Effects of pelvic rotation and needle angle on pubic arch interference during transperineal prostate implants.

PURPOSE: Pubic arch interference due to an enlarged prostate gland or a narrow pubic arch is often a limiting factor in adequate prostate coverage during transperineal brachytherapy. The purpose of this study was to evaluate the effects of both pelvic rotation and needle angles on pubic arch interference using CT-based 3-D information. METHODS AND MATERIALS: Seven patients had CT imaging in both supine and lithotomy positions and 3-D treatment planning was performed with three needle angles (20 downward, 0, 20 upward). The pubic arch interference was then measured and comparisons were made for each needle trajectory and pelvic position. RESULTS: Increasing pelvic rotation from supine to lithotomy position shows less pubic arch interference. Directing the needle tip upward shows less pubic arch interference in both supine and lithotomy positions when compared to needle tips directed downward. CONCLUSIONS: Both pelvic position and needle angles are important factors influencing pubic arch interference. Preplanning CT-based 3-D information may assist for individualized treatment planning in patients with a significant bony interference, thus avoiding pubic arch interference during implantation.

Retroperitoneal and pelvic extraperitoneal laparoscopy: an international perspective.

OBJECTIVES: To assess technical preferences and current practice trends of retroperitoneal and pelvic extraperitoneal laparoscopy. METHODS: A questionnaire survey of 36 selected urologic laparoscopic centers worldwide was performed. RESULTS: Twenty-four centers (67%) responded. Overall, 3988 laparoscopic procedures were reported: transperitoneal approach (n = 2945) and retroperitoneal/extraperitoneal approach (n = 1043). Retroperitoneoscopic/extraperitoneoscopic procedures included adrenalectomy (n = 74), nephrectomy (n = 299), ureteral procedures (n = 166), pelvic lymph node dissection (n = 197), bladder neck suspension (n = 210), varix ligation (n = 91), and lumbar sympathectomy (n = 6). Mean number of total laparoscopic procedures performed in 1995 per center was 41 (range 5 to 86). Major complications occurred in 49 (4.7%) patients and included visceral complications in 26 (2.5%) patients and vascular complications in 23 (2.2%). Open conversion was performed in 69 (6.6%) patients, electively in 41 and emergently in 28 (visceral injuries, n = 16; vascular injuries, n = 1 2). Retroperitoneoscopy/extraperitoneoscopy is gaining in acceptance worldwide: in 1993, the mean estimated ratio of transperitoneal laparoscopic cases versus retroperitoneoscopic/ extraperitoneoscopic cases per center was 74:26; however, in 1996 the ratio was 49:51. CONCLUSIONS: Retroperitoneoscopy and pelvic extraperitoneoscopy are important adjuncts to the laparoscopic armamentarium in urologic surgery. The overall major complication rate associated with retroperitoneoscopy/extraperitoneoscopy was 4.7%.

NCCN Practice Guidelines for Prostate Cancer.

Systemic therapies for prostate cancer are likely to improve, and as they do, they will have enormous impact on the treatment of high-risk and locally advanced cancers. Further technical improvements in radiotherapy and alternative local modalities, such as cryoablation, are also likely, and will bring even more options for local control. It is certain these guidelines will continue to evolve.

Laparoscopic nephropexy for symptomatic nephroptosis: initial case report.

Laparoscopic nephropexy was performed in a 25-year-old woman with intractable pain and a palpable pelvic mass associated with right nephroptosis for more than 1 year. Evaluation by a supine and an erect intravenous urogram (IVU) revealed right renal descent of three vertebral bodies with mild hydronephrosis. Laparoscopic transperitoneal nephropexy was performed in a 2 and a half hour procedure. The patient stayed in the hospital 2 days postoperatively and returned to full activities 3 weeks later. At 2 months postoperatively, she is asymptomatic. An upright IVU2 months postoperatively revealed renal descent of only one vertebral body and no hydronephrosis. This is the first report to our knowledge of a successful laparoscopic nephropexy.

Endo-ureteroplasty with a free urothelial graft.

Endo-urological therapy for ureteral strictures is usually limited to lesions 1 cm. or shorter. In an attempt to develop an endo-urological approach to treat longer ureteral strictures, we studied the clinical use of a transurethrally harvested free graft of bladder urothelium placed into the incised stricture bed. A total of 6 patients with ureteral strictures 1.5 to 8 cm. long (average 2.9 cm.) underwent endo-surgical management via free urothelial graft endo-ureteroplasty. Operative time averaged 5.5 hours. Complications included urinoma in 1 patient, hyponatremia in 1 and a postoperative renal pseudoaneurysm in 1. Four patients had long-term (that is 22 months or longer) successful results. Free urothelial graft endo-ureteroplasty, while tedious, may be a useful endo-surgical technique for treatment of long ureteral strictures.

Nephron-sparing surgery compared with radical nephrectomy for renal tumors: current indications and results.

BACKGROUND: Small asymptomatic solid renal masses are being found more often through the frequent use of abdominal ultrasonography and computed tomography. Nephron-sparing renal surgery is being done more often to treat these small lesions. A retrospective review was done to determine the effectiveness of this treatment. METHODS: Patients who had nephron-sparing renal surgery (group 1-35 patients) were compared with those who had radical nephrectomy (group 2-71 patients) for renal cell carcinoma smaller than 5 cm. RESULTS: The two groups had only small differences in fall in hematocrit, transfusion rates, operative time, and hospital stay. Major surgical complications were more frequent in group 1. After a median follow-up of 3.1 years, there has been no recurrence of tumor and there were no surgery-related or cancer-related deaths in either group. CONCLUSION: Nephron-sparing renal surgery appears to be a safe and effective alternative to radical nephrectomy for localized small renal tumors.

Organ entrapment and renal morcellation: permeability studies.

We collected 24 intact LapSacs* during a laparoscopy course at our institution. Following laparoscopic nephrectomy or nephroureterectomy in a pig using high speed electrical tissue morcellation, the sacks were examined for perforation. When filled with water, 4 of the 24 LapSacs (16%) were found to have small perforations. The 20 remaining sacks were randomly divided into 3 groups of 6 and 2 sacks, although intact, were kept as substitutes to use if a trial with the study sacks could not be completed. Each group of 6 sacks was tested for permeability using 10 mg./ml. bovine serum albumin, 8 mg./ml. indigo carmine or 1 x 10(5)/ml. mouse bladder tumor cells. The results in the 18 tested sacks showed no dialysis of bovine serum albumin in the dialysate at 1, 3 and 18 hours, and no dialysis of indigo carmine at 0, 1, 2 and 3 hours. In 1 of 6 sacks tested with a mouse bladder tumor cell line a single cell was noted on the hemocytometer at 1 and 3 hours. The lack of an increasing concentration of cells at the 3-hour interval likely indicates that this represented contamination of the dialysate rather than ongoing leakage from a perforated sack in this case. We conclude that the LapSac, when properly used, remains impermeable throughout the morcellation process.

Laparoscopic nephroureterectomy: evaluation of first clinical series.

Six patients underwent laparoscopic nephroureterectomy as treatment for upper tract transitional cell cancer. Mean operative time was 7.29 h and mean postoperative hospital stay was 4.6 days. In all but 1 case, the cuff of the bladder was obtained using a laparoscopic 12-mm GIA tissue stapler. With follow-up out to 16 months, we have not encountered any complications due to the transvesical staples, such as urine extravasation, stone formation, urinary tract infection or abscess formation. Our initial clinical data indicate that laparoscopic nephroureterectomy, albeit a lengthy procedure, can be performed with minimal morbidity and a short post-operative hospital stay.

Percutaneous stone removal with the patient in a flank position.

We report a case of percutaneous removal of a staghorn calculus that was accomplished in a morbidly obese patient while he was in a full flank position. In this position, the stone could be successfully accessed and fragmented without compromising the pulmonary status of the patient.

Laparoscopic repair of vesicoureteral reflux utilizing the Lich-Gregoir technique in the pig model.

To date, laparoscopic urological surgery has largely been limited to diagnostic or ablative procedures. Herein we report our experience with laparoscopic reconstructive surgery to perform an extravesical ureteral reimplantation. Seven anesthetized pigs with iatrogenic ureteral reflux underwent a laparoscopic extravesical ureteral reimplantation. The newly created ureteral tunnel varied from 2 to 4 cm. In 3 pigs, the tunnel was created with tacking staples, while in the other 4 pigs, the tunnel was created with intracorporeal suturing techniques using a 3-zero polyglyconate running suture. The procedure required an average of 132 minutes. There was one anesthetic death. There were no urinary tract infections. At 3 to 8 weeks after reimplantation, the cystograms were repeated on 5 pigs. One of 2 stapled reimplant pigs still had reflux; 1 of 3 sewn reimplant pigs had reflux. At 6 months following the reimplantation, only 1 pig had residual grade I reflux and this was a sutured reimplantation. None of the stapled reimplantations exhibited any residual reflux on the surgical side; however, in 1 animal a submucosal staple was noted at the time of harvest.

Elevated serum levels of p105(erbB-2) in patients with advanced-stage prostatic adenocarcinoma.

Expression of a truncated or extracellular form (p105erbB-2) of p185erbB-2 has been demonstrated in the sera of breast cancer patients. We examined the levels of p105erbB-2 in the sera of patients with various stages of prostatic adenocarcinoma, in patients with benign prostatic hyperplasia (BPH) and in a series of control male patients hospitalized for illnesses unrelated to the prostate. p105erbB-2 levels did not differ between the controls and BPH patients or between these groups and patients with stage A, B or C adenocarcinomas. In contrast, serum p105erbB-2 levels of patients with stage D adenocarcinomas were significantly elevated when compared with either control or BPH patients. There was no correlation between PSA and p105erbB-2 levels among controls, patients with BPH or patients with prostate cancer. Patients with poorly differentiated tumors (combined Gleason score >7) or moderately differentiated tumors (combined Gleason score 5-7) had higher p105erbB-2 levels as compared to patients with well-differentiated tumors (combined Gleason score <5), though this difference was not statistically significant. There was no correlation between serum p105erbB-2 levels and p185erbB-2 expression in malignant tissue, as determined by immunohistochemistry. However, patients with moderate to strong expression of p185erbB-2 within the adenocarcinomas were approximately 4 times more likely to demonstrate elevated serum p105erbB-2 levels as compared with patients with low expression of p185erbB-2.

Risk behaviours and benign prostatic hyperplasia.

OBJECTIVE: To identify risk factors for benign prostatic hyperplasia (BPH). SUBJECTS AND METHODS: Medical history data, including reported urological conditions and treatments, and risk factor data were collected from 34 694 participants in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, a randomized controlled trial designed to evaluate methods for the early detection of cancer. RESULTS: Asian men had the lowest risks (odds ratio, 95% confidence interval) for nocturia (0.7, 0.5-0.9), physician-diagnosed BPH (0.3, 0.2-0.5) and transurethral prostatectomy (TURP, 0.2, 0.1-0.6), while risks for Whites and Blacks were similar for most measures of BPH. Greater alcohol intake was associated with decreased nocturia (P trend = 0.002), BPH (P trend < 0.001) and TURP (P trend < 0.001). Current tobacco use was associated with decreased nocturia (0.8, 0.7-0.9), BPH (0.7, 0.6-0.8) and TURP (0.6, 0.4-0.8) but dose-response patterns were weak. CONCLUSION: Asian-Americans have the lowest risk of clinical BPH. Alcohol and possibly cigarettes are related to a lower risk for BPH.

Bayesian monitoring of a phase 2 chemoprevention trial in high-risk cohorts for prostate cancer.

The objective of phase 2 cancer chemoprevention trials is to evaluate whether a chemopreventive agent will cause significant modulation of intermediate endpoint biomarkers (IEB) in patients at high risk for the disease. A phase 2 chemoprevention trial of 4-hydroxyphenyl retinamide (4-HPR) versus placebo was conducted in men with a histologic diagnosis of early prostate cancer and scheduled to have radical prostatectomy. A Bayesian monitoring method was used to sequentially monitor this trial for evidence of biological activity or ineffectiveness based on a single IEB variable. Different prior distributions were used and posterior distributions were obtained to calculate the probability that treatment differences are greater than or less than a predetermined clinically significant effect. The interim analysis of transforming growth factor-alpha expression indicated a high probability of insufficient biological activity of 4-HPR on this IEB. This study demonstrates the potential utility of Bayesian methods in the decision-making process in the conduct of phase 2 chemoprevention trials.