Joseph A. Grocela

Selective bladder conservation using transurethral resection, chemotherapy, and radiation: management and consequences of Ta, T1, and Tis recurrence within the retained bladder.

OBJECTIVES Although radical cystectomy remains the standard of care for invasive bladder cancer in the United States, many groups are exploring the use of trimodality therapy using transurethral resection of the bladder tumor, radiation, and chemotherapy in an attempt to spare patients the need for cystectomy. As transitional cell carcinoma often arises from a urothelial field change, there is concern that the retained bladder is at risk of subsequent superficial (Ta, T1, Tis) tumors, some of which may have lethal potential. This study reports the outcomes of those patients with superficial relapse of transitional cell carcinoma after trimodality therapy. METHODS One hundred ninety patients were treated using a series of trimodality therapy protocols between 1986 and 1998. All patients received induction chemotherapy and radiation and were selected for bladder preservation on the basis of a cytologic and histologic complete response. One hundred twenty-one patients had a complete response and formed the subjects of this study. RESULTS With a median follow-up of 6.7 years for patients still alive, 32 experienced a superficial relapse (26%). The median time to this failure was 2.1 years. Sixty percent of the superficial failures were carcinoma in situ (Tis) and 67% arose at the site of the original invasive tumor. The risk of superficial failure was higher among those who had Tis associated with their original muscle-invasive tumor. Twenty-seven of these 32 cases were managed conservatively with transurethral resection and intravesical therapy. The irradiated bladder tolerated this therapy well and only 3 patients required treatment breaks. The 5 and 8-year survival was comparable for those who experienced superficial failure (68% and 54%, respectively) and those who had no failure at all (n = 74, 69% and 61%, respectively). However, a substantially lower chance of being alive with the native bladder owing to the need for late salvage cystectomies (61% versus 34%) was found. Cystectomy became necessary in 31% (10 of 32) either because of additional superficial recurrence (n = 7) or progression to invasive disease (n = 3). CONCLUSIONS A trimodality approach to transitional cell bladder cancer mandates lifelong cystoscopic surveillance. Although most completely responding patients retain their bladders free from invasive relapse, one quarter will develop superficial disease. This may be managed in the standard fashion with transurethral resection of the bladder tumor and intravesical therapies but carries an additional risk that late cystectomy will be required.

INTRACORPOREAL LITHOTRIPSY: Instrumentation and Development

This article describes the history of intracorporeal lithotripsy and the impact of previous techniques on modern devices. Technical and clinical specifics for several historical and current intracorporeal lithotripsy methods are described.

Corticosteroid use after prostate brachytherapy reduces the risk of acute urinary retention.

To evaluate the role of short‐term steroids after prostate brachytherapy to reduce oedema and thus the risk of urinary retention associated with brachytherapy, as this can require surgical intervention and may even result in incontinence.

Comparison of High-Dose Proton Radiotherapy and Brachytherapy in Localized Prostate Cancer: A Case-Matched Analysis

PURPOSE To report a case-matched analysis comparing high-dose external-beam radiation (EBRT) for prostate cancer delivered on Proton Radiation Oncology Group (PROG) 95-09, a randomized trial, with permanent prostate brachytherapy over the same era. METHODS From 1996 to 1999, 196 patients were accrued to the high-dose arm (79.2 Gray equivalent (GyE) using photons and protons) of PROG 95-09 at the Massachusetts General Hospital and Loma Linda University Medical Center. Entry criteria specified T1-2 and prostate-specific antigen ≤ 15 ng/mL. When Gleason score >7 was excluded, 177 men were left for case matching. At Massachusetts General Hospital, 203 similar patients were treated by a single brachytherapist from 1997 to 2002. Minimum follow-up was 3 years. Case matching, based on T stage, Gleason score, prostate-specific antigen, and age resulted in 141 matches (282 patients). Median follow-up was 8.6 and 7.4 years for EBRT and brachytherapy, respectively. The primary endpoint was biochemical failure (BF). RESULTS Using the Phoenix definition, the 8-year BF rates were 7.7% and 16.1% for EBRT and brachytherapy, respectively (p = 0.42). A stratified analysis was performed by risk group. In the EBRT group, 113 and 28 patients were low and intermediate risk, respectively. In the brachytherapy group, 118 and 23 were. When stratified by risk group, the BF rates were similar by either technique. CONCLUSIONS High-dose EBRT and brachytherapy result in similar BF rates for men with localized prostate cancer. Comparative quality-of-life and cost-effectiveness studies are warranted.

Body Mass Index and Prostate-Specific Antigen Failure Following Brachytherapy for Localized Prostate Cancer

PURPOSE Increasing body mass index (BMI) is associated with prostate-specific antigen (PSA) failure after radical prostatectomy and external beam radiation therapy (EBRT). We investigated whether BMI is associated with PSA failure in men treated with brachytherapy for clinically localized prostate cancer. PATIENTS AND METHODS Retrospective analyses were conducted on 374 patients undergoing brachytherapy for stage T1c-T2cNXM0 prostate cancer from 1996-2001. Forty-nine patients (13%) received supplemental EBRT and 131 (35%) received androgen deprivation therapy (ADT). Height and weight data were available for 353 (94%). Cox regression analyses were performed to evaluate the relationship between BMI and PSA failure (nadir + 2 ng/ml definition). Covariates included age, race, preimplantation PSA, Gleason score, T category, percent of prescription dose to 90% of the prostate, use of supplemental EBRT, and ADT. RESULTS Median age, PSA, and BMI were 66 years (range, 42-80 years), 5.7 ng/ml (range, 0.4-22.6 ng/ml), and 27.1 kg/m(2) (range, 18.2-53.6 kg/m(2)), respectively. After a median follow-up of 6.0 years (range, 3.0-10.2 years), there were 76 PSA recurrences. The BMI was not associated with PSA failure. Six-year PSA failure rates were 30.2% for men with BMI less than 25 kg/m(2), 19.5% for BMI of 25 or greater to less than 30 kg/m(2), and 14.4% for BMI of 30 kg/m(2) or greater (p = 0.19). Results were similar when BMI was analyzed as a continuous variable, using alternative definitions of PSA failure, and excluding patients treated with EBRT and/or ADT. In multivariate analyses, only baseline PSA was significantly associated with shorter time to PSA failure (adjusted hazard ratio, 1.12; 95% confidence interval, 1.05-1.20; p = 0.0006). CONCLUSIONS Unlike after surgery or EBRT, BMI is not associated with PSA failure in men treated with brachytherapy for prostate cancer. This raises the possibility that brachytherapy may be a preferred treatment strategy in obese patients.

New life after prostate brachytherapy? Considering the fertile female partner of the brachytherapy patient.

To examine several cases of unusual and unexpected pregnancy in the female partners of men treated with brachytherapy for cancer of the prostate

UTILITY OF NUCLEAR MATRIX PROTEIN (NMP22) IN THE DETECTION OF RECURRENT BLADDER CANCER

This article examines the Nuclear Matrix Protein (NMP22) urine test for recurrent bladder cancer detection. Studies with NMP22 are compared to cytology for sensitivity and specificity. False positives and false negatives do occur, and consequences of these are discussed. Speculations are made regarding possible future uses of this test.

Prediction of Medicare Drug Formulary Drugs for Treatment of Overactive Bladder

PURPOSE With the establishment and signing into law the Medicare and Prescription Drug Improvement and Modernization Act of 2003, also known as Medicare Part D, medical costs are expected to soar. In fact, the program is expected to cost more than a trillion dollars through 2015. Establishment of the Medicare Part D drug formulary will allow cost containment but still absorb patient and physician preferences as well as a consideration of efficacy and safety data. MATERIALS AND METHODS Potential Medicare formulary choices were examined in the anticholinergic class, as commonly used by urologists, and small in number of available drugs. Formulary selection parties and issues were individually analyzed, including the government in respect to cost containment, patients in relation to efficacy and cost, physicians in relation to preferences and influence and drug companies in relation to lobbying power, country of base of operations and market shares. Costs to Medicare and patients were calculated using discount Internet sites for pricing and simulated using Medicare Part D benefits. RESULTS Generic oxybutynin is likely to be included because it is the least expensive to patients and Medicare, but it has the lowest efficacy. Detrol LA is likely to be the long acting choice due to efficacy, cost and manufacture by a United States based company. CONCLUSIONS A simulation of cost analysis of anticholinergics for treatment of overactive bladder would help urologists better understand the Medicare formulary selection process.

Ammonium transport in the intestine chronically exposed to urine: is it reduced over time?

OBJECTIVES To determine whether chronic exposure of urine to intestinal segments alters ammonium transport and thereby would be expected to reduce the metabolic acidosis of intestinal diversion. METHODS Ileal patch cystoplasty specimens and control-matched ileum segments were harvested from mongrel dogs after 6 months. Acridine orange fluorescence quenching was used to determine the Km, Vmax, and Hill coefficient of ileal patch cystoplasty membrane vesicles and of control-matched ileum membrane vesicles. Enzyme activities for glucose uptake and sodium transport were also determined. RESULTS A shift of the Km and Vmax for ammonium occurred with chronic exposure of the intestine to urine. However, some specific enzyme activities remained unchanged, particularly those of intracellular and basolateral membrane locations. CONCLUSIONS Chronic exposure of the intestine to urine alters transport at the brush border by reducing the number of ports available for ammonium transport. It is less detrimental to intracellular and basolateral membrane enzyme activities.

Top-Vented Urinary Drainage Catheters Cause Fewer Epithelial and Vascular Changes in the Bladder Mucosa Compared to Conventional Catheters and May Reduce Susceptibility to Urinary Tract Infections

Introduction: We performed a prospective, randomized, double-blinded controlled trial to investigate whether use of DOVERTM Urine Collection Systems with top vent (Tyco Healthcare Group L.P. d/b/a Couidien, Marshfield, MA, USA) top-vented urinary catheters cause fewer epithelial and vascular changes in the bladder mucosa than conventional non-vented catheters. Materials and Methods: Women undergoing a mid-urethral sling were randomized to either placement of a non-vented or top-vented catheter. Primary outcome was change in appearance of the bladder mucosa as graded on a 4-point scale (0–3) after a single drainage event. Secondary outcome was change in red and white blood cell counts per high power field between urinalyses collected intraoperatively and after overnight bladder drainage. A paired T-test with Wilcoxon rank sum was used to compare the grade of mucosal change and the change in cell count. Results: Forty-one women were randomized. The mean change in appearance of the bladder mucosa was significantly greater in the conventional drainage catheter group (2.0 ± 0.23 vs. 0.4 ± 0.11, p < 0.0001). There was no significant difference in the mean cell count intervals on urinalyses between the two groups (1.2 ± 0.34 vs. 0.8 ± 0.34, p = 0.08). Conclusions: By avoiding suction on the bladder mucosa, top-vented urinary catheters cause fewer epithelial and vascular changes in the bladder mucosa compared to conventional catheters.