S.L. Goldenberg

Intermittent Androgen Suppression for Prostate Cancer: Rationale and Clinical Experience

The rationale behind intermittent androgen suppression (IAS) is based on: (1) observations that androgen ablation is palliative, not curative, in most patients with prostate cancer, and that quality of life must be considered; (2) the assumption that immediate androgen ablation is superior to delayed therapy in improving survival; (3) the hypothesis that if tumour cells surviving androgen withdrawal are forced into a normal pathway of differentiation by androgen replacement, then apoptotic potential might be restored and progression to androgen independence delayed. Several centres have now tested the feasibility of IAS therapy in non-randomized groups of prostate cancer patients using serum of prostate-specific antigen levels as trigger points. Clinical data suggest that prostate cancer is amenable to control by IAS and offers clinicians an opportunity to improve patients’ quality of life by balancing the benefits of immediate androgen ablation (delayed progression and prolonged survival) while reducing treatment-related side effects and expense. Whether time to progression and survival is affected in a beneficial or adverse way is being studied in randomized, prospective protocols.

Disseminated intravascular coagulation in carcinoma of prostate: role of estrogen therapy

Advanced carcinoma of the prostate may present as disseminated intravascular coagulation and its sequelae. It is postulated that the slow release of thromboplastic material from tumor cells eventually overcomes normal homeostatic mechanisms. High-dose intravenous diethylstilbestrol diphosphate successfully reversed this coagulopathy in 2 cases of metastatic carcinoma of the prostate.

Transurethral resection of prostatic abscess under sonographic guidance

Transrectal ultrasound may establish the diagnosis of prostatic abscess in an ambiguous clinical setting. Transurethral resection (deroofing) is the treatment preferred by many clinicians, yet intraoperative complete abscess obliteration may be difficult to confirm endoscopically. We report on a patient with a complex prostatic abscess endoscopically resected under transrectal ultrasound guidance. Adequacy of treatment was proved pathologically.

Low-dose cyproterone acetate plus mini-dose diethylstilbestrol--a protocol for reversible medical castration.

OBJECTIVESnTo determine whether a low dose of cyproterone acetate (CPA) (50 mg twice a day) with minidose diethylstilbesterol (DES) is efficacious in rapidly reducing and maintaining serum testosterone at less than 10% of pretreatment level and whether the effect is reversible upon cessation of therapy.nnnMETHODSnData were collected prospectively on 62 subjects, aged 50 to 90 years (mean 69) with histologically confirmed prostate cancer and normal serum testosterone levels. Treatment was initiated with CPA 50 mg twice a day plus DES 0.11 mg once a day, both administered orally, and continued or 6 months unless discontinued for reasons unrelated to the study. Subsequent management was at the discretion of the investigator/managing physician. Treatment was discontinued with determination of at least one follow-up testosterone level in 28 patients.nnnRESULTSnMean pretreatment testosterone level was 13.8 nmol/L (range 4.5 to 46.6, median 14.0, 95% confidence interval [CI] 12.0 to 15.0). Testosterone dropped to a mean of 0.6 nmol/L (range 0.1 to 2.2, median 0.5, 95% CI 0.4 to 0.6) by first follow-up (usually 1 month) in all patients (P <0.001) and remained at this level as long as treatment continued. Testosterone normalized in all subjects whose treatment was discontinued. Side effects were minimal.nnnCONCLUSIONSnAn oral dosage of CPA of 50 mg twice a day in combination with a mini-dose of DES results in rapid and reversible reduction in serum testosterone to castrate levels. This regimen minimizes morbidity and monetary costs of therapy and allows the implementation of novel treatment approaches such as intermittent or neoadjuvant withdrawal therapy.

Metastatic renal cell carcinoma: Unusual cause of addison disease

We report a case of adrenocortical insufficiency presenting thirty months after radical nephrectomy for renal cell carcinoma. Removal of the remaining contralateral adrenal gland revealed metastatic disease.

Transurethral electrovaporization of the prostate versus transurethral prostatic resection: a comparison of postoperative hemorrhage.

OBJECTIVESnTo determine the acute and delayed hemorrhage rate of transurethral electrovaporization of the prostate (TEVP) versus standard transurethral resection of the prostate (TURP).nnnMETHODSnA retrospective review of 524 consecutive patients who underwent TURP and 302 consecutive patients who underwent TEVP was conducted. The indications for both procedures were identical and based on history, physical examination, American Urological Association symptom score, and uroflowmetry. Parameters of evaluation included the incidence of both initial and delayed hemorrhages, the time until a delayed bleed occurred, blood transfusion rates, and the average length of stay in hospital after a bleed.nnnRESULTSnThe overall hemorrhage rate for TURP and TEVP was 4.8% and 4.0%, respectively. In the TURP group, there was a 1.1% incidence of acute bleeds and 3.6% incidence of delayed bleeds. For the TEVP group, 0.3% had an acute hemorrhage, and 3.6% were readmitted for clot retention. The average length of time from original discharge to readmission was 12.9 days for the TURP group with a mean repeat stay of 5.7 days. For the TEVP group, the average interval to readmission was 15.4 days with a stay of 3.1 days.nnnCONCLUSIONSnThe overall rate of hemorrhage for the TEVP group was slightly lower than for the TURP group due to fewer acute bleeds. However, the incidence of delayed bleeds and clot retention between the two was identical at 3.6%. Because of improved hemostasis intraoperatively with similar functional results in the long term as shown by other investigators, we foresee TEVP continuing as a viable alternative to TURP.

Female bladder neck reconstruction anatomic and physiologic approach

Postoperative scarring of the bladder neck and urethra after failed anti-incontinence surgery in the female can seriously disrupt the normal mechanisms of bladder storage and emptying. We have analyzed and treated this problem in 10 selected female patients. A wrap-flap technique with omental support has been applied to reconstitute the normal anatomy and physiology of the bladder neck. Excellent results were obtained in all patients, with up to fifty-four months of follow-up. We recommend this procedure prior to the implantation of prosthetic material, with its inherent difficulties.