Long-term results of salvage cryotherapy for prostate cancer

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Background: The optimum treatment of Prostate cancer recurrence following external bean radiation therapy (EBRT) remains a controversial topic. The primary problem with comparing salvage techniques following EBRT is the lack of long term data. We reviewed the long- term overall survival, disease-specific survival and disease free survival of patients who have undergone salvage cryotherapy to the prostate gland.

Methods: A retrospective analysis was performed on all patients undergoing salvage cryotherapy for locally recurrent prostate cancer after EBRT by a single surgeon at a single institution from 1995-2004. Patients preoperative, perioperative and postoperative data was reviewed and recorded. Should a patient no longer be followed by the urology service the Patients and the patient's primary care physician or urologist were contacted. Mortality data, PSA results, bone scan results and any details of hormone therapy were recorded for this study.

Results: 187 patients were included in the current study from which 176 patients had records available for follow up giving a follow up rate of 94%. Mean follow up was 7.46 years (1-14 years). 52 patients were followed for greater than 10 years. Average time to prostate cancer recurrence in patients who developed recurred was 2.3 years and average time to hormone therapy in these patients was 2.8 years. Overall survival at 10 years was high at 87%. Risk factors for recurrence of tumour identified were presalvage PSA, preradiation and presalvage gleason score. Preradiation gleason score had little impact on survival. PSA nadir of >1.0ng/mL was highly predictive of early recurrence. Disease-free survival rates of between 39 and 64% depending on risk factors.

Conclusions: Cryotherapy has a definite role in the management of prostate cancer, representing a minimally invasive salvage treatment with acceptable 10 year disease free survival (DFS) of upwards of 39% and specific groups attaining 10 year DFS of 64%. Presalvage PSA and Gleason score are the best predictors of disease recurrence, whilst preradiation gleason score did not correlate with risk of disease recurrence. A PSA Nadir greater than 1 ng/mL indicates a poor prognosis in which early ADT should be strongly considered.

No significant financial relationships to disclose.

Fournier's gangrene following penile self-injection with cocaine

To date, there have been no reports of Fournier's gangrene following penile self-injection of cocaine. We report a case of cocaine-induced Fournier's gangrene requiring parenteral antibiotics followed by primary surgical debridement and delayed reconstructive procedure of penile skin.

Retroperitoneoscopic-guided radiofrequency ablation of renal tumors

OBJECTIVE

Minimally invasive approaches to the management of renal tumors are being studied intensively in urology. Herein, we describe the use of multiple organ-sparing techniques for the management of tumors in a patient with von Hippel Lindau disease (VHL).

MATERIALS AND METHODS

A 42 year-old woman with VHL underwent a right partial adrenalectomy and a left renal radiofrequency ablation (RFA) of two renal tumors.

RESULTS

A 2.2 cm solitary right adrenal pheochromocytoma was resected using a transperitoneal approach. A retroperitoneal approach to the left kidney was performed and RFA of the two renal tumors completed using sonographic guidance. On the 5-month follow-up CT scan, there was no evidence of residual adrenal tumors and both renal lesions lacked contrast enhancement. No complications occurred during the post-operative recovery.

CONCLUSIONS

Multiple organ-ablative laparoscopic procedures may be performed in a single sitting. Laparoscopic partial adrenalectomy is an effective technique in patients with bilateral tumors or a familial syndrome predisposing to multiple adrenal tumors. Further study of renal RFA is required to assess the long-term durability of the procedure.

An articulating retractor holder to facilitate laparoscopic adrenalectomy and nephrectomy

PURPOSE

Minimally invasive surgical approaches to renal and adrenal tumors have gained increasing use. The addition of robotic assistance and mechanical devices has decreased the number of assistants required for these often long cases. We describe an articulating arm retractor holder to aid in liver and spleen retraction during laparoscopic surgery.

MATERIALS AND METHODS

The articulating retractor holder consists of 4 components, including a base rod, flexible extension arm, stainless steel precision clamp and table attachment. During laparoscopy the abdomen is visualized using standard approaches. The articulating retractor holder is clamped to the table via the base rod and brought into the surgical field using sterile technique. A retractor is placed intracorporeally to elevate the liver or spleen and the handle is secured in place using the precision clamp.

RESULTS

The articulating retractor holder was used in all right and approximately 50% of left laparoscopic cases. Adequate visualization was obtained in all patients. There were no device failures or retractor related complications.

CONCLUSIONS

The articulating retractor holder is a useful tool to aid in laparoscopic retraction that should be added to the urologist armamentarium.

Results of salvage cryoablation of the prostate after radiation: identifying predictors of treatment failure and complications

PURPOSE

We conduct a critical evaluation of cryoablation of prostate cancer after failure of full dose radiotherapy to identify predictors of treatment failure and complications.

MATERIALS AND METHODS

A total of 125 cryoablation procedures were performed in 118 patients with proved local recurrence after full dose radiotherapy. Followup includes serial prostate specific antigen (PSA) and biopsy at 6,12 and 24 months. Kaplan-Meier plots were constructed for different PSA cutoffs. We separately analyzed different cohorts based on T stage, Gleason score, PSA before cryoablation and endocrine therapy status.

RESULTS

Of the 118 patients 114 had serum PSA nadir less than 0.5 ng./ml. Median followup was 18.6 months (range 3 to 54). Of the biopsy cores 3.1% (23 of 745) from 7 patients contained persistent viable cancer. Kaplan-Meier plots showed patients free of histological failure leveling at 87% and free from biochemical failure at 68%, 55% and 34%, respectively, with PSA greater than 4, 2 and 0.5 ng./ml. PSA greater than 10 ng./ml. before cryoablation, Gleason score 8 or greater before radiation and stage T3/T4 disease appeared to predict an unfavorable biochemical outcome. Serious complications included 4 rectourethral fistulas (3.3%) and severe incontinence (6.7%). Strong predictors of complications included bulky disease for fistulas and prior transurethral surgery.

CONCLUSIONS

Salvage cryoablation after radiation can achieve reasonable biochemical and histological results with acceptable morbidity. Cryoablation appears to be a reasonable treatment option for this patient population with few viable therapeutic options, provided vigorous patient selection criteria are adhered to.

Priapism. From Priapus to the present time

Advances in the pharmacotherapeutic options available to treat erectile dysfunction over the past decade have transformed the field of impotence. The initial foray into this field with intracavernous injections of papaverine rapidly expanded the number of men seeking attention for priapism, a previously rare clinical condition. The recent widespread use and acceptance of oral agents for the treatment of erectile dysfunction, with a reduced incidence of priapism has decreased the number of men at risk for injection-related prolonged erections. The use of recreational drugs (cocaine) and perineal trauma leading to presentations of priapism seem to be rising in incidence. The urologist remains the consultant-specialist ultimately responsible for these men and should be cognizant of the array of treatments described for this condition. Early determination of the state of corporal oxygenation is essential and will define the optimal management approach. A wide range of medical conditions and risk factors may be etiologic and should be elicited from the patient at the initial interview. Low-flow ischemic priapism requires a rapid resolution, often achieved through use of alpha-agonists orally or by direct injection into the penile circulation, whereas nonischemic priapism can be treated more conservatively. Research into this condition has only recently been initiated. Through greater understanding of the pathophysiology of priapism, the clinician may become armed with etiology-specific medical alternatives providing timely detumescence for men with prolonged erections.

Ureteroscopic decompression of an unusual uroepithelial cyst using the holmium:YAG laser

We report a case of an unusual uroepithelial cyst arising from a renal calix in an African-American man with sickle cell trait. The lesion was incised and decompressed using a 7.5F flexible ureteroscope in conjunction with the holmium:YAG laser and a 200-microm quartz laser fiber. To our knowledge, endourologic management of this type of lesion has not been described in the literature.

Use of the internet for self-education by patients with prostate cancer

OBJECTIVES

To define use of the Internet for self-education by a cohort of patients with prostate cancer and to arrive at some relevant recommendations for the practicing urologist. Little has been published about patient use of the Internet in investigating their health conditions, specifically prostate cancer.

METHODS

In April 1999, a self-administered, anonymous questionnaire was mailed to 490 men with the diagnosis of prostate cancer. Institutional ethics approval was obtained. Standard statistical analyses were performed.

RESULTS

Of 490 questionnaires mailed, a total of 312 (63.7%) were available for analysis. Forty-eight percent of patients were 60 to 69 years old. Fifty-two percent of patients had never used a computer, and 25% described daily use. Only 35% of this cohort had used the Internet. Ninety-one patients had used the Internet to obtain information about prostate cancer, with 53 doing so after diagnosis but before deciding on treatment. Twenty-eight patients stated that Internet information influenced their decision about treatment. Not surprisingly, patients were more likely to use the Internet for health information if they were younger, had a higher education level, owned a personal computer, and had prior computing experience. Most patients could not recall the exact web sites they had visited but tended to recall the sites of some well-known institutions.

CONCLUSIONS

In this Canadian cohort study, we found a substantial (and most likely, rapidly increasing) number of patients used the Internet to obtain health information. This information may influence patients' decisions regarding treatment and, as urologists, we should participate in the development of web sites directed toward shared decision-making. A list of practical recommendations has been formulated.

Upper tract urokinase instillation for nephrostomy tube patency

PURPOSE

We describe a useful technique for declotting a nephrostomy tube blocked secondary to recurrent blood clot formation.

MATERIALS AND METHODS

Urokinase was instilled into the nephrostomy tube in a patient with a solitary kidney obstructed by malignancy on 2 separate occasions for 30 minutes each followed by manual irrigation with normal saline.

RESULTS

The nephrostomy tube and renal pelvis were successfully declotted, and we avoided a nephrostomy tube change or insertion of a second tube. The tumor was subsequently embolized to prevent further bleeding.

CONCLUSIONS

Instillation of urokinase into a nephrostomy tube blocked by a blood clot may obviate repeat nephrostomy tube changes and is a useful addition to the urological armamentarium.

Cystoid macular edema associated with latanoprost in aphakic and pseudophakic eyes

PURPOSE

To describe four patients who developed cystoid macular edema shortly after onset of treatment with latanoprost.

METHOD

Retrospective review of medical records of patients with open-angle glaucoma who developed cystoid macular edema shortly after starting latanoprost.

RESULTS

The use of topical latanoprost was temporally related to the development of cystoid macular edema in four patients (six eyes; two aphakic eyes and four pseudophakic eyes). Cystoid macular edema resolved in all patients after latanoprost was discontinued.

CONCLUSIONS

Cystoid macular edema is a potential complication of latanoprost therapy. Further observations are needed to determine if the risk of cystoid macular edema is limited to or greatest in patients who are pseudophakic or aphakic.

Renal autotransplantation for the loin pain-hematuria syndrome: long-term followup of 26 cases

PURPOSE

We review the long-term results of renal autotransplantation as a form of nephron sparing renal denervation for patients with the loin pain-hematuria syndrome.

MATERIALS AND METHODS

From 1985 to 1997, after exclusion of other urological, nephrological and psychiatric causes for severe intractable flank pain and recurrent hematuria, 22 patients with severe debility and heavy narcotic dependency underwent 26 renal autotransplantations for pain control. Postoperative pain relief, narcotic use, level of function in daily activities and status of the autograft were assessed.

RESULTS

Median and mean followup was 78.5 and 84.7 months (range 30 to 138), respectively. There were 2 technical failures. Pain recurred within 2 years after 6 procedures, of which 3 resulted in transplant nephrectomy and 3 were managed with a reduced analgesic requirement. Of the 16 patients with minimum 5 years of followup 12 (75%) were pain-free after surgery with 3 additional patients pain-free after transplant nephrectomy. Overall, 18 of the 26 autotransplant procedures (69.2%) resulted in pain relief, in some cases beyond 10 years, with patients returning to normal daily activities.

CONCLUSIONS

Renal autotransplantation results in durable narcotic-free favorable results in the majority of meticulously screened loin pain-hematuria syndrome patients. Although some failures, which usually occur within 2 years after surgery, can be expected, autotransplantation is justified as a nephron sparing denervation therapy for select loin pain-hematuria syndrome patients.

A long-term follow-up of choroidal osteoma

OBJECTIVE

To provide long-term follow-up information on a large series of patients with choroidal osteoma.

METHODS

Review of patients with a diagnosis of choroidal osteoma who had been examined at the Bascom Palmer Eye Institute, Miami, Fla, or known to one of us (J.D.M.G.). Information was obtained from hospital medical records or by a questionnaire sent to referring ophthalmologists. Life-table analysis was used to study the loss of vision and development of choroidal neovascularization.

RESULTS

We followed up 36 patients, 31 (89%) were female, mean age, 21 years (range, 5-54 years) for a mean of 10 years (range, 2-22 years). Growth was observed for 9 (41%) of 22 well-documented osteomas. The probability of loss of visual acuity to 20/200 or worse was 58% by 10 years and 62% by 20 years. The probability of developing choroidal neovascularization was 47% by 10 years and 56% by 20 years. Successful treatment of the choroidal neovascularization with laser photocoagulation was performed for 5 (25%) of 20 patients.

CONCLUSIONS

Most patients with choroidal osteomas maintain good vision in at least 1 eye, but they have a high risk of developing choroidal neovascularization. When this occurs, only a minority can be successfully treated with laser photocoagulation.

Isolation of new probes in the region of the Wilson disease locus, 13q14.2-->q14.3

A hybrid panel was used to refine the localizations of eight established markers useful for the diagnosis of Wilson disease. Two of the markers, D13S59 and D13S31, that map very close to the Wilson disease locus (WND) were localized to the region 13q14.2-->q14.3. We report the isolation of seven new probes from this region, using two different approaches. First, 16 clones from a chromosome 13-specific library were mapped using the hybrid panel. Three of the clones mapped to 13q14.2-->q14.3. As a second approach, Alu element-mediated PCR (Alu-PCR) was used to generate clones from a hybrid (ICD) that contains the proximal half of chromosome 13 as the only human component. To select for those that potentially mapped within the region 13q14.2-->q14.3, the clones were screened by differential hybridization using the labeled Alu-PCR products from a hybrid (KSF39) that is similar to ICD but has a deletion in the region 13q14.2-->q14.3. The procedure was successful even though KSF39 contains five additional human chromosomes. Six independent clones were selected. Five of these were found to be nonrepetitive, and four were found to map correctly to 13q14.2-->q14.3 when localized using the hybrid panel.

Isolation and regional localization of 25 anonymous DNA probes on a chromosome 13 hybrid panel

Clones were isolated from two flow-sorted chromosome 13 libraries. Twenty-five clones were localized to various regions of chromosome 13, using a well-characterized panel of rodent x human hybrid cell lines. Eight DNA markers were localized to 13q14.2----q22, where the gene for Wilson disease, a recessive disorder of copper metabolism, was previously assigned. The new markers will be useful for the diagnosis of presymptomatic sibs of Wilson disease patients. We isolated six DNA clones proximal to the retinoblastoma gene, a region in which a translocation associated with rhabdomyosarcoma has been observed. Probes for both of these regions will be useful for the cloning of the genes involved in these diseases.

Bilateral diffuse uveal melanocytic proliferation in patients with occult carcinoma

The development of multiple, round or oval, subtle, red patches at the level of the pigment epithelium in the posterior ocular fundus and their striking early hyperfluorescence angiographically are characteristic features of the bilateral diffuse uveal melanocytic proliferation syndrome. They may be accompanied by severe visual loss and may antedate the appearance of multiple melanocytic tumors, retinal detachment, and cataract in these patients with occult systemic carcinomas. These hyperfluorescent patches are caused by focal damage to the pigment epithelium overlying an intact choriocapillaris and diffuse benign nonpigmented uveal melanocytic infiltration of the outer choroid. We suggest that outer retinal damage may not be primarily caused by melanocytic proliferation, but rather by toxic and immune factors generated by interaction between a systemic carcinoma and congenital melanocytosis of the uveal tract. We report the longest survivor of this disorder to date (102 months).

Rhegmatogenous retinal detachment with subretinal exudates

Two young patients with probable longstanding traumatic retinal detachments underwent successful surgical repair. Dramatic subretinal exudates and crystalline material gradually resorbed; however, poor final vision resulted. No predisposing condition other than the longstanding retinal detachments was noted in these patients.

Toxemia of pregnancy pigment epitheliopathy masquerading as a heredomacular dystrophy

Patients with toxemia of pregnancy may develop permanent alterations of the pigment epithelium that if first discovered in later life may be mistaken for a heredomacular dystrophy, a diffuse tapetoretinal dystrophy or other diseases. These nonprogressive changes are caused by multifocal areas of fibrous platelet occlusion of the choriocapillaris that usually occur just prior to or following delivery and is usually associated with a transient period of exudative retinal detachment. The pattern of pigment epithelial derangement is often sufficiently characteristic to suggest the correct diagnosis.

Intrastromal iris hemorrhage in a patient with hemoglobin C trait

A 67-year-old man had a spontaneous intrastromal iris hemorrhage which resolved without complications. A thorough evaluation revealed no underlying abnormality except for the presence of hemoglobin C trait.