Arnold Bullock

USE OF LOWER PROSTATE SPECIFIC ANTIGEN CUTOFFS FOR PROSTATE CANCER SCREENING IN BLACK AND WHITE MEN

PURPOSE We evaluated differences in the prostate cancer detection rate among black and white men with serum prostate specific antigen (PSA) levels between 2.6 and 4.0 ng./ml., and benign findings on digital rectal examination. MATERIALS AND METHODS From May 1995 through June 1997 we screened 14,209 white and 1,004 black men 50 years old or older with serum PSA and rectal examinations at 6-month intervals. If PSA was greater than 2.5 ng./ml. or the rectal examination was suspicious for cancer, we recommended an ultrasound guided sextant biopsy of the prostate. We compared differences in clinical characteristics, compliance with the recommendation for biopsy, cancer detection rate, and stage and grade of tumors detected for 924 white and 57 black men. RESULTS Black men were younger (60 versus 63 years old, p = 0.005) and presented with slightly higher PSA levels (3.3 versus 3.1 ng./ml., p = 0.03) than white men. Overall cancer detection rate was 27% (106 of 391 patients), with cancer detection 2-fold higher among black (13 of 29, 45%) than among white (93 of 362, 26%) men (p = 0.03, odds ratio 2.4, 95% confidence interval 1.1 to 5.1). Controlling for age, total PSA, PSA density, percent free PSA and number of prior screening visits, race remained a significant predictor of cancer (adjusted odds ratio 3.4, confidence interval 1.4 to 8.4). We found trends for worse pathological stage and grade among black men but these differences did not reach statistical significance. CONCLUSIONS Black race was an independent predictor of prostate cancer even at lower PSA cutoffs (2.6 to 4.0 ng./ml.). Although the positive predictive value for cancer detection was relatively high in black men, long-term outcomes studies are necessary to determine whether the use of lower PSA cutoffs would result in favorable shifts in cancer stage and grade, and a reduction in racial differences in prostate cancer mortality rates.

Surgical treatment of renal neoplasia: evolving toward a laparoscopic standard of care

OBJECTIVES To determine the extent to which laparoscopy has replaced open surgery for renal malignancy. METHODS The records of all 537 patients at Washington University who underwent surgery for localized renal malignancies from January 1997 to December 2001 were examined for clinical and pathologic information. RESULTS The total procedures per year increased from 1997 to 2001, but the distribution of pathologic stages throughout the 5 years was similar. In 1997, laparoscopic approaches were used in 15% of cases; this increased to 65% by 2001. Nephron-sparing surgery (NSS) was used in 31% to 42% of patients yearly, but laparoscopic NSS increased in frequency. By 2001, only 3.3% of T1 tumors were removed by open radical nephrectomy compared with 55% treated by laparoscopic nephrectomy. The rest of the T1 tumors in 2001 were treated by open partial nephrectomy (20.2%) or laparoscopic NSS (21.3%). In 2001, 61% of T2 lesions were treated laparoscopically, an increase from 37% in 1997. Most open radical nephrectomies in 2001 were performed for T3 disease. The number of surgeons performing laparoscopic renal surgery has increased at our institution, from two in 1997, both endourologists, to eight in 2001, representing the entire urology faculty that treats renal cancer. CONCLUSIONS Laparoscopic radical nephrectomy has replaced open radical nephrectomy for low-stage renal neoplasia. Although laparoscopic NSS is increasing in frequency, it has not yet replaced open partial nephrectomy. At our institution, the laparoscopic approach has become the standard of care when radical nephrectomy is needed for T1 or T2 renal cancer.

RACIAL DIFFERENCES IN OPERATING CHARACTERISTICS OF PROSTATE CANCER SCREENING TESTS

PURPOSE We evaluated racial differences in the operating characteristics of prostate specific antigen (PSA) and digital rectal examination as screening tests for early detection of prostate cancer. MATERIALS AND METHODS We screened 18,527 white and 949 black men 50 years old or older using serum PSA measurement and digital rectal examination. We recommended biopsies if either test was suspicious for cancer. For PSA greater than 4.0 ng./ml. and rectal examination we calculated relative sensitivity (percentage of men with cancer who had a positive test), specificity (percentage of men without cancer who had a negative test) and positive predictive value (percentage of men with a positive test in whom cancer was detected) for the prediction of prostate cancer stratified by race. RESULTS In white and black men PSA greater than 4.0 ng./ml. detected more cancers than rectal examination (p < 0.002) with a trend for a greater increase in sensitivity in black men. PSA was associated with fewer false-positives than rectal examination in white (p < 0.0001) but not in black (p > 0.05) men. Positive predictive value for prostate cancer of PSA and rectal examination was greater in black than in white men (48 versus 34 and 38 versus 22%, respectively). CONCLUSIONS PSA detects more cancers than rectal examination in both races, although this advantage is more pronounced in black men. In white men PSA yielded fewer false-positive results than rectal examination. However, PSA had more false-positive results than rectal examination in black men. Cancer was detected in a higher percentage of black men with PSA greater than 4.0 ng./ml. and, therefore, the risk of cancer associated with PSA greater than 4.0 ng./ml. differs by race. In a screening setting the widely accepted 25 to 30% positive predictive value for PSA greater than 4.0 ng./ml. may only apply to white men. A higher risk estimate of 36 to 60% is more accurate in black men.

Racial Differences in a Prostate Cancer Screening Study

PURPOSE We attempted to determine whether black men have a higher prostate cancer prevalence and more advanced disease. MATERIALS AND METHODS We screened 17,157 white and 804 black men 50 years old or older by serum prostate specific antigen measurement and digital rectal examination. We recommended biopsy when either test was suspicious. RESULTS Black men had a higher prevalence of elevated prostate specific antigen (13.1 versus 8.9%) and cancer (5.1 versus 3.2%) than white men, and a higher prevalence of clinically but not pathologically advanced cancer. Fewer black men in lower income zip codes complied with recommendations for biopsy. CONCLUSIONS In our screening study black men had a higher prevalence of detectable cancer. However, unlike in clinical studies there was no striking racial difference in advanced cancer stage at diagnosis.

Positive Margin During Partial Nephrectomy: Does Cancer Remain in the Renal Remnant?

OBJECTIVE To examine the outcomes of patients with a positive surgical margin by gross and/or frozen examination during partial nephrectomy, in whom a re-resection of the margin or a completion nephrectomy was performed. METHODS Patients with renal cancer who underwent partial nephrectomy were considered. If the patient had a positive margin and underwent completion nephrectomy or re-excision of the margin, they were included. Patients with planned enucleation were excluded from the study. Clinical and pathologic information were reviewed to examine for residual cancer in the additionally resected tissue. RESULTS In the final cohort, 29 patients with a positive margin and subsequent complete parenchymal re-resection or completion nephrectomy were identified. Eight patients underwent nephrectomy, after which no residual cancer was found in the renal remnant. Twenty-one patients underwent total re-resection of the margin, of which two were found to have carcinoma. Renal functional outcomes revealed a decrease in estimated glomerular filtration rate of 25 mL/min/1.73 m(2) in patients who underwent radical nephrectomy, and 4 mL/min/1.73 m(2) in patients who underwent re-resection of the margin with preservation of the renal unit. CONCLUSIONS A positive surgical margin does not necessarily mean that cancer remains in the renal remnant in most cases. Therefore, radical nephrectomy or re-resection of the margin is overtreatment in many cases, but a small percentage of patients will harbor residual malignancy. Clinical correlation is recommended before reexcision or completion nephrectomy after a positive surgical margin, with careful consideration of the impact on subsequent renal function weighed against the possibility of residual disease.

A Comparison of Chlorhexidine-Alcohol Versus Povidone-Iodine for Eliminating Skin Flora Before Genitourinary Prosthetic Surgery: A Randomized Controlled Trial

PURPOSE We defined the relevant skin flora during genitourinary prosthetic surgery, evaluated the safety of chlorhexidine-alcohol for use on the male genitalia and compared chlorhexidine-alcohol to povidone-iodine in decreasing the rate of positive bacterial skin cultures at the surgical skin site before prosthetic device implantation. MATERIALS AND METHODS In this single institution, prospective, randomized, controlled study we evaluated 100 consecutive patients undergoing initial genitourinary prosthetic implantation. Patients were randomized to a standard skin preparation with povidone-iodine or chlorhexidine-alcohol. Skin cultures were obtained from the surgical site before and after skin preparation. RESULTS A total of 100 patients were randomized, with 50 in each arm. Pre-preparation cultures were positive in 79% of the patients. Post-preparation cultures were positive in 8% in the chlorhexidine-alcohol group compared to 32% in the povidone-iodine group (p = 0.0091). Coagulase-negative staphylococci were the most commonly isolated organisms in post-preparation cultures in the povidone-iodine group (13 of 16 patients) as opposed to propionibacterium in the chlorhexidine-alcohol group (3 of 4 patients). Clinical complications requiring additional operations or device removal occurred in 6 patients (6%) with no significant difference between the 2 groups. No urethral or genital skin complications occurred in either group. CONCLUSIONS Chlorhexidine-alcohol was superior to povidone-iodine in eradicating skin flora at the surgical skin site before genitourinary prosthetic implantation. There does not appear to be any increased risk of urethral or genital skin irritation with the use of chlorhexidine compared to povidone-iodine. Chlorhexidine-alcohol appears to be the optimal agent for skin preparation before genitourinary prosthetic procedures.

Comparison of anchors used in anti-incontinence surgery

OBJECTIVES To compare the resistance to caudally directed force at different fixation points used in female anti-incontinence surgery. METHODS Sutures were placed in Coopers ligament, rectus fascia, and in bone anchors on the pubic symphysis in 6 fresh, unembalmed cadavers and transposed vaginally with a ligature carrier. Force was applied in a caudal direction to each suture. Displacement of the suture with increasing force and the force required to overcome the cranial fixation point were measured with a highly precise force gauge. Two measurements were made for each anchor point and the measurements were averaged. RESULTS With caudally directed force, sutures fixed to Coopers ligament were displaced to an equal extent as sutures attached to a bone anchor. Sutures anchored to the rectus fascia were displaced the most with increasing force. The maximal force supported by Coopers ligament fixation and bone anchors was similar. The event limiting each test was suture breakage, except when one suture anchored in the rectus fascia tore out. CONCLUSIONS In a cadaver model, bone anchors placed in the pubic symphysis offer no structural advantage over Coopers ligament fixation.

Fascial closure of laparoscopic port sites: A new technique

The laparoscopic operative procedure is not complete until the port sites are closed with a fascial suture. Herein, we report a simple new technique that uses a venous catheter for suture placement and direct laparoscopic visualization to secure the abdominal wall fascia and peritoneum.

Delayed infection of a pelvic lymphocele following pelvic lymphadenectomy

Pelvic lymphocele is an infrequent complication of pelvic surgery, usually presenting shortly after surgery. We report a case of an infected pelvic lymphocele presenting more than 1 year after a staging pelvic lymphadenectomy for adenocarcinoma of the prostate. This case illustrates that late infection of pelvic lymphoceles can occur following a pelvic lymphadenectomy and radical prostatectomy.

Sperm Recovery and IVF after Testicular Sperm Extraction (TESE): Effect of Male Diagnosis and Use of Off-Site Surgical Centers on Sperm Recovery and IVF

Objective Determine whether testicular sperm extractions and pregnancy outcomes are influenced by male and female infertility diagnoses, location of surgical center and time to cryopreservation. Patients One hundred and thirty men undergoing testicular sperm extraction and 76 couples undergoing 123 in vitro fertilization cycles with testicular sperm. Outcome Measures Successful sperm recovery defined as 1–2 sperm/0.5 mL by diagnosis including obstructive azoospermia (n = 60), non-obstructive azoospermia (n = 39), cancer (n = 14), paralysis (n = 7) and other (n = 10). Obstructive azoospermia was analyzed as congenital absence of the vas deferens (n = 22), vasectomy or failed vasectomy reversal (n = 37) and “other”(n = 1). Sperm recovery was also evaluated by surgical site including infertility clinic (n = 54), hospital operating room (n = 67) and physician’s office (n = 11). Treatment cycles were evaluated for number of oocytes, fertilization, embryo quality, implantation rate and clinical/ongoing pregnancies as related to male diagnosis, female diagnosis, and use of fresh or cryopreserved testicular sperm. Results Testicular sperm recovery from azoospermic males with all diagnoses was high (70 to 100%) except non-obstructive azoospermia (31%) and was not influenced by distance from surgical center to laboratory. Following in vitro fertilization, rate of fertilization was significantly lower with non-obstructive azoospermia (43%, p = <0.0001) compared to other male diagnoses (66%, p = <0.0001, 59% p = 0.015). No differences were noted in clinical pregnancy rate by male diagnosis; however, the delivery rate per cycle was significantly higher with obstructive azoospermia (38% p = 0.0371) compared to diagnoses of cancer, paralysis or other (16.7%). Women diagnosed with diminished ovarian reserve had a reduced clinical pregnancy rate (7.4% p = 0.007) compared to those with other diagnoses (44%). Conclusion Testicular sperm extraction is a safe and effective option regardless of the etiology of the azoospermia. The type of surgical center and/or its distance from the laboratory was not related to success. Men with non-obstructive azoospermia have a lower chance of successful sperm retrieval and fertilization.