Richard Brough

Early prostate cancer – which treatment do men prefer and why?

Study Type – Preference (prospective cohort)
Level of Evidence 1b

Diethylstilboestrol for the treatment of prostate cancer: past, present and future

Abstract The aim of this review was to discuss the most recent data from current trials of diethylstilboestrol (DES) to identify its present role in advanced prostate cancer treatment as new hormonal therapies emerge. The most relevant clinical studies using DES in castration-refractory prostate cancer (CRPC) were identified from the literature. The safety, efficacy, outcomes and mechanisms of action are summarized. In the age of chemotherapy this review highlights the efficacy of oestrogen therapy in CRPC. The optimal point in the therapeutic pathway at which DES should be prescribed remains to be established.

Bilateral testicular metastases from prostatic carcinoma

Abstract  Testicular metastasis from carcinoma of the prostate is rare. We report a case of carcinoma of the prostate with bilateral testicular metastases 7 years after the initial diagnosis. The exact prognosis is not known but it usually indicates advanced disease. Although testicular metastasis is uncommon, it should be considered when a patient presents with a lump in the testis, particularly in a patient known to have another primary malignancy.

The ‘2-Week Wait’ Rule for Referrals for Suspected Urological Cancers – Urgent Need for Refinement of Criteria

INTRODUCTION All NHS-suspected cancers should be seen within 2 weeks of referral and are referred under government guidelines (Health Service Circular 205; HSC 205). This policy will be subject to review in 2009. Review is vital to allow the appropriate detection of malignancy without overburdening the premium clinic slots with the healthy. PATIENTS AND METHODS A total of 170 consecutive patients were referred from January-June 2005. Referral details, patient information, events and time to diagnosis were recorded. RESULTS Of these 170 patients, 143 were suitable for analysis. Forty-three patients (30%) were referred with frank haematuria, of whom 30% had bladder cancer. Nine percent of patients (n = 13) had microscopic haematuria none of whom had cancer. A quarter of the patients (n = 35) were referred with suspected testis cancer but none had cancer. Forty-one patients were referred with serum prostate-specific antigen (PSA) elevation; 18 cancers were detected in this group. Ten men had PSA values greater than 50 ng/ml. Only two cancers were suitable for radical prostatectomy. No cancer was found in patients less than 50 years of age. CONCLUSIONS A high cancer incidence was found (27.9%), the majority of which was bladder cancer or advanced prostate cancer. Out of the 143 patients, no malignancy was diagnosed in any patient less than 50 years of age, no malignancy was diagnosed in any of the microscopic haematuria group and there was no cancer diagnosed in the group of patients referred with scrotal swellings. We suggest that some guidelines are leading to referral of patients with low cancer risk. When the HSC 205 is revised in 2009, we hope studies such as ours are taken into consideration in order to improve resource utilisation.

Adenocarcinoma of the caecum metastatic to the bladder: an unusual cause of haematuria

BackgroundPrimary malignancies of colorectal origin can metastasise to the bladder. Reports are however extremely rare, particularly from the caecum.Case reportThe report describes the case of a 45-year old male with Dukes B caecal carcinoma treated with a laparoscopically-assisted right hemicolectomy and adjuvant 5-Fluorouracil chemotherapy. Subsequently, a metastatic lesion to the bladder was demonstrated and successfully excised by partial cystectomy.ConclusionIn order that optimal therapeutic options can be determined, it is important for clinicians to distinguish between primary disease of the bladder and other causes of haematuria. Various immunohistochemical techniques attempt to differentiate primary adenocarcinoma of the bladder from secondary colorectal adenocarcinoma. Suspicion of metastatic disease must be raised when histologically unusual bladder tumours are identified.

Acute urinary retention in women due to urethral calculi: A rare case

We present a case of a 51-year-old woman with acute urinary retention caused by a urethral calculus. Urethral calculi in women are extremely rare and are usually formed in association with underlying genitourinary pathology. In this case, however, no pathology was detected via thorough urological evaluation. We discuss the pathogenesis, clinical presentation and treatment of urethral calculi. To our knowledge, this is the second reported case of a primary urethral calculus in a female with an anatomically normal urinary tract and the first in a middle-aged Caucasian female.

Bladder neck sparing in radical prostatectomy

The role of a bladder neck sparing (BNS) technique in radical prostatectomy (RP) remains controversial. The potential advantages of improved functional recovery must be weighed against oncological outcomes. We performed a literature review to evaluate the current knowledge regarding oncological and functional outcomes of BNS and bladder neck reconstruction (BNr) in RP. A systematic literature review using on-line medical databases was performed. A total of 33 papers were identified evaluating the use of BNS in open, laparoscopic and robotic-assisted RP. The majority were retrospective case series, with only one prospective, randomised, blinded study identified. The majority of papers reported no significant difference in oncological outcomes using a BNS or BNr technique, regardless of the surgical technique employed. Quoted positive surgical margin rates ranged from 6% to 32%. Early urinary continence (UC) rates were ranged from 36% to 100% at 1 month, with long-term UC rate reported at 84-100% at 12 months if the bladder neck (BN) was spared. BNS has been shown to improve early return of UC and long-term UC without compromising oncological outcomes. Anastomotic stricture rate is also lower when using a BNS technique.

A rare case of testicular metastasis of bladder transitional cell carcinoma.

Metastases from bladder transitional cell carcinoma (TCC) to the testis are very rare. These are usually found on autopsy and occur in advanced or metastatic bladder cancers. More common, known primary tumors that metastasize to the testis include prostate, lungs, melanoma, gastro-intestinal tract and the kidney. We report a rare case of solitary and synchronous metastatic TCC of the bladder to the testis, discovered on histological examination. This case illustrates that metastatic neoplasm to uncommon sites should be considered in the differential diagnosis for patients with a history of advanced bladder TCC.

Post-prostatectomy lymphocoele presenting with renal failure

Since its advent in 2001, robotic-assisted laparoscopic prostatectomy has become the gold standard treatment for the management of localized prostate cancer. Pelvic lymphocoele is most commonly found after gynecological or renal transplant surgery or following extensive pelvic lymphadenectomy. Its formation following prostatectomy is not uncommon1 but it seldom causes major complications or morbidity.2 We present a case of a 66-year-old man who presented with left-sided abdominal pain, a palpable infra-umbilical mass, and renal failure. He was initially presumed to have high pressure chronic retention however catheterization did not result in any improvement in his renal function. Further investigations revealed a large lymphocoele causing bilateral ureteric obstruction with resultant hydronephrosis.

Prostate Cancer in Sub-Saharan Africa: Diagnosis and Management

Prostate cancer is the leading non-cutaneous cancer in the USA but very little is known about the disease in the developing world. It is known that the incidence and death rate in blacks in the USA and Caribbean is higher than the Caucasian population, and this would suggest the burden of prostate cancer is likely to be high in sub-Saharan Africa (SSA). The data currently available for this population is limited with only 11% of patients in SSA entered into a registry. The chapter deals with screening issues, the availability of prostate biopsy in SSA and the modern management of both localised and metastatic prostate cancer in the developed world, comparing this with the currently available treatment modalities in SSA. It is likely that as the sub-continent develops, prostate cancer will become an increasingly recognised and important health issue for the population and will demand an ever increasing part of the health care budget.