Harry Clarke

Evaluation of staging lymphadenectomy in prostate cancer.

OBJECTIVES To prospectively evaluate a clinical algorithm that predicts nodal status in patients with prostate cancer and to assess the impact on the outcome. METHODS Between September 1988 and December 1994, 192 patients with organ-confined prostate cancer and considered surgical candidates for radical perineal prostatectomy (RPP) were stratified using the algorithm: prostate-specific antigen (PSA) 20 ng/mL or less, Gleason score 7 or lower, and clinical Stage T2a or lower. Patients failing any of these criteria were placed in the high-risk group and underwent a pelvic lymphadenectomy. Patients who satisfied all the criteria were placed in the low-risk group and underwent RPP without evaluation of the pelvic lymph nodes. Another contemporaneous cohort of patients (n = 65) underwent pelvic lymphadenectomy and radical retropubic prostatectomy (RRP) without use of the algorithm and were used as a control group. Patients were monitored for at least 24 months. RESULTS In the RPP group, 177 patients were considered low risk according to the algorithm and were not offered staging lymphadenectomy before surgery, whereas 15 patients were categorized as high risk for metastasis and underwent staging lymphadenectomy. In the RRP and lymphadenectomy group, 41 patients were considered at low risk and 24 at high risk of disease spread according to the algorithm. In the RPP group, low-risk patients (no lymphadenectomy) had a PSA recurrence rate (27%) similar to that of low-risk patients in the RRP group with negative lymph nodes (29%), P = 0.8. Similarly, high-risk patients with negative lymph nodes in both groups had a similar recurrence rate (53% for RPP and 50% for RRP). Univariate logistic regression analysis showed that PSA was the most significant predictor for disease recurrence (P = 0.0004) followed by preoperative Gleason scores (P = 0.02) and clinical stages (P = 0.03). Multivariate stepwise analysis demonstrated that Gleason score and clinical stage did not add to the prediction of recurrence over PSA alone. CONCLUSIONS Staging lymphadenectomy can be omitted in low-risk patients without deleterious effects on the outcome as measured by PSA recurrence.

The Hyponatremia of Neonatal Urinary Ascites: Clinical Observations, Experimental Confirmation and Proposed Mechanism

A case of neonatal urinary ascites with severe hyponatremia is reported. Critical review of the literature on neonatal urinary ascites, which included determination of serum electrolytes, revealed a 70% incidence of hyponatremia. In an attempt to explain the mechanism of the hyponatremia, urinary ascites was produced in rats by creation of either a unilateral (uretero-peritoneal) or bilateral (vesicoperitoneal) shunt. Hyponatremia did not occur in the unilateral group but it was profound in the bilateral group. At 48 hours postoperatively renin was unchanged in the unilateral group but it was significantly elevated in the bilateral group. Aldosterone was elevated in the unilateral group and markedly elevated in the bilateral group. Urine entering the peritoneal cavity equilibrates with plasma. The proposed mechanism of hyponatremia in the bilateral group is autodialysis with intraperitoneal urine containing progressively lower sodium concentration secondary to increased renin and aldosterone.

Recruitment for a clinical trial of drug treatment for benign prostatic hyperplasia

OBJECTIVES To evaluate the effectiveness of various recruitment strategies for a 6-year multicenter clinical trial of medical therapy for benign prostatic hyperplasia, the Medical Therapy of Prostatic Symptoms Trial. METHODS How participants learned about the trial was obtained during initial contact with clinical centers and at the first screening visit. The yield of randomized participants from the initial contact and first screening visit was calculated for each of the recruitment techniques. RESULTS During a period of 28 months, 16,723 potential trial participants made an initial contact with the 17 clinical centers, and 2931 men were randomized. An average of four initial contacts were required for each first screen visit and six per randomized participant. Newspaper (29.9%) and mail (26.7%) were the two leading sources of randomized participants. Medical sources (9.6%), radio (8.8%), and newsletters (8.4%) were also important sources. All clinical centers achieved or exceeded their recruitment goals. CONCLUSIONS Mass mail and newspaper were the most effective recruitment techniques to enlist the interest of men with urinary symptoms for a long-term trial of drug therapy for benign prostatic hyperplasia.

Intravesical suramin in the prevention of transitional cell carcinoma

OBJECTIVES To examine the effects of intravesical suramin on N-methyl-N-nitrosurea (MNU)-induced bladder tumors in Fischer 344 rats. METHODS Multiple cohorts of female rats received four biweekly intravesical instillations of MNU. A control group received no other treatment, the experimental group received 25 mg/kg intravesical suramin twice a week beginning at week 6. RESULTS After 18 weeks from the first instillation of MNU, 60% to 65% of control animals developed papillary transitional cell carcinoma, compared with only 0% to 10% of the suramin-treated animals (P = 0.01 to P = 0.0007). There was no local or systemic toxicity observed. CONCLUSIONS Intravesical suramin is an effective chemopreventative therapy for transitional cell carcinoma in vivo with minimal toxicity.

MP79-07 INDICATIONS FOR NOVEL INTERPOSITION MYOCUTANEOUS FLAP FOR THE REPAIR OF RECTO-URINARY FISTULA

drainage of lesions is ineffective in curing the root cause of the problem, and persistence or worsening is the rule over time. Complete surgical resection followed by local flap or skin graft closure is possible, curative and most often successful, at the cost of a unsurprisingly high number of self limited wound complications. Urologists should endeavor to fix instead of merely manage this difficult problem.