Cystectomy and Orthotopic Ileal Neobladder Construction

INTRODUCTION

This study evaluates the outcome of orthotopic neobladder construction in a regional hospital setting.

MATERIAL AND METHODS

Orthotopic ileal neobladders were constructed in 51 patients between 1990 and 2001. All complications were reported systematically and continence was evaluated in a standardized manner.

RESULTS

One patient died perioperatively (2%). Early complications occurred in 56.9%. They were related to the neobladder in 21.6% and unrelated to the neobladder in 47.1%. 31.4% experienced complications in the late postoperative period. In 25.5%, these complications were neobladder related and in 11.8% they were not. After 1 year, daytime continence was 91.7% and nighttime continence 80.6%. Our results are comparable to those reported by others.

CONCLUSION

We conclude that the construction of a Hautmann neobladder can be performed with acceptable results in a regional hospital. The democratization of recent bladder replacement techniques may offer more patients a better quality of life and prevent the formation of waiting lists. Radical treatment may then be opted for sooner and thus improve cancer-related survival.

Identification by quantitative chromatin pattern analysis of patients at risk for recurrence of superficial transitional bladder carcinoma

PURPOSE

Based on the actual clinical outcomes of 132 fully documented patients with superficial transitional cell carcinoma of the bladder, we characterize the risk of recurrence and/or progression by computer assisted image microscopy applied to Feulgen stained nuclei.

MATERIALS AND METHODS

Each tumor was characterized by the conventional grading and staging systems as well as by cytometry generated variables describing nuclear DNA content, nuclear morphometry and chromatin patterns. These data were submitted to discriminant analysis to establish a model distinguishing between 2 groups of patients. Group 1 included cases with remission for more than 60 months and group 2 cases presented with recurrence with or without progression within 12 months of transurethral bladder resection. This latter model was then validated by Kaplan-Meyer analysis of the full data set.

RESULTS

As evidenced by Kaplan-Meier analysis, the discriminant factor generated by discriminant analysis of cytometry generated variables provided a cutoff value for distinguishing between low and high risks of recurrence (p <0.00001). In contrast, conventional grading and staging systems were not able to make such efficient distinction.

CONCLUSIONS

These 2 groups can be used as references with which new cases can be compared to prognosticate disease behavior independently of histopathological grading and/or clinical staging.

Ureteroscopic treatment of ureteric lithiasis. Analysis of 354 urs procedures in a community hospital

INTRODUCTION

The optimal treatment of ureteric lithiasis continues to be a point of discussion, as there are different treatment modalities. Conservative treatment, EWSL, ureteroscopy (URS), percutaneous litholapaxy, and (laparoscopic) ureterolithotomy, all have there place in the treatment of ureteric lithiasis. In order to evaluate if ureteroscopy is a valuable alternative to ESWL in the treatment of ureteric lithiasis, an analysis of all the ureteroscopies performed in our institution was made and these results were compared with results (both ESWL and URS) described in literature.

PATIENTS AND METHODS

During the period 1990 till 1997, 292 patients underwent in our institution in total 354 ureteroscopies for ureteric lithiasis. In all procedures a rigid 9 Fr. ureteroscope was used, together with laser lithotripsy or pneumatic lithotripsy as fragmentation device.

RESULTS

Overall success rate in our series was 90.1%, with distal and middle ureteric stone location being more favorable (94% and 95%) than proximal location (73%). Overall complication rate was 7.6% (including minor complications, such as ureteral mucosal tear), for which open surgical intervention had to be performed in 2.3% of cases.

CONCLUSIONS

Although invasive, ureteroscopy proved to be a very competitive alternative to ESWL, when treating ureteric lithiasis. Success rates are equal, if not better, using ureteroscopy when compared to ESWL. Complications of ureteroscopy are infrequent, but do exist. Therefore ureteroscopy should be performed by experienced urologists.

Radical prostatectomy and prognostic factors

OBJECTIVES

Prognosis of patients who have been treated by radical prostatectomy, because of prostatic carcinoma, is dependent on a number of factors. In this study we try to determine these factors, their relationship with each other, their relationship with progression of disease and the prognostic value of this relationship.

METHODS

"Progression" (or relapse) of disease is defined as clinical evidence of local or general recurrence and/or isolated elevation of postoperative PSA level more than 0.2 ng/ml (Hybritech) at two consecutive outpatient visits. In our institution, 62 radical retropubic prostatectomies were performed over a period of 66 months. Without any exclusion, these patients were included in the analysis (with respect to "progression"), which consisted of bi- and multivariate analyses, Kaplan-Meier estimations and multivariate survival analyses using the "Cox proportional hazards model". Median follow-up time was 32 months.

RESULTS

"Progression" was seen in 24.5% of cases, after a median progression-free interval of 13 months. Overall survival and freedom from "progression" (FFP) after 32 months were respectively 98.11% and 81.11%. Significant relations can be demonstrated between on one side preoperative PSA level, and on the other side "progression". FFP after 32 months for pathological T3-T4NO-1 tumors is 67.12% compared to 100% for pathological T2 tumors; FFP after 32 months is 88.98% for Gleason score of resection specimen < 7 and 73.86% for Gleason score > or = 7. Age, preoperative PSA level, Gleason score of resection specimen, surgical margin and 1-month-postoperative PSA level have in our analysis significant value (p < 0.05) in predicting "progression".

CONCLUSIONS

Most in the literature described predictive factors for "progression" are fairly well reproduced in our analysis. Elimination of bias from applied (neo-)adjuvant therapy and less heterogeneity of the study group would most certainly improve this reproducibility.

PSA evolution: a prognostic factor during treatment of advanced prostatic carcinoma with total androgen blockade. Data from a Belgian multicentric study of 546 patients

OBJECTIVES

To study the prognostic value of the prostate-specific antigen (PSA) response and its relationship with other initial prognostic factors during the treatment of advanced prostatic carcinoma with total androgen blockade.

METHODS

Five hundred forty-six patients with advanced loco-regional (M0) or distant metastatic (M1) prostatic carcinoma treated with flutamide combined with either orchiectomy or LHRH analogues were included in this analysis. Initial patients characteristics and the PSA response were evaluated in relation to progression-free survival using a univariate and multivariate (Cox regression) analysis.

RESULTS

The following prognostic factors were indicative of a decrease in progression-free survival: the absence of PSA normalization (< 4 ng/ml) after 3 or 6 months, M1 stage, high G grade, ECOG performance status > 1, presence of pain and absence of dysuria. In M1 patients the combination of PSA normalization after 3 or 6 months with initial G grade and ECOG performance status had the strongest predictive value.

CONCLUSIONS

This study demonstrates that PSA normalization after 3 or 6 months along with initial tumor stage, grade and health status of the patient are the most important prognostic factors related to progression-free survival in the hormonal treatment of advanced prostatic carcinoma.

Tolerability and safety of flutamide in monotherapy, with orchiectomy or with LHRH-a in advanced prostate cancer patients. A Belgian multicenter study of 905 patients

OBJECTIVE

In a multicenter study, 905 patients with newly diagnosed advanced prostate cancer treated with flutamide were followed for safety and side effects.

METHODS

Flutamide was administered in monotherapy (75 patients (8%)) or as part of total androgen blockade (TAB groups): the latter group had orchiectomy (196 patients (22%)) or an LHRH (634 patients (70%)).

RESULTS

The incidence of gastrointestinal complaints such as loss of appetite, vomiting/nausea and diarrhea (+/- 15%) was similar in the TAB and the monotherapy groups. Eighteen patients (2%) were withdrawn because of severe diarrhea. Hot flushes was the most frequently reported adverse event in TAB groups (40% of patients), leading to withdrawal in 4 patients (0.4%). Breast tenderness occurred most frequently in the monotherapy group (49%) and was reported as severe in 7% of the patients. Only 0.8% of the patients were withdrawn because of liver function changes. No unexpected potentially dangerous adverse events were reported.

CONCLUSION

Flutamide alone or in combination therapy appears to be safe and well tolerated.

Prognostic factors in advanced prostatic carcinoma treated with total androgen blockade. Flutamide with orchiectomy or with LHRH analogues. A Belgian multicentric study of 546 patients

Prognostic factors were evaluated in advanced loco-regional (M0) or distant metastatic (M1) prostatic carcinoma treated with total androgen blockade (flutamide with either orchiectomy of LHRH-analogues), in 546 patients from a Belgian multicentric study. After a mean follow-up of 16.5 months (maximum 37 months) 113 (21%) patients had progressed (90 were patients with M1 disease (31%)). The estimated median progression-free survival exceeded 37.5 months. The results of a univariate analysis show that the following parameters are important prognostic factors with respect to progression-free survival in these patients: M stage, G grade, ECOG performance status, weight loss, concomitant disease, pain, dysuria and haemoglobin (Lee-Desu test, p < or = 0.01). From a multivariate analysis (Cox regression) the following prognostic factors were indicative of a decrease in progression-free survival: M1 stage, high initial G grade, ECOG performance status > I, high serum PSA, presence of concomitant disease, presence of pain and absence of dysuria. Age did not appear to be a statistically significant prognostic factor.

Endocrine profiles during administration of the new non-steroidal anti-androgen Casodex in prostate cancer

OBJECTIVE

Casodex (Zeneca) is a new potent, long-acting non-steroidal anti-androgen, which produces androgen deprivation by blocking the androgen receptor. We evaluated the endocrine effects of Casodex 150 mg daily given in monotherapy as primary treatment for patients with prostate cancer.

DESIGN

As part of a large, multicentre study comparing the therapeutic effects of surgical castration with 150 mg/day Casodex in monotherapy for patients with prostate cancer, a subgroup of 23 patients on Casodex were studied in detail for changes in endocrine parameters. Serum levels of LH, FSH, testosterone, DHT, oestradiol, prolactin, sex hormone binding globulin and free testosterone were measured at the start of therapy and after 1, 4, 8, 12 and 24 weeks. Effects on libido, sexual activity and the appearance of hot flushes, breast pain and gynaecomastia were recorded.

RESULTS

Administration of Casodex resulted in a rise in LH levels in all patients with a mean increase after 24 weeks of 102% (P < 0.001). Mean FSH levels showed a limited increase (7%) after 24 weeks, which was significant only after 1 week (P < 0.001). As a result of the high LH levels, total testosterone levels increased after 24 weeks by 66% (P < 0.001), free testosterone by 57% (P < 0.001) and dihydrotestosterone by 24% (P = 0.0112). Parallel to testosterone, oestradiol levels rose by a mean of 66% (P < 0.001). Mean sex hormone binding globulin and prolactin levels rose by respectively 8% (P = NS) and 65% (P < 0.01). Despite an increase in testosterone levels, excellent androgen blockade was obtained, as shown by a decrease in prostate specific antigen levels in 22/23 patients. Libido was maintained in 8/11 patients, and sexual activity in 5/6. No patient complained of hot flushes. However, mild gynaecomastia and/or breast tenderness were seen in 48 and 30% of cases respectively.

CONCLUSION

Casodex 150 mg/day monotherapy resembles surgical castration in achieving androgen deprivation, despite an increase in LH and testosterone levels. In contrast to castration, libido and sexual activity are usually maintained and hot flushes are rare. However, mild gynaecomastia and/or breast tenderness were noted in 48 and 30% of patients.

Adenoid cystic carcinoma of the prostate

A case of a patient with this extremely rare tumor is described. Adenoid cystic carcinoma of the prostate should be considered as a subtype of prostate adenocarcinoma. Since this tumor can be associated with a prostatic adenocarcinoma, it should be regarded as malignant.

Use of transrectal longitudinal sonography in the placement of a prostatic coil

Patients with acute or chronic urinary retention, not suitable for operation, no longer need permanent transurethral or suprapubic catheters. The prostatic coil is an excellent alternative. A series of 25 patients is presented. The technique of placement is described in detail as well as the use of longitudinal transrectal sonography in the preparation and follow-up of patients with a coil.

Inverted papilloma of bladder: clinical significance

Based on 15 cases of inverted urothelial papilloma, we present the clinical significance of these lesions in view of the current literature. An inverted papilloma should raise suspicion with respect to the whole urothelial surface. However, approaching every lesion of this type as a (pre-)neoplastic tumor does not seem justified, since 90 percent of all cases reported so far do not present any clinical or histologic feature of malignancy. Some factors, such as the patient's history, eventually associated urothelial carcinomas, or histologic features of malignant transformation within an inverted papilloma, must be taken into consideration. If no single indication in favor of malignancy has been disclosed, we believe follow-up with yearly endoscopic investigations, in addition to regular urine cytologies, may suffice.

Method for inserting cystostomy catheter in patients with contracted bladder

An easy and safe method for inserting a cystostomy catheter in patients with a contracted bladder is described. It requires only a curved benique with threaded tip and a filiform guide for bougie.

Treatment of chronic bacterial prostatitis by local injection of antibiotics into prostate

Experiences with localized antibiotic treatment of chronic bacterial prostatitis by direct injection into the caudal prostate is presented. Very high antibiotic levels are found in the prostatic fluid without correlation with the time after injection. The pain and discomfort experienced by the patients during direct injection into the prostate are minimal. Hematuria and hemospermia during some weeks are practically always present after the injection. Local necrosis was not found after several histologic and electronic microscopic studies. Results demonstrated that this method deserves its place in the treatment of the hard-core group of chronic bacterial prostatitis.