Joseph W. Basler

Return of erections and urinary continence following nerve sparing radical retropubic prostatectomy

We evaluated recovery of erections and urinary continence following anatomical radical retropubic prostatectomy in a series of 784 consecutive patients with clinical stage A or B prostate cancer. Nerve sparing radical prostatectomy was performed in men deemed appropriate candidates. Recovery of erections sufficient for intercourse and urinary continence were analyzed controlling for patient age, pathological tumor stage and the performance of unilateral or bilateral nerve sparing surgery in men followed for a minimum of 18 months. Erections were regained in 149 of 236 preoperatively potent men (63%) treated with bilateral and 24 of 59 (41%) treated with unilateral nerve sparing surgery. Recovery of erections correlated with patient age and pathological tumor stage in patients treated with bilateral nerve sparing surgery. Continence was regained in 409 of 435 patients (94%) and did not correlate with patient age, tumor stage or nerve sparing surgery. Anatomical radical retropubic prostatectomy can be performed with favorable results in preserving potency and urinary continence. Better results are achieved in younger men with organ confined cancer.

The association of body mass index and prostate-specific antigen in a population-based study

Recent studies of men with prostate carcinoma suggest that obesity may be associated with more advanced‐stage disease and lower overall survival rates. One possible link between body mass index (BMI) and prostate carcinoma prognosis may be disease ascertainment. Prostate‐specific antigen (PSA) is widely used to screen for prostate carcinoma.

RENAL MEDULLARY CARCINOMA

PURPOSE Renal medullary carcinoma is a rare and extremely aggressive neoplasm that almost always develops in young patients with sickle cell trait. To our knowledge all cases to date have been metastatic at surgical resection. Pathological examination reveals an aggressive tumor mainly involving the renal medulla with a varied morphology. The prognosis is dismal. Mean survival from the time of resection is 15 weeks (range 2 to 52). The disease course has not been altered by surgery, radiotherapy or various regimens of chemotherapeutic agents. MATERIALS AND METHODS We add to the literature our experience treating renal medullary carcinoma in 2 cases and review the existing literature on this disease. RESULTS Both patients whom we treated died of the disease, as have the other 35 patients described in the literature. CONCLUSIONS A high index of suspicion may lead to earlier diagnosis and treatment, and survival of patients with renal medullary carcinoma.

Biological Variation of Total, Free and Percent Free Serum Prostate Specific Antigen Levels in Screening Volunteers

PURPOSE We determined the biological variation of the total, free and percent free serum prostate specific antigen (PSA) in men 50 years old or older. MATERIALS AND METHODS Between July 1995 and February 1996 we studied 84 healthy men from our PSA screening study to determine biological variation by calculating the coefficients of variation of 3 PSA measurements on blood samples drawn from each subject 2 weeks apart. RESULTS The mean coefficients of variation for total, free and percent free serum PSA were 15, 17 and 14%, respectively. Age, total PSA and ejaculation were not confounding factors in this analysis (that is multivariate R2 less than 5% for all indexes). CONCLUSIONS There is a mean variation of approximately 15% in measurements of total, free and percent free PSA that does not appear to be significantly affected by age and total PSA level.

Impact of Previous Local Treatment for Prostate Cancer on Subsequent Metastatic Disease

PURPOSE Metastatic prostate cancer, which is the precursor of most deaths from the disease, is treated most commonly with hormonal therapy. Generally the primary tumor is never treated. Due to evidence that controlling other primary neoplasms affects patient survival we examined the impact of radical prostatectomy and radiotherapy on the outcome in patients with metastatic prostate cancer in the context of a randomized clinical trial. MATERIALS AND METHODS Southwest Oncology Group Study 8894 randomized 1,286 men with metastatic prostate cancer to orchiectomy and placebo or orchiectomy and flutamide. We performed proportional hazards analysis of variables previously identified to have a significant impact on survival. In this analysis we determined the impact of previous radical prostatectomy or radiotherapy on survival. RESULTS Previous radical prostatectomy in patients with metastatic prostate cancer was associated with a statistically significant decrease in the risk of death (hazard ratio 0.77, 95% confidence interval 0.53 to 0.89) relative to those who did not undergo earlier prostatectomy. Conversely previous radiotherapy was associated with a greater risk of death in those who had previously undergone prostatectomy and those who received no definitive earlier therapy. CONCLUSIONS It must be stressed that this intriguing observation was a secondary analysis of a phase III study. Nevertheless, it raises the question of whether control of the primary tumor impacts the ultimate outcome in patients with advanced prostate cancer. The suggestion of the role of radical prostatectomy in locally advanced prostate cancer, the now established role of extirpative therapy for renal cell carcinoma and the suggestion of this phenomenon in ovarian carcinoma should prompt further evaluation of this finding in other data sets. It may provide new opportunities for clinical trials.

Effect of Digital Rectal Examination and Needle Biopsy on Serum Total and Percentage of Free Prostate Specific Antigen Levels

PURPOSE We determined the effect of digital rectal examination and prostatic biopsy on serum total and free prostate specific antigen (PSA) concentrations in men undergoing screening for prostate cancer. MATERIALS AND METHODS In 93 men recruited from our PSA screening program we measured the serum concentrations of total and free PSA on 3 occasions during a 30-day interval before performing digital rectal examination. Total and free PSA measurements were repeated 1 and 24 hours after the rectal examination. Serum total and free PSA also was measured immediately before, and 1 hour, 24 hours and 1 week after prostatic biopsy in 30 men. RESULTS Biological variation for total and free PSA was 14.7 and 14.0%, respectively. At 1 hour after rectal examination total and free PSA increased by more than the biological variation in 31 and 48% of the men, respectively. Increases were significantly greater in men whose initial PSA concentrations were less than 4.0 ng./ml. There was a dramatic increase in total and percentage of free PSA in all men 1 hour after prostatic biopsy. Increases in percentage of free PSA were greater in men whose biopsies revealed cancer. Total PSA remained elevated for at least 1 week in most men, while percentage of free PSA returned to within or less than the biological variation of the baseline level in 90% of the men by 24 hours. CONCLUSIONS Digital rectal examination causes a modest increase in total and percentage of free PSA. Prostate needle biopsy causes more dramatic increases in both forms of PSA. Free PSA is preferentially released into the serum after prostatic manipulation and appears to be cleared more rapidly than complexed PSA. The differential return of the different PSA forms to baseline levels after biopsy could affect the use of measurements of the percentage of free PSA in clinical practice.

Flexible, Actively Deflectable Fiberoptic Ureteronephroscopy

We performed 76 flexible, actively deflectable ureteronephroscopic procedures in 68 patients. Of the patients 61 were examined transurethrally, 3 via an ileal loop, 2 percutaneously and 2 via ureterostomy. Indications for flexible, actively deflectable ureteronephroscopy included urolithiasis in 28 patients, upper tract filling defect in 25, lateralizing hematuria in 8, retrograde endopyelotomy in 2, post-endopyelotomy evaluation in 6, surveillance for transitional cell carcinoma in 4 and other reasons in 3. The area of interest was accessed successfully in 96% of the patients. In 57 instances an attempt was made to inspect all calices and was successful in two-thirds of the patients. However, greater than 75% of the collecting system was accessed in all but 2 of these 57 patients. Over-all, diagnostic and/or therapeutic maneuvers were successful in 84% of the patients. Flexible, actively deflectable ureteronephroscopy provides the urologist with a minimally invasive means to evaluate and treat pathological conditions of the upper urinary tract.

Current status of lymph node-positive prostate cancer: Incidence and predictors of outcome.

In early surgical series, the incidence of positive lymph nodes in patients with prostate cancer was approximately 40%. In the modern era of screening and improved patient selection, the incidence is now <10%, although most series excluded patients with higher risk disease. The risk of having positive lymph nodes is influenced by disease stage, prostate‐specific antigen level, and tumor grade and by the aggressiveness of lymph node dissection. Many of the same factors predict the outcome of these patients. Although the percentage of patients with positive lymph nodes has declined, there remain significant numbers of patients with lymph node‐positive prostate cancer, and it remains a therapeutic dilemma. Cancer 2006.

Selenium Accumulation in Prostate Tissue During a Randomized, Controlled Short-term Trial of l-Selenomethionine: a Southwest Oncology Group Study

Purpose: Epidemiologic and clinical data suggest that selenium could prevent prostate cancer, but it has not been shown that supplemental selenium leads to an increased concentration of selenium in prostate tissue compared with adjacent tissue. Experimental Design: We conducted a randomized, controlled, short-term trial of l-selenomethionine (SeMet) versus observation in men with organ-confined prostate cancer. The primary endpoint was the measurement of selenium concentration in prostate tissue and seminal vesicle (SV). We assessed baseline selenium levels in serum and in toenail specimens (reflecting long-term intake) and post-intervention selenium levels in serum, and in prostate and SV tissues using hydride generation atomic fluorescence spectroscopy. Results: Sixty-six eligible patients were randomly assigned to the SeMet (n = 34) or observation (n = 32) arm; both arms had similar baseline patient characteristics. Baseline serum selenium was similar in the two groups (P = 0.64). Baseline toenail selenium levels were slightly higher in the SeMet group than in the control group (P = 0.07). After the intervention, the mean serum selenium level increased 15% in the SeMet arm and was higher than in the observation arm (P = 0.001). The selenium concentration in prostate tissue was 22% higher in the SeMet arm (n = 26) than in the observation arm (n = 25; 1.80 versus 1.47 ppm; P = 0.003, Wilcoxon rank sum test) and remained significantly higher after adjusting for chronic selenium intake (P = 0.021, ANCOVA). SV selenium concentration was similar in both groups (P = 0.384) and was lower than in prostate tissue. Conclusions: The present study is the first to show that selenium taken as oral supplementation accumulates preferentially in the human prostate gland as opposed to the SV. These findings support the hypothesis that oral selenium supplementation may contribute to the cancer preventive effects of selenium.

Alvimopan for prevention of postoperative paralytic ileus in radical cystectomy patients: a cost‐effectiveness analysis

No cost‐effectiveness studies exist in patients after radical cystectomy for the routine use of alvimopan for the prevention of postoperative ileus. The present study provides a reasonable estimate of the cost‐effectiveness of alvimopan for the prevention of postoperative ileus in the patient after radical cystectomy.