Erik Kouba

Management of Ureteral Obstruction Due to Advanced Malignancy : Optimizing Therapeutic and Palliative Outcomes

PURPOSE Treatment of ureteral obstruction due to advanced abdominal or pelvic malignancy is a clinical challenge. We discuss improvements and modern day outcomes in the palliative treatment of patients with ureteral obstruction by antegrade or retrograde ureteral decompression. Also, potential areas of clinical investigation involving ureteral stent improvement and pharmacological management of relief of symptoms resulting from ureteral obstruction are discussed. MATERIALS AND METHODS A literature search was performed using the Entrez-PubMed(R) database. All relevant literature on ureteral obstruction, advanced malignancy and nephrostomy, ureteral stent and associated topics concerning palliative care and quality of life were reviewed and analyzed. RESULTS Presenting symptoms are varied and depend on the acuity of the underlying problem. Mechanisms underlying the pain and symptoms of extrinsic ureteral compression have not fully been explored but they may include prostaglandin and renin-angiotensin pathways with medical interventions potentially directed at such therapeutic targets. Progressive obstructive uropathy may likely lead to clinical manifestations, such as uremia, electrolyte imbalances and persistent urinary tract infections, if obstruction is not bypassed. New approaches to antegrade and retrograde stenting, and the evaluation of new stent materials may help minimize the complications and side effects of such procedures. Unfortunately the finding of ureteral obstruction due to malignancy carries a poor prognosis with a resulting median survival of 3 to 7 months. This prognosis highlights the importance of maintaining quality of life in these patients. CONCLUSIONS Patients presenting with symptoms of ureteral obstruction due to advanced malignancy should be informed of the therapeutic options in the context of the poor prognosis. In the meantime research is needed to find methods of urinary diversion and pharmacological intervention for symptomatic relief without compromising quality of life in patients at the end of life.

Incisional Hernia in a 12-mm Non-Bladed Trocar Site following Laparoscopic Nephrectomy

Non-bladed trocars, radially-dilating systems, and conical blunt devices are considered less traumatic to the abdominal wall because they do not incise the fascia itself. Consequently, several authors have suggested that closure of the abdominal fascia may be unnecessary if such non-bladed laparoscopic trocars are used. We report of a case in whom a port-site hernia was diagnosed at the site of a 12-mm non-bladed trocar 11 days after laparoscopic nephrectomy.

Androgen-independent prostate cancer treated with resection of the solitary metastatic site.

The concept of resection of a solitary metastatic lesion is quite foreign in prostate cancer, as metastases to regional lymph nodes or to other distant sites are most likely suggestive of disseminated disease. The current report demonstrates a very unique case, in whom excision of a solitary pulmonary metastasis has resulted in continued undetectable prostate-specific antigen values over 3 years after resection. Nevertheless, the presence of unusual cases such as this, as well as the work of others, may suggest that surgical excision of solitary or oligometastatic sites could at least be considered for the most highly selected and well-informed patients, whose clinical scenario indicates a potential benefit from such an approach.

Clinical use of serum CA-125 levels in patients undergoing radical cystectomy for transitional cell carcinoma of the bladder

PURPOSE It has recently been reported that serum CA-125 levels may serve as a prognostic indicator of extravesical disease in patients with bladder cancer. This study evaluated the role of CA-125 as a prognostic marker in patients with transitional cell carcinoma of the bladder undergoing radical cystectomy and urinary diversion. METHODS Ninety-two consecutive patients underwent planned radical cystectomy and urinary diversion with curative intent (2005-2006). Serum CA-125 levels were obtained in all patients and correlations were made to clinical and operative findings and pathological outcomes. Outcomes were evaluated with regard to normal vs. abnormal CA-125 values and with regard to absolute values of CA-125 levels. Results were also stratified by short-term recurrence rates. RESULTS Mean CA-125 values varied significantly by pathological stage and by resectability. No patient (0/56) with organ-confined disease (<or= pT2N0) had an abnormal CA-125, and only 1 patient (1/75 = 1.3%) with <or= pT3N0 disease had an abnormal value. Conversely, 35% of patients with regionally-advanced disease (pT4 or N+) had an elevated CA-125, and all patients with unresectable disease (5/5) had an elevated value. In addition, patients with abnormal values of CA-125 (i.e., <35 U/ml) had a significantly higher upstaging rate compared to non-upstaged patients (18.8% vs. 3.5%, respectively; P = 0.0233). As well, patients with CA-125 levels <15 U/ml had a significantly higher upstaging rate compared with non-upstaged patients (53.1% vs. 15.8%, respectively; P = 0.0005). At a mean follow-up of 15 months (median = 14 months), patients with T2/T3N0 disease who recurred had a higher mean value than patients with pT2/T3 disease who did not recur (20.1 vs. 10.8 U/ml). CONCLUSIONS Serum CA-125 levels may serve as a useful predictor of pathological outcomes in patients undergoing cystectomy for urothelial carcinoma of the bladder. Further studies will be carried out to determine the predictability of CA-125 on long-term recurrence and survival rates, and to evaluate the utility of CA-125 as a marker for disease response in patients with recurrent or advanced disease undergoing systemic therapy.

The Use of Erythropoietin in Patients Undergoing Radical Prostatectomy: Effects on Hematocrit, Transfusion Rates and Quality of Life

Objective: It was the aim of this study to prospectively study the effects on hematocrit levels, transfusion rates and quality of life (QOL) indices in men preoperatively supplemented with recombinant erythropoietin (rEPO) undergoing radical prostatectomy for clinically localized prostate cancer. Methods: Thirty men undergoing radical prostatectomy were randomized either to receive rEPO (n = 25) or to serve as controls (n = 25). Outcome measurements obtained preoperatively, as well as 10 days and 6 weeks postoperatively included serum hematocrit levels, transfusion rates and QOL indices (using SF-12 validated questionnaires). Results: The rEPO group had a significant increase in preoperative hematocrit (median increase = 4 points; p = 0.002). Although there were no significant differences in hematocrit at 10 days, the rEPO had a significantly higher hematocrit value at 6 weeks (p = 0.0086). No differences were observed in transfusions rates between groups (4% in each group). SF-12 mental and SF-12 physical scores were not different between the two groups at any time point. Conclusion: Preoperative administration of rEPO significantly increases preoperative and postoperative hematocrit levels. However, no differences were observed with regard to transfusion rates or postoperative QOL indices despite these higher hematocrit values.

A prospective evaluation of the short‐term impact and recovery of health‐related quality of life in men undergoing radical prostatectomy

To prospectively evaluate the acute and short‐term effects of radical retropubic prostatectomy (RRP) on health‐related quality of life (HRQoL) using a validated generic HRQoL instrument that measures overall health status, as although there is increasing interest in the HRQoL of patients being treated for prostate cancer, most studies have focused on long‐term outcomes.

Incisional Hernia in a 12-mm Nonbladed Trocar Site Following Laparoscopic Nephrectomy

Non-bladed trocars and radially dilating systems are considered less traumatic to the abdominal wall because they do not incise the fascia itself. Since the fascia is not cut, it has believed that the fascia closes by itself. Consequently, several authors have suggested that closure of the abdominal fascia may be unnecessary when such non-bladed laparoscopic trocars are used. We report of a case in which a port site hernia was diagnosed at the site of a 12 mm non-bladed trocar 11 days after laparoscopic nephrectomy. Although it may be true that in many cases port site closure is unnecessary and does not result in bowel herniation, this case along with a prior report serve as important reminders that port site hernias are possible even in the use of non-bladed or radial dilating systems, and that there exists a number of potential variables that may predispose to herniation and consequently the ability to predict such events in individual patients remains uncertain. As such, we recommend closing 10 mm or larger port sites irrespective of trocar design.