Ricardo Sanchez-Ortiz

An Interval Longer than 12 Weeks Between the Diagnosis of Muscle Invasion and Cystectomy is Associated with Worse Outcome in Bladder Carcinoma

PURPOSE The standard of care for muscle invasive transitional cell carcinoma of the bladder is radical cystectomy. Definitive therapy may often be delayed for various reasons. We assessed whether pathological stage and survival correlated with the length of time between diagnosis of muscle invasion and cystectomy. MATERIALS AND METHODS The records of 290 consecutive patients who underwent radical cystectomy between February 1987 and July 2000 were reviewed. Of 265 (91.4%) cystectomies performed for transitional cell carcinoma data were available for 247 (85.2%) and 189 (65.2%) patients were identified who underwent surgery for muscle invasive disease (T2 or greater). The interval between diagnosis of muscle invasion and cystectomy was calculated for each patient. Patients were divided into groups based on time to surgery as group 1-less than 4 weeks, 2-4 to 6 weeks, 3-7 to 9 weeks, 4-10 to 12 weeks, 5-13 to 16 weeks, and 6-greater than 16 weeks. Exploratory univariate and multivariate analyses were performed to test the association of time lag with clinical features and postoperative survival. RESULTS Mean patient age was 66 years (range 37 to 84) and overall 3-year Kaplan-Meier estimated survival was 59.1% +/- 4% (median followup 36 months). For all patients mean interval from diagnosis to cystectomy was 7.9 weeks (range 1 to 40). Extravesical disease (P3a or greater) or positive nodes were identified in 84% (16 of 19) of patients when the delay was longer than 12 weeks, compared with 48.2% (82 of 170) in those with a time lag of 12 weeks or less (p < 0.01). Similarly 3-year estimated survival was lower (34.9% +/- 13.5%) for patients with a surgery delay longer than 12 weeks compared to those with a shorter interval 62.1% +/- 4.5% (hazards ratio 2.51, 95% CI 1.30-4.83, p = 0.006). When adjusted for nodal status, and clinical and pathological stages the interval was still statistically significant (adjusted hazards ratio 1.93, 95% CI 0.99-3.76, p = 0.05). CONCLUSIONS In patients undergoing radical cystectomy a delay in surgery of greater than 12 weeks was associated with advanced pathological stage and decreased survival. Although this relationship persisted after adjusting for nodal status, and clinical and pathological stages, the presence of lymph node metastasis remained the strongest predictor of patient outcome.

Collagen injection therapy for post-radical retropubic prostatectomy incontinence : Role of valsalva leak point pressure

PURPOSE We retrospectively evaluated the role of Valsalva leak point pressure as a predictor of successful management of post-radical retropubic prostatectomy incontinence with collagen injection. MATERIALS AND METHODS Urodynamic studies and Valsalva leak point pressures of 31 men who received retrograde collagen injection for post-radical retropubic prostatectomy incontinence were reviewed. Patients were interviewed before and after treatment to assess pad use and the American Urological Association quality of life index (scale 0 to 6). Parameters for success were postoperative quality of life score 3 or less or 50% or greater decrease in pad use and that the patient would recommend collagen therapy to someone else. RESULTS Of 31 patients 11 (35%) met the criteria for success, 2 (6%) were completely dry and 9 (29%) were improved. Successfully treated patients had a mean Valsalva leak point pressure of 64.0 cm. water compared to 42.2 cm. water in the failure group (p <0.01). Of patients with Valsalva leak point pressure of 60 cm. water or greater, 70% responded favorably to collagen injection (positive predictive value), while 81% with Valsalva leak point pressure less than 60 cm. water had treatment failure (negative predictive value) (p <0.02). There were no other statistically significant differences between those successfully treated with collagen injection and those in whom treatment failed, including mean age (62.7 to 68.1 years), mean volume of collagen (26.1 to 28.9 ml.), mean number of treatment sessions (2.45 to 2.65), mean followup (14.9 to 15.1 months), preoperative quality of life score (5.1 to 4.9), and preoperative pads per day (4.0 to 3.37). CONCLUSIONS Our data suggest that collagen injection improves 35% but cures a minority of patients (less than 10%) with post-radical retropubic prostatectomy incontinence. A pretreatment Valsalva leak point pressure of 60 cm. water or greater has high predictive value for a beneficial outcome after collagen injection. We propose a role for Valsalva leak point pressure to select men cost-effectively with post-radical retropubic prostatectomy incontinence for therapy with collagen injection.

ARTIFICIAL URINARY SPHINCTER FOR POST-PROSTATECTOMY INCONTINENCE: IMPACT OF PRIOR COLLAGEN INJECTION ON COST AND CLINICAL OUTCOME

PURPOSE We retrospectively reviewed our experience with the artificial urinary sphincter in men with post-prostatectomy incontinence to determine the impact of prior collagen injection therapy on surgical outcome and overall cost of treatment. MATERIALS AND METHODS The records and preoperative urodynamic studies of 30 men with post-prostatectomy incontinence who underwent artificial urinary sphincter placement were reviewed. Of these patients 23 (76.6%) had undergone prior collagen injection (collagen group) and 7 had not (noncollagen group). Preoperative and postoperative severity of incontinence was assessed with the American Urological Association quality of life index (scale 0 to 6) and number of pads used daily. Using a Valsalva leak point pressure of less than 60 cm. water as a predictor of failure with collagen injection, we calculated the potential savings had these patients foregone collagen injection and chosen artificial urinary sphincter primarily. RESULTS Of the 30 patients 24 (80%) were incontinent following radical retropubic prostatectomy and 6 (20%) after transurethral resection. Intrinsic sphincter deficiency was the sole etiology of incontinence in most patients (83.3%) and 5 (16.7%) had concomitant detrusor instability. Six patients alternated the use of pads with the use of clamps or a condom catheter to aid in controlling leakage. Mean number of collagen treatment sessions for the injection group was 2.9 (range 1 to 7). There was a significant difference in mean time from prostatectomy to artificial urinary sphincter between the noncollagen (25.3 months) and collagen (35.8 months) groups (p = 0.04). There were no other statistically significant differences between the groups, including mean age (66.2 years, range 45 to 83), mean followup (26.2 months), mean preoperative pads daily (5.8+/-3.4), median preoperative quality of life index (6, range 3 to 6), median preoperative American Urological Association symptom score (13, range 3 to 35) and mean preoperative Valsalva leak point pressure (42.7+/-21.4 cm. water). For all patients in the study the mean postoperative pads daily was 0.8, mean quality of life index 1 and surgical complication rate 13.3%. There were no statistically significant differences between the collagen and noncollagen groups in any of these parameters. Among the collagen group 17 patients (73.9%) had a Valsalva leak point pressure less than 60 cm. water. Considering the mean additional period of incontinence (time between prostatectomy and artificial urinary sphincter) to be 12.9 months and the additional treatment costs (including pads daily and mean number of collagen syringes per patient), the direct costs of treatment for the collagen group were 85.6% higher than those for patients who chose artificial urinary sphincter primarily. CONCLUSIONS Prior collagen therapy did not adversely influence the surgical complication rate or compromise effectiveness of the artificial urinary sphincter. However, patients with Valsalva leak point pressure less than 60 cm. water have lower rates of success with collagen injection therapy and could benefit from a more successful, timely and cost-effective treatment of incontinence by choosing the artificial urinary sphincter as primary therapy.

Significance of hematuria in patients with interstitial cystitis: review of radiographic and endoscopic findings

OBJECTIVES Hematuria may be found in up to 30% of patients with interstitial cystitis (IC). However, few studies have described its etiology based on the findings of a complete evaluation. We reviewed the clinical significance of hematuria in the setting of IC. METHODS We retrospectively reviewed the records of 148 patients fulfilling the National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases inclusion criteria for IC. Patients with gross or microscopic hematuria were identified. Evaluation consisted of urine culture and cytology, cystoscopy, and intravenous urography (or retrograde pyelography plus renal ultrasound). Patients with urinary tract infections were excluded. RESULTS Of 148 patients, 60 (41%) were found to have had at least one episode of hematuria during a mean follow-up of 18 months. Of 56 patients who agreed to be evaluated, 8 (14%) had positive urologic findings. Of these, none were highly significant; five were simple renal cysts (8.9%), one was a renal stone (1.8%), one was reflux nephropathy (1.8%), and one was medullary sponge kidney (1.8%). Cystoscopy, cytology, and bladder biopsy did not demonstrate malignancy in any patient. No statistically significant differences were found in age (49.9 versus 46.7 years), sex (90% versus 91% female), bladder capacity (792 versus 808 mL), and the presence of Hunners ulcers (5% versus 2.4%), glomerulations (60% versus 59.9%), or detrusor mastocytosis (55% versus 47.6%) between patients with hematuria and those without (P >0.05). CONCLUSIONS The incidence of hematuria in patients with IC may be higher than previously reported. Nevertheless, although many of these patients present with pelvic pain and irritative voiding symptoms, the hematuria evaluation is unlikely to reveal a life-threatening urologic condition.

RENAL CELL CARCINOMA PRESENTING WITH MESENTERIC THROMBOSIS AND ANTICARDIOLIPIN ANTIBODIES: ECHOES OF TROUSSEAU'S SYNDROME?

Hematological manifestations of renal cell carcinoma are common. However, while red blood cell abnormalities may be found in 30 to 60% of patients, coagulation disorders are exceedingly We report a case of renal cell carcinoma presenting with mesenteric venous thrombosis associated with anticardiolipin antibodies. To our knowledge our case is the fourth report in the literature of renal cell carcinoma presenting with distant venous thrombosis and the first report of mesenteric thrombosis associated with anticardiolipin antibodies and renal cell carcinoma. CASE REPORT

Vascular Evaluation of Erectile Dysfunction

In the era of only two specific treatments for erectile dysfunction (ED) (penile prosthesis and vasoactive penile injection), most patients could be easily directed to therapy following a good sexual history, assessment of medical risks, and physical examination. Without diagnostic testing, efficacy, and satisfaction was a matter of chance.

Genetic ancestry and prostate cancer susceptibility SNPs in Puerto Rican and African American men

The Puerto Rican (PR) population is a racially admixed population that has a high prostate cancer (PCa) mortality rate. We hypothesized in this pilot study that West African Ancestry (WAA) was associated with PCa in this heterogeneous (PR) population.

URINARY FISTULA BETWEEN THE BLADDER AND LOWER EXTREMITY FOLLOWING BURCH URETHROPEXY

A 73-year-old woman presented elsewhere with right thigh pain, weakness and lower extremity edema 2 weeks after Burch urethropexy. Medical history was significant for urinary incontinence, colon cancer treated with surgery and external beam radiotherapy, and noninsulin dependent diabetes mellitus. Physical examination revealed a fever (101.7F), suprapubic tenderness and bilateral thigh edema greater on the right side than on the left side. Lower extremity sensation was intact with limitation of motion of the right hip due to severe pain. Relevant laboratory evaluations were significant for leukocytosis (19, 600/ml., 6% bands). Noncontrast computerized tomography (CT) of the abdomen, pelvis and lower extremity showed extensive fasciitis and myositis involving the adductor magnus bilaterally and the right vastus intermedius and lateralis. The patient subsequently underwent right thigh fasciotomy without resolution of symptoms. Bone scan was negative for osteitis pubis. Cystography demonstrated a fistula between the floor of the bladder and fascial planes overlying the pubic symphysis, extending into the thighs. The patient was referred to us for treatment. Repeat cystogram demonstrated urinary extravasation into both lower extremities (fig. 1). CT of the pelvis and lower extremities showed improving fasciitis with a urinary fistula between the bladder and both thighs in continuity with the fasciotomy incision (fig. 2). Cystoscopy demonstrated an area of bullous edema on the anterior bladder wall. No foreign body was seen. Review of the original operative report of the urethropexy revealed chromic suture placement through the bladder wall laterally and anteriorly. Intravenous antibiotics and nutritional supplementation were initiated. An indwelling Foley catheter was left in place for 1 month while the patient underwent hyperbaric oxygen therapy (20 treatments). Repeat cystogram after completion of hyperbaric oxygen therapy revealed no leakage.

MP14-11 QUANTIFYING ANXIETY AND DEPRESSION AFTER A RECENT PROSTATE CANCER DIAGNOSIS: SHOULD ROUTINE MENTAL HEALTH COUNSELING FOLLOW THE BAD NEWS?

CONCLUSIONS: The evidence fails to support significant adverse effects associated with T flare. Most studies show no increase in PSA or disease progression during flare. Rates of vertebral collapse were identical to castration or DES. These results are consistent with the saturation model. There seems little value in adding AA to LHRH agonists, except for men with severely reduced T levels at baseline with extensive bony metastases.

MP14-16 INCREASED PROSTATE SIZE AND HISTORY OF PREOPERATIVE VOIDING DYSFUNCTION ASSOCIATED WITH GREATER URINARY TOXICITY AFTER POST-PROSTATECTOMY ADJUVANT OR SALVAGE RADIATION

INTRODUCTION AND OBJECTIVES: Animal models using the rabbit bladder have shown that outlet obstruction is associated with bladder fibrosis and diminished aerobic metabolism. Given that genitourinary toxicity in men undergoing radiation therapy (RT) after radical prostatectomy (RP) is related to ischemia, we set out to correlate the relationship between clinical factors affecting bladder circulation and urinary complications after RT. METHODS: Patients with a history of postoperative (postop) RT were identified from a database of 542 consecutive men who underwent RP by a single surgeon. Indications included positive margins, pT3, or a serum PSA 0.2. All were continent and waited 6 months before RT. Of 508 patients with 6 months (mo.) follow-up, 50 received adjuvant (3.3%, 17/508) or salvage (6.5%, 33/508) intensity modulated RT (median dose of 69 Gy), with 15.1% (5/33) receiving androgen ablation in the salvage group. Urinary complications were classified using the Clavien-Dindo system. SPSS was used for statistical analysis. RESULTS: After a median follow-up of 37.9 mo., transient incontinence developed in 1 patient (2%) (Clavien-Dindo grade II), and permanent incontinence in 3 men (6%), one managed medically (grade II), and the others with a sling and an artificial sphincter, respectively (grade III). Three patients (6%) developed bladder neck scars requiring incision. No urothelial malignancies were identified. Twenty percent of patients (10/50) developed hematuria requiring fulguration (grade III) (5 salvage and 5 adjuvant RT) followed by hyperbaric oxygen therapy in 3 patients. Patients with hematuria had higher preop International Prostate Symptom Scores (IPSS) (15.5 vs. 6.5, p<0.01) and larger prostates (51.7 vs. 39.3 g, p<0.01) compared with those without. Seventy five percent of patients with prostates 60 g developed hematuria compared with 9.5% of those with smaller glands (p<0.001). Diabetic patients showed a trend for hematuria (25% vs. 19.5%) and incontinence (12.5% vs. 7.3%) but this was not significant (only 8/50 radiated patients had DM). Urinary complications did not correlate with age, surgery type (80% robotic), salvage vs. adjuvant RT, body-mass index, smoking, hyperlipidemia, or hypertension. CONCLUSIONS: Our data show that grade III urinary complications may develop in up to 30% of patients treated with RT after RP. Gross hematuria was 3 times more common (20%) than incontinence (6%) or strictures (6%) and predominantly affected men with preop voiding dysfunction or large prostates ( 60 g). The association between preoperative gland size and complications of RT in the postprostatectomy setting warrants validation with a larger cohort of patients.