Glenn S. Gerber

Results of Conservative Management of Clinically Localized Prostate Cancer

BACKGROUND The selection of treatment for patients with localized prostate cancer requires reliable information about the outcome of conservative management. Previous studies of this question are generally considered unreliable because they were uncontrolled and nonrandomized. METHODS We performed a pooled analysis of 828 case records from six nonrandomized studies, published since 1985, of men treated conservatively (with observation and delayed hormone therapy but no radical surgery or irradiation) for clinically localized prostate cancer. A Cox regression analysis was performed to determine which factors influenced survival among patients who did not die of causes other than prostate cancer (disease-specific survival). Kaplan-Meier curves for overall and metastasis-free survival among such patients were compared with use of the log-rank method and the Mantel-Haenszel test. RESULTS Factors that had a significant effect on disease-specific survival were grade 3 tumors (risk ratio, 10.04), residence in Israel (risk ratio, 2.48) or New York (risk ratio, 0.37), and age under 61 years (risk ratio, 0.32). Ten years after diagnosis, disease-specific survival (with data on men who died from causes other than prostate cancer censored) was 87 percent for men with grade 1 or 2 tumors and 34 percent for those with grade 3 tumors; metastasis-free survival among men who had not died of other causes was 81 percent for grade 1, 58 percent for grade 2, and 26 percent for grade 3 disease. These findings were not affected by the inclusion of men who had early-stage cancer, were older, had worse-than-average health, or underwent delayed radiation therapy or radical prostatectomy. CONCLUSIONS The strategy of initial conservative management and delayed hormone therapy is a reasonable choice for some men with grade 1 or 2 clinically localized prostate cancer, particularly for those who have an average life expectancy of 10 years or less. New treatment strategies are needed for men with grade 3 prostate cancer.

Effect of preoperative biofeedback/pelvic floor training on continence in men undergoing radical prostatectomy.

OBJECTIVES To determine whether preoperative biofeedback training improves urinary continence overall or the rate of return of continence in men undergoing radical prostatectomy. METHODS One hundred men scheduled to undergo radical prostatectomy were randomized to receive graded pelvic muscle exercise training with biofeedback 2 to 4 weeks before surgery or to a control group performing pelvic muscle exercises without biofeedback. The biofeedback group was instructed to continue exercises four times per day until surgery and to resume exercises when the urethral catheter was removed following surgery. The control group received written and brief verbal instructions in pelvic muscle exercises before surgery and again after catheter removal. Urinary continence was assessed by personal or phone interviews. RESULTS Six months following surgery, the continence rates, as defined by the use of one pad or less per day, were 94% (44 of 47) and 96% (48 of 50) in the biofeedback and control groups, respectively (P = 0.596). Also, the rate of return as determined at time points 1, 2, 3, and 4 months after surgery was not significantly different between the two groups. CONCLUSIONS Preoperative biofeedback training did not improve the outcome of pelvic muscle exercises on overall continence or the rate of return of urinary control in men undergoing radical prostatectomy.

Female Urinary Tract Fistulas

Urinary tract fistulas in women are an uncommon complication of a variety of surgical procedures. However, such fistulas lead to significant patient and physician distress, and have important medicolegal implications. Successful repair of urinary tract fistulas requires careful preoperative evaluation and adherence to basic surgical principles. A variety of approaches and techniques may be used, and the choice of procedure is less important than achieving adequate resection of fibrosis with watertight, tension-free closure of well vascularized tissues in layers. Interposition grafts of omentum, muscle, peritoneum and labial fat may be used in recurrent, complicated or radiated fistulas, and add significantly to the rate of success. Overall, successful repair of urinary tract fistulas can be achieved in the majority of cases.

Transdermal estrogen in the treatment of hot flushes in men with prostate cancer

OBJECTIVES To assess the effectiveness and tolerability of transdermal estrogen in men with hot flushes after hormonal therapy for prostate cancer. METHODS Twelve men with moderate to severe hot flushes were randomized to receive either low-dose (0.05 mg) or high-dose (0.10 mg) estrogen patches applied twice weekly for 4 weeks. After a 4-week washout period in which no treatment was given, each patient received the alternative dose for 4 weeks. Treatment response was assessed by daily logs and questionnaires completed every 4 weeks that included a visual analog assessment. Serum luteinizing hormone, follicle-stimulating hormone, testosterone, and estradiol levels were also measured every 4 weeks during the study. RESULTS There was a significant reduction in the overall severity of the hot flushes seen in patients with both the low and high-dose estrogen patch. A significant reduction in the daily frequency of the hot flushes was seen with the high-dose patch only. Overall, 10 (83%) of 12 men reported either mild, moderate, or major improvement in symptoms with either the low or high-dose patch. Mild, painless breast swelling or nipple tenderness was noted in 2 (17%) and 5 (42%) of 12 men treated with the low and high-dose estrogen patch, respectively. FSH levels decreased significantly with both the low and high-dose patch. Estradiol levels increased from 12.1 to 16.4 pg/mL and 26.9 pg/mL with the low and high-dose patch, respectively. There was no significant change in serum testosterone or luteinizing hormone levels. CONCLUSIONS Transdermal estrogen appears to be a promising, well-tolerated therapy for men with hot flushes after endocrine treatment for prostate cancer. Further study in larger groups of patients is necessary to assess the relative effectiveness and morbidity of this treatment.

Endourological Management of Upper Tract Urothelial Tumors

Advances in ureteroscopic and percutaneous techniques have made it possible to treat many upper tract malignancies by conservative, parenchyma sparing surgery. Percutaneous techniques generally allow for easier and better access to the renal pelvis and improved tumor resection. However, concerns for tumor spillage and nephrostomy tract seeding make the ureteroscopic approach best for initial management of accessible renal pelvic lesions, particularly when the diagnosis is unclear. Ureteral tumors, especially those arising in the lower third of the ureter, are technically easier to treat endoscopically than are renal pelvic tumors. Fulguration or laser photocoagulation may be used to ablate the tumor following cold-cup biopsy for histological diagnosis. Supplemental therapy using laser treatment of the tumor base, and postoperative instillation of BCG and mitomycin C offer great potential benefit in terms of improved tumor control. Confirmation of such benefit awaits the results of larger trials. Presently, standard nephroureterectomy remains the procedure of choice for most transitional cell carcinomas of the upper urinary tract in patients with a normal contralateral kidney. For those with a solitary kidney, renal insufficiency, bilateral tumors or severe intercurrent disease preventing a major open operation conservative management using endoscopic techniques is a viable alternative. Overall, it appears that grade and stage are far more important determinants of long-term out-come than the type of operation in those with transitional cell carcinoma of the upper urinary tract. For this reason, some physicians have recommended conservative management of low grade, noninvasive lesions even in the face of a normal opposite kidney. However, the majority of patients with upper tract urothelial tumors are best treated by nephroureterectomy, which leads to a low risk of local recurrence and obviates the need for rigorous postoperative upper tract surveillance.

Management of acute ureteral obstruction in pregnancy utilizing ultrasound-guided placement of ureteral stents

Of 6,275 pregnancies seen at our institution over a two-year period, 5 patients required operative intervention for acute urinary obstruction unresponsive to medical management. Ultrasonography was able to definitively diagnose the presence of an obstructing calculus in 4 of 5 patients. Using ultrasound guidance, 7 indwelling ureteral stents were successfully placed with local anesthesia supplemented by intravenous sedation. Complications consisted of distal stent migration in 1 patient. This method of management was successful for symptomatic nephrolithiasis in a pregnant renal transplant patient. Endoscopic placement of ureteral stents under ultrasound guidance is an effective, safe method of urinary decompression, with no radiation risks imparted to the mother or fetus. Definitive therapy then can be safely deferred to the post-partum period.

The use of hyperbaric oxygen in urology.

PURPOSE We review the use of hyperbaric oxygen therapy in urology, and present the mechanisms of hyperoxia action in whole body hyperbaric chamber treatments, patient outcomes and patient selection criteria. MATERIALS AND METHODS The literature on hyperbaric oxygen use in urology was reviewed. RESULTS Hyperbaric oxygen is a treatment alternative for patients with an underlying ischemic process unresponsive to conventional therapy. Specific factors which may influence patient selection of hyperbaric oxygen include cancer and absolute contraindications of active viral disease, intercurrent pneumothorax and treatment with doxorubicin or cisplatin. This technique is particularly useful in the treatment of intractable hemorrhagic cystitis secondary to pelvic radiation therapy. Further investigation of the efficacy of hyperbaric oxygen is warranted for patients with necrotizing fasciitis (Fourniers gangrene), posttraumatic ischemic injury and/or impaired wound healing. CONCLUSIONS Hyperbaric oxygen is a therapeutic alternative which complements the surgical and medical options for select patients.

Saw Palmetto (Serenoa repens) in Men with Lower Urinary Tract Symptoms: Effects on Urodynamic Parameters and Voiding Symptoms

OBJECTIVES To assess the effects of saw palmetto on voiding symptoms and urodynamic parameters in men with lower urinary tract symptoms (LUTS) presumed secondary to benign prostatic hyperplasia (BPH). METHODS Fifty men with previously untreated LUTS and a minimum International Prostate Symptom Score (IPSS) of 10 or greater were treated with a commercially available form of saw palmetto (160 mg twice per day) for 6 months. The initial evaluation included measurement of peak urinary flow rate, postvoid residual urine volume, pressure-flow study, and serum prostate-specific antigen (PSA) level. Patients completed an IPSS, serum PSA was determined, and flow rate was measured every 2 months during the course of the study. A urodynamic evaluation was repeated at the completion of the 6-month trial. RESULTS The mean IPSS (+/-SD) improved from 19.5+/-5.5 to 12.5+/-7.0 (P <0.001) among the 46 men who completed the study. Significant improvement in the symptom score was noted after treatment with saw palmetto for 2 months. An improvement in symptom score of 50% or greater after treatment with saw palmetto for 2, 4, and 6 months was noted in 21% (10 of 48), 30% (14 of 47), and 46% (21 of 46) of patients, respectively. There was no significant change in peak urinary flow rate, postvoid residual urine volume, or detrusor pressure at peak flow among patients completing the study. No significant change in mean serum PSA level was noted. CONCLUSIONS Saw palmetto is a well-tolerated agent that may significantly improve lower urinary tract symptoms in men with BPH. However, we were unable to demonstrate any significant improvement in objective measures of bladder outlet obstruction. Placebo-controlled trials of saw palmetto are needed to evaluate the true effectiveness of this compound.

Pharmacological Erection Program Using Prostaglandin E1

A total of 72 impotent patients entered into a pharmacological erection program using prostaglandin E1. Of the men 35 (49%) used prostaglandin E1 on a regular basis, while 37 (51%) failed to continue in the program beyond the in-office dose titration period. In patients who continue to use prostaglandin E1 the median duration of drug use is 7 months, with a range of 2 to 28 months. There have been no instances of cavernous fibrosis, systemic reaction or chemical priapism (erection present longer than 4 hours) in any patient. Only 8 men (11%) were unable to achieve an adequate erection with prostaglandin E1 injections. The most common adverse effect of prostaglandin E1 was penile pain after injection. The incidence of severe pain leading to drug discontinuation was 17% (12 of 72 patients) while mild to moderate pain occurred in 22% (16 of 72). Over-all, intracavernous prostaglandin E1 injections appear to be a safe, effective treatment for impotence in most men.

ENDOSCOPIC MANAGEMENT OF URETERAL STRICTURES

PURPOSE We investigated and defined the role of endourological methods in the treatment of patients with ureteral stricture. MATERIALS AND METHODS A literature search was performed of the MEDLINE data base from 1978 through August 1996 concerning endoscopic treatment of patients with ureteral strictures. Additional articles from before 1978 were also selectively included. RESULTS Many endourological methods are available to treat patients with ureteral strictures. Ureteral dilation via an antegrade or retrograde approach may be accomplished in most cases with varying rates of success depending on stricture etiology, location and length. Endoscopic ureterotomy may also lead to long-term patency in select cases and appears to be superior to dilation alone in patients with anastomotic ureteral strictures. However, no randomized studies comparing endourological methods in the treatment of ureteral stricture disease were found. CONCLUSIONS Significant advances in technique and technology have led to an improved ability to treat ureteral strictures without the need for open surgery in many patients.