant mesothelioma of the tunica vaginalis testis]

A case of malignant mesothelioma of the tunica vaginalis testis is reported in a 77-year-old male patient. There was no history of asbestos exposure. Recurrent right hydrocele with a papillar inguinal mass was the main clinical feature. An inguinal radical orchiectomy with en bloc resection of the surrounding tissue was performed. The therapeutic options for this rare, but aggressive neoplasm are discussed. Because of the disappointing results of antineoplastic chemotherapy or radiation therapy, the importance of initial radical surgical treatment with complete excision is emphasized.

["Since when have you had mucoviscidosis?" Comment on as yet rarely recognized disease entity in internal medicine]

In Germany, many adult patients with cystic fibrosis are still treated by pediatricians. There are still not enough specialists for internal medicine (and particularly pulmonologists) with sufficient knowledge about cystic fibrosis for the treatment of estimated 2000 adult CF-patients. The knowledge about the three basic principles of cystic fibrosis therapy--regular high-dose antibiotics, high-energy and high-fat nutritional support and specific physiotherapy--has to be transferred to adult medicine in order to assure competent care for this "new" group of patients. Cystic fibrosis is also becoming more and more and more important in the field of intensive care medicine and transplantation. Specific diagnostic procedures are important in adult respiratory medicine in order to confirm or exclude late manifestations of the disease. Understanding of the genetic basis of cystic fibrosis and the correlations between genotype and phenotype is beginning to emerge.

[Therapy of extrinsic ureteral obstruction by 2 parallel double-J ureteral stents]

We present our experiences with the approach of placing 2 parallel ureteral Double-J stents simultaneously in extrinsically obstructed ureters. In all 5 reported patients therapy with single ureteral stents had failed despite correct stent position. With the increased stiffness of 2 parallel ureteral silicon 7F Double-J stents ureteral kinking and luminal compression could be reduced leading to sufficient reduction of hydronephrosis. This approach with potential space between the stents preserves urinary flow through as well as around the stents which is considered to be the most important mechanism in stented ureters. In cases of extrinsic ureteral obstruction with failure of a single stent the simultaneous use of 2 parallel Double-J ureteral stents should be taken into account as a technically easy therapeutic option. It may obviate percutaneous nephrostomy tube placement or more invasive therapy.

[Lung transplantation in Hanover: an interim balance-sheet after ten years]

BACKGROUND

We reviewed our experience with various forms of lung transplantation (heart-lung [HLTx], bilateral lung [BLTx] and single lung [SLTx]) from December 1987 to September 1998 at Hannover University.

PATIENTS

In 258 patients 282 procedures (46 HLTx, 142 BLTx and 94 SLTx) were performed. Major indications were pulmonary fibrosis (n = 73), obstructive lung disease (n = 55), cystic fibrosis (n = 48), primary pulmonary hypertension (PPHT, n = 36), secondary pulmonary hypertension (n = 30) and retransplantation (n = 24).

RESULTS

The 1-, 3- and 5-year survival rates in all 258 recipients were 77%, 70% and 63% respectively. Significantly better 1-year survival was noted in patients with cystic fibrosis (90%), pulmonary fibrosis (81%), obstructive lung disease (71%) and secondary pulmonary hypertension (83%) when compared to patients with primary pulmonary hypertension (58%). There was no significant difference in actuarial 1-year survival rates between the different procedures (HLTx 78%, BLTx 77%, SLTx 77%). Bronchiolitis obliterans syndrome (BOS) proved to be the major obstacle for long term survival. Actuarial freedom from BOS was 80% at 1 year and only 45% at 5 years. Various treatment strategies including augmentation of immunosuppression could only temporarily halt the deterioration of lung function in the majority of patients with BOS.

CONCLUSIONS

Lung transplantation provides a true therapeutic option for patients with endstage lung disease. However, improved long term outlook will depend on a better understanding and treatment of bronchiolitis obliterans.

[Results of ureterocystoneostomy for inner urinary diversion in locally advanced prostate carcinoma]

Ureterneoimplantation (unilateral in 6 cases) was performed as palliative urinary diversion in 8 patients (age 64-81 years) due to locally advanced prostate cancer and bilateral ureteral obstruction (serum creatinine 2.1 to 9.8 mg. per dl.) between 1991 and 1995. In these cases the application of a double-J-catheter had failed or a percutaneous nephrostomy was refused. Postoperative time of survival (237 days, 2 patients still living for 20 and 21 months after therapy), mortality (1 of 8 patients), morbidity and time to hospital discharge (26 days) are compared to the results of the published retrospective investigations concerning percutaneous nephrostomy. The opportunity of a natural micturition without external urinary diversion could be gained for a longer period of time (5 and 20 months) in 2 of 3 patients. The other patients with in situ double-j-catheters were drained sufficiently by a suprapubic cystostomy (serum creatinine postoperatively 1.3 to 2.0 mg. per dl.). Bilateral ureterocystoneostomy being more invasive than unilateral diversion showed no benefits and was no more performed since 1991. Uretemeoimplantation with comparable postoperative results to percutaneus nephrostomy seems to be a sufficient therapeutic possibility in patients with natural micturition, repeated catheter complications, refusal or failure of alternative urinary diversion.

[Pancreas anulare as a rare differential diagnosis of duodenal stenosis in adulthood]

Annular pancreas is rare congenital malformation of the pancreas. In about 50% of the cases the malformation is asymptomatic until the third to fifth decade. We report on a 52-year-old male patient who presented with subtotal duodenal and gastric outlet stenosis. Duodenohemipancreatectomy (Whipple's procedure) was performed. The histological examination showed an annular pancreas with complicating inflammatory reactions (tryptic sialadenitis) of the pancreatic head causing additional obstruction. Annular pancreas should be taken into account as a possible cause of adult duodenal obstruction. Endoscopic retrograde cholangiopancreatography (ERCP) is the diagnostic modality of choice, and in combination with computed tomography the diagnosis can be obtained preoperatively in many patients. However, there are still patients in whom the diagnosis can finally be obtained only intraoperatively especially in cases where inflammatory pseudotumors or subtotal duodenal stenosis make ERCP impossible.

[Primary non-Hodgkin lymphoma of the pancreas]

A 71-year-old patient had been suffering from pain-free obstructive jaundice for 8 weeks. Ultrasonography and computed tomography revealed an inhomogeneous mass (diameter 7 x 6 cm) in the head of the pancreas. In combination with a CA 19-9 of 329 U/l, the findings were highly suggestive of a pancreatic carcinoma. Endoscopic implantation of a pigtail drain into the dilated choledochal duct was performed. A partial duodenopancreatectomy (Whipple's procedure) became necessary because of continuous bleeding with hemodynamic disorders after endoscopic papillotomy. In the histopathological examination a low-grade malignant non-Hodgkin lymphoma of the pancreas (follicular centroblastic-centrocytic) was diagnosed. The differential diagnosis of primary pancreatic lymphoma from pancreatic carcinoma is usually impossible. Neither clinical nor laboratory nor imaging methods indicate to the correct diagnosis. In cases of relatively large pancreatic tumor masses and impression of the pancreatic duct without infiltration, a primary pancreatic lymphoma should be considered and a histological diagnosis by biopsy should be performed.