Paul Ray

Levofloxacin versus ciprofloxacin in the treatment of chronic bacterial prostatitis: a randomized double-blind multicenter study

OBJECTIVESnTo compare the safety and efficacy of levofloxacin with that of ciprofloxacin for the treatment of chronic bacterial prostatitis.nnnMETHODSnIn a multicenter, double-blind, active-control trial, 377 men with a history of chronic bacterial prostatitis, current clinical signs and symptoms, and laboratory evidence of prostatitis were randomized to treatment with levofloxacin 500 mg once daily or ciprofloxacin 500 mg twice daily for 28 days. The primary endpoint was microbiologic efficacy in the microbiologically assessable population. The Meares-Stamey four-glass procedure was used to obtain prostatic secretions and urine for culture.nnnRESULTSnA total of 377 subjects received the study drug. The clinical success rates, including cured plus improved patients, were similar (75% for levofloxacin and 72.8% for ciprofloxacin; 95% confidence interval for the difference in the success rates: -13.27 to 8.87), as were the microbiologic eradication rates (75% for levofloxacin and 76.8% for ciprofloxacin; 95% confidence interval for the difference -8.98 to 12.58). Enterococcus faecalis and Escherichia coli were the most common isolates. The 6-month relapse rates were similar for both regimens. Both levofloxacin and ciprofloxacin were well tolerated, with similar rates of adverse events.nnnCONCLUSIONSnLevofloxacin 500 mg once daily for 28 days is as effective as ciprofloxacin 500 mg twice daily for 28 days for the treatment of chronic bacterial prostatitis. Isolation of a high proportion of gram-positive organisms, as well as gram-negative pathogens, underscores the necessity of choosing an antimicrobial agent with broad-spectrum activity.

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

OBJECTIVESnTo assess the effectiveness and tolerability of transdermal estrogen in men with hot flushes after hormonal therapy for prostate cancer.nnnMETHODSnTwelve 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.nnnRESULTSnThere 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.nnnCONCLUSIONSnTransdermal 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.

Effect of dutasteride on intraprostatic androgen levels in men with benign prostatic hyperplasia or prostate cancer

OBJECTIVESnDutasteride exerts its beneficial effects on the prostate through suppression of intraprostatic dihydrotestosterone (DHT). The aim of this analysis was to assess the effects of the approved dose of dutasteride (0.5 mg/d), given for 2 weeks to 4 months, on the serum and intraprostatic DHT and testosterone levels in 3 randomized studies.nnnMETHODSnIntraprostatic androgen levels were measured in benign prostatic tissue collected during transurethral resection of the prostate (benign prostatic hyperplasia studies, n = 256) or radical prostatectomy (prostate cancer study, n = 51), performed after 2 weeks, or 1, 3, or 4 months of treatment with dutasteride or with placebo or surgery alone. The serum androgen levels were assessed at the same points during treatment. Data from the control groups were pooled to provide 1 comparison group.nnnRESULTSnDutasteride reduced the intraprostatic DHT levels by 83%, 90%, 92%, and 93% after 2 weeks and 1, 3, and 4 months of treatment, respectively, compared with placebo/surgery alone. Dutasteride reduced the serum DHT levels from baseline by 84% at 2 weeks and by approximately 90% at 1, 2, 3, and 4 months compared with a 5.2% increase in the control group. The decrease in DHT levels with dutasteride was accompanied by a reciprocal increase in the serum and intraprostatic testosterone levels. However, the intraprostatic testosterone levels in the dutasteride groups generally remained lower than the intraprostatic DHT levels in the control group.nnnCONCLUSIONSnThe results of our study have shown that dutasteride provides near-maximal suppression of both serum and intraprostatic DHT levels in men with benign prostatic hyperplasia or prostate cancer at all points assessed.

The potential for normal tissue dose reduction with neoadjuvant hormonal therapy in conformal treatment planning for stage C prostate cancer

PURPOSEnPreirradiation hormonal cytoreduction of prostate cancer has been proven to reduce exposure of normal structures by decreasing the size of the target volume. Dose-volume histogram (DVH) analysis, however, does not always appear to demonstrate a strong positive benefit with the use of neoadjuvant hormone therapy. This study analyzes various other factors influencing dose to normal organs, which may determine the success or failure of neoadjuvant hormonal therapy in achieving its goals.nnnMETHODS AND MATERIALSnPatients with bulky clinical Stage C adenocarcinoma of the prostate were given 3 months of hormone treatment consisting of oral Flutamide and monthly Zoladex injections prior to irradiation. Computerized tomography (CT) scans of the pelvis were obtained both prior to and following hormonal treatment. Treatment plans were generated by three-dimensional (3D) conformal treatment planning. The change in the volume of the prostate was assessed along with the percentage of prescribed dose delivered to the rectum and bladder. Various factors such as prostate size, bladder/rectum size, and organ shape were studied. Both dose-volume histograms (DVH) and dose-surface area histograms (DSH) were used for analysis.nnnRESULTSnSix of seven patients had reduction in the size of their prostates. The mean volumes of the prostate before and after hormonal manipulation were 129.1 +/- 32.9 standard deviation (SD) cm3 and 73.0 +/- 29.5 SD cm3, respectively (p = 0.0059). The volume of rectum receiving 80% of the prescribed dose was reduced in five of seven patients from a mean of 83.2 to 59.9 cm3 (p = 0.045). The volume of bladder receiving 80% of the prescribed dose was also reduced in five out of seven patients from a mean of 74.5 to 40.2 cm3 (p = 0.098). Correlation between the size of the prostate and volume of rectum and bladder treated was not always consistent: greater reduction in prostate size did not necessarily result in large decreases in dose to bladder or rectum. The total size of the bladder and rectum were found to be important factors in normal tissue radiation exposure; the benefits of hormone therapy may be lost if the bladder and rectum are allowed to decrease in size. Also, the bladder may be prone to sagging into the pelvis of some patients following hormone therapy, resulting in a less optimal therapeutic ratio.nnnCONCLUSIONnReduction in prostate size by neoadjuvant hormonal manipulation does decrease the amount of normal tissue irradiated in most patients. However, the correlation between the reduction in prostate size and amount of rectum or bladder treated is not linear if other variables are not controlled. Factors such as the shape of the organs, as well as the distensible nature of the bladder and rectum, play major roles in dose to normal tissues. These facts may mask the benefits of cytoreduction and could be obstacles in realizing consistent benefits from preirradiation hormonal treatment in the clinical setting if they are ignored.

Self-assessed health-related quality of life in men being treated for prostate cancer with radiotherapy: instrument validation and its relation to patient-assessed bother of symptoms

OBJECTIVESnTo develop a psychometrically valid and clinically useful questionnaire to assess health-related quality of life (HRQOL) in patients with prostate cancer (PCa) undergoing external beam radiotherapy. The most important factors in three dimensions (bowel function [BF], urinary function [UF], and sexual function [SF]) were identified by patient survey.nnnMETHODSnThree HRQOL dimensions were assessed using Likert-type questions. Responses were analyzed by factor analysis to create HRQOL scales. Reliability and validity of the scales were assessed. Because patients can suffer symptoms yet not report their lives to be affected, the scales were compared with patient-reported bother.nnnRESULTSnTwo scales were identified within each dimension: BF, urgency and daily living; UF, urgency and weakness of stream; and SF, interest/satisfaction and impotence. Cronbachs alpha for the scales ranged from 0.63 to 0.94, and item-scale correlations and item-scale divergence correlations supported scale validity. Rising median scores correlated with rising levels of perceived bother.nnnCONCLUSIONSnThe questionnaire is a suitable tool for assessing HRQOL in three distinct dimensions for patients undergoing radiotherapy for PCa. Six dimensions of HRQOL were found to be related to bother, suggesting important relationships to be monitored for patients. Urgency of bowel movements, urgency of urination, and level of interest/satisfaction in sex correlated most strongly with bother.

Comparison of serum prostate-specific antigen levels and PSA density in african-american, white, and hispanic men without prostate cancer

OBJECTIVESnTo determine the influence of race or ethnicity on serum prostate-specific antigen (PSA) levels and PSA density (PSAD) in a population of healthy men without clinically evident prostate cancer.nnnMETHODSnThis retrospective study was conducted between January 1988 and January 1993. The serum PSA levels were measured in 859 men (586 African Americans, 142 whites, and 131 Hispanics) who were participants in a prostate cancer screening program or had urinary symptoms suggestive of prostate gland pathology. All men underwent a detailed clinical examination, including digital rectal examination, serum PSA determination, and transrectal ultrasound (TRUS). None of the subjects included had clinical or TRUS evidence of prostate cancer (furthermore, 283 men were pathologically proved to be cancer-free by prostate biopsies). Serum PSA levels and PSA densities as a function of each individuals ethnic background were determined.nnnRESULTSnThe mean serum PSA level in African Americans was 2.1 ng/mL, which was significantly higher than that of whites (mean PSA of 1.53 ng/mL) and Hispanics (mean PSA of 1.83 ng/mL) (P = 0.003). Similar differences among the three groups were observed in PSA density (the mean PSAD was 0.078, 0.057, and 0.065 for African Americans, whites, and Hispanics, respectively). A separate analysis for the biopsy-negative men was performed, and the findings were consistent with the observations for the entire study group. After adjustment for age and prostate volume, the differences remained statistically significant.nnnCONCLUSIONSnAmong men without evidence of prostate cancer, African Americans have higher serum PSA levels and PSA densities than do whites or Hispanics. Race or ethnicity was an independent factor that affected serum PSA levels even after adjustment for age and prostate volume.

Persistent müllerian duct syndrome in a man with transverse testicular ectopia.

A 33-year-old Pakistani man with transverse testicular ectopia underwent surgery for repair of a left inguinal hernia. At operation a uterine structure with attached vasa deferentia was found in the left inguinal area and it was removed. Transverse testicular ectopia has been reported previously in association with the persistent müllerian duct syndrome. A deficiency of activity of a müllerian inhibiting substance during gestation is believed to be responsible for this syndrome. Most patients usually are sterile. Cloning of the gene for a müllerian inhibiting substance should permit studies of the pathogenesis of the persistent müllerian duct syndrome.

Racial differences in prostate-specific antigen levels and prostate-specific antigen densities in patients with prostate cancer.

To compare serum prostate-specific antigen (PSA) levels and PSA density (PSAD) among African American (AA), white, and Hispanic men with prostate cancer (PC) seen in an urban, equal-access urology clinic. Between January 1988 and January 1993, 1,105 men were screened for PC at Cook County Hospital in Chicago, Illinois. A total of 529 men underwent transrectal ultrasound-guided prostate gland biopsies for abnormal digital rectal examination, suspect transrectal ultrasound, elevated PSA, or any combination of these abnormalities. PC was found in 246 patients (204 AAs, 22 whites, and 20 Hispanics). We analyzed the differences in PSA and PSAD among the three racial groups using univariate and multivariate analyses adjusting for race, age, clinical stage, and grade. AAs have a higher mean serum PSA levels (21.56 ng/ml) than whites (mean PSA of 10.96 ng/ml) and Hispanics (mean PSA of 8.25 ng/ml) (p = 0.04). The mean PSAD also was higher in AAs than in the other two groups (0.68 versus 0.34 for whites and 0.31 for Hispanics, p = 0.05). On a multivariate analysis, the PC stage and grade were overwhelmingly significant, whereas the race and age lost their statistical significance. AAs have higher serum PSA and PSAD than whites or Hispanics in an equal-access healthcare environment. Race is a significant factor in determining PSA and PSAD on univariate but not on multivariate analysis. Preliminary studies suggest that these differences are due to sociological, not biologic causes. These findings warrant a large, prospective study to investigate the extent and the causes of the racial differences in PSA and PSAD.

Early experience with walsh technique of radical retropubic prostatectomy

We analyzed the operative experience and postoperative and late complications of pelvic lymphadenectomy and radical retropubic prostatectomy in 27 consecutive cases in which the modifications of prostatectomy described by Walsh were employed, and compared the results with those of 29 cases performed in the preceding three years when the Campbell technique of prostatectomy was employed. The mean operative time, mean blood loss, and incidences of early postoperative complications and incontinence were less for patients treated with the Walsh technique than with the Campbell technique. After surgery 85 per cent of evaluable patients remained potent with the Walsh technique compared with 16 per cent of patients treated with the Campbell technique. Although other factors besides operative approach may have biased our results, we are persuaded that the innovations of radical retropubic prostatectomy detailed by Walsh constitute important advances in surgical technique, and we now use this procedure in all suitable patients electing treatment by radical prostatectomy for localized prostatic cancer.

Percutaneous Identification and Removal of Fungus Ball from Renal Pelvis

Fungus balls in the upper urinary tract are uncommon infectious processes that usually occur in diabetic patients. We report a case of an obstructing fungus ball of the renal pelvis, which was identified and removed successfully by percutaneous techniques.