Scott K. Swanson

The use of radiotherapy for patients with isolated elevation of serum prostate specific antigen following radical prostatectomy

PURPOSE An analysis was performed to assess the outcome of patients who received radiotherapy for isolated elevation of serum prostate specific antigen (PSA) levels following radical retropubic prostatectomy. MATERIALS AND METHODS Forty-six patients were initially treated for localized prostate cancer with radical retropubic prostatectomy following negative pelvic lymphadenectomy. These patients had detectable serum PSA 6 or more months postoperatively. No patient had other clinical evidence of recurrent disease as determined by history, physical examination, bone scan, computerized tomography of the abdomen and pelvis, chest radiographs, complete blood cell counts and serum chemistry profiles. The patients received prostate bed irradiation using 10 MV. x-rays and a 4-field approach. Doses ranged from 60.0 to 67.0 Gy. in 1.8 to 2.0 Gy. fractions. Freedom from failure after radiotherapy was defined as maintaining a PSA of 0.3 ng./ml. or less without hormonal intervention. RESULTS In 27 of the 46 patients (59%) PSA had decreased to 0.3 ng./ml. or less at last measurement without hormonal intervention. The freedom from failure rate was 50% at 3 and 5 years. More favorable responses to salvage radiotherapy occurred in patients with low grade tumors and serum PSA 1.1 ng./ml. or less at initiation of radiotherapy. Patients, receiving radiation doses of 64 Gy. or more had more favorable response rates than those receiving lesser doses. CONCLUSIONS Isolated elevations of serum PSA following prostatectomy reflect residual disease. Radiotherapy administered to the prostate bed effectively decreased serum PSA in approximately half of the cases. This effect appears to be accomplished by eradicating tumor cells in the prostate bed.

The results of radical retropubic prostatectomy and adjuvant therapy for pathologic Stage C prostate cancer

PURPOSE The results of therapy in 288 men with pathologic Stage C prostate cancer who underwent radical retropubic prostatectomy (RRP) were analyzed to determine the effects of adjuvant therapy. METHODS AND MATERIALS Twenty-seven of the 288 patients received preoperative neoadjuvant hormonal therapy (leuprolide acetate). Postoperatively, 60 patients received adjuvant radiotherapy (RT) to the prostate bed. Follow-up ranged from 3 to 83 months (median = 32 months). Freedom from failure (FFF) was defined as maintaining a serum PSA level of < or = 0.3 ng/ml. RESULTS The FFF was 61% at 3 years and 45% at 5 years for the entire group. The FFF following RRP plus RT was 75% at 3 years and 57% at 5 years as compared to 56% at 3 years and 40% at 5 years for RRP without RT (p=0.049). The FFF following RRP plus neoadjuvant hormonal therapy was 58% at 3 years and 40% at 5 years as compared to 60% at 3 years and 45% at 5 years following RRP without hormonal therapy (p=0.3). In patients without seminal vesicle (SV) invasion, the FFF was 81% at 3 years and 5 years for RRP plus RT as compared to 61% at 3 years and 50% at 5 years for RRP without RT (p=0.01). In patients with SV invasion, the FFF was 61% at 3 years and 36% at 5 years for RRP plus RT as compared to 44% at 3 years and 23% at 5 years for RRP without RT (p=0.23). The projected local control rate was 83% at 5 years for those with RRP alone as compared to 100% for RRP plus RT (p=0.02). Survival at 5 years was projected to be 92% and was not significantly altered by the administration of adjuvant therapies. CONCLUSIONS Postoperative RT was associated with significantly improved local control and FFF rates, especially in patients with tumors which did not involve the seminal vesicles.

Urinary Tract Stones in Pregnancy

The presence of stones during an otherwise uneventful pregnancy is a dramatic and potentially serious issue for the mother, the fetus, and the treating physicians alike. The incidence and predisposing factors are generally the same as in nonpregnant, sexually active, childbearing women. Unique metabolic effects in pregnancy such as hyperuricuria and hypercalciuria, changes in inhibitors of lithiasis formation, stasis, relative dehydration, and the presence of infection all have an impact on stone formation. The anatomic changes and physiologic hydronephrosis of pregnancy make the diagnosis and treatment more challenging. Presenting signs and symptoms include colic, flank pain, hematuria, urinary tract infection, irritative voiding, fever, premature onset or cessation of labor, and pre-eclampsia. The initial evaluation and treatment are again similar to those used for the nonpregnant population. The most appropriate first-line test is renal ultrasonography, which may, by itself, allow the diagnosis to be made and provide enough information for treatment. Radiographic studies, including an appropriately performed excretory urogram, give specific information as to size and location of the stones, location of the kidneys, and differential renal function and can be used safely, but the ionizing radiation risks should be considered. All forms of treatment with the exception of extracorporeal shock wave lithotripsy and some medical procedures are appropriate in the pregnant patient. Close coordination by the urologist, the obstetrician, the pediatrician, the anesthesiologist, and the radiologist is required for the appropriate care of these patients.

Bilateral laparoscopic nephrectomy for significantly enlarged polycystic kidneys: a technique to optimize outcome in the largest of specimens

To present our experience with bilateral laparoscopic nephrectomy (BLN) for symptomatic autosomal‐dominant polycystic kidney disease (ADPKD), as surgical management of massively enlarged polycystic kidneys can be a daunting task.

Bilateral renal cell carcinoma: influence of synchronous and asynchronous occurrence on patient survival.

Twenty-seven patients with synchronous (19 cases) or asynchronous (8 cases) bilateral renal cell carcinoma were treated and followed for as long as 20 years. Tumor grade and stage generally were more favorable in the former group, which is reflected in the higher surgical intervention rate. Nonsurgical treatment yielded poor results. The 5-year survival rate for patients with synchronous bilateral renal cell carcinoma (77.8 per cent) was significantly higher than that for patients with asynchronous lesions (37.5% per cent). Because of its different presentation and favorable prognosis when treated surgically synchronous bilateral renal cell cancer should be distinguished from the asynchronous form, with its dismal outcome. For the latter cases thorough long-term followup may make early surgical intervention feasible, and thus, improve patient survival.

Relationship of Leukoplakia to Urothelial Malignancy

The records of 108 patients presenting with leukoplakia of the urinary tract during the last 35 years were reviewed to define the natural history of this disease, with emphasis upon its association with urothelial cancer. Of the 108 patients 24 had upper urinary tract, 78 bladder and 10 urethral leukoplakia (1 with renal and bladder involvement, 3 with bladder and urethral involvement, and 1 with ureteral and renal involvement). Presenting complaints were primarily irritative. To date, 41 patients (37 per cent) have had associated carcinoma of the urothelium: 23 (21 per cent) presented with a concomitant or previous carcinoma and 18 of 85 (21 per cent) presenting without a concomitant or previous neoplasm have had documented progression to cancer. These figures support the concept that leukoplakia is a premalignant disease and that patients with this diagnosis deserve careful and frequent followup.

Radiation dose escalation for localized prostate cancer: Intensity-modulated radiotherapy versus permanent transperineal brachytherapy

In the current study, the effects of dose escalation for localized prostate cancer treatment with intensity‐modulated radiotherapy (IMRT) or permanent transperineal brachytherapy (BRT) in comparison with conventional dose 3‐dimensional conformal radiotherapy (3D‐CRT) were evaluated.

Interstitial cystitis in men

OBJECTIVES To determine the personal characteristics, the mode of presentation, the duration of the delay in diagnosis, the number of misdiagnoses, the means to achieve diagnosis, and previous treatment provided for a group of men with interstitial cystitis (IC). METHODS A chart review of 29 men diagnosed with IC at our facility from 1988 to 1996 was performed. Basic demographic data, historical information, laboratory findings, and endoscopic and biopsy results were tabulated. RESULTS IC in this series of men was diagnosed at a mean age of 67.3 years. There was approximately a 4-year diagnostic lag between presentation and diagnosis. The most common prior erroneous diagnoses were prostatitis in 48% and benign prostatic hypertrophy (BPH) in 38% of the men. Ulcers were encountered cystoscopically in about 70% and biopsy specimens uniformly showed nonspecific chronic cystitis at the time of diagnosis. CONCLUSIONS IC should be considered in the differential diagnosis of voiding disorders accompanied by irritative symptoms and pelvic pain in older men. The diagnosis should be especially considered in men who are refractory to the usual treatments for BPH and prostatitis. Cystoscopy and bladder distention under anesthesia provided the most useful objective information in our hands. Biopsy is useful to rule out inflammatory cancer but adds little to the diagnosis of IC.

Outcome and Toxicity for Patients Treated with Intensity Modulated Radiation Therapy for Localized Prostate Cancer

PURPOSE We evaluate long-term disease control and chronic toxicities observed in patients treated with intensity modulated radiation therapy for clinically localized prostate cancer. MATERIALS AND METHODS A total of 302 patients with localized prostate cancer treated with image guided intensity modulated radiation therapy between July 2000 and May 2005 were retrospectively analyzed. Risk groups (low, intermediate and high) were designated based on National Comprehensive Cancer Network guidelines. Biochemical control was based on the American Society for Therapeutic Radiology and Oncology (Phoenix) consensus definition. Chronic toxicity was measured at peak symptoms and at last visit. Toxicity was scored based on Common Terminology Criteria for Adverse Events v4. RESULTS The median radiation dose delivered was 75.6 Gy (range 70.2 to 77.4) and 35.4% of patients received androgen deprivation therapy. Patients were followed until death or from 6 to 138 months (median 91) for those alive at last evaluation. Local and distant recurrence rates were 5% and 8.6%, respectively. At 9 years biochemical control rates were 77.4% for low risk, 69.6% for intermediate risk and 53.3% for high risk cases (log rank p = 0.05). On multivariate analysis T stage and prostate specific antigen group were prognostic for biochemical control. At last followup only 0% and 0.7% of patients had persistent grade 3 or greater gastrointestinal and genitourinary toxicity, respectively. High risk group was associated with higher distant metastasis rate (p = 0.02) and death from prostate cancer (p = 0.0012). CONCLUSIONS This study represents one of the longest experiences with intensity modulated radiation therapy for prostate cancer. With a median followup of 91 months, intensity modulated radiation therapy resulted in durable biochemical control rates with low chronic toxicity.

Comparison of the modified vest and the direct anastomosis for radical retropubic prostatectomy

OBJECTIVES This retrospective study was undertaken to compare the efficacy of the Vest and direct vesicourethral anastomosis for radical prostatectomy. METHODS Five hundred six patients who underwent consecutive radical prostatectomies at our institution were analyzed. Two hundred fifty-nine patients underwent vesicourethral anastomosis using the Vest technique and 247 underwent a direct suture anastomosis. The groups were analyzed relative to time until healing, the occurrence of anastomotic strictures, and the continence rate 1 year after surgery. RESULTS Approximately twice as many patients who underwent the Vest procedure experienced delayed healing and 8.5% developed anastomotic strictures compared with 1.2% of the direct anastomosis group. The Vest group experienced slightly better urinary continence 1 year postoperatively. CONCLUSIONS The Vest procedure is a reasonable alternative to direct anastomosis for radical prostatectomy and provides similar results. We suggest specific circumstances when the Vest anastomosis may be particularly useful.