Pratap K. Reddy

Prostatic Specific Antigen and Prostatic Acid Phosphatase in the Monitoring and Staging of Patients with Prostatic Cancer

Serum prostatic specific antigen and prostatic acid phosphatase levels were measured retrospectively and evaluated in 357 men with benign prostatic hypertrophy and in 209 men with various stages of prostatic carcinoma. Although prostatic specific antigen values were elevated in 21 per cent of the patients with benign prostatic hypertrophy, the elevations usually were low and did not interfere with clinical interpretation. Prostatic specific antigen was elevated in 98 per cent of 86 men with active stage D2 disease; in 22 per cent of the men prostatic specific antigen was the only elevated marker. In contrast, prostatic acid phosphatase was the only elevated marker in 1 per cent of the patients with stage D2 disease and neither marker was elevated in 2 per cent. Among 74 patients in whom prostatic specific antigen and prostatic acid phosphatase determinations were made before radical prostatectomy, prostatic specific antigen was elevated substantially (greater than 10 ng. per ml.) in 59 per cent (26 of 44) with extracapsular disease and in only 7 per cent (2 of 30) without extracapsular disease. More importantly, of those 28 patients with substantially elevated prostatic specific antigen levels 26 (93 per cent) had extracapsular disease. Serial serum measurements showed that prostatic specific antigen either reflected or predicted clinical status in more than 97 per cent of the patients. We conclude that prostatic specific antigen is an excellent serum tumor marker for monitoring patients with prostatic carcinoma and that it surpasses prostatic acid phosphatase in this regard. Prostatic specific antigen also may be useful in staging prostatic carcinoma and it may change our attitudes significantly about the therapeutic responses to this cancer.

Prostate Specific Antigen and Local Recurrence after Radical Prostatectomy

We evaluated the location of recurrent disease in 63 patients with carcinoma of the prostate who had abnormal levels of prostate specific antigen (greater than 0.4 ng./ml., Tandem-R assay) 6 to 240 months after radical prostatectomy but who were otherwise considered to be without evidence of disease. The evaluation involved physical examination including digital rectal examinations by 3 urologists, isotopic bone scans, computerized tomography scans of the abdomen and pelvis, cystoscopy, and random needle biopsies of the urethrovesical anastomotic area. In 6 patients metastatic disease to the bone and/or lymph nodes was found and local prostate cancer was discovered in 5. Among 57 patients without evidence of disease by the usual methods of evaluation needle biopsies of the anastomosis revealed local disease in 42%. No local disease was discovered in 30 post-radical prostatectomy patients with normal prostate specific antigen levels. There was a wide range of transrectally palpable contours after radical prostatectomy in patients with and without elevated prostate specific antigen levels. We conclude that prostate specific antigen but not digital rectal examination is an excellent early indicator of possible local recurrence after radical prostatectomy. Whether the prevalence of local disease after radical prostatectomy using prostate specific antigen levels and needle biopsies of the anastomosis is greater than heretofore has been appreciated will require further study.

A pilot study on the early use of the vacuum erection device after radical retropubic prostatectomy

To evaluate the effect of the early use of the vacuum erection device (VED) on erectile dysfunction (ED) and penile shortening after radical retropubic prostatectomy (RP), as these are important concerns for men choosing among treatment alternatives for localized prostate cancer.

The Effect of Radiation Therapy after Radical Prostatectomy in Patients with Elevated Prostate Specific Antigen Levels

We analyzed the effects of pelvic radiation therapy given to patients who had an elevated prostate specific antigen level after radical prostatectomy. Among men who previously received adjuvant radiation therapy and had appropriately stored serum 15 had elevated prostate specific antigen levels after radical prostatectomy but before radiation therapy. After radiation therapy the prostate specific antigen level decreased by more than 50% in 80% and to female levels in 53% of the patients. We also prospectively treated 29 men who had increasing levels of prostate specific antigen 9 to 95 months after radical prostatectomy but who were otherwise without evidence of disease by the usual criteria. However, 19 of the patients had local disease as evidenced by random needle biopsy of the urethrovesical anastomosis. Complications of radiation therapy were minimal and maximal prostate specific antigen decrease occurred by 6 months after treatment. In 82% of the patients prostate specific antigen levels decreased by more than 50% and in 43% they decreased to female levels. Female levels were achieved after radiation therapy given many years postoperatively even in stage D1 cancer patients but some of the patients subsequently had increasing prostate specific antigen levels. These data suggest that local-regional disease may be the only site of disease persistence after radical prostatectomy in some of the patients who subsequently have distant metastasis. We conclude that radiation therapy after radical prostatectomy can cause elevated prostate specific antigen to decrease to undetectable levels in many patients but the durability and ultimate therapeutic value of this effect are unknown.

Percutaneous removal of renal and ureteral calculi: experience with 400 cases.

Percutaneous removal of renal and ureteral calculi was performed in 500 patients since 1979. Experience with our first 100 cases enabled us to accumulate a variety of techniques. We report our experience with the subsequent 400 cases. As judged by plain films of the kidneys, ureters and bladder, and renal tomograms without contrast medium we attained a status free of stones in 99 per cent of the patients with renal and 94.5 per cent with ureteral calculi. Intravenous-assisted local anesthesia was used in 94 per cent of the cases. There was no mortality and the incidence of complications was low. Most patients with renal and ureteral calculi can be managed successfully and safely by percutaneous methods with good patient tolerance and minimal convalescence.

The North American experience with the urolume endoprosthesis as a treatment for benign prostatic hyperplasia: Long-term results

OBJECTIVES To determine the efficacy and safety of the UroLume endoprosthesis as a treatment for obstructive benign prostatic hyperplasia in healthy men. METHODS One hundred twenty-six men were enrolled prospectively in a multicenter North American Clinical Trial. Ninety-five men (mean age 68 +/- 7 years) had moderate or severe prostatism, whereas 31 participants (mean age 76 +/- 8 years) were in urinary retention. Voiding function for all patients was assessed prior to stent placement and in follow-up at 1, 3, 6, 12, and 24 months with the Madsen-Iversen symptom questionnaire, peak urinary flow rate, postvoid residual urine volume, and cystoscopic examination. RESULTS For the nonretention cohort at 24-month follow-up, the results were as follows: (1) total symptom score decreased from 14.3 +/- 0.5 preinsertion to 5.4 +/- 0.5 (p < 0.001); (2) peak urinary flow rate increased from 9.1 +/- 0.5 mL/s preinsertion to 13.1 +/- 0.7 mL/s (p < 0.001); and (3) postvoid residual urine volume decreased from 85 +/- 9 mL to 47 +/- 8 mL (p = 0.02). For the retention group, the total symptom score, peak urinary flow rate, and postvoid residual urine volume at 24 months were 4.1 +/- 0.5, 11.4 +/- 1.0 mL/s and 46 +/- 7 mL, respectively. By 12-month follow-up, most endoprostheses were completely covered with urothelium. Although significant long-term complications were minimal, 17 endoprostheses have been explanted for an overall removal rate of 13%. All devices were removed transurethrally without subsequent sequelae to the external urinary sphincter or urethra. CONCLUSIONS The long-term results from this North American Clinical Trial suggest that the UroLume endoprosthesis can be an effective and safe treatment for properly selected healthy men with obstructive benign prostatic hyperplasia. Randomized clinical trials comparing this minimally invasive procedure with transurethral resection of the prostate are now underway to document further its efficacy and safety.

Percutaneous techniques for the management of caliceal diverticula containing calculi

Most frequently caliceal diverticula are found incidentally on routine excretory urograms. Smaller diverticula are associated with a low incidence of complications but larger diverticula with a narrow communication to the main collecting system will predispose to calculous formation as a result of stasis of urine within the diverticulum. The techniques used and results achieved in 10 patients with such calculi who have been successfully managed percutaneously are discussed. Particular reference is made to techniques used specifically to obliterate the diverticula.

Flexible Fiberoptic and Rigid-Rod Lens Endoscopy of the Lower Urinary Tract: A Prospective Controlled Comparison

Cystourethroscopy was performed on 80 men by separate examiners with a rigid-rod lens instrument and a flexible fiberoptic choledochonephroscope. Findings with the flexible system were equivalent to or more accurate than those with the rigid endoscope in 94 per cent of the cases. With the flexible instrument the duration of the examination was unchanged, patient comfort was improved, the amount of irrigation fluid was reduced, and patient preparation and positioning were simpler and quicker.

Metabolic Alterations Following Continent Urinary Diversion Through Colonic Segments

This study examined acid-base metabolism in patients with continent colonic urinary diversions and compared them to a control population. Diverted patients demonstrated mild acidosis and a urinary acidification defect. Ammonium chloride loading failed to demonstrate any major differences in the ability of these patients to handle an acute acid challenge. Continent colonic urinary diversions do not appear to create significant acid-base changes in patients with normal hepatic and renal function.

Total Bladder Replacement Using Detubularized sigmoid Colon: Technique and Results

We performed total bladder replacement with a detubularized segment of sigmoid colon in patients after cystoprostatectomy. The surgical technique and long-term results in 27 patients are reported. This neobladder configuration compared favorably with other neobladder types regarding ease of construction. The surgical complications were acceptable. Initial reservoir function was good but improved further with time. After 1 year the capacity averaged 600 cc, pressures during filling and at capacity were low (average 12 and 16 cm. water) and emptying was satisfactory (residual urine 4 to 80 cc). All patients were continent during the day and 67% were continent at night without excessive voiding habits. Nighttime incontinence was further resolved in 2 patients by using the AMS 800 artificial sphincter around the bulbous urethra. The detubularized sigmoid is an excellent neobladder configuration after cystoprostatectomy.