Anton J. Bueschen

Bilateral orchiectomy with or without flutamide for metastatic prostate cancer

BACKGROUND Combined androgen blockade for the treatment of metastatic prostate cancer consists of an antiandrogen drug plus castration. In a previous trial, we found that adding the antiandrogen flutamide to leuprolide acetate (a synthetic gonadotropin-releasing hormone that results in medical ablation of testicular function) significantly improved survival as compared with that achieved with placebo plus leuprolide acetate. In the current trial, we compared flutamide plus bilateral orchiectomy with placebo plus orchiectomy. METHODS We randomly assigned patients who had never received antiandrogen therapy and who had distant metastases from adenocarcinoma of the prostate to treatment with bilateral orchiectomy and either flutamide or placebo. Patients were stratified according to the extent of disease and according to performance status. RESULTS Of the 1387 patients who were enrolled in the trial, 700 were randomly assigned to the flutamide group and 687 to the placebo group. Overall, the incidence of toxic effects was minimal; the only notable differences between the groups were the greater rates of diarrhea and anemia with flutamide. There was no significant difference between the two groups in overall survival (P=0.14). The estimated risk of death (hazard ratio) for flutamide as compared with placebo was 0.91 (90 percent confidence interval, 0.81 to 1.01). Flutamide was not associated with enhanced benefit in patients with minimal disease. CONCLUSIONS The addition of flutamide to bilateral orchiectomy does not result in a clinically meaningful improvement in survival among patients with metastatic prostate cancer.

Preoperative Biofeedback Assisted Behavioral Training to Decrease Post-Prostatectomy Incontinence: A Randomized, Controlled Trial

PURPOSE We tested the effectiveness of preoperative biofeedback assisted behavioral training for decreasing the duration and severity of incontinence, and improving quality of life in the 6 months following radical prostatectomy. MATERIALS AND METHODS We performed a prospective, randomized, controlled trial comparing preoperative behavioral training to usual care. The volunteer sample included 125 men 53 to 68 years old who elected radical prostatectomy for prostate cancer. Patients were stratified according to age and tumor differentiation, and randomized to 1 preoperative session of biofeedback assisted behavioral training plus daily home exercise or a usual care control condition, consisting of simple postoperative instructions to interrupt the urinary stream. The main outcome measurements were duration of incontinence (time to continence), as derived from bladder diaries, incontinence severity (the proportion with severe/continual leakage), pad use, Incontinence Impact Questionnaire, psychological distress (Hopkins Symptom Checklist) and health related quality of life (Medical Outcomes Study Short Form Health Survey). RESULTS Preoperative behavioral training significantly decreased time to continence (p = 0.03) and the proportion of patients with severe/continual leakage at the 6-month end point (5.9% vs 19.6%, p = 0.04). There were also significant differences between the groups for self-reported urine loss with coughing (22.0% vs 51.1%, p = 0.003), sneezing (26.0% vs 48.9%, p = 0.02) and getting up from lying down (14.0% vs 31.9%, p = 0.04). No differences were found on return to work and usual activities or quality of life measures. CONCLUSIONS Preoperative behavioral training can hasten the recovery of urine control and decrease the severity of incontinence following radical prostatectomy.

Short-term and long-term changes in renal function after donor nephrectomy

We retrospectively examined the effect of nephrectomy on renal function in 55 living related donors. Renal function was measured with 131iodine-orthoiodohippurate scans. All patients were studied preoperatively, and 1 week and 1 year postoperatively. In 20 patients 10-year followup was available. Compensatory hypertrophy was complete 1 week postoperatively: effective renal plasma flow of the remaining kidney was 32.5% higher than preoperatively. The increase remained stable for at least a year. The degree of compensatory hypertrophy was significantly greater in male patients (46.9% after 1 week) than in female patients (26.7%). Compensatory hypertrophy occurred in all age groups studied and it was most pronounced in patients less than 30 years old. In the patients followed for 10 years effective renal plasma flow decreased from 387.7 ml. per minute 1 week after nephrectomy to 367.4 ml. per minute at 10 years. This result is similar to the decrease seen in the normal population. According to our results, renal donation by living related persons does not lead to long-term decrease in renal function.

Renal Angiomyolipoma Associated with Lymph Node Involvement and Renal Cell Carcinoma in Patients with Tuberous Sclerosis

Renal angiomyolipomas are found in more than half of the patients with tuberous sclerosis. We report on 3 patients with tuberous sclerosis and pathologically aggressive renal angiomyolipoma with retroperitoneal lymph node involvement and/or renal cell carcinoma. All patients have had a benign course. The literature is reviewed and supports the benign nature of this seemingly aggressive disorder. An approach to the evaluation and treatment of a child with tuberous sclerosis and renal angiomyolipoma is presented.

Tumor Associated Glycoprotein-72 is Highly Expressed in Prostatic Adenocarcinomas

We examined the expression of two well-characterized oncofetal antigens, the tumor associated glycoprotein-72 (TAG-72) and carcinoembryonic antigen (CEA), in malignant prostatic tissues. Three specific monoclonal antibodies, B72.3, CC49 and CC83, were used to examine the expression of TAG-72. Immunoreactivity was detected in 63% of the malignant specimens using B72.3. CC49 and CC83 were more sensitive than B72.3 in detecting TAG-72 expression. Immunoreactivity was detected in approximately 80% of prostatic adenocarcinomas with CC49 or CC83. The pattern and localization of TAG-72 immunoreactivity were similar for the three antibodies with most immunoreactivity observed within the cytoplasm of malignant cells and within the lumens of malignant glands. TAG-72 immunoreactivity was not detected within benign epithelium or stroma, with the exception of focal epithelial expression in areas of acute prostatitis. The COL-1 antibody to CEA did not detect CEA in benign glands, stroma, or malignant cells of prostate specimens resected for prostatic adenocarcinoma. These results demonstrate that TAG-72, but not CEA, is frequently expressed in prostatic adenocarcinomas.

Effects of pelvic rotation and needle angle on pubic arch interference during transperineal prostate implants.

PURPOSE Pubic arch interference due to an enlarged prostate gland or a narrow pubic arch is often a limiting factor in adequate prostate coverage during transperineal brachytherapy. The purpose of this study was to evaluate the effects of both pelvic rotation and needle angles on pubic arch interference using CT-based 3-D information. METHODS AND MATERIALS Seven patients had CT imaging in both supine and lithotomy positions and 3-D treatment planning was performed with three needle angles (20 downward, 0, 20 upward). The pubic arch interference was then measured and comparisons were made for each needle trajectory and pelvic position. RESULTS Increasing pelvic rotation from supine to lithotomy position shows less pubic arch interference. Directing the needle tip upward shows less pubic arch interference in both supine and lithotomy positions when compared to needle tips directed downward. CONCLUSIONS Both pelvic position and needle angles are important factors influencing pubic arch interference. Preplanning CT-based 3-D information may assist for individualized treatment planning in patients with a significant bony interference, thus avoiding pubic arch interference during implantation.

LIVE DONOR NEPHRECTOMY IN PATIENTS WITH FIBROMUSCULAR DYSPLASIA OF THE RENAL ARTERIES

PURPOSE We determine the suitability of patients with fibromuscular dysplasia of the renal arteries as renal donors. MATERIALS AND METHODS We evaluated 37 patients with fibromuscular dysplasia who were potential renal donors. Renal artery lesions were graded I (mild) to IV (severe). Of the patients 19 underwent donor nephrectomy and 18 were rejected as donors. Reasons for rejection included severity of disease or availability of a better donor. Nephrectomy was performed on the side with fibromuscular dysplasia when disease was unilateral or on the side with more advanced disease when the lesions were bilateral. Patients were followed at 1 month, 1 year and then yearly. RESULTS Of the 19 patients undergoing donor nephrectomy serum creatinine increased by a mean of 0.4 mg./dl. (range 0.1 to 1.1) on postoperative day 1. Effective renal plasma flow of the remaining kidney increased by 25% on postoperative day 5 and by 29% after 1 year. After a mean followup of 4.5 years no patient had hypertension, proteinuria or any significant change in serum creatinine compared to baseline values. Of the 18 patients not undergoing nephrectomy 11 were contacted at a mean followup of 4 years, and none had hypertension, proteinuria or abnormal serum creatinine. CONCLUSIONS Patients with fibromuscular dysplasia may be acceptable renal donors. The decision to use a patient with fibromuscular dysplasia as a donor is based on patient age, the availability of other suitable donors, and the extent and severity of disease.

Computed tomographic diagnosis of ectopic ureter with seminal vesicle cyst

A rare case of dysplastic kidney with ectopic ureter entering a cystic seminal vesical is reported. This demonstrates the usefulness of computerized tomography in noninvasively delineating such anomalies. Thus accurate preoperative diagnosis can be done, aiding in surgical planning.

Complications of radical cystectomy and correlation with nutritional assessment

Single stage radical cystectomy and ileal conduit remains the procedure of choice for invasive bladder cancer and is a formidable operation performed on an elderly population. A retrospective review of 69 radical cystectomies was done to evaluate not only operative mortality and complication rate, but also the nutritional status of the patients and its relationship to the frequency of complications. Preoperative nutritional status was assessed by total lymphocyte count and serum albumin. There was an operative mortality rate of 2.9 per cent and early complication rate of 41 per cent. The findings suggest that patients with severe nutritional depletion should receive hyperalimentation prior to cystectomy to reduce serious postoperative complications.

Adjuvant surgical techniques in the removal of staghorn calculi.

Surgical removal of staghorn calculi can be difficult. We describe a retrospective review of 21 patients who underwent 22 operations for the removal of staghorn calculi. Subsequent urinary infections occurred in 30 per cent and recurrent stones developed in 20 per cent of the patients. We emphasize the accuracy and importance of intraoperative roentgenography, the usefulness and morbidity of hemiacidrin irrigation and the postoperative stability of renal function measured by a radionuclide renal function test.