Immune-inflammatory-nutritional status predicts oncologic outcomes after radical cystectomy for urothelial carcinoma of bladder.

OBJECTIVE: To perform the first investigation of the role of immune-inflammatory-nutritional status (INS) on oncological outcomes in patients undergoing open radical cystectomy (ORC) for urothelial carcinoma (UC). MATERIALS AND METHODS: The records of consecutive patients who underwent ORC for non-metastatic bladder cancer between 2009 and 2020 were retrospectively analyzed. Neoadjuvant chemotherapy, non-urothelial tumor biology, and absence of oncological follow-up were exclusion criteria. Systemic immune-inflammatory index (SII) and Prognostic Nutritional Index (PNI) values were calculated and optimal cut-off values for these were used to designate four subgroups: "high SII-high PNI", "low SII-high PNI", "low SII-low PNI", and "high SII-low PNI". The Low SII-high PNI INS group had best overall survival (OS) rate while the remainder were included in non-favorable INS group. Survival curves were constructed, and a multivariate Cox regression model was used for OS and recurrence-free survival (RFS). RESULTS: After exclusions, the final cohort size was 173 patients. The mean age was 64.31 ± 8.35 and median follow-up was 21 (IQR: 9-58) months. Optimal cut-off values for SII and PNI were 1216 and 47, respectively. The favorable INS group (low SII-high PNI, n = 89) had the best OS rate (62.9%). Multivariate Cox regression analysis indicated that non-favorable INS (n = 84) was a worse independent prognostic factor for OS (HR: 1.509, 95%CI: 1.104-3.145, p = 0.001) and RFS (HR: 1.285; 95%CI: 1.009-1.636, p = 0.042). CONCLUSION: Preoperative assessment of INS may be a useful prognostic panel for OS and RFS in patients who had ORC for UC.

Transrectal periprostatic lidocaine injection anesthesia for transrectal prostate biopsy: a prospective study.

Transrectal ultrasound (TRUS)-guided biopsy remains the mainstay of the diagnosis of prostate cancer. Although this diagnostic method is a safe procedure and well tolerated by most patients a significant number of patients report discomfort and pain during prostate biopsy. In order to define the best method of anesthesia, many studies, in which different methods were compared, have been performed. To determine the effectiveness of local injection anesthesia in TRUS-guided prostate biopsy, we designed and performed this prospective study in order to evaluate the utility of periprostatic nerve block for pain management. A total of 100 patients who had elevated total prostate-specific antigen (tPSA) and/or abnormal digital rectal examination (DRE) were included in this study. Half of the patients received periprostatic injection anesthesia (group I) and the remaining half received placebo (group II). Patients received 10 cm3 (5 cm3 each side) 1% lidocaine injected into the periprostatic nerve plexus under transrectal ultrasonic guidance. Pain during biopsy was assessed using a 10-point modified visual analog scale (VAS). In groups I and II, mean patient age was 66.8+2.5 and 65.6+11.5 y, mean tPSA was 7.87+/-3.6 and 11.3+/-1.7 ng/ml, mean biopsy duration was 6.5+/-2.5 and 6.6+/-2.2 min and mean pain score during TRUS-guided biopsy was 1.46+/-2.2 and 4.5+/-2.1, respectively. No statistically significant difference was observed with respect to age, tPSA and mean biopsy duration between these groups. Mean pain VAS score was statistically or significantly better (P=0.0001) in the lidocaine injection group (group I), and furthermore no patient had a VAS pain score > or =5 in this group. Only minor and transient complications occurred in both groups. This study reinforces the usage of periprostatic nerve block as a standard method of pain management during TRUS-guided prostate biopsy, because it is simple, safe, uncostly and significantly effective without requiring additional time.

Fenretinide therapy in prostate cancer: effects on tissue and serum retinoid concentration.

PURPOSE: To examine the feasibility of using fenretinide (4-HPR) for the prevention and treatment of prostate cancer. MATERIALS AND METHODS: We measured the impact of 4-HPR therapy on retinoid concentrations in vivo, in a mouse model of prostate cancer and clinically, in patients with prostate cancer who were given oral 4-HPR (200 mg/d) or placebo for 4 weeks before undergoing a radical prostatectomy. RESULTS: Prostate tumors in mice treated with 4-HPR contained high levels of 4-HPR and of all-trans-retinoic acid (RA) and reduced levels of retinol (ROH). Patients given 4-HPR were found to have significantly higher concentrations of 4-HPR in the cancerous prostate as compared with the serum levels (463 nmol/L v 326 nmol/L; P =.049), but they were only 1/10 the levels found in mice and were far below the concentrations reported in human breast tissue. Serum and tissue ROH levels were reduced to less than half the concentrations found in untreated controls. RA concentrations in human serum and in cancerous prostates were not significantly affected by 4-HPR treatment, in contrast with the findings in mice. CONCLUSION: The standard oral dose of 4-HPR proposed for breast cancer (200 mg/d) achieved only modest drug levels in the prostate and is unlikely to be effective for prostate cancer prevention or treatment. Higher doses need to be explored.

Clinical and pathological significance of the level and extent of capsular invasion in clinical stage T1-2 prostate cancer.

This study was performed to assess the relationship between the level and extent of prostatic capsular invasion (PCI) by cancer and the clinical and pathological features and prognosis of early-stage prostate cancer. We conducted a retrospective analysis of the clinical (age, stage, grade, prostate specific antigen [PSA] level) and pathological (tumor volume, stage, grade, surgical margins) features of 688 patients treated with radical prostatectomy to determine the pathological features and probability of recurrence associated with various levels of PCI. Radical prostatectomy specimens were serially sectioned and examined by whole-mount technique. Progression-free probabilities (PFP) after radical prostatectomy were determined by Kaplan-Meier and Cox proportional hazards regression analysis. Progression was defined as a rising serum PSA < or = 0.4 ng/mL or clinical evidence of recurrent cancer. Increasing clinical stage, Gleason grade in the biopsy specimen, and pretreatment serum PSA levels were each associated with increasing levels of PCI (P < .001). In the radical prostatectomy specimen, increasing levels of PCI were significantly associated with increasing tumor volume (P < .001), Gleason grade (P < .0001), seminal vesicle involvement (SVI, P < .001) and lymph node metastases (+LN, P < .001). None of 138 patients without capsular invasion had SVI or lymph node metastases (+LN), and all remained free of progression, even though some had large volume (up to 6.26 cm3) or poorly differentiated (Gleason sum up to 8) cancers. Invasion into the capsule (n = 271) was occasionally associated with SVI (6%) or +LN (3%) and a significantly (log-rank test) lower PFP of 87% at 5 years. Focal and extensive extraprostatic extension (EPE) were associated with progressively increased risk of SVI and +LN and lower PFP (73% and 42%, respectively). In a multivariate analysis, the level of PCI was an independent prognostic factor (P < .001). There is a strong association between the level of invasion of cancer into or through the prostatic capsule and the volume, grade, pathological stage, and rate of recurrence after radical prostatectomy. Prostate cancer does not appear to metastasize in the absence of invasion into the capsule regardless of the volume or grade of the intracapsular tumor. Subclassification of patients according to the levels of PCI provides valuable prognostic information.

Impact of a clinical pathway for radical retropubic prostatectomy.

OBJECTIVES: Cost containment has become an important issue in medical practice. With the implementation of collaborative care programs and critical pathways, substantial reduction in overall costs can be achieved while maintaining the quality of care and patient satisfaction. METHODS: Our series consists of 856 consecutive patients treated with radical retropubic prostatectomy by 24 surgeons in a single hospital between January 1, 1994, and January 31, 1997. A clinical pathway for radical retropubic prostatectomy was implemented July 1, 1994. The patients were subdivided into three groups: (1) baseline: patients who underwent surgery in the 6 months immediately before the pathway onset (n = 113); (2) nonpathway: 75 patients treated off the clinical pathway; and (3) pathway: 668 men placed on the clinical pathway. We compare average length of stay and average hospital charges among the three groups. We also compare average length of stay among physician volume groups: high volume physicians performed at least 12 operations per year; low volume physicians performed less than 12 operations per year. Charges were further broken down by department. Patient satisfaction was recorded by an outside source after discharge. Postoperative complications were assessed in the clinical pathway and nonpathway groups. RESULTS: Average hospital charges and average length of stay were $12,926 and 5.8 days for baseline patients, $11,795 and 5.0 days for nonpathway patients, and $10,042 and 4.0 days for pathway patients, respectively. Implementation of the clinical pathway was associated with lower charges and length of stay in the pathway group as well as the nonpathway group, with larger reductions in pathway patients. With continuous reassessment and modification of the clinical pathway, both average hospital charges and average length of stay have progressively decreased from $10,540 and 4.9 days in 1994 to $8766 and 2.7 days in January 1997. Charges were uniformly reduced in radiology, laboratory, pharmacy, operating room, anesthesia, and nursing or routine care. Patient satisfaction was similar in the pathway group and the nonpathway group. Incidence of postoperative complications did not differ significantly between the pathway and nonpathway groups. Length of stay and hospital charges were significantly lower for high than low volume surgeons, irrespective of the declines observed over time (P = 0.0001 and 0.0001, respectively). CONCLUSIONS: Average hospital charges and average length of stay for all surgeons were lowered significantly with the implementation of a clinical pathway and continue to decrease with continuous reassessment. The pathway was not associated with any increase in postoperative complications or patient dissatisfaction. Surgeons who operate frequently have lower average lengths of stay and hospital charges than those who operate infrequently.

Prostate-specific antigen doubling times are similar in patients with recurrence after radical prostatectomy or radiotherapy: a novel analysis.

PURPOSE: Some investigators have analyzed the rate of growth of prostate cancer that has recurred after definitive radiotherapy or radical prostatectomy using serum prostate-specific antigen (PSA) doubling times (DT). We examined all PSA values in recurrent patients to determine the pattern and rate of increase in PSA after radiation therapy and radical prostatectomy. PATIENTS AND METHODS: Charts of 96 recurrent radical prostatectomy patients (mean age, 62.8 years; range, 47 to 76) and 42 recurrent radiation therapy patients (mean age, 67.2 years; range, 52 to 83) were reviewed. All available PSA values between the date of operation/radiation treatment and last follow-up evaluation or the initiation of second-line therapy are included. Rate of PSA DT was not assumed to be constant over time; it was instead allowed to vary. We use a piecewise linear random-coefficients model in time for log (PSA), which allowed different mean models for both treatments. RESULTS: The PSA DT in the first year after radiation therapy was--1.17 years, which reflects the continuous decline in PSA in the average patients during the first year after radiotherapy despite eventual biochemical progression. In contrast, the PSA DT in the radical prostatectomy group was 0.66 in the first year. In year 2, after radiation therapy, the PSA DT was lengthy at 1.82 years, significantly longer (P = .0025) than in the radical prostatectomy group (0.76 years). After year 2, there were no significant differences between the two groups (P > .05). CONCLUSION: A piecewise linear random-coefficients model enables interval analysis of PSA DT. While the PSA DT after radiation therapy and radical prostatectomy are different in the first 2 years, the rate of increase in PSA appears to be similar in the two groups after year 2, which suggests the rate of growth of cancers that recur after radiation therapy and radical prostatectomy is similar.

Hazard rates for progression after radical prostatectomy for clinically localized prostate cancer.

OBJECTIVES: We calculated the annual hazard rate (HR) for prostate cancer recurrence after radical prostatectomy (RP) to elucidate the pattern of treatment failure over time and to assess the efficacy of definitive therapy. METHODS: We calculated the progression-free probabilities (PFP) and HRs after RP for a cohort of 611 consecutive men with clinically localized (cT1-2, NX, M0) prostate cancer and no other treatment before documented progression. RESULTS: PFP for the entire study population was 78% at 5 and 76% at 10 years. The highest HR (0.09) was observed in the year immediately after surgery and dropped to 0 by year 7 (no patient recurred after year 6). Average annual HRs calculated for 3-year intervals resulted in steadily declining HRs over time for the entire study population and for all subsets, except those with a cancer pathologically confined to the prostate. Overall, the more ominous the prognostic factor, the higher the initial HR. For poorly differentiated cancers (biopsy Gleason sum 8 to 10), the HR was high in years 1 and 2 and dropped rapidly to 0 thereafter. CONCLUSIONS: Prostate-specific antigen (PSA) progression after RP usually occurred early (77% within the first 2 years) and was largely due to understaging. Late recurrences were rare in patients who were regularly evaluated with PSA. However, because the confidence intervals in our study were broad, larger patient populations with longer follow-up are needed for a definitive establishment of the time, course, and pattern of recurrence after surgery.

Risk factors for complications and morbidity after radical retropubic prostatectomy.

PURPOSE: With recognition of the efficacy of surgical therapy for prostate cancer, there has been a marked increase in the number of radical prostatectomies performed, and substantial changes in surgical technique and perioperative management have decreased the morbidity of this procedure. We assessed the rate of perioperative complications with time and the risk factors for these complications, particularly age, operative time and co-morbidity. MATERIALS AND METHODS: A detailed review of all medical records of a consecutive series of 472 patients treated with radical retropubic prostatectomy by 1 surgeon between 1990 and 1994 was performed to document any complication within 30 days postoperatively. American Society of Anesthesiologists (ASA) physical status classification recorded by the staff anesthesiologist was used as a standard index of co-morbidity. RESULTS: Major complications were identified in 46 patients (9.8%), minor complications in 101 (21.4%) and none in 341 (72.2%). There were 2 deaths (0.42%). Major complications were not associated with age, operative time or year of operation but were significantly associated with ASA class (p = 0.006) and operative blood loss (p = 0.015) in a logistic regression analysis. Only 16% of patients were assigned to ASA class 3, yet this group included both deaths, a 3-fold increase in major complications, prolonged hospital stay, greater need for intensive care unit admission and more frequent blood transfusions. Major complications were almost 3 times more frequent in class 3 (21.3%) than in class 1 or 2 (7.6%) cases (p <0.005). Minor complications significantly increased hospital stay by a mean of 26% and major complications by 47% (p <0.0001). CONCLUSIONS: Radical retropubic prostatectomy was performed with no perioperative complication in 72% of patients. Major complications resulted in more intensive use of medical resources and were related to co-morbidity rather than age.

The role of digital rectal examination, biopsy Gleason sum and prostate-specific antigen in selecting patients who require pelvic lymph node dissections for prostate cancer.

OBJECTIVE: To examine the usefulness of clinical stage, tumour differentiation and prostate-specific antigen (PSA) level, alone and in combination, to predict regional nodal metastases in individual patients with localized prostate cancer. PATIENTS AND METHODS: The usefulness of digital rectal examination (DRE), biopsy Gleason sum and PSA, alone and in combination, to predict nodal metastases in an individual patient was examined. The study included 689 patients who had laparoscopic or open pelvic lymph node dissection for clinical stage T1-3 prostate cancer. The Kruskal-Wallis test, Mantel-Haenszel test, chi-squared test and logistic regression were used for continuous, ordinal, categorical, and multivariate analysis, respectively. RESULTS: Of the 689 patients who underwent radical prostatectomy, 52 (8%) had nodal metastases. Although clinical stage, DRE, pre-operative PSA level and biopsy Gleason sum were significantly related in the univariate analysis, only pre-operative PSA level and biopsy Gleason sum were significant predictors of lymph node status in a multivariate analysis. However, based on a receiver operating characteristic curve, a model with satisfactory sensitivity and specificity could not be obtained. CONCLUSION: Current estimations of primary prostate cancer biology using pre-operative PSA level, clinical stage and biopsy Gleason sum are not sufficiently sensitive to predict nodal metastases, and pelvic lymphadenectomy remains the definitive method of detection.

Spontaneous fracture of indwelling ureteral stents in patients treated with extracorporeal shock wave lithotripsy: two case reports.

Placement of indwelling ureteral stents adjunctive to ESWL treatment has been a widespread practice. We herein present two cases of spontaneous breakage of double pigtail ureteral stents and their management. Prevention of this complication may be possible by careful examination of the stents prior to insertion, by following the instructions of manufacturers on maximum time limits and by using stent logs to keep track of patients.

Distant metastasis after radical prostatectomy in patients without an elevated serum prostate specific antigen level.

BACKGROUND: Serum prostate specific antigen (PSA) is a sensitive indicator of prostate cancer recurrence after radical prostatectomy. Prostate cancer rarely recurs after radical surgery without PSA elevation. Of the few patients noted in the literature who had a recurrence of cancer without PSA elevation, all had local recurrence alone, except for one, who had bone metastases. METHODS: In the authors' series of 628 patients, PSA was the first indicator of recurrence in all but 2 (2.6%) of 77 patients with clinical T1-T3NxM0 classification prostate cancer. RESULTS: Two of our patients, despite having undetectable PSA levels, had distant recurrence, including one with multiple visceral (lung and brain) metastases. CONCLUSIONS: These two cases demonstrate that although uncommon, prostate cancer can recur and metastasize after radical prostatectomy without an increase in the serum PSA level.

Screening for prostate cancer: an analysis of the early experience.

Several common misconceptions have fueled the debate over the early detection and treatment of prostate cancer. While prostate cancer is often described as a common cancer that older men die with rather than of, the reality is that the incidence, mortality, and mean age and stage at diagnosis of prostate cancer are very similar to those of breast cancer, which is rarely the subject of similar concerns. Many studies have confirmed that given enough time, all clinically detected prostate cancers will inexorably progress locally and eventually metastasize to regional lymph nodes as well as to distant sites. The relatively slow doubling time compared to that of other cancers and the wide spectrum of biologic activity of prostate cancer have made retrospective studies reporting the long-term survival of conservatively treated patients highly suspect due to selection bias and inadequate follow-up. While it is accepted that a large number of men harbor clinically insignificant cancers in their prostate glands, these estimates have been based on careful pathologic step-sectioning studies of prostates obtained either at autopsy or after cystoprostatectomy for bladder cancer. Several studies have now demonstrated that currently available diagnostic modalities for detecting prostate cancer, DRE, PSA, and TRUS, are not able to detect a significant proportion of small, clinically unimportant cancers. Rather, studies have shown that while the traditional DRE has been largely unsuccessful in detecting prostate cancers at a sufficiently early stage for effective treatment with either radical prostatectomy or radiation therapy, a combination of the DRE and PSA followed by TRUS and ultrasound-guided biopsy in those with abnormal results can detect an increased proportion of clinically significant prostate cancers while they are still confined to the prostate gland and thus more likely to be eradicated by treatment. Several randomized trials are now under way in this country and in Europe that may settle many of these issues over the next decade. However, currently available data suggest that prostate cancer screening holds the promise of decreasing the considerable morbidity and mortality caused by this disease.

Correction of primary and secondary vesicoureteral reflux by subureteric Teflon injection.

Polytetrafluoroethylene (Teflon) has been used for various purposes since 1963 and in urologic practice for the treatment of vesicoureteral reflux (VUR) since the 1980s. In this study we report on our experience with Teflon injection for the treatment of 28 children with primary or secondary reflux. An overall success rate of 91.3% was achieved in the treatment of primary and 66.6% in secondary reflux. With these results we conclude that Teflon injection is a good alternative in the treatment of VUR.

Flow cytometric DNA studies and AgNOR counts in patients with transitional cell carcinoma of the bladder.

Flow cytometry appears to be a promising diagnostic method which may influence the therapeutic approach to transitional cell carcinoma (TCC) of the bladder. The number of silver-stained nuclear organizer regions (AgNORs) seems to correlate with the growth fractions of the cells. In this study, we report the results of combined flow cytometric analysis and AgNOR in 37 patients with TCC of the bladder. A positive correlation was observed in the histological grade, stage and growth pattern in relation to the ploidy of tumors. There were statistically significant differences among the mean AgNOR counts of the different groups as defined by DNA content, histological grade, growth pattern and disease outcome. In different stage groups, the AgNOR counts were related both to recurrence and progression. It was concluded that AgNOR counts performed on routine formalin-fixed paraffin sections furnish significant kinetic information. According to our preliminary results AgNOR counts and the DNA content of the tumors should also be measured to decide on more aggressive treatment in some cases.

Current controversies in the management of localized prostate cancer.

As longevity has improved and mortality from cardiovascular and other diseases has declined, the risk of death from prostate cancer has increased steadily. Though slow growing, prostate cancer is not a benign disease. Nearly 10% of men in Western countries will be diagnosed with prostate cancer sometime during their life and 3% will die of the disease. The prospects for long-term control of prostate cancer diminish rapidly once the cancer has spread beyond the immediate periprostatic tissue. The 5-year survival rate for men with metastases is less than 30% and almost all will eventually die of their disease. A simple blood test, prostate-specific antigen (PSA), is available. This test, when used in conjunction with ultrasound-guided systematic needle biopsy of the prostate, will detect potentially lethal prostate cancers earlier than digital rectal examination (DRE). Definitive treatment, especially with radical prostatectomy, can eradicate the tumor in 90% of patients if the cancer is still confined to the prostate pathologically, regardless of the tumor grade. Randomized, prospective clinical trials are now underway to demonstrate conclusively whether screening or early definitive therapy will substantially reduce the mortality rate from this disease. Until the results of these trials are available, we recommend that healthy men over age 50, who have a life expectancy of 10 years or longer, have an annual PSA and DRE to detect prostate cancer while it is still curable.

The role of ureteroscopy as a diagnostic and therapeutic tool in various indications.

Ureteroscopy is now in routine use for the diagnosis and treatment of various pathologies in the upper urinary tract. We report here on our experience in diagnostic and therapeutic applications of the 11.5 F rigid ureteroscope in 85 patients and 88 ureters. An overall success rate of 68.18% (60/88) was achieved when therapeutic and diagnostic interventions were evaluated together. Success rate was 66.65% in the treatment of ureteral stones (all locations), 100% in the removal of retained catheters, and 81.82% in diagnostic interventions. Frequencies of complications like postoperative fever, stone migration, and various degrees of ureteral perforation were 5.68%, 5.68%, and 7.95%, respectively, consistent with current literature. We conclude that rigid ureteroscopy can be safely applied for appropriate indications in the hands of competent urologists.

Impact of prostate-specific antigen density in benign prostatic hyperplasia and prostate carcinoma. Preliminary results.

In an attempt to enhance the success of prostate-specific antigen (PSA) in the diagnosis and staging of prostate carcinoma (PCa) the concept of PSA density (PSAD) has been introduced by Benson et al. Likewise a study to investigate the role of PSAD in 53 patients with PCa and 47 patients with benign prostatic hyperplasia (BPH) has been done. PSADs seemed to increase directly proportional to the grade in PCa and differed significantly between patient groups with BPH and localized+metastatic PCa, BPH and localized PCa, and localized PCa and metastatic PCa. Although 0.6 level for PSAD seemed to be a rational cut-off level in our study, this issue needs to be studied in multiple centers involving an increased number of patients for resolution.

Single dose of ofloxacin treatment in women with dysuria and frequency.

The efficacy of single dose ofloxacin in lower urinary tract infections was investigated in this study. Fifty-one women with complaints of dysuria and frequency were treated with a single dose of 400 mg ofloxacin orally. The results of urinalysis and urine culture which were performed 4-7 days after the administration of the drug were evaluated. Thirty-eight of the 47 evaluable patients (80.85%) were asymptomatic with normal urinalysis and sterile urine, thus cured. The data of the study suggest that single dose ofloxacin may be the first treatment option in the particular group of women with uncomplicated urinary tract infection.

The cost and availability of therapeutic options in advanced prostatic carcinoma in Turkey.

Advanced prostatic carcinoma may be treated by a variety of methods of endocrine manipulation which affect the production of androgens. This can either be done by bilateral orchiectomy or by a number of drugs. Orchiectomy has two advantages: low cost and being a once-only procedure. This report outlines the costs of various methods of hormonal treatment and compares them with each other in Turkey.

Efficacy of prophylactic gentamicin use in postoperative urinary tract infections after endoscopic procedures of the urinary tract.

In this study, the efficacy of prophylactic antibiotic use was investigated. A total of 110 patients undergoing endoscopic procedures of the urinary tract were enrolled in the study. Fifty-five of the patients were treated with 8-hourly, 80 mg gentamicin sulfate of total three doses. The drug administration began just prior to the operation. Seven postoperative infections (12.7%) were detected, the same number as in the control group of 55 patients. The results confirm that there is no place for gentamicin prophylaxis in endoscopic procedures of the urinary tract.