Acute bowel morbidity after prostate brachytherapy with cesium-131.

PURPOSE: The present study evaluates the severity and time to resolution of bowel symptoms in men undergoing prostate brachytherapy (PB) with cesium-131 ((131)Cs). METHODS AND MATERIALS: A longitudinal, prospective study of patients who had undergone PB with (131)Cs at a single institution was performed. All patients were asked to complete the Expanded Prostate Cancer Index Composite preoperatively and at 2 weeks and 1, 3, and 6 months postoperatively. Outcomes were analyzed using descriptive statistics and Student's t test. RESULTS: The first 142 patients to have undergone PB with (131)Cs at our institution were included in the study. The mean Expanded Prostate Cancer Index Composite bowel summary score at baseline was 90.1±11.0 compared with 71.5±22.8 (p=0.000), 70.1±20.7, 87.1±13.8 (p=0.01), and 90.7±9.2 (p=0.70) at 2 weeks and 1, 3, and 6 months postoperatively, respectively. CONCLUSIONS: In men undergoing PB as monotherapy with (131)Cs, bowel symptoms returned to baseline by 3 months after the procedure. For patients undergoing PB with (131)Cs as part of combination therapy, bowel symptoms return to their post-external beam radiotherapy, pre-PB baseline by 3 months after the procedure.

Resection of a staggering 36-cm angiomyolipoma.

Angiomyolipomas (AMLs) are benign tumours characterized by fat, smooth muscle and vascular components. Epithelioid AML is a recognized variant of AML that is comprised of epithelioid smooth muscle cells. We present a case of a 41-year-old male who presented with light-headedness, dizziness, right-sided abdominal pain and, on subsequent computed tomography, was found to have an enormous right kidney mass characteristic of an AML. The patient underwent preoperative selective arterial embolization followed by a right radical nephrectomy. The pathology revealed a 36-cm AML with focal epithelioid features. Although uncommon, AMLs can present as enormous retroperitoneal masses.

Partial nephrectomy without hilar control or cooling: longitudinal data over 5 years.

INTRODUCTION: Partial nephrectomy for the management of small renal masses has become a well accepted technique. Contemporary series have shown its safety and efficacy in well selected patients. We present our experience of partial nephrectomies exclusively without hilar control or parenchymal cooling stratified into imperative and elective patients. METHODS: We retrospectively reviewed our experience in 124 patients who underwent partial nephrectomy between December 1995 and September 2003. Patients were followed with regular radiographic and laboratory studies at 6 months postsurgery and then annually. Renal function was followed by serum creatinine. RESULTS: Of the 124 patients, 105 were performed without hilar control or renal cooling and met our criteria for analysis. The operation was elective in 78 patients (74%) and imperative in 27 patients (26%). Mean specimen size was 2.8 cm for elective cases and 3.3 cm for imperative cases. The mean estimated blood loss was 606 533 cc and 950 656 cc in elective and imperative cases respectively. Surgical margins were positive in 6.6% with an overall recurrence rate of 3.8%. At a mean follow up time of 31 months and 23 months in the elective and imperative groups respectively, there were no statistically significant differences between baseline and follow up serum creatinine levels in either elective or imperative cases at time intervals of 0-12, 13-24, 25-48 and > 48 months. The intraoperative complication rate was 5.7% and the postoperative complication rate was 4.7% including three patients requiring blood transfusions. CONCLUSION: Partial nephrectomy without hilar control or renal cooling is a safe and reliable method of removing small renal tumors. In this cohort, intraoperative blood loss is slightly higher than historical series. However, blood transfusion rates, complications, renal function and oncologic outcomes are comparable to historical series of patients in whom vascular control and renal cooling are used.

Management of bilateral synchronous renal cell carcinoma in a single versus staged procedure.

OBJECTIVES: The presentation of synchronous bilateral renal lesions is rare. We report our experience with the surgical management of these lesions in both a single and staged procedure. METHODS: We retrospectively reviewed the records of all patients with bilateral synchronous renal lesions who underwent surgical management by one surgeon between 2000-2007. We compared characteristics including pre and postoperative renal function, complication rates, and oncological outcomes between the single and staged cohorts. Data were analyzed using descriptive statistics, Student's t-test, and Fisher's exact test. RESULTS: A total of 26 patients (73% male, mean age 65.5 +/- 12.2 years) with bilateral synchronous lesions were identified with a mean follow-up of 25.9 +/- 19.7 months. Of these, 18 (69%) were performed as a single procedure, 5 (19%) were done as a staged procedure, and 3 (12%) had only the first part of the staged procedure performed. The single and staged cohorts were comparable in regards to preoperative creatinine (Cr) (1.1 +/- 0.4 mg/dl versus 1.1 +/- 0.2 mg/dl, p = 0.70), postoperative Cr (1.5 +/- 1.0 mg/dl versus 1.4 +/- 0.5 mg/dl, p = 0.73), and median hospital length of stay (HLOS) (5 days versus 4 days). The complication rate was 22% and 20% for the single and staged cohorts, respectively. One patient had a local recurrence and one patient developed metastatic disease in the single cohort versus no local recurrence or metastatic disease in the staged cohort. CONCLUSION: In the appropriate setting, surgical management of synchronous bilateral renal lesions can be done safely in a single procedure with comparable outcomes to those done in a staged manner.

Dosimetric outcomes in prostate brachytherapy: is downsizing the prostate with androgen deprivation necessary?

OBJECTIVES: A large prostate volume has historically been a relative contraindication to prostate brachytherapy (PB) because of concerns of toxicity and potential pubic arch interference. Common practice has been to downsize large prostates with androgen deprivation therapy (ADT) before proceeding with brachytherapy. The present study compares postimplant dosimetry in patients with prostate volumes >50 cc with those with prostate volumes 50 cc (mean 58.1 cc, range 50.2-86.0 cc); the mean D(90), V(100), V(150), and V(200) was 125.1%, 95.2%, 68.2%, and 41.7%, respectively. The rectal V(100) was 1.0 cc for both cohorts. There was no statistically significant difference between the cohorts with respect to postimplant dosimetry for D(90), V(100), and V(150). The V(200) for prostate volumes >50 cc was significantly lower (p<0.05). CONCLUSIONS: In the present study, patients with prostate volumes >50 cc have postimplant dosimetry parameters similar to patients with prostate volumes

Overcoming pubic arch interference with free-hand needle placement in men undergoing prostate brachytherapy.

PURPOSE: The present study evaluates the postimplant dosimetry when free-hand needles were placed to overcome interference from the pubic arch. METHODS AND MATERIALS: A review of all patients who underwent prostate brachytherapy at our institution from 2001 to 2006 was performed. Postimplant dosimetry in men requiring free-hand needle placement was compared with postimplant dosimetry in men not requiring free-hand needle placement. RESULTS: Of the 145 patients who underwent prostate brachytherapy, 8 patients required free-hand needle placement. The mean prostate volume in the free-hand needle cohort was 46.0cc with a mean of 3.4 free-hand needles placed. In the 137 patients not requiring free-hand needle placement, the mean volume was 39.7cc. The mean D(90), V(100), V(150), and rectal V(100) for the free-hand cohort was 129.5%, 96.3%, 81.6%, and 1.45cc, respectively. The mean D(90), V(100), V(150), and rectal V(100) in men not requiring free-hand needle placement was 126.8%, 97.1%, 78.7%, and 1.03cc, respectively. CONCLUSION: The present study finds that adequate postimplant dosimetry can be obtained if free-hand needles are required due to pubic arch interference.

Prostate brachytherapy after ileal pouch-anal anastomosis reconstruction.

OBJECTIVE: To determine the safety of prostate brachytherapy in patients with clinically localized prostate cancer who have undergone proctocolectomy with ileal pouch-anal anastomosis (IPAA). METHODS: We performed a retrospective chart review of patients with a prior history of IPAA reconstruction who underwent prostate brachytherapy at our institution. Clinical records were reviewed for demographic characteristics, postoperative dosimetry, changes in bowel function, and oncologic outcomes. Data were analyzed using descriptive statistics. RESULTS: Five patients with an IPAA underwent prostate brachytherapy for clinically localized prostate cancer. Mean time from colorectal reconstruction to prostate brachytherapy was 6.3 years. Adequate dosimetry (mean D90 114.9%, mean V100 91.1%, mean R100 0.76 mL) was achieved in each patient. Bowel frequency worsened in the immediate postoperative period in all patients, but all patients returned to their baseline bowel pattern by 4 months after their procedure. Serious complications, such as J-pouch ulcers, fistulas, or fecal incontinence, did not occur in these patients. CONCLUSIONS: Prostate brachytherapy is a safe treatment option in patients with clinically localized prostate cancer and a history of proctocolectomy and IPAA reconstruction.

Laparoscopic nephrectomy using the EnSeal Tissue Sealing and Hemostasis System: successful therapeutic application of nanotechnology.

The potential impact of nanotechnology in the field of urology is broad with diagnostic and therapeutic benefits that have only recently begun to be explored. Application of nanotechnology principles to tissue and vessel sealing during laparoscopic procedures may reduce associated thermal injury and inflammatory response. We report our initial experience using the EnSeal Tissue Sealing and Hemostasis System during laparoscopic nephrectomy and discuss its potential advantages and disadvantages compared with those of contemporary technologies.

Feasibility and outcome of retrograde endoscopy in a post-prostatectomy population.

PURPOSE: To determine the feasibility of retrograde endoscopy after radical retropubic prostatectomy (RRP) and its effects on post-prostatectomy continence. PATIENTS AND METHODS: We retrospectively reviewed all patients who underwent RRP at our institution between 1999 and 2005, identifying those who subsequently required endoscopic instrumentation. Patient records were examined for the interval between procedures, method of endoscopy, and continence after endoscopy compared with baseline post-prostatectomy continence. RESULTS: Twenty-one patients were identified who required endoscopic instrumentation from 4 to 49 months after RRP. Of these, 13 patients underwent ureteroscopy for stones (N = 8) or stricture disease (N = 5). In 3 cases, a ureteral access sheath was used, and in 12 cases, a ureteral stent placed postoperatively. Review of the operative reports revealed no complications or difficulty with cannulation of the ureteral orifice(s) or sheath placement. Eight patients underwent rigid cystoscopy for hematuria, removal of a foreign body, or treatment of bladder stones (N = 2 each) or for stent placement and frequency (N = 1 each). The ureter could not be identified in one case of attempted stent placement for hydronephrosis because of a distal-ureteral stone. A follow-up intravenous urogram confirmed passage of the stone and resolution of the hydronephrosis. There were no other reported difficulties with rigid cystoscopy. There was no documented change or adverse outcome regarding continence after endoscopy. CONCLUSIONS: Post-prostatectomy retrograde endoscopy is feasible for the management of common urologic pathologies. Endoscopic instrumentation across the urethrovesical anastomosis did not have an adverse effect on urinary continence.

Complete ureteral stent encrustation managed with serial nephroscopy and laser lithotripsy.

Encrustation is a well-established complication of retained biomaterials in the urinary tract. Severe stent encrustation is a potentially serious complication of prolonged indwelling ureteral stenting often managed with open surgery when endoscopic techniques are unsuccessful. We present a case of a 2800-mm2 stent encrustation managed with serial nephroscopy and laser lithotripsy.

Correlation between risk factors for vascular disease and the American Urological Association Symptom Score.

OBJECTIVE: To evaluate the correlation between risk factors for vascular disease and the American Urological Association Symptom Score (AUA-SS), by comparing the presence of these risk factors with the degree of lower urinary tract symptoms (LUTS). PATIENTS AND METHODS: We retrospectively reviewed the medical history, AUA-SS, and prostate volume of men who had a radical prostatectomy. The degree of LUTS in men with and without risk factors for cardiovascular disease was compared. RESULTS: The mean AUA-SS was 7.2 for the entire cohort, 5.6 in men with no risk factors, and 7.9 in men with at least one risk factor (P < 0.05). In men with one to four risk factors, the mean AUA-SS was 6.9, 7.9, 10.7, and 19.5, respectively. There was no correlation between the AUA-SS and prostate size in the entire cohort or among any groups. CONCLUSIONS: Men with risk factors for vascular disease are more likely to have a higher AUA-SS than men without these risk factors. These findings suggest the possibility of an association between vascular disease and the development and severity of LUTS in men.