Lloyd H. Harrison

SERUM PROSTATE SPECIFIC ANTIGEN IS A STRONG PREDICTOR OF FUTURE PROSTATE GROWTH IN MEN WITH BENIGN PROSTATIC HYPERPLASIA

PURPOSE We analyze patterns of prostate growth in men diagnosed with benign prostatic hyperplasia (BPH) and treated with placebo during 4 years, and determine which baseline parameters were the strongest predictors of growth. MATERIALS AND METHODS A total of 3,040 men were enrolled in the 4-year randomized, placebo controlled Proscar Long-Term Efficacy and Safety study. Of these men a subgroup of 10% underwent pelvic magnetic resonance imaging prostate volume measurement at baseline and yearly thereafter. Absolute and percent volume changes during 4 years were calculated in the 164 placebo treated men in the subgroup. The ability of age, baseline prostate volume and prostate specific antigen (PSA) to predict prostate growth in placebo treated patients was assessed by multiple linear regression analyses, receiver operator characteristics curves, and evaluations of growth stratified by tertiles of baseline serum PSA and decades of life. RESULTS In placebo treated patients a steady increase in mean plus or minus standard deviation prostate volume from year to year was noted (2.5+/-6.1, 4.9+/-6.8, 6.4+/-8.5 and 7.2+/-8.8 ml. at years 1, 2, 3 and 4, respectively). Mean volume changes at 4 years ranged from -9 to +30 ml. Mean percent change from baseline ranged from 12.5% to 16.6% for men 50 to 59 years old to those 70 to 79 years old. Baseline serum PSA was a strong predictor of growth with 7.4% to 22.0% change at 4 years from the lowest to highest PSA tertiles. Annualized growth rates from baseline were 0.7 ml. per year for PSA 0.2 to 1.3, 2.1 for PSA 1.4 to 3.2 and 3.3 for PSA 3.3 to 9.9 ng./ml. Multiple linear regression analysis showed that serum PSA was a stronger predictor of prostate growth than age or baseline prostate volume. All but 1 man with baseline serum PSA greater than 2.0 ng./ml. had prostate growth during 4 years, and 32.6% of men with serum PSA less than 2.0 exhibited a decrease in volume. CONCLUSIONS Serum PSA is a stronger predictor of growth of the prostate in placebo treated patients than age or baseline prostate volume. Since prostate volume is a risk factor for acute urinary retention and the need for BPH related surgery, the ability of PSA to predict prostate growth may be an important factor when considering individual treatment options for BPH. Such use of PSA represents a shift in paradigm away from focusing solely on symptoms of BPH toward a more comprehensive approach with consideration of predicting and preventing risk factors of BPH related outcomes.

The role of open stone surgery since extracorporeal shock wave lithotripsy

Of 893 stone procedures 37 (4.1 per cent) performed during the first 19 months after extracorporeal shock wave lithotripsy was instituted at our medical center were open operations. Procedures included ureterolithotomy in 23 patients (with simultaneous pyelolithotomy in 1), anatrophic nephrolithotomy in 8, pyelolithotomy in 3 (with concomitant pyeloplasty in 2), partial nephrectomy in 2 and nephrolithotomy with a bowel segment inlay in 1. The most common reasons for electing an open operation were unsuccessful endoscopic stone manipulation, presence of anatomical obstruction in the intrarenal collecting system or ureter, morbid obesity and underlying medical problems precluding lengthy repeated endourological procedures. Over-all surgical results were excellent. Our study indicates that patients who presently require an open stone operation have complex calculous disease associated with a variety of anatomical and physiological problems. Despite this finding good results may be attained.

Primary renal lymphoma: does it exist?

Although secondary renal involvement from systemic lymphoma is common, primary lymphoma of the kidney is not well recognized. One case is reported and 27 cases purported to be primary tumors are reviewed. From these cases three conclusions have been drawn: (1) it is reasonable to assume that renal lymphoma can be a primary lesion; (2) almost all patients with primary renal lymphoma will develop extrarenal lymphomatous disease shortly after diagnosis of their renal tumor; and (3) survival for more than 1 year after diagnosis is rare.

Extracorporeal shock wave lithotripsy in childhood

Extracorporeal shock wave lithotripsy is the treatment of choice for the majority of upper urinary calculi in adults. Technical limitations, including patient size and concerns over post-treatment stone fragment passage, have made the application of extracorporeal shock wave lithotripsy in children less clearly defined. We report the successful application of the Dornier lithotriptor in the management of 18 children (22 kidneys) with upper urinary calculi.

Selective Elevation of Urinary Enzyme Levels after Extracorporeal Shock Wave Lithotripsy

Urinary enzyme testing has been used by many investigators to diagnose and monitor various types of renal injury. Three urinary enzymes, N-acetyl-beta-glucosaminidase, beta-galactosidase and gamma-glutamyl transferase were monitored in 17 patients before and after a single, unilateral extracorporeal shock wave lithotripsy treatment. Stones were in the renal pelvis or calices except for 1 treated in situ in the proximal ureter. Urine specimens were collected before extracorporeal shock wave lithotripsy and at 1, 3, 5, 7, 10, 14, 21 and 28 days after treatment. N-acetyl-beta-glucosaminidase and beta-galactosidase levels increased significantly after treatment (p less than 0.05). Gamma-glutamyl transferase levels increased after treatment but this was not statistically significant. All enzyme levels were highest on days 1 and 3 after lithotripsy and returned to baseline by day 28. Factors associated with post-treatment enzyme elevation included female sex, a lower pre-treatment creatinine clearance and stone size greater than 1 cm. These findings indicate that there is a transient selective increase in urinary enzyme excretion after extracorporeal shock wave lithotripsy.

A Comparison of Anatrophic Nephrolithotomy and Percutaneous Nephrolithotomy with and without Extracorporeal Shock Wave Lithotripsy for Management of Patients with Staghorn Calculi

A retrospective study was conducted comparing anatrophic nephrolithotomy (10 cases), percutaneous nephrolithotomy alone (4 cases) or percutaneous nephrolithotomy combined with extracorporeal shock wave lithotripsy (23 cases) for the treatment of large staghorn calculi. A comparison based on collecting system anatomy demonstrated that anatrophic nephrolithotomy resulted in a greater stone-free rate, shorter hospitalization and lower costs while complication rates were similar. Anatrophic nephrolithotomy should still be considered a viable treatment option, especially for patients with large branched calculi in complex collecting systems.

Intraoperative Renal Ultrasonography: A Useful Adjunct to Partial Nephrectomy

Several evolutionary changes in ultrasonographic instrumentation, including miniaturization of transducers and marked improvement in resolution, have made intraoperative renal ultrasonography a valuable adjunct for intrarenal surgery. We investigated its use in 6 patients undergoing partial nephrectomy for treatment of renal cell carcinoma. In addition, 14 kidneys with renal tumors were scanned immediately after radical nephrectomy and the specimens were subjected to simulated partial nephrectomy. Transverse and longitudinal real-time sonographic images were obtained with a 5 MHz. sector scanner or a 7.5 MHz. convex array transducer. With ultrasonography to define tumor extent and location, negative surgical margins were obtained in all 6 individuals undergoing partial nephrectomy. A negative surgical margin was obtained in 13 of the 14 radical nephrectomy specimens subjected to simulated partial nephrectomy. A small satellite lesion was not identified and not resected in 1 of the radical nephrectomy specimens. We found that intraoperative renal ultrasonography helps to identify the location and extent of deep intraparenchymal lesions. It also provides a guide for a more accurate nephrotomy, which facilitates the attainment of negative resection margins during partial nephrectomy.

Percutaneous Management of Localized Emphysematous Pyelonephritis

The authors report a case of emphysematous pyelonephritis that was successfully treated with radiologically guided percutaneous drainage. This case illustrates that in certain patients with focal abnormalities, functioning renal tissue can be salvaged and emphysematous pyelonephritis can be eradicated with a combination of antibiotics and radiologically guided percutaneous drainage.

Neoadjuvant Treatment of Stages T2 to T4 Bladder Cancer with Cis-Platinum, Cyclophosphamide and Doxorubicin

In an ongoing phase II study 17 patients with potentially operable transitional cell carcinoma of the bladder (stages T2 to T4, Nx, Mo) have been treated with intravenous cis-platinum (50 mg.per m.2), cyclophosphamide (400 mg.per m.2) and doxorubicin (40 mg.per m.2). They were to receive 3 treatments at 3-week intervals before cystectomy and 2 treatments at 3-week intervals commencing 5 weeks after cystectomy. Of 17 patients 14 (82 per cent) completed all 3 preoperative treatments but only 7 (41 per cent) continued on to complete the entire 5 treatments. In most cases incomplete therapy was due to patient refusal. Toxicity was low as measured by World Health Organization standards. Of the 17 patients 9 (53 per cent) exhibited objective tumor response (pathological downstaging or greater than 50 per cent reduction of tumor volume determined by either computerized tomography scan and/or endoscopic examination. When the determination was made by endoscopy the changes were dramatic and not borderline.) No patient demonstrated a pathological complete response. All 9 of the responders (100 per cent) remain clinically free of disease at a median follow-up of 19 months (range 4 to 30 months). The 8 nonresponders have done poorly with 5 dead of disease, 1 alive with pelvic recurrence and 2 free of disease at 4 and 12 months. These tumor response rates compare favorably with other cis-platinum-based combination regimens. The response to the chemotherapy appears to be an important prognostic indicator. Phase III trials must be conducted to determine whether this neoadjuvant chemotherapy regimen has a significant effect on long-term patient survival.

Recurrent Urolithiasis following Anatrophic Nephrolithotomy

Analysis of 18 patients who suffered recurrent urolithiasis after anatrophic nephrolithotomy is presented. These patients form a subgroup of 80 patients who underwent 100 consecutive extensive anatrophic nephrolithotomies between 1967 and 1972. Careful documentation of the 18 patients who had recurrent calculi was done in an effort to delineate the causative factors. The recurrence interval varied from less than 6 months to more than 8 years during an over-all followup period of 9.94 years. Marked differences in the characteristics between 14 male and 4 female patients were noted. In the male patients a significant relationship among recurrent staghorn calculi, anomalous urinary drainage and Pseudomonas urinary tract infections was noted. The female patients had recurrent or persistent urinary tract infections or undiagnosed metabolic problems as the primary reason for the recurrent urolithiasis.