[SURGEON QUESTIONNAIRE FOR ESTABLISHING A SURGEON EDUCATION SYSTEM FOR TRANSURETHRAL LASER RESECTION OF THE PROSTATE (HoLEP)].

(Introduction)HoLEP's role in the surgical management of benign prostatic hyperplasia (BPH) is steadily growing. In this study, a questionnaire containing questions about perioperative management was submitted to HoLEP surgeons to help establish standard surgical training procedures. (Methods)We sent a comprehensive 17 questionnaires on HoLEP procedures to 18 surgeons. The questionnaire asked, "Which method are you using, the 1-LOBE or 3-LOBE method?", "What educational methods are being used for surgeons?", "How long is the catheter insertion period after HoLEP?", and "What is the most difficult problem encountered in surgical HoLEP education and what aspect of training is the most emphasized?" (Results)Sixteen (88.9%) surgeons answered these questionnaires. Five surgeons reported using the one lobe method, five surgeons reported using the three lobe method, and four surgeons answered that it depends on the case. Regarding educational methods, the main answer was that it is important to evaluate pre-HoLEP imaging tests such as MRI and cystoscopy and to simulate surgery for education. Regarding the postoperative catheter insertion period, 1 day: 1 surgeon, 2 days: 9 surgeons, 3 days: 3 surgeons, 4 days or more: 1 surgeon. The most important thing reported for surgical education was to help beginners understand the characteristics of lasers, including direction, distance to prostate tissue, and adenoma removal. (Conclusions)The surgeons' responses clearly indicated some differences in practices between institutions. More detailed data from these results will provide a step towards designing standardized surgical and educational protocols for HoLEP.

Laparoscopic adrenalectomy: troublesome cases.

Among 143 cases of laparoscopic adrenalectomy carried out from 1993 to the present, 13 patients in whom the surgical manipulation presented problems were examined. Problems occurred due to the condition of the adrenal tumors themselves in six patients, whereas problems occurred due to the operative history in four patients. There were three patients with no operative history but with strong intraperitoneal adhesion. In patients with a history of laparotomy in other fields such as open cholecystectomy, gastrectomy or colostomy, operations were possible in most patients by examining the trocar site preoperatively. Patients with strong adhesion even without a history of surgery could be handled by full separation of the adhesion during surgery. In patients with bleeding in the adrenal tumors, large adrenal tumors, or tumors impacted in the liver, methods such as changing the sequence of separation procedures were required. In patients with a history of renal subcapsular hematomas due to extracorporeal shock wave lithotripsy (ESWL), it was not possible to understand the conditions of adrenal or perinephritic adhesion in preoperative imaging diagnosis, but resection was possible by changing the order of separation procedures and by using optimal instruments and devices. As with any surgery, including open surgeries, it is necessary to obtain knowledge on how to deal with variations in laparoscopic adrenalectomy to assure safe outcomes and to always consider effective methods for coping with unexpected difficulties.

[Hemorrhagic radiation cystitis: a transurethral treatment with formalin-soaked pledgets].

An 80-year-old woman presented with gross hematuria and clot retention about 20 years after postoperative radiation therapy for uterine cancer. Endoscopic evaluation revealed a hyperemic bladder mucosa and bleeding foci localized to the posterior wall. Electrocauterization and continuous bladder irrigation with normal saline failed to resolve the hemorrhage, Maalox (aluminum hydroxide/magnesium hydroxide) was instilled intravesically. The events of gross hematuria and clot retention recurred frequently, cotton pledgets soaked in 5% formalin were placed endoscopically onto the bleeding sites of the bladder posterior wall for 15 minutes with success. We consider this technique useful for intractable hemorrhage secondary to radiation cystitis.

Clinical outcome of combined immunotherapy with low-dose interleukin-2 and interferon-alpha for Japanese patients with metastatic renal cell carcinoma who had undergone radical nephrectomy: a preliminary report.

BACKGROUND: The objective of this study was to evaluate the clinical outcome of combined immunotherapy with interferon-alpha (IFN-alpha) and low-dose interleukin-2 (IL-2) for Japanese patients with metastatic renal cell carcinoma (RCC) who had undergone radical nephrectomy. METHODS: This study included 13 patients who were diagnosed as having metastatic RCC following radical nephrectomy. These patients received a subcutaneous injection of IFN-alpha (6 x 10(6) IU per day) three times per week and an intravenous injection of IL-2 (1.4 x 10(6) IU per day) twice per week. Tumor response was evaluated every 16 weeks, and as a rule, this weekly regimen was repeated 50 times in patients with evidence of objective response or stable disease. RESULTS: One of the 13 patients dropped out because of severe toxicity; hence, 12 patients were evaluable, with a median follow-up period of 18 months after the start of this combined therapy. Six patients (50.0%) achieved objective responses, with 1 complete response (CR), while only 2 (16.7%) demonstrated progressive disease. The median duration of response in the 6 responders was 13.5 months. Toxicity associated with this combined immunotherapy was limited to WHO grade 1 or 2 in these 12 patients. All patients were alive at last follow-up, and 2 remain disease-free after 1 additional patient showed a CR following surgical resection of the remaining metastatic disease. CONCLUSION: Our preliminary experience suggests that long-term, repeated treatment with IFN-alpha and low-dose IL-2 is feasible in Japanese patients with metastatic RCC who have undergone radical nephrectomy. Although it will be necessary to accumulate data from a larger number of patients with a longer follow-up period, the combined immunotherapy tested in this study may become the preferred therapy for Japanese patients with metastatic RCC.

Prognostic significance of the tumor volume in radical prostatectomy specimens after neoadjuvant hormonal therapy.

INTRODUCTION: The objective of this study was to determine whether the tumor volume in radical prostatectomy specimens of patients with prostate cancer who underwent neoadjuvant hormonal therapy (NHT) could be used as a prognostic predictor. PATIENTS AND METHODS: In this study, we included 96 patients who underwent NHT followed by radical prostatectomy between January 1995 and July 2003 in our institutions. Several clinicopathological factors of these patients were analyzed, focusing on the association between tumor volume in radical prostatectomy specimens and disease recurrence. RESULTS: The tumor volume in radical prostatectomy specimens after NHT was significantly associated with capsular penetration, seminal vesicle invasion, and lymph node metastases, among the factors examined in this study. The biochemical recurrence-free survival rates in patients with tumor volumes <1.0 cm(3) were significantly higher than in those having tumor volumes > or =1.0 cm(3). However, multivariate analysis showed that the tumor volume could not be used as an independent predictor for biochemical recurrence. CONCLUSIONS: In patients who received NHT prior to radical prostatectomy, the tumor volume was shown to correlate with other prognostic indicators. Furthermore, a higher probability of biochemical recurrence was noted, when there was a residual tumor volume > or =1.0 cm(3) after NHT. Thus, careful follow-up and, if necessary, additional treatment should be considered in cases demonstrating tumor volumes > or =1.0 cm(3) after NHT.

The significance of prostate-specific antigen alpha-1-antichymotrypsin complex and its indices for the detection of prostate cancer.

We examined the usefulness of prostate specific antigen alph-1-antichymotrypsin complex (PSA-ACT) and its indices for the detection of prostate cancer in patients with a prostate specific antigen (PSA) level between 2.1 and 10.0 ng/ml. Between July 1999 and October 2001, 151 patients with a PSA level between 2.1 and 10.0 ng/ml underwent a systematic biopsy under transrectal ultrasound (TRUS) guidance. The clinical values of total PSA, PSA-ACT, PSA density (PSAD), PSA-ACT density (PSA-ACTD), PSA transition zone density (PSATZD) and PSA-ACT transition zone density (PSA-ACTTZD) for the detection of prostate cancer were compared by using receiver operating characteristic (ROC) curve analysis. Of the 151 patients, 36 (23.8%) were histologically confirmed as having prostate cancer. The differences between patients with prostate cancer and benign prostatic disease were significant with respect to the PSA and PSA-ACT related parameters examined in this study. According to ROC curve analysis, the area under the curve (AUC) of PSA-ACTTZD was the greatest of all the parameters. The differences was significant between the AUC of PSA-ACTTZD and total PSA (p < 0.05). The cutoff value of PSA-ACTTZD with 0.20 ng/ml2 showed the highest sum of sensivitity (90%) and specificity (55%). Also, in 86 patients with a PSA level between 2.1 and 6.0 ng/ml, the AUC of PSA-ACTTZD was the greatest of all the parameters. Measuring the level of PSA-ACT and its indices may provide a better differentiation of prostate cancer and benign prostatic disease than total PSA alone in patients with intermediate PSA levels. PSA-ACTTZD is the most useful indicator among PSA-ACT and its volume indices.

Clinical outcome of conservative therapy for stage T1, grade 3 transitional cell carcinoma of the bladder.

BACKGROUND: The objective of this study was to retrospectively investigate the effectiveness of transurethral resection of bladder tumor (TURBT) and intravesical instillation therapy for stage T1, grade 3 (T1G3) transitional cell carcinoma (TCC) of the urinary bladder. METHODS: Between January 1995 and December 1997, 97 patients with T1G3 TCC of the urinary bladder were treated by TURBT and adjuvant intravesical instillation with bacillus Calmette-Guérin (BCG) or other anticancer agents. The recurrence-free survival rates were evaluated according to several clinicopathological factors. The cases that progressed to muscle invasive disease were also analysed. RESULTS: In this series, the median follow-up period was 25 months (range, 5- 41) after the initial TURBT. Intravesical recurrence was noted in 44 patients (45%), and the 1, 2, and 3 year recurrence-free survival rates were 72%, 58%, and 42%, respectively. Multivariate analyses revealed that the risk of intravesical recurrence was significantly higher for patients who did not receive BCG therapy, irrespective of age, gender, tumor size, multiplicity, pathological stage, concomitant carcinoma in situ, and lymphovascular involvement. Moreover, after a median of 10 months, disease progression occurred in seven patients (7%), of which only one patient was treated by BCG therapy after initial TURBT. CONCLUSION: These findings suggest that intravesical instillation with BCG combined with TURBT is an effective conservative treatment for T1G3 TCC of the bladder. Patients with negative prognostic factors should be treated by BCG rather than other anticancer agents after TURBT.

Neoadjuvant androgen withdrawal prior to external radiotherapy for locally advanced adenocarcinoma of the prostate.

BACKGROUND: It is unclear whether positive interactions between radiation and androgen withdrawal for patients with locally advanced prostate cancer is synergistic or additive. The present study aimed to clarify the significance of neoadjuvant androgen ablation prior to external radiotherapy in a human prostate LNCaP tumor model and in patients with locally advanced prostate cancer. METHODS: Comparisons were made between the effect of castration prior to radiation on the growth of subcutaneous LNCaP tumors implanted into male nude mice and their serum prostate-specific antigen (PSA) levels, and the results of castration or radiation alone. Twenty-nine patients with histologically proven and locally advanced adenocarcinoma of the prostate were treated with luteinizing hormone-releasing hormone analog at least 3 months before, during, and after external radiation therapy with a total dose of 70 Gy. The toxicity and response to this therapy were evaluated. RESULTS: Treatment combining castration and radiation resulted in synergistic inhibition of LNCaP tumor growth and a significant delay in the emergence of androgen-independent recurrence as opposed to either treatment alone. The external radiotherapy was completed in 28 patients (96.6%), resulting in a reduction of serum PSA levels in all 28 patients to below 1.0 ng/mL. All patients were alive after a mean follow-up period of 34 months (range 11-53) with a 3-year PSA relapse-free survival rate of 83.7%. Among several factors examined, only the Gleason score was significantly associated with PSA relapse-free survival in univariate analysis, but not in multivariate analysis. Thirteen of 28 patients (46%) and 7 of 28 (25%) also showed at least one form of gastrointestinal or genitourinary toxicity, respectively. Of these patients, 8 with gastrointestinal toxicities, and 1 with genitourinary toxicity, experienced acute complications higher than grade 3. CONCLUSION: The experimental findings objectively suggested the use of neoadjuvant androgen withdrawal prior to radiation therapy. Although our clinical experience is preliminary, combined androgen ablation and radiation therapy may also be effective in controlling locally advanced prostate cancer, with tolerable side-effects.

Nephrostomy tract tumor seeding following percutaneous manipulation of a renal pelvic carcinoma.

We report a case of nephrostomy tract tumor seeding following percutaneous pyeloscopic manipulation of a renal pelvic carcinoma. To our knowledge, this is the second reported case of such a lesion surrounding the nephrostomy tract. Percutaneous pyeloscopic treatment carries a potential risk of local tumor spillage and implantation in the nephrostomy tract.

Increased serum carcinoembryonic antigen level in patients undergoing colon neobladder replacement compared with ileal neobladder replacement.

OBJECTIVES: To compare the serum and urinary carcinoembryonic antigen (CEA) levels for assessment of possible risk of malignant transformation in patients with orthotopic neobladder. METHODS: The serum and urinary levels of CEA, nutritional status, and acid-base and electrolyte balances were studied in 87 patients after radical cystectomy (22 with ileal neobladder, 28 with colon neobladder, and 37 with ileal conduit). The results of these groups were compared. RESULTS: The serum CEA level in patients with colon neobladder, ileal neobladder, and ileal conduit was 5.4 +/- 3.0, 3.7 +/- 1.6, and 3.1 +/- 1.5 ng/mL, respectively. The serum CEA level in the colon neobladder group was significantly higher than the levels in the remaining two groups (P <0.05); 16 patients (57%) with colon neobladder had elevated serum CEA values (ie, greater than 5 mg/mL). Elevated serum CEA was observed in only 5 (23%) and 3 (8%) patients with ileal neobladder or ileal conduit, respectively. The serum CEA value in these patients was associated with the urinary CEA value (P <0.001), but not the other factors examined. CONCLUSIONS: These findings suggest that colon bladder replacement caused significantly increased serum CEA values compared with ileal neobladder or ileal conduit; however, the elevated serum CEA level correlated with the urinary CEA level, irrespective of other clinical factors. Therefore, the elevated serum CEA in the colon neobladder group may have been due to reabsorption of CEA in urine rather than to an association with malignant changes in the bowel segments used for neobladder creation.

Predicting the extent of prostate cancer using a combination of serum prostate-specific antigen-alpha(1)-antichymotrypsin complex and systematic biopsy.

OBJECTIVE: The objective of the present study was to evaluate the usefulness of the combined systematic biopsy with serum prostate-specific antigen-alpha(1)-antichymotrypsin complex (PSA-ACT) level to predict the extent of prostate cancer. MATERIALS AND METHODS: Sixty-two patients with clinically organ-confined disease who underwent radical prostatectomy were evaluated for serum PSA and PSA-ACT levels, systematic biopsy, and the pathological stage. RESULTS: The incidence of extraprostatic disease in patients with more than half the biopsy cores positive or > or = 8 ng/ml PSA-ACT was significantly higher than those with less than half positive or <8 ng/ml PSA-ACT, respectively, whereas cancer in bilateral lobes or > or = 10 ng/ml PSA could not be used as a predictor of extraprostatic disease. Furthermore, in those with more than half the biopsy cores positive and > or = 8 ng/ml PSA-ACT or those with more than half the biopsy cores positive and > or = 10 ng/ml PSA, extraprostatic disease was significantly more common than in those with less than half positive and <8 ng/ml PSA-ACT or those with less than half positive and <10 ng/ml PSA, respectively. However, the incidence of extraprostatic disease predicted by these three variables was not significantly better than those by the two variables (percentage positive biopsy cores plus serum PSA-ACT or PSA). CONCLUSIONS: The combined systematic biopsy with serum PSA-ACT or PSA could be used as a useful predictor for the extent of prostate cancer. Patients with more than half the biopsy cores positive and > or = 8 ng/ml PSA-ACT or > or = 10 ng/ml PSA could avoid a prostatectomy because there is a high probability that they have extraprostatic disease.