A clinical evaluation of an ex vivo organ culture system to predict patient response to cancer therapy

Introduction

Ex vivo organ cultures (EVOC) were recently optimized to sustain cancer tissue for 5 days with its complete microenvironment. We examined the ability of an EVOC platform to predict patient response to cancer therapy.

Methods

A multicenter, prospective, single-arm observational trial. Samples were obtained from patients with newly diagnosed bladder cancer who underwent transurethral resection of bladder tumor and from core needle biopsies of patients with metastatic cancer. The tumors were cut into 250 μM slices and cultured within 24 h, then incubated for 96 h with vehicle or intended to treat drug. The cultures were then fixed and stained to analyze their morphology and cell viability. Each EVOC was given a score based on cell viability, level of damage, and Ki67 proliferation, and the scores were correlated with the patients' clinical response assessed by pathology or Response Evaluation Criteria in Solid Tumors (RECIST).

Results

The cancer tissue and microenvironment, including endothelial and immune cells, were preserved at high viability with continued cell division for 5 days, demonstrating active cell signaling dynamics. A total of 34 cancer samples were tested by the platform and were correlated with clinical results. A higher EVOC score was correlated with better clinical response. The EVOC system showed a predictive specificity of 77.7% (7/9, 95% CI 0.4-0.97) and a sensitivity of 96% (24/25, 95% CI 0.80-0.99).

Conclusion

EVOC cultured for 5 days showed high sensitivity and specificity for predicting clinical response to therapy among patients with muscle-invasive bladder cancer and other solid tumors.

Adjuvant chemotherapy after radical cystectomy: Do all patients who need chemotherapy after surgery actually receive it?

Background

Compliance with the guideline recommendations for neoadjuvant chemotherapy in patients with muscle-invasive bladder cancer is incomplete. The adjuvant chemotherapy approach has the advantage of pathology-based decision-making, allowing for patient selection. In addition, radical surgery is not delayed and treatment-related toxicity does not impair surgical fitness. The proportion of patients who completed chemotherapy after cystectomy among those who were fit and in need of treatment were evaluated. The reasons for not completing adjuvant chemotherapy were determined.

Materials and methods

We retrospectively evaluated all patients who had undergone radical cystectomy at our center over the last 7 years. Indications for adjuvant chemotherapy included pathological T > 2, any node+, or surgical margin involvement. Only patients who were fit for chemotherapy before surgery were included in the study.

Results

Of the 52 patients with muscle-invasive bladder cancer, 14 received neoadjuvant chemotherapy or unfit for chemotherapy were excluded. Of the remaining 38 patients, 14 (37%) had bladder-confined cancers and did not require additional chemotherapy. Of the 24 patients who needed chemotherapy and were fit to receive it, 8 patients completed treatment (33%), and 3 discontinued treatment due to toxicity. Twelve patients (50%) declined chemotherapy, whereas 1 patient became unfit for chemotherapy after surgery.

Conclusions

While the adjuvant chemotherapy approach could save unnecessary treatment in 37% of patients, two-thirds of those who needed chemotherapy did not complete it. Patient refusal was the primary reason for not receiving treatment.

Fascial dehiscence after radical cystectomy: Is abdominal exploration mandatory?

BACKGROUND

Fascial dehiscence after radical cystectomy may have serious clinical implications. To optimize its management, we sought to describe accompanying intraabdominal findings of post-cystectomy dehiscence repair and determine whether a thorough intraabdominal exploration during its operation is mandatory.

METHODS

We retrospectively reviewed a multi-institutional cohort of patients who underwent open radical cystectomy between 2005 and 2020. Patients who underwent exploratory surgery due to fascial dehiscence within 30 days post-cystectomy were included in the analysis. Data collected included demographic characteristics, the clinical presentation of dehiscence, associated laboratory findings, imaging results, surgical parameters, operative findings, and clinical implications. Potential predictors of accompanying intraabdominal complications were investigated.

RESULTS

Of 1301 consecutive patients that underwent cystectomy, 27 (2%) had dehiscence repair during a median of 7 days post-surgery. Seven patients (26%) had accompanying intraabdominal pathologies, including urine leaks, a fecal leak, and an internal hernia in 5 (19%), 1 (4%), and 1 (4%) patients, respectively. Accompanying intraabdominal findings were associated with longer hospital stay [20 (IQR 17, 23) vs. 41 (IQR 29, 47) days, P = 0.03] and later dehiscence identification (postoperative day 7 [IQR 5, 9] vs. 10 [IQR 6, 15], P = 0.03). However, the rate of post-exploration complications was similar in both groups. A history of ischemic heart disease was the only predictor for accompanying intraabdominal pathologies (67% vs. 24%; P = 0.02).

CONCLUSIONS

A substantial proportion of patients undergoing post-cystectomy fascial dehiscence repair may have unrecognized accompanying surgical complications without prior clinical suspicion. While cardiovascular disease is a risk factor for accompanying findings, meticulous abdominal inspection is imperative in all patients during dehiscence repair. Identification and repair during the surgical intervention may prevent further adverse, possibly life-threatening consequences with minimal risk for iatrogenic injury.

Potential Markers to Reduce Non-Contrast Computed Tomography Use for Symptomatic Patients with Suspected Ureterolithiasis

Most patients with ureterolithiasis are managed successfully with conservative treatment. In this context, delineation of clinical risk factors that identify patients with low risk for surgical intervention may reduce use of Non-Contrast Computed Tomography (NCCT). Here, emergency department patient files from a 14-month period were reviewed retrospectively, to identify patients who underwent NCCT and showed a ureteral stone. Demographic, clinical and laboratory information was collected. Patients were grouped to either requiring surgical intervention (Group 1) or having successful conservative management (Group 2). The cohort included 368 patients; 36.1% ultimately required surgical intervention (Group 1) and 63.9% were successfully treated conservatively (Group 2). On univariate analysis, patients who required surgical intervention were older, had longer duration of symptoms, had history of urolithiasis and surgical intervention for urolithiasis and had higher serum creatinine levels. Multivariate analysis identified the following risk factors associated with surgical intervention: creatinine >1.5 mg/dL, duration of symptoms ≥ 1.5 days and age > 45 years. Patients with 0, 1, 2 or 3 of the identified risk factors had 19%, 32%, 53% and 73% likelihood, respectively, of surgical intervention. Incorporating these data may reduce the use of NCCT scans in patients who are likely to pass a stone via conservative management.

Surgical Outcomes in High-risk Prostate Cancer and Salvage Radical Prostatectomy

BACKGROUND

Patients with high-risk prostate cancer are at higher risk of treatment failure, development of metastatic disease, and mortality. There is no consensus on the treatment of choice for these patients, and either radical prostatectomy (RP) or external beam radiation therapy (EBRT) is recommended. Surgery is less common as the initial treatment for high-risk patients, possibly reflecting the concerns regarding morbidity as well as oncological and functional outcomes. Another high-risk group includes patients with failure of previous EBRT or focal treatment. For these patients, salvage radical prostatectomy (SRP) can be offered.

OBJECTIVES

To describe our experience with surgery of high-risk patients and SRP.

METHODS

This cohort included all high-risk patients undergoing RP or SRP at our institution between January 2012 and December 2019. We reviewed the electronic medical charts and collected pathological, functional, and oncological outcomes.

RESULTS

Our cohort included 39 patients; average age was 67.8 years, and average follow-up duration was 40.9 months. The most common postoperative morbidity was transfusion of packed cells. There were no life-threatening events or postoperative mortality. Continence was preserved (zero to one pad) in 76% of the patients. Twenty-three patients (59%) had undetectable prostate specific antigen levels following the surgery, 11 (30%) were treated with either adjuvant or salvage EBRT, and 12 patients (31%) were found with no evidence of disease and no additional treatment was needed.

CONCLUSIONS

Radical prostatectomy and SRP are safe options for patients presenting with high-risk prostate cancer, with good functional and oncological outcomes.

Radical Cystectomy after Previous Radiation or Pelvic Surgery: Is It Associated with Increased Morbidity?

BACKGROUND

Radical cystectomy is a complicated surgery with significant risks. Complications of Clavien-Dindo grade 3-4 range from 25% to 40% while risk of mortality is 2%. Pelvic surgery or radiotherapy prior to radical cystectomy increases the challenges of this surgery.

OBJECTIVES

To assess whether radical cystectomy performed in patients with prior history of pelvic surgery or radiation was associated with increased frequency of Clavien-Dindo grade 3 or higher complications compared to patients without prior pelvic intervention.

METHODS

We retrospectively evaluated all patients who underwent radical cystectomy at our center over a 7-year period. All patients with pelvic radiation or surgery prior to radical cystectomy comprised group 1, while group 2 included the remaining patients.

RESULTS

In our study, 65 patients required radical cystectomy at our institution during the study period. Group 1 was comprised of 17 patients and group 2 included 48 patients. Four patients from group 2 received orthotopic neobladder, while an ileal conduit procedure was performed in the remaining patients. Estimated blood loss and the amount of blood transfusions given was the only variable found to be statistically different between the two groups. One patient from group 1 had four pelvic interventions prior to surgery, and her cystectomy was aborted.

CONCLUSIONS

Radical cystectomy may be safely performed in patients with a history of pelvic radiotherapy or surgery, with complication rates similar to those of non-irradiated or operated pelvises.

Repurposed floxacins targeting RSK4 prevent chemoresistance and metastasis in lung and bladder cancer

Lung and bladder cancers are mostly incurable because of the early development of drug resistance and metastatic dissemination. Hence, improved therapies that tackle these two processes are urgently needed to improve clinical outcome. We have identified RSK4 as a promoter of drug resistance and metastasis in lung and bladder cancer cells. Silencing this kinase, through either RNA interference or CRISPR, sensitized tumor cells to chemotherapy and hindered metastasis in vitro and in vivo in a tail vein injection model. Drug screening revealed several floxacin antibiotics as potent RSK4 activation inhibitors, and trovafloxacin reproduced all effects of RSK4 silencing in vitro and in/ex vivo using lung cancer xenograft and genetically engineered mouse models and bladder tumor explants. Through x-ray structure determination and Markov transient and Deuterium exchange analyses, we identified the allosteric binding site and revealed how this compound blocks RSK4 kinase activation through binding to an allosteric site and mimicking a kinase autoinhibitory mechanism involving the RSK4's hydrophobic motif. Last, we show that patients undergoing chemotherapy and adhering to prophylactic levofloxacin in the large placebo-controlled randomized phase 3 SIGNIFICANT trial had significantly increased (P = 0.048) long-term overall survival times. Hence, we suggest that RSK4 inhibition may represent an effective therapeutic strategy for treating lung and bladder cancer.

Abstract CT209: A clinical trial of cResponse, a functional assay for cancer precision medicine

Precision cancer therapy has the potential to revolutionize treatment outcome. While genomic analysis has become central to cancer personalized medicine, recent studies have not shown that it drastically improves patient survival as compared to standard drug selection. Additionally, genomic mutations may suggest several treatment protocols without elucidating which approach will yield the best clinical response. Moreover, for many drugs no genetic predictive biomarkers are available. To advance cancer precision diagnostics, we have developed cResponse, a functional drug sensitivity platform to determine individualized patient treatment regimens. Fresh patient cancer samples are taken by biopsy or resection and sectioned into 300 uM slices which when cultured in the cResponse platform demonstrate similar architecture and tissue proliferation to those found in vivo. We show that cResponse is able to preserve human cancer tissue in 3D together with its microenvironment, including endothelial and immune cells, at a high viability (>90%) with continued cell division for 7 days in over twenty types of solids tumors. Importantly, the high viability of the tissue over an extended period of time allows for a rapid genomic profiling to help prioritize drugs to be tested by cResponse, as well as the capacity to evaluate the effects of slow acting drugs such as targeted therapy. To validate the capacity of the cResponse platform to predict patient response to cancer treatment, forty two patients with different cancer types receiving diverse chemotherapeutic and targeted agents were recruited to the study and their tumors were tested using cResponse prior to initiation of treatment. Cancer types included bladder, pancreatic, lung, colorectal, breast and sarcoma. After five days of treatment ex-vivo, the samples were fixed and designated a viability score (ranging from 0 to 100) based on an algorithm composed of a panel of histological and morphological markers. The cResponse score was compared to the clinical response to treatment of 27 patients for which this data is already available. The results demonstrated that cResponse could predict the patient's response with a specificity of 82% (9/11) and a sensitivity of 93.75% (15/16) when compared to the patient's imaging results. In the future, the integration of this platform in directing anti-cancer treatment may lead to better response rate of cancer patients to therapy.

Citation Format: Seth Salpeter, Vered Bar, Sara Aharon, Luba Torovsky, Adi Zundelevich, Hamutal Shachar, Hagit Shapira, Nancy Gavert, Ravid Straussman, Shay Golan, Eli Rosenbaum, Talia Golan, Raanan Berger, Zohar Dotan, Dan Leibovici, Shani Breuer, Yakir Rotenberg, Aviad Zick, Ayala Hubert, Hovav Nechushtan, Guy Neev. A clinical trial of cResponse, a functional assay for cancer precision medicine [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr CT209.

Single Instillation of Hypertonic Saline Immediately Following Transurethral Resection of Bladder Tumor for Recurrence Prevention –A Phase I Study

BACKGROUND: Urologic guidelines recommend perioperative instillation of chemotherapy after transurethral resection of bladder tumor (TURBT) to decrease tumor recurrence, yet implementation of this recommendation is partial due to associated morbidity. Hypertonic saline destroys cells by osmotic dehydration and might present a safer alternative. OBJECTIVE: To evaluate the safety of 3% hypertonic saline (Hypersal) intravesical instillation following TURBT in rats and in humans. METHODS: In 8 rats whose bladders were electrically injured, intravesical blue-dyed Hypersal was administered. We measured serum sodium levels before and after instillation and pathologically evaluated their pelvic cavity for signs of inflammation or blue discoloration. Twenty-four patients were recruited to the human trial (NIH-NCT04147182), 15 comprised the interventional and 10 the control group (one patient crossed over). Hypersal was given postoperatively. Serum sodium was measured before, 1 hour and 12–24 hours after instillation. Adverse effects were documented and compared between the groups. RESULTS: In rats, average sodium levels were 140.0 mEq/L and 140.3 mEq/L before and following instillation, respectively. Necropsy revealed no signs of inflammation or blue discoloration. In humans the average plasma sodium levels were 138.6 mEq∖L, 138.8 mEq∖L and 137.7 mEq∖L before, 1 hour and 12–24 hours after instillation, respectively. During the postoperative follow-up there was one case of fever. A month after the surgery, dysuria was reported by 5 patients while urgency and hematuria were reported by one patient each. The most severe adverse events were grade 2 on the Clavien-Dindo scale. Adverse events were similar in the control group. CONCLUSIONS: Hypersal instillation is safe and tolerable immediately after TURBT.

Do organic substances act as a degradable binding matrix in calcium oxalate kidney stones?

BACKGROUND

Calcium oxalate (CaOx) stones are considered to be highly resistant to chemolysis. While significant organic matter has been identified within these stones, which is presumed to bind (inorganic) CaOx particles and aggregates, most chemolysis efforts have focused on methods to attack the CaOx components of a stone. We examine the feasibility of inducing chemolysis of CaOx kidney stones, within hours, by specifically attacking the organic matrix present in these stones.

METHODS

In contrast to previous studies, we focused on the possible "brick and mortar" stone configuration. We systematically tested, via in vitro experiments, the ability of an extensive range of 26 potential chemolysis agents to induce relatively fast disintegration (and/or dissolution) of a large set of natural CaOx stone fragments, extracted during endourological procedures, without regard to immediate clinical application. Each stone fragment was monitored for reduction in weight and other changes over 72 h.

RESULTS

We find that agents known to attack organic material have little, if any, effect on stone chemolysis. Similarly, protein and enzymatic agents, and oral additive medical treatments, have little immediate effect.

CONCLUSIONS

These findings suggest that the organic and inorganic constituents present in CaOx stones are not structured as "brick and mortar" configurations in terms of inorganic and organic components.

Do patients with ureterolithiasis treated conservatively return to follow up?

INTRODUCTION Distal ureteral stones (DUS) are common in patients presenting to the emergency department (ED) with renal colic. The majority of DUS will pass spontaneously and therefore conservative care is common. Follow up is imperative as some of these stones might not pass and potentially lead to complications. The aim of our study was to evaluate the rate of compliance with follow up and to find predictive variables for it.

MATERIALS AND METHODS

We retrospectively surveyed the medical records of all patients who had a non-contrast computed tomography (NCCT) at our ED between 01/03/16 and 31/5/17. We included patients with a DUS smaller than 10 mm that were treated conservatively. We obtained demographic, clinical, laboratory and imaging data. Compliance to follow up was evaluated by surveying the medical records and by calling the patients. We then compared the characteristics of patients who returned for follow up to those who did not.

RESULTS

A total of 230 consecutive patients were included in our cohort: 194 (84%) patients were male and the average age was 46 y (21-82); 138 patients (60%) returned for a follow up visit while 92 patients (40%) did not. Univariate analysis revealed stone size and admission to hospital to be predictive of compliance to follow up while multivariate analysis revealed only hospital admission to be predictive of compliance.

CONCLUSIONS

Only 60% of the patients with DUS treated conservatively return for a follow up visit. Hospital admission, which likely reflects appropriate patients counseling by a urologist and adequate follow up scheduling, was found to be associated with increased compliance with follow up.

The Impact of Ureteral Deformation and External Ureteral Pressure on Stent Failure in Extrinsic Ureteral Obstruction: An In Vitro Experimental Study

Background and Purpose: Extrinsic ureteral obstruction is caused frequently by pelvic malignancies or metastatic lymphadenopathy, necessitating renal drainage with ureteral stents to prevent renal failure and kidney damage. Understanding the nature of stent behavior under deformation and realistic external pressures may assist in evaluation of stent performance. Few published studies have investigated the flow and mechanical properties of stents within ureters, and none has considered the effects of deformation and compression on flow in realistic, in vitro, ureter-stent systems. The purpose of this work was to determine whether or not stent failure is due only to stent compression and deformation in the presence of extrinsic obstruction. Methods: We developed an in vitro ureter-stent experimental setup, using latex tubing to simulate a flexible ureter connecting a renal unit and a bladder side. We examined flow behavior in three stents (4.8F, 6F, 7F). The ureter-stent configuration was varied, simulating four levels of deformation (0°, 20°, 40°, 60°) and then simulating different external compressive forces on a stented ureter with 40° deformation. A constant, realistic fluid flow was applied through the ureter-stent configurations, and pressure fluctuations in the renal unit were monitored. Results: Deformation alone on four different levels (0°, 20°, 40°, 60°) has essentially no influence on fluid flow and renal pressure variation. Under increasing external compressive forces of 500, 1000, 2000, and up to 5000 g at 40° deformation, no effect on fluid flow and pressure within the renal unit was noted for the 6F and 7F stents. The only exception was for the 4.8F stent, which demonstrated complete failure at compressive forces near 4000 g. Conclusions: Neither realistic extrinsic ureteral compression forces nor ureteral deformation explain the high frequency of stent failure in extrinsic ureteral obstruction. Other factors such as urine composition may be a major contributor to stent failure.

Spermatogenesis in Testicles with Germ Cell Tumors

BACKGROUND

Almost 50% of patients with germ-cell tumors (GCT) are subfertile, and every step of the treatment may further impair fertility. As a result, sperm banking is often advised prior to radical orchiectomy. However, whether affected testes contribute to fertility is unclear.

OBJECTIVES

To determine whether maximal tumor diameter (MTD) is correlated with ipsilateral fertility (IF) in patients treated for GCT.

METHODS

We reviewed medical charts for demographic and clinical data of patients with GCT who had undergone orchiectomy at our institution between 1999 and 2015. The extent of spermatogenesis was categorized into three groups: full spermatogenesis, hypospermatogenesis, and absence of spermatogenesis. The presence of mature spermatozoa in the epididymis tail was also assessed. We defined IF as the combination of full spermatogenesis in more than 100 tubules and the presence of mature spermatozoa in the epididymis tail. Mann-Whitney was applied to determine the correlation between MTD and IF.

RESULTS

Of 57 patients, IF was present in 28 (49%). Mean patient age was 32.8 years in patients with positive IF and 33.4 years those with negative IF. Seminoma was diagnosed in 46.4% of patients with positive IF and in 65.5% of patients with negative IF. Full spermatogenesis was observed in 33 patients (57.8%). In 48 (82.7%), mature epididymal spermatozoa were found. No correlation was found between MTD and IF.

CONCLUSIONS

IF is present in almost half of the patients undergoing radical orchiectomy. Because IF cannot be predicted by MTD, routine pre-orchiectomy sperm banking is suggested.

Anterior fascial fixation does not reduce the parastomal hernia rate after radical cystectomy and ileal conduit

OBJECTIVE

To compare the rate of parastomal hernia in patients undergoing anterior fascial fixation of the ileal conduit with that in patients without fascial fixation. Limited data exist on whether anterior fascial fixation of the ileal conduit impacts the rate of parastomal hernia.

METHODS

A total of 496 consecutive patients undergoing radical cystectomy and ileal conduit reconstruction from 1995 to 2012 were retrospectively evaluated for parastomal hernia. All patients had a 2-fingerbreadth aperture and the ileal conduit brought through the rectus muscle and sheath. Patients were divided into 1 of 3 groups based on stoma fixation and/or reinforcement: anterior fascial fixation, posterior reinforcement, or no fascial fixation. A parastomal hernia was defined as a palpable bulge at the stoma site. Multivariate logistic regression was conducted for the primary end point of parastomal hernia, controlling for other patient- and treatment-related factors that might affect the rate of parastomal hernia.

RESULTS

Median follow-up was 16 months (range, 1-189 months). The parastomal hernia rate was significantly greater in the anterior fascial suture group (43 of 281; 15.3%) than the no fascial suture group (12 of 164; 7.3%; P=.02). Multivariate logistic regression analysis modeled for the occurrence of a parastomal hernia demonstrated that anterior fascial fixation was an independent predictor of the development of parastomal hernia (odds ratio, 2.3; 95% confidence interval, 1.03-5.14; P=.04).

CONCLUSION

Anterior fascial fixation of the ileal conduit does not reduce the risk of parastomal hernia formation compared with the patients treated without fascial fixation. Surgeons should consider avoiding anterior suture fixation during ileal conduit creation.

Self-induced plantar-flexion objectively reduces wave amplitude of detrusor overactivity and subjectively improve urinary urgency: a pilot study

AIMS

To estimate the effect of plantar-flexion on the wave amplitude of involuntary detrusor contraction and the severity of urinary urgency during filling cystometry in patients with detrusor overactivity (DO).

METHODS

Twenty-two consecutive patients with DO were enrolled. During urodynamics, the mean peak detrusor pressures of each contraction were documented and compared. At the beginning of the 2nd or 3rd wave, patients were asked to perform continuous plantar-flexion by pushing their tiptoes against the floor. Following each wave, patients were asked to grade the severity of the urgency by a visual analogue scale (VAS).

RESULTS

The mean peak detrusor pressure without plantar-flexion was 58 cmH2 O (95% CI: 46.3-69.7) compared to 31 cmH2 O (95% CI: 23.1-38.9) with plantar-flexion (P < 0.001). All patients reported a reduced degree of urgency during plantar-flexion reflected in a significant reduction in mean VAS score from 9.3 (95% CI: 9-9.5) to 4.7 (95% CI: 3.9-5.4; P < 0.0001).

CONCLUSIONS

Self-performed plantar-flexion maneuver might reduce the severity of urinary urgency and the magnitude of overactive detrusor contractions, which may have a role in the conservative therapy of detrusor overactivity.

How accurate is our clinical prediction of "minimal prostate cancer"?

BACKGROUND

Recommendations for active surveillance versus immediate treatment for low risk prostate cancer are based on biopsy and clinical data, assuming that a low volume of well-differentiated carcinoma will be associated with a low progression risk. However, the accuracy of clinical prediction of minimal prostate cancer (MPC) is unclear.

OBJECTIVES

To define preoperative predictors for MPC in prostatectomy specimens and to examine the accuracy of such prediction.

METHODS

Data collected on 1526 consecutive radical prostatectomy patients operated in a single center between 2003 and 2008 included: age, body mass index, preoperative prostate-specific antigen level, biopsy Gleason score, clinical stage, percentage of positive biopsy cores, and maximal core length (MCL) involvement. MPC was defined as < 5% of prostate volume involvement with organ-confined Gleason score < or = 6. Univariate and multivariate logistic regression analyses were used to define independent predictors of minimal disease. Classification and Regression Tree (CART) analysis was used to define cutoff values for the predictors and measure the accuracy of prediction.

RESULTS

MPC was found in 241 patients (15.8%). Clinical stage, biopsy Gleason's score, percent of positive biopsy cores, and maximal involved core length were associated with minimal disease (OR 0.42, 0.1, 0.92, and 0.9, respectively). Independent predictors of MPC included: biopsy Gleason score, percent of positive cores and MCL (OR 0.21, 095 and 0.95, respectively). CART showed that when the MCL exceeded 11.5%, the likelihood of MPC was 3.8%. Conversely, when applying the most favorable preoperative conditions (Gleason < or = 6, < 20% positive cores, MCL < or = 11.5%) the chance of minimal disease was 41%.

CONCLUSIONS

Biopsy Gleason score, the percent of positive cores and MCL are independently associated with MPC. While preoperative prediction of significant prostate cancer was accurate, clinical prediction of MPC was incorrect 59% of the time. Caution is necessary when implementing clinical data as selection criteria for active surveillance.

Hyperbaric oxygen therapy for hemorrhagic radiation cystitis

BACKGROUND

Hemorrhagic radiation cystitis (HRC) is a significant clinical problem that occurs after pelvic radiation therapy and is often refractory.

OBJECTIVES

To evaluate the efficacy and safety of hyperbaric oxygen therapy (HBO) for HRC.

METHODS

Daily 90 minute sessions of HBO at 2 ATM 100% oxygen were given to 32 HRC patients with ASTRO grades 3-4 hematuria.

RESULTS

The median age was 72.5 (48-88 years). The median time interval between radiation therapy and HBO was 4 years (1-26 years). The patients received a median of 30 HBO sessions (3-53). Hematuria resolved in 27 patients (84%) and persisted in 5. Cystectomy was required in two, and ileal-conduit and bilateral percutaneous nephrostomies were performed in one and two patients, respectively. With a median follow-up of 12 months (5-74 months), the hematuria cleared completely in 16 patients (59%) and mild hematuria requiring no further treatment recurred in 10 others. Another patient with ASTRO grade 4 hematuria needed bladder irrigation and blood transfusions. Complications included eardrum perforation in four patients and transient vertigo and mild hemoptysis in one case each. None of them required HBO discontinuation.

CONCLUSIONS

HBO controlled bleeding in 84% of the patients. A durable freedom from significant hematuria was achieved in 96% of the patients. HBO seems to be an effective and safe modality in patients with HRC.

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.