Donald E. Novicki

The use of radiotherapy for patients with isolated elevation of serum prostate specific antigen following radical prostatectomy

PURPOSEnAn analysis was performed to assess the outcome of patients who received radiotherapy for isolated elevation of serum prostate specific antigen (PSA) levels following radical retropubic prostatectomy.nnnMATERIALS AND METHODSnForty-six patients were initially treated for localized prostate cancer with radical retropubic prostatectomy following negative pelvic lymphadenectomy. These patients had detectable serum PSA 6 or more months postoperatively. No patient had other clinical evidence of recurrent disease as determined by history, physical examination, bone scan, computerized tomography of the abdomen and pelvis, chest radiographs, complete blood cell counts and serum chemistry profiles. The patients received prostate bed irradiation using 10 MV. x-rays and a 4-field approach. Doses ranged from 60.0 to 67.0 Gy. in 1.8 to 2.0 Gy. fractions. Freedom from failure after radiotherapy was defined as maintaining a PSA of 0.3 ng./ml. or less without hormonal intervention.nnnRESULTSnIn 27 of the 46 patients (59%) PSA had decreased to 0.3 ng./ml. or less at last measurement without hormonal intervention. The freedom from failure rate was 50% at 3 and 5 years. More favorable responses to salvage radiotherapy occurred in patients with low grade tumors and serum PSA 1.1 ng./ml. or less at initiation of radiotherapy. Patients, receiving radiation doses of 64 Gy. or more had more favorable response rates than those receiving lesser doses.nnnCONCLUSIONSnIsolated elevations of serum PSA following prostatectomy reflect residual disease. Radiotherapy administered to the prostate bed effectively decreased serum PSA in approximately half of the cases. This effect appears to be accomplished by eradicating tumor cells in the prostate bed.

The results of radical retropubic prostatectomy and adjuvant therapy for pathologic Stage C prostate cancer

PURPOSEnThe results of therapy in 288 men with pathologic Stage C prostate cancer who underwent radical retropubic prostatectomy (RRP) were analyzed to determine the effects of adjuvant therapy.nnnMETHODS AND MATERIALSnTwenty-seven of the 288 patients received preoperative neoadjuvant hormonal therapy (leuprolide acetate). Postoperatively, 60 patients received adjuvant radiotherapy (RT) to the prostate bed. Follow-up ranged from 3 to 83 months (median = 32 months). Freedom from failure (FFF) was defined as maintaining a serum PSA level of < or = 0.3 ng/ml.nnnRESULTSnThe FFF was 61% at 3 years and 45% at 5 years for the entire group. The FFF following RRP plus RT was 75% at 3 years and 57% at 5 years as compared to 56% at 3 years and 40% at 5 years for RRP without RT (p=0.049). The FFF following RRP plus neoadjuvant hormonal therapy was 58% at 3 years and 40% at 5 years as compared to 60% at 3 years and 45% at 5 years following RRP without hormonal therapy (p=0.3). In patients without seminal vesicle (SV) invasion, the FFF was 81% at 3 years and 5 years for RRP plus RT as compared to 61% at 3 years and 50% at 5 years for RRP without RT (p=0.01). In patients with SV invasion, the FFF was 61% at 3 years and 36% at 5 years for RRP plus RT as compared to 44% at 3 years and 23% at 5 years for RRP without RT (p=0.23). The projected local control rate was 83% at 5 years for those with RRP alone as compared to 100% for RRP plus RT (p=0.02). Survival at 5 years was projected to be 92% and was not significantly altered by the administration of adjuvant therapies.nnnCONCLUSIONSnPostoperative RT was associated with significantly improved local control and FFF rates, especially in patients with tumors which did not involve the seminal vesicles.

Interstitial cystitis in men

OBJECTIVESnTo determine the personal characteristics, the mode of presentation, the duration of the delay in diagnosis, the number of misdiagnoses, the means to achieve diagnosis, and previous treatment provided for a group of men with interstitial cystitis (IC).nnnMETHODSnA chart review of 29 men diagnosed with IC at our facility from 1988 to 1996 was performed. Basic demographic data, historical information, laboratory findings, and endoscopic and biopsy results were tabulated.nnnRESULTSnIC in this series of men was diagnosed at a mean age of 67.3 years. There was approximately a 4-year diagnostic lag between presentation and diagnosis. The most common prior erroneous diagnoses were prostatitis in 48% and benign prostatic hypertrophy (BPH) in 38% of the men. Ulcers were encountered cystoscopically in about 70% and biopsy specimens uniformly showed nonspecific chronic cystitis at the time of diagnosis.nnnCONCLUSIONSnIC should be considered in the differential diagnosis of voiding disorders accompanied by irritative symptoms and pelvic pain in older men. The diagnosis should be especially considered in men who are refractory to the usual treatments for BPH and prostatitis. Cystoscopy and bladder distention under anesthesia provided the most useful objective information in our hands. Biopsy is useful to rule out inflammatory cancer but adds little to the diagnosis of IC.

Detection of residual prostate cancer after radical prostatectomy with the Abbott IMx PSA assay

OBJECTIVESnThis analysis was performed to define the level of serum prostate-specific antigen (PSA) measured with the Abbott IMx assay that indicates residual or progressive prostate cancer after radical retropubic prostatectomy (RRP).nnnMETHODSnSince March 1992, we have used the Abbott IMx assay to determine PSA levels. Between March 1992 and June 1994, 102 of those patients having RRPs were found to have pathologic Stage C prostate cancer. Fifty-one of these patients had at least one serum PSA measurement of 0.1 ng/mL or greater. Eight patients were excluded from the analysis because they received postoperative radiotherapy that might have influenced subsequent PSA levels. The remaining 43 patients are the subjects of this analysis and were evaluated to determine the clinical threshold or minimal serum PSA level after RRP indicative of progressive disease. Patients were followed for 6 to 36 months (median 23 months) from the date of the RRP. Failure was defined as a subsequent increase of PSA to greater than 0.3 ng/mL. Freedom from failure was determined using the Kaplan-Meier product limit method.nnnRESULTSnOf the patients with at least one postoperative serum PSA level of 0.1 ng/mL, the subsequent freedom from failure was 80% at 23 months as compared with 13% in patients with at least one postoperative PSA level of 0.2 ng/mL (P = 0.003).nnnCONCLUSIONSnFollowing RRP for pathologic Stage C prostate cancer, a solitary PSA level of 0.1 ng/mL (measured with the IMx assay) was followed by a progressive rise in PSA levels in only a minority of patients within the first 2 years after surgery. In contrast, the majority of patients with a postoperative PSA level of 0.2 ng/mL subsequently had progressively rising PSA levels. This indicates that a serum PSA level of 0.2 ng/mL is reflective of residual prostate cancer.

Cost-effective evaluation of indeterminate urinary cytology

PURPOSEnWe reviewed our management of indeterminate urinary cytologies to determine which patients warrant urological evaluation. Our goal was to develop a cost-effective evaluation scheme that detects the most cancers.nnnMATERIALS AND METHODSnWe analyzed case histories of 389 patients with indeterminate urinary cytology who had undergone complete urological evaluations. Upper urinary tract imaging and cystoscopy were required to exclude malignancy, and tissue biopsy results were recorded in all individuals diagnosed with cancer. Multivariate analysis was used to assess the significance of clinical factors that would suggest the necessity of complete urinary system evaluation. Marginal cost-effectiveness rates were applied to various clinical scenarios.nnnRESULTSnOf 389 patients 60 (15%) had urinary tract malignancy. A history of urothelial malignancy and hematuria were the only significant factors that suggested complete evaluation was necessary. If smoking history were included 59 of the 60 malignancies would have been detected.nnnCONCLUSIONSnPatients with indeterminate urinary cytology who are nonsmokers and have neither hematuria nor a history of urothelial cancer are at low risk for malignancy and do not warrant complete evaluation.

Comparison of the modified vest and the direct anastomosis for radical retropubic prostatectomy

OBJECTIVESnThis retrospective study was undertaken to compare the efficacy of the Vest and direct vesicourethral anastomosis for radical prostatectomy.nnnMETHODSnFive hundred six patients who underwent consecutive radical prostatectomies at our institution were analyzed. Two hundred fifty-nine patients underwent vesicourethral anastomosis using the Vest technique and 247 underwent a direct suture anastomosis. The groups were analyzed relative to time until healing, the occurrence of anastomotic strictures, and the continence rate 1 year after surgery.nnnRESULTSnApproximately twice as many patients who underwent the Vest procedure experienced delayed healing and 8.5% developed anastomotic strictures compared with 1.2% of the direct anastomosis group. The Vest group experienced slightly better urinary continence 1 year postoperatively.nnnCONCLUSIONSnThe Vest procedure is a reasonable alternative to direct anastomosis for radical prostatectomy and provides similar results. We suggest specific circumstances when the Vest anastomosis may be particularly useful.

Detailed prostatic interstitial thermal mapping during transurethral grooved rollerball electrovaporization and loop electrosurgery for benign prostatic hyperplasia

OBJECTIVESnTo determine the detailed pattern of prostatic interstitial temperature change during rollerball electrovaporization and loop electrosurgery in patients with benign prostatic hyperplasia (BPH).nnnMETHODSnFour patients with symptomatic BPH necessitating prostate surgery were subjected to rollerball electrovaporization on one side of their prostate glands, as well as contralateral loop electrosurgery. Continuous temperature readings were recorded from 20 to 24 interstitially implanted fiber-optic thermosensors using a novel stereotactic thermal mapping technique. Ultrasound and video endoscopic visualization were used to evaluate and quantify the spatial relationship between the thermosensors and the rollerball or loop.nnnRESULTSnThe patterns of temperature change during rollerbal electrovaporization and loop electrosurgery were substantially similar. Temperatures decreased steeply and significantly with increasing distance from both the rollerball (P < 0.001) and loop (P < 0.001). Marked mean temperature increases occurred at 1 to 2 mm from both the rollerball (30.8 degrees C, 95% confidence interval [CI] 27.8 to 33.8 degrees C) and loop (34.8 degrees C, 95% CI 24.0 to 45.6 degrees C), and temperatures at this distance were significantly higher than those at greater distances (P < 0.05). At 3 to 5 mm, the mean temperature increases declined by 58% for the rollerball and 68% for the loop. Further declines of 68% and 63%, respectively, were observed at 6 to 10 mm, and at distances exceeding 10 mm the temperature changes were minimal (0.5 degree C [95% CI 0.3 to 0.8 degree C] for the rollerball and 0.5 degree C [95% CI 0.1 to 0.8 degree C] for the loop). There was no change in temperature at any of the thermosensors near the neurovascular bundles and rectum.nnnCONCLUSIONSnThe patterns of temperature change with rollerball electrovaporization and loop electrosurgery are closely similar. Interstitial temperature changes during use of the rollerball and loop are transient and highly localized, posing minimal risk of unintended thermal damage to adjacent tissues, including the neurovascular bundles and rectum.

Venous air embolism during transurethral resection of the prostate.

Venous air embolism during transurethral surgery is a rare event. There have been case reports in the anesthesia and urology literature of fatal air embolism during transurethral prostate resection and transurethral incision of the bladder neck. We present a case of nonfatal venous air embolism during transurethral prostate resection in which incorrect assembly of the bladder irrigation-resectoscope-drain system led to a rapid entrainment of air into the open venous channels of the prostate bed.

Should the Upper Tracts be Imaged for Microscopic Haematuria

OBJECTIVEnTo determine the relative prevalence of various definitions of microscopic haematuria (MH) in patients with renal neoplasms and controls, and to predict the likely outcome of renal imaging for those definitions.nnnPATIENTS AND METHODSnIn a retrospective case-control study 278 adult men and woman seen between 1998 and 2003 with untreated renal neoplasms were compared to controls matched for age and sex. All cases and controls had renal imaging within 6 months of a urine analysis. Patients were excluded for gross haematuria or other conditions associated with MH but not relevant to upper tract imaging. Adjusted odds ratios (OR) computed for 13 definitions of MH by conditional logistic regression were the primary outcome measures. Additional outcome measures were ORs in selected subsets. Hypothetical performance characteristics of a positive urine analysis were then derived to predict the likely results of detecting renal neoplasms for each definition of MH.nnnRESULTSnThe OR (95% confidence interval) for the entire series of cases and controls, both symptomatic and asymptomatic, was 2.0 (1.02-3.92, P = 0.04) for MH defined as > or = 4 red blood cells per high-power field (RBC/HPF) and 2.2 (1.09-4.52, P = 0.03) for > or = 5 RBC/HPF. No significant OR was calculated for < or = 3 RBC/HPF, nor for a subgroup of patients with MH in a routine urine analysis obtained during a periodic health examination. Symptomatic patients had an OR of 13.68 (1.6-117.1, P = 0.02) for MH defined as > or = 5 RBC/HPF. The sensitivity of a positive test decreased from 24.8% to 5.04% as the definition for MH became more stringent. The theoretical positive predictive value (assuming a prevalence of renal cell neoplasms of 0.25%) of the most stringent definition of MH was 0.58%.nnnCONCLUSIONSnPatients with renal neoplasms have about twice the prevalence of MH with > or = 4 or 5 RBC/HPF in a single urine sample compared with matched controls, but this difference has little impact on the hypothetical detection rate of renal cancer. Imaging the kidney for low-grade MH in a routine urine analysis discovered at a periodic health examination in an otherwise asymptomatic patient is tantamount to screening without cause, and can be deferred for selected patients. The clinical context is as important as the degree of MH when deciding to image the kidneys.