Robert S. Waldbaum

Urinary morbidity following ultrasound-guided transperineal prostate seed implantation

PURPOSE To assess the urinary morbidity experienced by patients undergoing ultrasound-guided, permanent transperineal seed implantation for adenocarcinoma of the prostate. METHODS AND MATERIALS Between September 1992 and September 1997, 693 consecutive patients presented with a diagnosis of clinically localized adenocarcinoma of the prostate, and were treated with ultrasound-guided transperineal interstitial permanent brachytherapy (TPIPB). Ninety-three patients are excluded from this review, having received neoadjuvant antiandrogen therapy. TPIPB was performed with 125I in 165 patients and with 103Pd in 435 patients. Patients treated with implant alone received 160 Gy with 125I (pre TG43) or 120 Gy with 103Pd. One hundred two patients received preimplant, pelvic external beam radiation (XRT) to a dose of either 41.4 or 45 Gy because of high-risk features including PSA > or = 10 and/or Gleason score > or = 7. Combined modality patients received 120 Gy and 90 Gy, respectively for 125I or 103Pd. All patients underwent postimplant cystoscopy and placement of an indwelling Foley catheter for 24-48 h. Follow-up was at 5 weeks after implant, every 3 months for the first 2 years, and then every 6 months for subsequent years. Patients completed AUA urinary symptom scoring questionnaires at initial consultation and at each follow-up visit. Urinary toxicity was classified by the RTOG toxicity scale with the following adaptations; grade 1 urinary toxicity was symptomatic nocturia or frequency requiring none or minimal medical intervention such as phenazopyridine; grade 2 urinary toxicity was early obstructive symptomatology requiring alpha-blocker therapy; and grade 3 toxicity was considered that requiring indwelling catheters or posttreatment transurethral resection of the prostate for symptom relief. Log-rank analysis and Chi-square testing was performed to assess AUA score, prostate size, isotope selection, and the addition of XRT as possible prognosticators of postimplant urinary toxicity. The prostate volume receiving 150% of the prescribed dose (V150) was studied in patients to assess its correlation with urinary toxicity. RESULTS Median follow-up was 37 months (range 6-68). Within the first 60 days, 37.3% of the patients reported grade 1 urinary toxicity, 41% had grade 2, and 2.2% had grade 3 urinary toxicity. By 6 months, 21.4% still reported grade 1 urinary toxicity, whereas 12.8% and 3% complained of grade 2 and 3 urinary difficulties, respectively. Patients with a preimplant AUA score < or = 7 had significantly less grade II toxicity at 60 days compared to those with an AUA score of >7 (32% vs. 59.2%, respectively, p = 0.001). Similarly, prostatic volumes < or = 35 cc had a significantly lower incidence of grade II urinary toxicity (p = 0.001). There was no difference in toxicity regarding the isotope used (p = 0.138 at 60 days, p = 0.45 at 6 months) or the addition of preimplant XRT (p = 0.069 at 60 days, p = 0.84 at 6 months). Twenty-eight patients (4.7%) underwent TURP after 3 isotope half-lives for protracted obstructive symptoms. Five of these men (17%) developed stress incontinence following TURP, but all patients experienced relief of their obstructive symptoms without morbidity at last follow-up. The percent of the prostate receiving 150% of the prescribed dose (V150) did not predict urinary toxicity. CONCLUSIONS TPIPB is well tolerated but associated with mild to moderate urinary morbidity. Pretreatment prostatic volume and AUA scoring were shown to significantly predict for grade 2 toxicity while the use of preimplant, pelvic XRT and isotope selection did not. Patients undergoing TURP for protracted symptoms following TPIPB did well with a 17% risk of developing stress incontinence. V150 did not help identify patients at risk for urinary morbidity. As transperineal prostate implantation is used more frequently the associated toxicities and the definition of possible pretreatment prognostic factors is necessary to

Isotope selection for patients undergoing prostate brachytherapy.

PURPOSE Ultrasound-guided transperineal interstitial permanent prostate brachytherapy (TIPPB) is generally performed with either 103Pd or 125I. The use of 125I for low Gleason score tumors and 103Pd for higher Gleason scores has been suggested based on isotope dose rate and cell doubling time observed in in vitro studies. While many centers follow these isotope selection criteria, other centers have elected to use only a single isotope, regardless of Gleason score. No clinical data have been published comparing these isotopes. This study was undertaken to compare outcomes between 125I and 103Pd in a matched pair analysis for patients undergoing prostate brachytherapy. METHODS AND MATERIALS Six hundred forty-eight consecutively treated patients with clinically confined prostate cancer underwent TIPPB between June 1992 and February 1997. Five hundred thirty-two patients underwent TIPPB alone, whereas 116 received pelvic external beam irradiation and TIPPB. Ninety-three patients received androgen deprivation therapy prior to TIPPB. The prescribed doses for TIPPB were 160 Gy for 125I (pre-TG43) and 120 Gy for 103Pd. Patients treated with combination therapy received 41.4 or 45 Gy (1.8 Gy/fraction) external beam irradiation followed by a 3- to 5-week break and then received either a 120-Gy 125I or a 90-Gy 103Pd implant. Until November 1994, all patients underwent an 125I implant after which the isotope selection was based on either Gleason score (Gleason score 2-5:125I; Gleason 5-8:103Pd) or isotope availability. A matched pair analysis was performed to assess any difference between isotopes. Two hundred twenty-two patients were matched according to Gleason score, prostate-specific antigen (PSA), and stage. PSA relapse-free survival (PSA-RFS) was calculated based on the American Society for Therapeutic Radiology and Oncology (ASTRO) Consensus Group definition of failure. Kaplan-Meier actuarial survival curves were compared to assess differences in pretreatment PSA and Gleason score. RESULTS Univariate analysis of the 648 patients identified Gleason score, pretreatment PSA value, and stage as significant factors to predict PSA-RFS, but failed to identify isotope selection as significant. To address the significance of isotope selection further, the matched pair groupings were performed. The minimum follow-up for all 222 matched patients is 24 months with a median follow-up of 42 months (24-82). The actuarial PSA-RFS at 5 years for all 222 patients is 86.5%. One hundred eleven of the 222 matched patients received a 103Pd implant with an 87.1% 5-year PSA-RFS. The remaining 111 patients underwent a 125I implant with an 85.9% 5-year PSA-RFS (p = n.s.). Analysis of Gleason score subgroups 2-4, 5-6, and 7-9 failed to show any significant difference in PSA-RFS comparing isotopes. Pretreatment PSA subgroups of < or = 10 or > 10 ng/ml also failed to show any significant difference in PSA-RFS survival comparing isotopes. Analysis of postimplant dosimetry using dose delivered to 90% of the prostate volume (D90) did not identify any difference between the isotope groups. CONCLUSIONS This matched pair analysis failed to demonstrate a difference for 125I and 103Pd in PSA-RFS for patients undergoing TIPPB. In addition, there were no observed advantages for either 125I or 103Pd in either the low or high Gleason score groups. This data indicates that the role of isotope selection for patients undergoing TIPPB requires further clarification.

Kaposi’s Sarcoma of the Penis in a Patient with the Acquired Immune Deficiency Syndrome

We report a case of secondary Kaposis sarcoma of the penis and the acquired immune deficiency syndrome. Recognition of the penile lesion as being secondary Kaposis sarcoma is paramount, since the clinical course appears to be dependent upon systemic disease. Local therapy is reserved for palliation upon disease recurrence.

The role of external beam irradiation in patients undergoing prostate brachytherapy

6. From this cohort, a matched-pair analysis was performed to better assess the role of EBT and TIPPB (n = 215). PSA relapse-free survival was based on the American Society for Therapeutic Radiology and Oncology Consensus Panel definition. Kaplan-Meier actuarial survival curves were compared to assess various prognostic factors. The median follow-up for all 215 matched patients was 44 months (range, 24-81) with an actuarial PSA relapse-free survival (RFS) at 5 years of 81.1%. Patients treated with EBT and TIPPB had a 5-year PSA RFS of 83.5% whereas patients treated with TIPPB only had a 5-year PSA RFS of 79.4% (p = 0.715)10 ng/ml. Risk group analysis combining PSA, Gleason score, and stage failed to identify any risk group for which the addition of EBT was significant. Analysis of postimplant dosimetry using the dose to 90% of the prostate volume (D90) failed to distinguish any difference between groups. A significant advantage for combining EBT and TIPPB could not be demonstrated in this retrospective matched-pair analysis. These data indicate that the role and rationale of combined treatment in prostate brachytherapy requires better clarification, with a prospective randomized trial.

Spontaneous rupture of renal pelvis

A seventy-seven-year-old female with progressive abdominal sighs for twenty-four hours was found to have had a spontaneous rupture of the renal pelvis with massive urinary extravasation.

Normalization of hematocrit in a uremic patient receiving hemodialysis: Role of erythropietin**

of the kidney biopsy revealed thickened capillary walls with swollen endothelial cells and focal fibrin deposition. Pathologic changes of myoglobinuric renal failure (tubular necrosis with myoglobin casts in the tubules) were not detected. 4 Immunofluorescence studies revealed focal and segmental intracapillary deposits of fibrin, IgM, IgG, and IgA in a pattern suggestive of intracapillary thrombosis. Electron microscopy studies showed typical widening of the subendothelial space with electron-lucent material.

PARASITIC LUMBAR ARTERIAL BLOOD SUPPLY IN RENAL ANGIOMYOLIPOMA

A young woman with azotemia was found to have an angiomyolipoma which had parasitic blood supply from a lumbar artery. Parasitic lumbar arterial blood supply from a lumbar artery. Parasitic lumbar arterial blood supply has previously been considered a strong indication of malignancy. Since this benign lesion had not invaded the adjacent retroperitoneal structures, the phenomenon tends to confirm the postulate that parasitic blood supply to a lesion may occur through hypertrophy of small anastomotic channels normally present between adjacent vessels but not normally seen in angiography.

Use of porcine xenografts in treatment of Fournier's gangrene

Abstract The use of porcine xenografts as a biologic dressing has become increasingly popular, particularly in cases of extensive tissue loss, as in severe thermal injuries. It not only minimizes protein and fluid loss, acts as a barrier to infection, but also prevents conversion of second-degree burns through its ability to control existing infection. In this case, it was used successfully to treat Fourniers gangrene. We believe it significantly eased and shortened the patients hospital stay and enabled us to apply autogenous split thickness skin grafts sooner than with conventional modes of wound care.

Venous infarction of the testis owing to vena caval thrombosis.

A 37-year-old man presented with what appeared to be acute epididymitis but was later found to be venous infarction of the testis owing to vena caval thrombosis.

Tubular Duplication of the Rectum with a Rectourethral Fistula

An infant with pneumaturia and fecaluria was found to have a rectal duplicatation with a fistula between the duplicated rectum and the urethra. Rectal duplication, although rare, should be considered in cases of bizarre lower bowel symptoms in children. Correction in our case was effected by exclusion of the duplicated segment along with removal of its mucosal lining and division of its urethral fistula. The termination of the duplicated rectum in the urinary tract, as in cases of imperforate anus, suggests a related embryologic mechanism for the 2 types of anomalies.