Urinary fistulas following external radiation or permanent brachytherapy for the treatment of prostate cancer.

PURPOSE: Prostate cancer (PCa) radiotherapy (RT), including brachytherapy, may lead to significant morbidity, including urinary fistulas. If conservative measures fail, urinary and/or fecal diversion is often required. In this study we examined a series of patients with fistulas that developed after pelvic radiation therapy and explored potential predisposing factors and treatment recommendations for refractory fistulas. MATERIALS AND METHODS: Patients were identified who received radiation therapy for PCa between 1977 and 2002, and subsequently had a fistula to the urinary tract. Patients were excluded who had diverticulitis, inflammatory bowel disease, a history of recent radical retropubic prostatectomy (possible iatrogenic etiology) or cancer in the excised fistula. Data were extracted from patient charts, mailed questionnaires and outside records. RESULTS: A total of 51 patients were identified with a history of radiation for PCa who subsequently had a urinary fistula. Of 20 patients meeting inclusion criteria 30% received external beam RT alone, 30% received brachytherapy and 40% received combined external beam RT/brachytherapy. Most fistulas (80%) were from the rectum to the urinary tract with an average diameter of 3.2 cm. Of patients with rectal fistulas 81% had a history of rectal stricture, urethral stricture, rectal biopsy, rectal argon beam therapy or transurethral prostate resection after radiation. All patients with rectourethral fistulas who achieved symptomatic resolution required urinary and fecal diversion. CONCLUSIONS: Conservative treatment is generally ineffective in the management of large urinary fistulas. Surgical intervention offers symptomatic relief and improved quality of life in most patients.

Competing risk analysis after radical prostatectomy for clinically nonmetastatic prostate adenocarcinoma according to clinical Gleason score and patient age.

PURPOSE: Factors important for determining appropriate therapy for localized prostate cancer are biopsy tumor grade, patient age and co-morbidity. We estimated the probability of dying from prostate cancer or other competing causes stratified by age at diagnosis and clinical histological grade in men diagnosed with clinically nonmetastatic prostate cancer who were treated with radical prostatectomy. MATERIALS AND METHODS: A total of 751 men comprised a retrospective cohort with clinically nonmetastatic prostate cancer diagnosed and treated with bilateral pelvic lymphadenectomy and radical prostatectomy at our institution between 1971 and 1984. All patients were between 55 and 74 years old (median age 65) at diagnosis and they were followed a median of 14.7 years. The cumulative incidence of prostate cancer death or death from any cause was estimated using methods of competing risk survival analysis. RESULTS: Overall 435 men died with 32% of the deaths attributable to prostate cancer. In 62%, 27% and 11% of patients the Charlson co-morbidity score was 0, 1 and 2+, respectively. The only significant predictor of death from prostate cancer was clinical Gleason score (p <0.001), while only age and Charlson co-morbidity score were significant independent predictors of death from other causes (p <0.001). The estimated cumulative incidence of prostate cancer death after considering competing risks increased with Gleason score regardless of patient age. In men with Gleason scores 2 to 4, 5, 6, 7 and 8 to 10 disease the cumulative incidence of prostate cancer death within 20 years was 6% to 7%, 10% to 13%, 15% to 19%, 29% to 35% and 36% to 43%, respectively, depending on age at diagnosis. Clinical stages T2 and T3 outcomes were indistinguishable. CONCLUSIONS: This study shows that for any given Gleason score the prostate cancer death rate is similar in older and younger patients with few to no co-morbidities. Men with a score of 7 to 10 were at 29% to 43% risk of death from prostate cancer even when cancer was diagnosed as late as age 74 years and treated surgically.

Injectable agents: present and future.

Stress urinary incontinence (SUI) is primarily managed by conservative strategies. When these methods fail, minimally invasive treatments, if effective, safe, and durable, can result in a considerable reduction in current medical costs for this common condition. Injection of currently available bulking agents is a safe, minimally invasive procedure and offers a degree of efficacy. The long-term durability of several of these agents is yet to be determined. The use of bulking agents for the treatment of anatomic SUI has been demonstrated to produce success rates similar to those observed when these materials are used in patients with intrinsic sphincter deficiency, opening up new therapeutic options for women with SUI. We review the current basic science and clinical research into the development of newer agents for soft-tissue bulking.

Polypropylene mesh tape for stress urinary incontinence: complications of urethral erosion and outlet obstruction.

PURPOSE: Gynecare tension-free vaginal tape (Ethicon, Inc., New Brunswick, New Jersey) is a propylene mesh tape recently introduced in the United States as minimally invasive treatment for stress urinary incontinence. We report the combined experience at 3 tertiary care institutions with graft erosion and bladder outlet obstruction after procedures performed elsewhere. MATERIALS AND METHODS: We reviewed the records of 5 patients with complications who presented to 1 of 3 institutions after polypropylene mesh tape placement. All pertinent information was obtained from the medical records and the operating surgeon at the referring institution. RESULTS: Treatment was required in 2 patients with urethral erosion, 1 with vaginal and bladder erosion, and 2 with bladder outlet obstruction. Common presenting symptoms included urge, urge incontinence and gross hematuria. Cystoscopy showed polypropylene graft erosion at the urethra or through the bladder wall. Each patient required explantation of the polypropylene mesh tape and further surgery to restore continence. The graft was divided transvaginally in the 2 patients presenting with outlet obstruction. Urge incontinence resolved and they returned to complete spontaneous voiding. CONCLUSIONS: High clinical suspicion is necessary when evaluating patients presenting with urinary symptoms after polypropylene mesh tape placement. Bladder outlet obstruction and possible graft erosion should be considered.

Treatment of organ confined prostate cancer with third generation cryosurgery: preliminary multicenter experience.

PURPOSE: Cryosurgical ablation of the prostate is 1 approach to the treatment of localized prostate cancer. Third generation cryosurgery uses gas driven probes that allow for a decrease in probe diameter to 17 gauge (1.5 mm). The safety, morbidity and preliminary prostate specific antigen (PSA) results of 122 cases are reported. MATERIALS AND METHODS: A total of 106 patients have undergone percutaneous cryosurgery using a brachytherapy template with at least 12 months of PSA followup. Immediate and delayed morbidities were evaluated. PSA results at 3 and 12 months were recorded, and failure was defined as the inability to reach a nadir of 0.4 ng/ml or less. RESULTS: Complications in patients undergoing primary cryosurgery included tissue sloughing (5%), incontinence (pads, 3%), urge incontinence/no pads (5%), transient urinary retention (3.3%) and rectal discomfort (2.6%). There were no cases of fistulas or infections. Postoperative impotence was 87% in previously potent patients. For patients who underwent salvage cryosurgery there were no fistulas reported and 2 (11%) patients required pads after salvage cryosurgery. A total of 96 (81%) patients achieved a PSA nadir of 0.4 ng/ml or less at 3 months of followup, while 79 of 106 (75%) remained free from biochemical recurrence at 12 months. A total of 42 (78%) low risk patients (Gleason score 7 or less and PSA 10 or less) remained with a PSA of 0.4 ng/ml or less at 12 months of followup, compared to 37 (71%) high risk patients. All patients were discharged within 24 hours. CONCLUSIONS: After a followup of 1 year 3rd generation cryosurgery appears to be well tolerated and minimally invasive. The use of ultrathin needles through a brachytherapy template allows for a simple percutaneous procedure and a relatively short learning curve. A prospective multicenter trial is ongoing to determine the long-term efficacy of this technique.