Long-term results of antegrade endoureterotomy using the holmium laser in patients with ureterointestinal strictures

OBJECTIVES

To investigate the effectiveness and morbidity of percutaneous laser endoureterotomy in the management of ureterointestinal anastomotic strictures after radical cystectomy and urinary diversion.

METHODS

Between May 1997 and August 2000, 19 percutaneous endoureterotomy incisions, including 3 repeated incisions, were performed on 15 patients with a mean age of 61 years (range 41 to 80) to treat ureterointestinal strictures. A total of 16 renal units were treated (9 left, 7 right), including one bilateral procedure. All procedures were performed using a 200-micrometer holmium laser fiber in antegrade fashion with a 7.5F flexible ureteroscope. A nephroureteral stent was left in place for 4 to 6 weeks postoperatively. Success was defined as radiologic improvement and/or the ability to return to full activity in the absence of flank pain, infection, or the need for ureteral stents or nephrostomy tubes.

RESULTS

With a median follow-up of 20.5 months (range 9 to 41), the overall success rate was 57% (8 of 14 renal units). Two patients were lost to follow-up. The mean operative time was 91 minutes, and no perioperative complications occurred. Three patients required repeated endoureterotomies, with two requiring open reimplantation. Overall, the endoureterotomy failed in 6 patients in the series, with five of the six failures involving left-sided strictures.

CONCLUSIONS

Percutaneous endoureterotomy is an effective, minimally invasive treatment option for patients with ureterointestinal strictures after urinary diversion. Better visualization and a more precise incision may make the holmium laser a safer cutting modality than alternative methods in patients with ureteroenteric strictures. Patients with left-sided ureterointestinal strictures should be cautioned that endourologic management might have a lower success rate.

Randomized, double-blind, placebo-controlled trial of saw palmetto in men with lower urinary tract symptoms

OBJECTIVES

To assess the effects of saw palmetto on urinary symptoms, sexual function, and urinary flow rate in men with lower urinary tract symptoms using a double-blind, randomized, placebo-controlled trial.

METHODS

The eligible patients were 45 years of age or older and had an International Prostate Symptom Score of 8 or greater. After a 1-month placebo run-in period, 85 men were randomized to receive saw palmetto or placebo for 6 months. Patients were evaluated using the International Prostate Symptom Score, a sexual function questionnaire, and by measurement of the urinary flow rate.

RESULTS

The mean symptom score decreased from 16.7 to 12.3 in the saw palmetto group compared with 15.8 to 13.6 in the placebo group (P = 0.038). The quality-of-life score improved to a greater degree in the saw palmetto group, but this difference was not statistically significant. No change occurred in the sexual function questionnaire results in either group. The peak flow rate increased by 1.0 mL/s and 1.4 mL/s in the saw palmetto and placebo groups, respectively (P = 0.73).

CONCLUSIONS

Saw palmetto led to a statistically significant improvement in urinary symptoms in men with lower urinary tract symptoms compared with placebo. Saw palmetto had no measurable effect on the urinary flow rates. The mechanism by which saw palmetto improves urinary symptoms remains unknown.

Results of treatment with tamsulosin in men with acute urinary retention

PURPOSE

The aim of this study was to prospectively assess the outcome in men treated with temporary catheter drainage and tamsulosin after an episode of acute urinary retention (AUR).

MATERIALS AND METHODS

Thirty-three consecutive men with AUR were treated with tamsulosin 0.4 mg daily for at least 4 days before a trial of voiding. Those men who were able to void adequately continued taking tamsulosin and were evaluated at 2-week and 3-month follow-up. After 3 months, additional follow-up was obtained at regular intervals as determined by the treating physician.

RESULTS

Median follow-up was 6.5 months. Mean urine volume at the time of initial bladder drainage was 790 mL. Eighty-eight percent (29/33) of men were able to void initially. Transurethral prostatectomy or intermittent catheterization were necessary in 9 (27%) of 33 patients during the follow-up period. A poor quality-of-life score on the initial International Prostate Symptom Score (p = .038) and a high postvoid residual volume 2 weeks after catheter removal (p = .013) correlated with failure of medical therapy. Patients with AUR after nonurologic surgery had a significantly better outcome than those with AUR that did not occur postoperatively. Mean symptom score, quality-of-life score, and postvoid residual urine volume were 12.9, 2.7, and 111 mL, respectively, at 2-week follow-up and were 11.9, 2.8, and 61.7 mL, respectively, at 3-month follow-up. Mean peak urinary flow rate at 3 months was 7.7 mL/s.

CONCLUSIONS

Tamsulosin appears to be helpful in the management of men with AUR. The majority of men were able to avoid surgery after temporary catheter drainage.

Should laparoscopy be the standard approach used for pelvic lymph node dissection?

Involvement of the pelvic lymph nodes in patients with prostate cancer worsens the overall prognosis of this common disease entity. Prior radiographic staging techniques, including fine-needle aspiration, are limited by a poor sensitivity and are not reliable. The gold standard for the evaluation of pelvic lymph nodes in men with prostate cancer involves performing a lymphadenectomy. Historically, this procedure was performed using an open surgical technique. Unfortunately, this invasive procedure is associated with significant morbidity. In response, modern surgical technology has provided newer, less invasive techniques, including laparoscopic pelvic lymphadenectomy (LPLND). Improved detection of localized prostate cancer through the institution of screening protocols and early detection programs has decreased the number of patients presenting with lymph node involvement. Various clinical indicators, including prostate-specific antigen, grade, and stage, have been used to improve the selection of "high-risk" patients that are appropriate candidates for pelvic lymph node dissection. The technique of LPLND is a valid option in the armamentarium for staging of prostate cancer. The laparoscopic approach provides the same staging accuracy as the open surgical technique and is superior with respect to morbidity. LPLND is limited to patients who present with a high risk of advanced prostate cancer. In addition, the urologist must accept the additional training, financial expense, and "learning curve" associated with this technique.

Results of radical prostatectomy in men with locally advanced prostate cancer: multi-institutional pooled analysis

OBJECTIVE

We investigated the disease-specific and metastasis-free survival rates in men with locally advanced (clinical stage T3) prostate cancer who were treated surgically.

METHODS

A retrospective, multi-institutional pooled analysis of the results of surgical treatment in 345 men with clinical stage T3 disease was performed. Survival curves were generated using the Kaplan-Meier method.

RESULTS

Among 298 evaluable patients, pelvic lymphadenectomy alone was performed in 56 men (19%), while 242 men (81%) underwent node dissection and radical prostatectomy. In total, 122 of 298 patients (41%) had nodal metastases and/or seminal vesicle tumor spread. Pathologically organ-confined disease was noted in 27 men (9%). The actuarial 10-year disease-specific and metastasis-free survival rates for all patients managed surgically were 57 and 32%, respectively. For patients with well, moderately and poorly differentiated tumors, cancer-specific survival rates at 10 years were 73, 67 and 29%, respectively.

CONCLUSIONS

A large number of men with clinical stage T3 prostate cancer have advanced disease and are unlikely to achieve improved long-term survival with surgery alone. Although there may be a role for radical prostatectomy in selected patients with low to intermediate grade tumors, such treatment appears unlikely to result in long-term survival in men with high grade disease. A prospective study is necessary to determine the optimal treatment approach in men with locally advanced prostate cancer.

Dual stent placement for the treatment of a persistent urine leak after partial nephrectomy

Persistent urine leak is a known complication after partial nephrectomy. In the present case, a partial nephrectomy was performed to remove a large, centrally located, renal mass in an elderly man with a solitary functioning kidney. A persistent urine leak refractory to single stent drainage was successfully treated after two stents were placed in the ipsilateral renal unit such that the upper and lower calices were drained by separate stents.

High-grade prostatic intraepithelial neoplasia with adjacent atypia is associated with a higher incidence of cancer on subsequent needle biopsy than high-grade prostatic intraepithelial neoplasia alone

OBJECTIVES

High-grade prostatic intraepithelial neoplasia (HGPIN) is often considered a premalignant lesion of the prostate. Its incidence ranges from 0.7% to 20% in all prostate biopsies, and patients with HGPIN on initial biopsy are reportedly found to have a higher risk of cancer on subsequent biopsy. The purpose of our study was to determine the incidence of HGPIN in our patients who underwent prostate biopsy and to determine whether a further pathologic subclassification of HGPIN between HGPIN alone and HGPIN with adjacent atypical glands has any prognostic value in predicting the rate of prostate cancer on subsequent prostate biopsy.

METHODS

A total of 485 patients who underwent prostate biopsy between January 1998 and October 1999 were included in the study. Each set of slides was reviewed by a single urologic pathologist to determine the presence of HGPIN alone or HGPIN with adjacent atypical glands. If any HGPIN was identified, a repeat biopsy was performed, and the presence of cancer was recorded.

RESULTS

The overall incidence of HGPIN alone and HGPIN with adjacent atypical glands on initial biopsy was 33 (6.8%) of 485. Of these 33 patients, 21 (64%) had HGPIN alone and 12 (36%) had HGPIN with adjacent atypical glands. Three (14%) of 21 patients with HGPIN alone were found to have cancer on subsequent biopsy compared to 9 (75%) of 12 patients with HGPIN with adjacent atypia on initial biopsy. This difference is statistically significant (P <0.005).

CONCLUSIONS

The incidence of HGPIN alone in our experience is 4.3% (21 of 485). Patients with HGPIN with adjacent atypical glands suspicious for cancer have a significantly higher incidence of cancer on subsequent biopsy than patients with HGPIN alone.

Practice patterns in the treatment of female urinary incontinence: a postal and internet survey

OBJECTIVES

To survey American urologists to assess practice patterns in treating female incontinence. Advances in the treatment of female incontinence have changed the way urologists practice.

METHODS

Postal and e-mail surveys were sent to 2502 members of the American Urological Association.

RESULTS

From the postal group (n = 1000), 419 (42%) responses were obtained; from the e-mail group (n = 1502), 160 (11%) responses were obtained. For types I, II, and III stress urinary incontinence (SUI), 239 (44%) of 546, 388 (68%) of 570, and 512 (94%) of 547 urologists, respectively, recommended a sling procedure. For type I SUI, 75 (53%) of the 143 respondents in practice for less than 10 years recommended a sling procedure. The sling was recommended by 62 (35%) of the 176 respondents in practice for longer than 20 years (P <0.001). Most urologists (75%, 358 of 480) referred patients with significant vaginal prolapse to a gynecologist; however, urologists in full-time academic practice were more likely to offer surgical treatment (56%, 29 of 52). Most urologists recommended medical treatment for urge incontinence (94%, 461 of 491), and the medications most commonly selected were tolterodine (41%, 202 of 491), oxybutynin (26%, 129 of 491), and extended-release oxybutynin (25%, 125 of 491).

CONCLUSIONS

Overall, a sling procedure was the most commonly recommended surgical procedure for all types of SUI. Most urologists referred patients with significant vaginal prolapse to a gynecologist. For type I SUI, older urologists were more likely than younger urologists to perform needle bladder neck suspension.

Comparative viewing modalities for CT cystography

BACKGROUND

To define the speed and accuracy of two different reconstructive techniques using computed tomography (CT) cystography for the detection and measurement of urinary bladder masses and determine the overall ease of use.

METHODS

Ten patients scheduled for cystoscopy for the evaluation of hematuria or bladder masses were studied by means of thin-section CT of the air-distended bladder. Two techniques were employed by two radiologists to blindly interpret the data: conventional two-dimensional data with interactive three-dimensional problem solving (2D3DPS) and surface-shaded display (SSD) three-dimensional images. The results were compared with the data from cystoscopy.

RESULTS

Twenty-two (100%) of 22 masses detected on cystoscopy were visualized using the reconstructive techniques. Both modalities were shown to have high accuracy, but only the 2D3DPS had a sensitivity and specificity of 100% for both observers at the patient-level diagnosis. The sensitivities for detecting individual masses for the two observers were 100% and 64% for 2D3DPS and 64% and 70% for SSD.

CONCLUSION

Both methods used to display the CT data had a high sensitivity and specificity for masses, but only the 2D3DPS had a sensitivity and specificity of 100% at the patient-level diagnosis, thus making it a feasible imaging modality for cystography. It was also preferred overall for ease of use, high accuracy, and relative low cost.

Use of new technology in endourology and laparoscopy by american urologists: internet and postal survey

OBJECTIVES

To assess the use of new technology by American urologists.

METHODS

Using the American Urological Association directory, surveys were sent via the U.S. postal service to 1000 randomly selected American urologists and 3065 urologists who had an Internet address listed in the directory.

RESULTS

Responses were received from 601 urologists (415 postal, 186 Internet). Overall, 81% of survey respondents reported performing fewer or the same number of percutaneous procedures as compared with 3 to 4 years ago and 84% reported carrying out more or the same number of ureteroscopic procedures in the treatment of patients with stone disease. Open dismembered pyeloplasty (43%) and Acucise endopyelotomy (42%) were most frequently reported as the preferred treatment for adult patients with symptomatic ureteropelvic junction obstruction. Although 60% of respondents reported that they have taken a laparoscopy course, 67% currently do not perform any laparoscopy in their practice. In addition, only 7% of urologists stated that laparoscopy comprises more than 5% of their practice. When stratified by the number of years in practice, those in practice less than 10 years were more likely than those in practice 10 to 20 years and those in practice longer than 20 years to have performed an endopyelotomy (77%, 60%, and 48%, respectively, P <0.001) and to be currently performing laparoscopy (49%, 36%, and 18%, respectively, P <0.001).

CONCLUSIONS

Compared with 3 to 4 years ago, American urologists are performing more ureteroscopy and fewer percutaneous stone procedures. Although most urologists have taken laparoscopy courses, this modality has not been widely incorporated into their practices at present.

Effect of preoperative biofeedback/pelvic floor training on continence in men undergoing radical prostatectomy

OBJECTIVES

To determine whether preoperative biofeedback training improves urinary continence overall or the rate of return of continence in men undergoing radical prostatectomy.

METHODS

One hundred men scheduled to undergo radical prostatectomy were randomized to receive graded pelvic muscle exercise training with biofeedback 2 to 4 weeks before surgery or to a control group performing pelvic muscle exercises without biofeedback. The biofeedback group was instructed to continue exercises four times per day until surgery and to resume exercises when the urethral catheter was removed following surgery. The control group received written and brief verbal instructions in pelvic muscle exercises before surgery and again after catheter removal. Urinary continence was assessed by personal or phone interviews.

RESULTS

Six months following surgery, the continence rates, as defined by the use of one pad or less per day, were 94% (44 of 47) and 96% (48 of 50) in the biofeedback and control groups, respectively (P = 0.596). Also, the rate of return as determined at time points 1, 2, 3, and 4 months after surgery was not significantly different between the two groups.

CONCLUSIONS

Preoperative biofeedback training did not improve the outcome of pelvic muscle exercises on overall continence or the rate of return of urinary control in men undergoing radical prostatectomy.

Role of transurethral biopsy sampling of the prostate to diagnose prostate cancer in men undergoing surgical intervention for benign prostatic hyperplasia

PURPOSE

Newer minimally invasive surgical procedures are being used to treat men with significant benign prostatic hyperplasia (BPH). These modalities do not allow retrieval of prostate tissue for histologic review. The goal of our study was to assess the value of transurethral biopsies in detecting prostate cancer in men who would undergo surgical intervention for BPH.

MATERIALS AND METHODS

Between September 1997 and January 1999, 422 men undergoing transurethral resection of the prostate (TURP) had transurethral biopsies obtained before completing the TURP. Pathology reports as well as prostate-specific antigen (PSA) results were reviewed and analyzed to determine when cancer was present.

RESULTS

Pathological examination revealed that cancer was found in 53 men (12.5%). The transurethral biopsies detected cancer in 32 of 53 (60.4%). No cancers were found in the transurethral biopsy specimen only. Of the 21 cancers missed by transurethral biopsy, 7 were stage T1b. PSA level >10 ng/mL increased the likelihood of finding cancer.

CONCLUSIONS

Transurethral biopsy sampling is unreliable for detecting prostate cancer in men with clinically significant BPH. Significant cancers are missed if transurethral biopsies are used to determine the presence of carcinoma before minimally invasive surgical therapy for BPH.

Management of entrapped ureteral stone baskets

Entrapped stone baskets can occur and can lead to significant ureteral injury and long-term morbidity. We describe two patients in whom semirigid ureteroscopy was used to facilitate safe removal of impacted baskets from the ureter.

Internet and postal survey of endourologic practice patterns among American urologists

PURPOSE

We determine endourological practice patterns among American urologists for the management of distal ureteral calculi, ureteropelvic junction obstruction, staghorn calculi and the use of ureteral stents with extracorporeal shock wave lithotripsy (ESWLdagger).

MATERIALS AND METHODS

Surveys were mailed by the United States postal service to 1,000 American urologists selected randomly from the American Urological Association membership roster. The same survey was sent via the Internet to 3,065 American urologists with an electronic mail address listed in the roster.

RESULTS

Responses were received from 1,029 urologists (postal 601, Internet 428). Ureteroscopy was the preferred treatment for all distal ureteral calculi less than or equal to 10 mm. Acucisedouble dagger endopyelotomy was the most frequently selected therapy for adults with ureteropelvic junction obstruction (50.3%, 514 of 1,022). Open pyeloplasty was recommended by a significantly greater percentage of urologists in practice longer than 15 years compared with the remaining survey respondents (166 of 485, 34.2% versus 92 of 427, 21.5%). For patients with renal pelvic stones 10, 15 or 20 mm. who are treated with ESWL routine stent placement was preferred by 25.3% (259 of 1,022), 57.1% (584 of 1,022) and 87.1% (888 of 1, 019) of urologists, respectively. Percutaneous nephrolithotomy was preferred for patients with staghorn calculi by 80.5% (828 of 1,028) of survey respondents.

CONCLUSIONS

Most urologists follow the American Urological Association practice guidelines for patients with distal ureteral calculi and staghorn stones. There is a significant difference of opinion regarding the use of stents with ESWL. No clear consensus has been reached concerning the management of adults with ureteropelvic junction obstruction. These data may be useful in designing physician education programs and/or future investigations to help define standard treatment practices for urological diseases.

Saw palmetto for the treatment of men with lower urinary tract symptoms

PURPOSE

A comprehensive review of the literature on the use of saw palmetto in men with lower urinary tract symptoms is provided.

MATERIALS AND METHODS

A literature search of studies that have assessed the mechanism of action and clinical results of saw palmetto in men with benign prostatic hyperplasia was performed.

RESULTS

A variety of potential mechanisms of action of saw palmetto have been demonstrated through in vitro studies, including 5-alpha reductase inhibition, adrenergic receptor antagonism and intraprostatic androgen receptor blockade. Clinical evidence of the relevance of these effects is largely unavailable. The use of saw palmetto in men with benign prostatic hyperplasia is safe with no recognized adverse effects. No effect on serum prostate specific antigen has been noted. Placebo controlled trials and meta-analyses have suggested that saw palmetto leads to subjective and objective improvement in men with lower urinary tract symptoms. However, most studies are significantly limited by methodological flaws, small patient numbers and brief treatment intervals.

CONCLUSIONS

Evidence suggests that saw palmetto may have a significant effect on urinary flow rates and symptom scores compared to placebo in men with lower urinary tract symptoms. However, large scale, placebo controlled trials are needed to assess the efficacy of saw palmetto.

Retrograde ureteroscopic incision for the treatment of nonureteroenteric ureteral strictures

A variety of methods are available for the management of patients with ureteral strictures. Ureteroscopic, retrograde incision using the holmium laser was performed on an outpatient basis or with hospitalization for <24 hours in three patients with strictures of varying etiologies. With follow-up of 4 to 12 months, all patients have remained asymptomatic without radiographic evidence of recurrent strictures. Retrograde ureteroscopic incision is an effective, minimally invasive option for patients with benign ureteral strictures.

Retrograde ureteroscopic endopyelotomy for the treatment of primary and secondary ureteropelvic junction obstruction in children

The use of endopyelotomy in children with ureteropelvic junction (UPJ) obstruction remains controversial. Although most investigators reported good results with percutaneous or retrograde balloon cautery incision, there are distinct advantages associated with a ureteroscopic approach. Three male children, ages 11, 12 and 17 years, underwent ureteroscopic endopyelotomy for treatment of UPJ obstruction (one primary and two secondary). The procedures were performed using 6F to 8.5F semirigid instruments and the holmium laser. All three patients underwent endopyelotomy without complication. The mean operative time was 80 minutes. Two patients were discharged home the day of the procedure, and the third patient was hospitalized for less than 24 hours postoperatively. With follow-up of 6 to 11 months, two patients are asymptomatic, with no radiographic evidence of obstruction. The 12-year-old boy had continued obstruction following endopyelotomy. At the time of open pyeloplasty, a large crossing vessel was noted, which appeared to be the source of obstruction. Ureteroscopic endopyelotomy can be performed with minimal morbidity and hospitalization in children. Further clinical experience is needed to assess the relative efficacy of this procedure in comparison with other forms of endopyelotomy in children.

Ureteroscopic endopyelotomy in the treatment of patients with ureteropelvic junction obstruction

OBJECTIVES

To investigate the effectiveness and morbidity of ureteroscopic endopyelotomy in adults with ureteropelvic junction (UPJ) obstruction.

METHODS

Twenty-two patients (13 women, 9 men) with a mean age of 44 years (range 18 to 86) underwent retrograde ureteroscopic endopyelotomy in the treatment of primary (n = 18) or secondary (n = 4) UPJ obstruction. All procedures were performed using a 6F to 8.5F semirigid ureteroscope with either a 3F electrocautery probe (n = 16) or a 365-microm holmium laser fiber (n = 6). Postoperatively, a tapered 14/7F endoureterotomy stent (n = 11) or standard 7F to 8F double pigtail stent (n = 11) was left in place for 6 to 7 weeks. Radiographic follow-up was obtained using intravenous urography or renal scintigraphy.

RESULTS

With a median follow-up of 20.5 months, the success rate was 82% (18 of 22 patients). Follow-up of at least 6 and 12 months was available in 21 (95%) and 17 (77%) of 22 patients, respectively. The mean operative duration was 63 minutes, and all but 1 patient was hospitalized for less than 24 hours. No bleeding complications or other serious morbidity were encountered. No difference in treatment outcome was found on the basis of the size of the stent placed postoperatively, the incision type (cautery versus laser), or the etiology of the obstruction.

CONCLUSIONS

Ureteroscopic endopyelotomy is an effective, minimally invasive treatment option for patients with primary or secondary UPJ obstruction.

Double-blind randomized comparison of single-dose ciprofloxacin versus intravenous cefazolin in patients undergoing outpatient endourologic surgery

OBJECTIVES

To compare the efficacy of single-dose oral ciprofloxacin with intravenous cefazolin as a prophylactic agent in patients undergoing outpatient endourologic surgery.

METHODS

One hundred patients were enrolled in a double-blind, randomized study to receive either ciprofloxacin (500 mg) or cefazolin (1 g) before surgery. A postoperative clinical evaluation and urine cultures were performed 5 to 10 days after surgery. Patients undergoing ureteral stent insertion or exchange, ureteroscopy, bladder biopsy, retrograde pyelography, collagen injection, and internal urethrotomy were included.

RESULTS

Postoperative urinary tract infection occurred in 7 (9.1%) of 77 patients, including 3 (8.1%) of 37 and 4 (10.0%) of 40 of those who received ciprofloxacin and cefazolin, respectively (P = 0.77). There were no episodes of sepsis, and no patient with infection required hospitalization. The total cost associated with the administration of prophylactic antibiotics in the study population was $3657 less in those 50 patients who received ciprofloxacin than in the 50 patients who received cefazolin.

CONCLUSIONS

A single oral dose of ciprofloxacin in patients undergoing outpatient endourologic surgery was equally effective as cefazolin in preventing postoperative urinary tract infection, but was associated with markedly lower overall costs.

Use of ureteroscopy and holmium:yttrium-aluminum-garnet laser in the treatment of an infundibular stenosis

An infundibular stenosis is defined by a dilated calyx draining through a narrowed infundibulum into a nondistended renal pelvis. We describe the use of ureteroscopy and the holmium:yttrium-aluminum-garnet (YAG) laser to successfully treat an infundibular stenosis in a 27-year-old woman who presented with left flank pain. The holmium:YAG laser is well suited for this application. It can be applied with precise control of the direction and depth of the cut. The retrograde approach avoids the morbidity of a percutaneous nephrostomy and is well suited for treating an anterior infundibular stenosis.

Improved patient positioning for percutaneous nephroscopic procedures using a surgical saddle

PURPOSE

We describe modified patient positioning on the Cloward surgical saddle for use during percutaneous nephroscopic procedures.

MATERIALS AND METHODS

The Cloward surgical saddle, which was designed for prone patient positioning, has been used primarily for lumbar surgery. We evaluated the use of the surgical saddle for ease of patient positioning during percutaneous nephroscopic procedures.

RESULTS

We have used the surgical saddle in 10 patients to date, including 1 who was 5 feet 8 inches (173 cm.) tall and who weighed 370 pounds (168 kg.). In all cases pulmonary airway pressure was maintained at less than 30 cm. water. We have observed no incidence of pressure injury or other complications associated with position.

CONCLUSIONS

Patient positioning during percutaneous nephroscopic surgery is important for preventing pressure injury and allowing adequate pulmonary ventilation. The surgical saddle is an excellent aid for secure patient positioning during percutaneous nephroscopic procedures that helps to minimize the risk of pressure injury and pulmonary compromise.

Transdermal estrogen in the treatment of hot flushes in men with prostate cancer

OBJECTIVES

To assess the effectiveness and tolerability of transdermal estrogen in men with hot flushes after hormonal therapy for prostate cancer.

METHODS

Twelve men with moderate to severe hot flushes were randomized to receive either low-dose (0.05 mg) or high-dose (0.10 mg) estrogen patches applied twice weekly for 4 weeks. After a 4-week washout period in which no treatment was given, each patient received the alternative dose for 4 weeks. Treatment response was assessed by daily logs and questionnaires completed every 4 weeks that included a visual analog assessment. Serum luteinizing hormone, follicle-stimulating hormone, testosterone, and estradiol levels were also measured every 4 weeks during the study.

RESULTS

There was a significant reduction in the overall severity of the hot flushes seen in patients with both the low and high-dose estrogen patch. A significant reduction in the daily frequency of the hot flushes was seen with the high-dose patch only. Overall, 10 (83%) of 12 men reported either mild, moderate, or major improvement in symptoms with either the low or high-dose patch. Mild, painless breast swelling or nipple tenderness was noted in 2 (17%) and 5 (42%) of 12 men treated with the low and high-dose estrogen patch, respectively. FSH levels decreased significantly with both the low and high-dose patch. Estradiol levels increased from 12.1 to 16.4 pg/mL and 26.9 pg/mL with the low and high-dose patch, respectively. There was no significant change in serum testosterone or luteinizing hormone levels.

CONCLUSIONS

Transdermal estrogen appears to be a promising, well-tolerated therapy for men with hot flushes after endocrine treatment for prostate cancer. Further study in larger groups of patients is necessary to assess the relative effectiveness and morbidity of this treatment.

Endoscopic management of ureteropelvic junction obstruction in children

A variety of endoscopic methods are available for managing ureteropelvic junction obstruction in children, and these methods can be considered for use in selected circumstances.

The use of hyperbaric oxygen in urology

PURPOSE

We review the use of hyperbaric oxygen therapy in urology, and present the mechanisms of hyperoxia action in whole body hyperbaric chamber treatments, patient outcomes and patient selection criteria.

MATERIALS AND METHODS

The literature on hyperbaric oxygen use in urology was reviewed.

RESULTS

Hyperbaric oxygen is a treatment alternative for patients with an underlying ischemic process unresponsive to conventional therapy. Specific factors which may influence patient selection of hyperbaric oxygen include cancer and absolute contraindications of active viral disease, intercurrent pneumothorax and treatment with doxorubicin or cisplatin. This technique is particularly useful in the treatment of intractable hemorrhagic cystitis secondary to pelvic radiation therapy. Further investigation of the efficacy of hyperbaric oxygen is warranted for patients with necrotizing fasciitis (Fournier's gangrene), posttraumatic ischemic injury and/or impaired wound healing.

CONCLUSIONS

Hyperbaric oxygen is a therapeutic alternative which complements the surgical and medical options for select patients.

Combination therapy in the treatment of patients with staghorn calculi

The treatment of patients with staghorn calculi remains a challenging problem. Combination therapy using percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy has been recommended as the best option for most patients. Using this technique, 10 (83%) of 12 renal units with partial or complete staghorn calculi were rendered stone-free, with no significant septic episodes or serious complications. Blood transfusion was necessary in three patients. "Sandwich" therapy using initial percutaneous debulking followed by extracorporeal shock wave lithotripsy and/or "second-look" nephroscopy offers patients a high likelihood of achieving a stone-free state while avoiding the morbidity and lengthy recovery associated with open surgery.

Performing flexible ureteroscopy through a cystoscopy introducer sheath

Performing flexible ureteroscopy through a cystoscope sheath positioned with its tip near the orifice of the ureter prevents buckling of the ureteroscope and decreases the friction against the ureteroscope. This results in more precise translation of the surgeon's movements to the tip of the instrument and facilitates the procedure.

Phytotherapeutic agents in the treatment of lower urinary tract symptoms: a demographic analysis of awareness and use at the University of Chicago

OBJECTIVES

To assess awareness and use of phytotherapeutic agents in treating lower urinary tract symptoms (LUTS).

METHODS

A survey was conducted of 1280 patients presenting to the University of Chicago Hospitals urology clinic. The questions pertained to age, race, educational level, and use of prescription and nonprescription medications for urinary symptoms.

RESULTS

Of 1264 patients filling out the surveys correctly, the 51 to 60-year-old age range demonstrated the greatest percentage of use of these agents. Whites were nearly twice as likely as their African American counterparts to use medicinal botanicals. Men with college or graduate school degrees were 1.5 times as likely to use medicinal botanicals in treating LUTS. More than 50% of men using phytotherapeutic drugs were also taking prescription medications for the urinary symptoms.

CONCLUSIONS

There is significant use of phytotherapeutic agents in men with LUTS, although there is variability in their use between patient groups. American physicians need some understanding of these agents to best advise and treat their patients.

Endourologic treatment of renal pelvic and ureteral transitional cell carcinoma

Endoscopic treatment of patients with upper urinary tract transitional cell carcinoma is recommended in those with tumor in a solitary kidney, bilateral disease, renal dysfunction, and significant intercurrent illness that precludes a major abdominal surgical procedure. Endoscopic management also may be appropriate in selected patients with small, low-grade lesions in the presence of a normal contralateral kidney. Almost all ureteral tumors and some renal collecting system lesions can be managed using rigid and/or flexible ureteroscopy, which is associated with less bleeding and more rapid recovery than a percutaneous approach. However, larger renal malignancies can be managed effectively using percutaneous resection. Six patients with upper tract transitional cell carcinoma underwent endoscopic resection. The antegrade and retrograde surgical techniques are described. With follow-up up to 23 months, local recurrence in two patients was managed successfully by repeat endoscopic resection. No patient has experienced disease progression or developed metastases.

Holmium: YAG laser endoureterotomy in the treatment of ureteroenteric strictures following orthotopic urinary diversion

The management of ureteroenteric strictures in patients who have undergone urinary diversion can be challenging. In those patients with an orthotopic neobladder, anastomotic ureteral strictures can be treated endoscopically using a retrograde or antegrade approach. The availability of small (7.5F) flexible ureteroscopes, as well as the use of the Holmium laser has facilitated the ability to precisely incise the stricture under direct endoscopic visualization (endoureterotomy). We describe our technique for laser endoureterotomy in patients with ureteroenteric strictures following orthotopic urinary diversion.

Benign adenomatous multicystic kidney tumor (Perlmann's tumor) and renal cortical carcinoma with adenomatous multicystic features: 12 cases

OBJECTIVES

To re-examine clear cell cystic lesions of the kidney and to assess their potential clinicopathologic significance, as the long-forgotten diagnosis of benign adenomatous multicystic kidney tumor (Perlmann's tumor) has not been cited in the literature in more than 35 years.

METHODS

We identified 12 patients between 1959 and 1996 who underwent a radical nephrectomy at our institution and were diagnosed with either adenomatous multicystic clear cell kidney tumor (n = 4) or with renal cell carcinoma (RCC) associated with features of adenomatous clear cell multicystic kidney tumors (n = 8). All diagnoses were reviewed histologically by a single pathologist.

RESULTS

Nine of 1 2 patients had Stage T2NOMO disease, and 3 patients had Stage T1 NOMO disease. There were 8 men and 4 women. The average age at the time of surgery was 60.5 years (range 25 to 74). Six patients are still alive with a mean follow-up of 4.7 years (range 1.5 to 16.3) and have no evidence of recurrent disease. Of the 6 patients who died, mean survival time was 8.8 years (range 0 to 15.7). One patient died in the perioperative period, and the other 5 patients died of other causes, unrelated to their kidney tumor.

CONCLUSIONS

Adenomatous clear cell multicystic kidney disease may represent a histologically distinct benign neoplasm, and its presence in association with RCC may confer a more favorable prognosis. Its distinction from usual solid hemorrhagic or focally necrotic RCC is important.

Use of novel urodynamic parameters, detrusor contraction duration and detrusor contraction index, in men with lower urinary tract symptoms

The aim of this study was to correlate the results of the urodynamic measures, detrusor contraction duration (DCD) and detrusor contraction index (DCI), with voiding symptoms in untreated men with lower urinary tract symptoms (LUTS) and in men treated with doxazosin. Ninety-one men with untreated LUTS underwent urodynamic evaluation. DCD (duration of detrusor contraction in seconds), DCI (interval, in seconds, that urine is passed divided by the total duration of the bladder contraction), and standard urodynamic measures of obstruction were determined. The urodynamic findings were correlated with the severity of voiding symptoms as assessed by the International Prostate Symptom Score (I-PSS). Fifty of these men were treated subsequently with 4 mg of doxazosin for 3 months and then underwent repeat urodynamic evaluation, in which changes in symptom score and urodynamic results were analyzed. DCD was the only urodynamic measure that correlated significantly with the I-PSS results in untreated patients. Although DCD, detrusor pressure at maximum flow, and the Abrams-Griffiths number decreased in men treated with doxazosin, only DCI and symptom score improved significantly after treatment for 3 months. No urodynamic parameter was useful in predicting the likelihood of a favorable response to treatment with doxazosin. DCD and DCI may be useful urodynamic measures in untreated men with LUTS and in those treated with doxazosin. Further study of these parameters is warranted.

Saw palmetto (Serenoa repens) in men with lower urinary tract symptoms: effects on urodynamic parameters and voiding symptoms

OBJECTIVES

To assess the effects of saw palmetto on voiding symptoms and urodynamic parameters in men with lower urinary tract symptoms (LUTS) presumed secondary to benign prostatic hyperplasia (BPH).

METHODS

Fifty men with previously untreated LUTS and a minimum International Prostate Symptom Score (IPSS) of 10 or greater were treated with a commercially available form of saw palmetto (160 mg twice per day) for 6 months. The initial evaluation included measurement of peak urinary flow rate, postvoid residual urine volume, pressure-flow study, and serum prostate-specific antigen (PSA) level. Patients completed an IPSS, serum PSA was determined, and flow rate was measured every 2 months during the course of the study. A urodynamic evaluation was repeated at the completion of the 6-month trial.

RESULTS

The mean IPSS (+/-SD) improved from 19.5+/-5.5 to 12.5+/-7.0 (P <0.001) among the 46 men who completed the study. Significant improvement in the symptom score was noted after treatment with saw palmetto for 2 months. An improvement in symptom score of 50% or greater after treatment with saw palmetto for 2, 4, and 6 months was noted in 21% (10 of 48), 30% (14 of 47), and 46% (21 of 46) of patients, respectively. There was no significant change in peak urinary flow rate, postvoid residual urine volume, or detrusor pressure at peak flow among patients completing the study. No significant change in mean serum PSA level was noted.

CONCLUSIONS

Saw palmetto is a well-tolerated agent that may significantly improve lower urinary tract symptoms in men with BPH. However, we were unable to demonstrate any significant improvement in objective measures of bladder outlet obstruction. Placebo-controlled trials of saw palmetto are needed to evaluate the true effectiveness of this compound.

Benign prostatic hyperplasia in older men

Urinary tract symptoms secondary to benign prostatic hyperplasia (BPH) may adversely affect quality of life in many older men. Evaluation of patients with BPH should be focused on excluding complicating factors such as urinary tract infection, renal dysfunction, and malignancy. Watchful waiting is an appropriate option for men in whom such complicating conditions have been excluded. For those men who elect to be treated, therapy using alpha blockers (terazosin, doxazosin) or 5-alpha reductase inhibitors (finasteride) should be offered initially. Surgical treatment is generally reserved for patients who do not have a sufficient response to medical therapy and those with absolute indications for intervention, such as complete retention, recurrent infection or hematuria, renal insufficiency, and bladder stones.

Evaluation of changes in prostate specific antigen in clinically localized prostate cancer managed without initial therapy

PURPOSE

We define changes in prostate specific antigen (PSA) measurements with time in 49 men 71.9 +/- 7.0 years old (mean plus or minus standard deviation) with clinically localized prostate cancer who remain untreated.

MATERIALS AND METHODS

We retrospectively analyzed PSA changes in prostate cancer patients managed by watchful waiting. In all patients a minimum of 3 PSA levels were measured at intervals of at least 6 months after malignancy was diagnosed. The rate of change in serum PSA level with time (PSA velocity) was determined using an exponential, log linear model.

RESULTS

In 49 patients treated conservatively mean initial PSA level plus or minus standard deviation was 12.3 +/- 11.1 ng./ml. and mean PSA followup during which no therapy for prostate cancer was introduced was 32.1 +/- 13.2 months. PSA levels decreased during the observation period in 11 of the 49 patients (22%) and median PSA doubling time in the remaining 38 was 55.7 months (range 15.1 to 994.5). There was no significant correlation between age at diagnosis, Gleason sum, initial PSA level or clinical stage and PSA velocity. The short-term rate of change in PSA during the first 9 months after prostate cancer was diagnosed correlated poorly with overall PSA velocity. The short-term rate of PSA change was greater than the overall rate of change in 14 of 37 patients (38%).

CONCLUSIONS

There is significant variability in the rate of change of PSA with time in men with clinically localized prostate cancer who remain untreated. The usefulness of serial PSA measurements in the management of watchful waiting is unclear. Changes in PSA may not be helpful or appropriate in determining the need for therapy after a period of observation.

Ambulatory urodynamic evaluation of men with lower urinary tract symptoms treated with doxazosin

We investigate the results of ambulatory urodynamic evaluation of men with lower urinary tract symptoms (LUTS) believed secondary to benign prostatic hyperplasia (BPH) treated with doxazosin and compare these results to conventional urodynamic study. Ten men with previously untreated LUTS underwent conventional urodynamic evaluation, which was repeated after treatment with doxazosin (4 mg daily) for 3 months. All patients continued on doxazosin and subsequently underwent ambulatory urodynamic evaluation. All men completed an International Prostate Symptom Score (I-PSS) questionnaire with a decrease in score from a mean of 20.4 initially to 8.7 after treatment with doxazosin for 3 months. The mean maximum urinary flow rate increased from 11.9 to 15.3 cc/s and the mean detrusor pressure at peak flow decreased from 99 to 82 cm H2O. The mean duration of ambulatory study was 5 h and 8 minutes (mean 6 voiding cycles). The mean ambulatory voiding pressure in the ten patients treated with doxazosin was 75 cm H2O. Ambulatory urodynamic monitoring is well tolerated by most men with LUTS. Intravesical voiding pressures remain in the obstructed range in most men treated with doxazosin despite marked improvement in urinary symptoms. Ambulatory urodynamic evaluation demonstrates that these elevated detrusor pressures are present during routine daily activities. The long-term effect of increased voiding pressures on urinary tract function is unclear.

Doxazosin in men with lower urinary tract symptoms: urodynamic evaluation at 15 months

OBJECTIVES

To assess the results of doxazosin treatment in men with lower urinary tract symptoms (LUTS) treated for 15 months and to correlate symptomatic changes with alterations in urodynamic measures.

METHODS

After an initial 3-month treatment period with doxazosin 4 mg/day, 50 men with LUTS were given the choice of continued treatment with this agent or other therapeutic options. All patients were evaluated by International Prostate Symptom Score (IPSS) questionnaires and urodynamic evaluation initially and after 3 months of treatment. Patients were followed for an additional 12 months and those who continued doxazosin treatment underwent repeat urodynamic testing.

RESULTS

Among the original 50 patients, 24 men (48%) continued doxazosin treatment for 15 months, 18 men (36%) discontinued therapy, and 8 men (16%) were either dead or lost to follow-up or had been diagnosed and treated for prostate cancer. Comparison of values at 3 and 15 months of follow-up (9.4 versus 13.4, P = 0.03) showed significant worsening of voiding symptoms, as assessed by the IPSS, in the 24 men still receiving doxazosin. This deterioration of subjective results with doxazosin occurred despite continued improvements in peak urinary flow rate (Qmax), detrusor pressure at peak flow (PdetQmax), and objective measures of obstruction (Abrams-Griffiths number) from 3 to 15 months of follow-up.

CONCLUSIONS

Relief of voiding symptoms in men with LUTS treated with doxazosin over prolonged intervals of 15 months does not correlate well with changes in urodynamic measures.

Serum creatinine measurements in men with lower urinary tract symptoms secondary to benign prostatic hyperplasia

OBJECTIVES

To determine the usefulness of routine serum creatinine measurements in men with lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH) and to correlate these findings with patient age, symptom severity, and comorbid diseases.

METHODS

We analyzed serum creatinine measurements in 246 consecutive men presenting for evaluation of voiding symptoms and BPH. Multiple logistic regression analysis was used to determine whether the International Prostate Symptom Score (IPSS), quality-of-life measure from the IPSS, patient age, or a history of diabetes mellitus or hypertension predicted abnormal creatinine levels.

RESULTS

An elevated serum creatinine level was noted in 11% (26 of 245) of evaluable patients. Only a history of diabetes or hypertension predicted the presence of renal insufficiency. Among men with no history of comorbid disease, increasing age was significantly associated with the finding of an abnormal creatinine. Neither the overall symptom score nor the quality-of-life measure was significantly associated with the likelihood of detectable renal dysfunction.

CONCLUSIONS

Medical renal disease secondary to diabetes or hypertension appears to be the most likely cause of elevated serum creatinine measurements in men with BPH and renal insufficiency. We were unable to identify subgroups of patients in whom the risk of renal dysfunction is sufficiently low to avoid routine serum creatinine measurements.

Endoscopic management of ureteral strictures

PURPOSE

We investigated and defined the role of endourological methods in the treatment of patients with ureteral stricture.

MATERIALS AND METHODS

A literature search was performed of the MEDLINE data base from 1978 through August 1996 concerning endoscopic treatment of patients with ureteral strictures. Additional articles from before 1978 were also selectively included.

RESULTS

Many endourological methods are available to treat patients with ureteral strictures. Ureteral dilation via an antegrade or retrograde approach may be accomplished in most cases with varying rates of success depending on stricture etiology, location and length. Endoscopic ureterotomy may also lead to long-term patency in select cases and appears to be superior to dilation alone in patients with anastomotic ureteral strictures. However, no randomized studies comparing endourological methods in the treatment of ureteral stricture disease were found.

CONCLUSIONS

Significant advances in technique and technology have led to an improved ability to treat ureteral strictures without the need for open surgery in many patients.

Transurethral vaporization of the prostate in the treatment of bladder outlet obstruction at two university hospitals

Transurethral vaporization of the prostate (TVAP) is a new technique for the surgical treatment of men with benign prostatic hyperplasia (BPH). The primary advantage of TVAP appears to be shortened hospitalization and less bleeding than is associated with transurethral resection of the prostate (TURP). Since February 1995, 66 consecutive men with bladder outlet obstruction (47 with persistent voiding symptoms and 19 in complete urinary retention) secondary to prostatic disease underwent TVAP at two university hospitals. TVAP was utilized in all patients regardless of prostate size. The mean length of follow-up was 3.2 months. All 19 men in complete retention were able to void adequately following surgery with a mean postvoid residual volume of 18cc and a mean International Prostate Symptom Score (I-PSS) of 7.5. In the remaining patients, the I-PSS decreased from a mean of 19.6 to 8.4. Pre- and postoperative peak urinary flow rate data were available in 17 men and increased from 9 to 18 cc/s. Limited transurethral resection of prostatic tissue at the completion of TVAP was necessary to adequately relieve bladder outlet obstruction in 18% (12/66) of patients. Hospitalization of < 24 h was needed in 68% (45/66) patients. The urinary catheter was removed within 1 day of surgery in 68% (45/66) of men as well. Seven patients required catheter replacement postoperatively due to difficulty voiding (five men) or bleeding (two men). No patient required blood transfusion. TVAP is effective in relieving bladder outlet obstruction in men with and without urinary retention. The majority of patients require brief or no hospitalization and are able to void adequately within 24 h of surgery. TVAP appears to be less effective in men with large prostate glands, and limited TURP is more frequently needed in these cases. The long-term results of TVAP will require further study.

Randomized, prospective, double-blind study of the effects on pain perception of lidocaine jelly versus plain lubricant during outpatient rigid cystoscopy

PURPOSE

There is no clear evidence that intraurethral lidocaine jelly decreases pain and/or makes rigid cystoscopy more tolerable for patients. Since lidocaine jelly is significantly more expensive than plain lubricant, we attempted to assess the true benefit of this agent.

MATERIALS AND METHODS

We performed a randomized, prospective, double-blind study to compare the anesthetic effects of intraurethral 2% lidocaine jelly versus plain lubricant in patients undergoing rigid cystoscopy. Unlike previous studies, we ensured adequate urethral filling by using 30 cc of each agent and we waited 20 minutes after instillation of the agent before performing cystoscopy to allow adequate absorption. Cystoscopy was performed using a 17 to 21F rigid instrument. A total of 189 patients was entered into the study but 10 were excluded from analysis due to incomplete questionnaires. A 10-point scale (1-least to 10-most painful) was used to measure pain perception.

RESULTS

In men pain perception was significantly decreased when lidocaine jelly was used (mean plus or minus standard error 3.00 +/- 0.21 versus 4.36 +/- 0.37 points, p = 0.002). In women there was no observed difference in pain perception when lidocaine jelly or plain lubricant was used (3.21 +/- 0.38 versus 3.11 +/- 0.30 points, p = 0.823). Patient race, performance of a related procedure, cystoscope size or history of cystoscopy did not significantly affect reported pain scores. There was a slight decrease in pain perception with increasing age (-0.23 +/- 0.10 points per decade, p = 0.021). The level of patient anxiety before cystoscopy was also significantly associated with pain perception (p < 0.001).

CONCLUSIONS

Lidocaine jelly offers no advantage over plain lubricant in regard to pain control during rigid cystoscopy in women. However, when used in adequate amounts and allowed to dwell in the urethra for 20 minutes before cystoscopy, lidocaine jelly can significantly decrease pain in men.

Results of radical prostatectomy in men with clinically localized prostate cancer

OBJECTIVE

To assess the results of radical prostatectomy in men with early prostate cancer.

DESIGN

Retrospective, nonrandomized, multi-institutional pooled analysis.

SETTING

Eight university medical centers in the United States and Europe.

PATIENTS

A total of 2758 men with stage Tl and T2 prostatic cancer.

MAIN OUTCOME MEASURES

Disease-specific and metastasis-free survival rates.

RESULTS

Tumor grade was the most important preoperative factor in determining outcome. Disease-specific survival 10 years following surgery and associated 95% confidence intervals were 94% (range, 87%-98%), 80% (range, 74%-85%), and 77% (range, 65%-86%) for those men with grade 1, 2, and 3 tumors, respectively. Metastasis-free survival at 10 years was 87% (range, 78%-92%), 68% (range, 62%-73%), and 52% (range, 38%-64%) for patients with grade 1, 2, and 3 cancers, respectively.

CONCLUSIONS

Radical prostatectomy leads to high 10-year disease-specific survival rates in men with all tumor grades. However, caution is needed in comparing these results with similar studies of alternative treatment strategies, such as watchful waiting, due to the inherent potential biases in uncontrolled trials. Nevertheless, these results offer the best currently available estimates of 10-year outcome of radical prostatectomy in men with clinically localized prostate cancer and may be useful in counseling patients with early malignancy.

Treatment of prostate cancer using external beam radiotherapy after laparoscopic pelvic lymph node dissection

OBJECTIVES

To evaluate the results of prostatic irradiation in men with clinically localized prostate cancer and no laparoscopic evidence of nodal metastases compared with a cohort of patients who received radiation therapy with no prior surgical staging.

PATIENTS AND METHODS

Thirty-one men with clinically localized prostate cancer and no evidence of pelvic nodal metastases after laparoscopic pelvic lymph node dissection received external beam radiation therapy to the prostate (65-70 Gy). The mean and median prostate specific antigen (PSA) levels in these men before treatment were 41.6 ng/mL and 28.0 ng/mL, respectively, and the mean Gleason sum was 6.1 (range 3-7). During the same interval, a group of 42 consecutive men with clinically localized prostate cancer were treated by external beam radiation therapy with no laparoscopic staging of the pelvic nodes. Treatment failure was defined by the development of bone metastases or a rising PSA level at least 6 months after the completion of radiotherapy.

RESULTS

Radiation therapy was generally well tolerated after laparoscopy and no patient required hospitalization or surgery for side-effects related to the treatment. The median duration of follow-up in the 31 men who underwent laparoscopy was 21.5 months. The probability of treatment failure in this group was 41.8% and 56.3% with 24 and 30 months follow-up, respectively. When controlling for pre-treatment PSA level, grade and stage, there was no significant difference in the treatment failure rate between the groups treated with and without laparoscopic staging.

CONCLUSIONS

These results suggest that there is no difference in treatment outcome with laparoscopic pelvic lymphadenectomy before external beam radiation therapy in high-risk patients who have significant pre-treatment elevations of PSA level.