Cystectomy and orthotopic ileal neobladder construction. Evaluation of continence and complications in a regional hospital.

INTRODUCTION: This study evaluates the outcome of orthotopic neobladder construction in a regional hospital setting. MATERIAL AND METHODS: Orthotopic ileal neobladders were constructed in 51 patients between 1990 and 2001. All complications were reported systematically and continence was evaluated in a standardized manner. RESULTS: One patient died perioperatively (2%). Early complications occurred in 56.9%. They were related to the neobladder in 21.6% and unrelated to the neobladder in 47.1%. 31.4% experienced complications in the late postoperative period. In 25.5%, these complications were neobladder related and in 11.8% they were not. After 1 year, daytime continence was 91.7% and nighttime continence 80.6%. Our results are comparable to those reported by others. CONCLUSION: We conclude that the construction of a Hautmann neobladder can be performed with acceptable results in a regional hospital. The democratization of recent bladder replacement techniques may offer more patients a better quality of life and prevent the formation of waiting lists. Radical treatment may then be opted for sooner and thus improve cancer-related survival.

Identification by quantitative chromatin pattern analysis of patients at risk for recurrence of superficial transitional bladder carcinoma.

PURPOSE: Based on the actual clinical outcomes of 132 fully documented patients with superficial transitional cell carcinoma of the bladder, we characterize the risk of recurrence and/or progression by computer assisted image microscopy applied to Feulgen stained nuclei. MATERIALS AND METHODS: Each tumor was characterized by the conventional grading and staging systems as well as by cytometry generated variables describing nuclear DNA content, nuclear morphometry and chromatin patterns. These data were submitted to discriminant analysis to establish a model distinguishing between 2 groups of patients. Group 1 included cases with remission for more than 60 months and group 2 cases presented with recurrence with or without progression within 12 months of transurethral bladder resection. This latter model was then validated by Kaplan-Meyer analysis of the full data set. RESULTS: As evidenced by Kaplan-Meier analysis, the discriminant factor generated by discriminant analysis of cytometry generated variables provided a cutoff value for distinguishing between low and high risks of recurrence (p <0.00001). In contrast, conventional grading and staging systems were not able to make such efficient distinction. CONCLUSIONS: These 2 groups can be used as references with which new cases can be compared to prognosticate disease behavior independently of histopathological grading and/or clinical staging.

Some historical aspects of urinals and urine receptacles.

In the history of mankind the first receptacles for urine were made and employed for diagnostic purposes and developed over centuries to a sophisticated matula. In ancient Greek and Roman history, chamber pots existed and urine was collected to bleach sheets, but it was only in the late medieval and renaissance times that a real urine receptacle or urinal for daily use was developed. We give a short description of the materials used, including clay, pewter, copper, and silver, but more sophisticated receptacles made of china, such as the bourdaloue, and of glass, such as the Kuttrolf, were also developed for use during long church ceremonies. Less known are the wooden "pipes" from Turkestan, used to keep babies dry. In the long history of mankind, urinals sometimes became very original objects.

Ureteroscopic treatment of ureteric lithiasis. Analysis of 354 urs procedures in a community hospital.

INTRODUCTION: The optimal treatment of ureteric lithiasis continues to be a point of discussion, as there are different treatment modalities. Conservative treatment, EWSL, ureteroscopy (URS), percutaneous litholapaxy, and (laparoscopic) ureterolithotomy, all have there place in the treatment of ureteric lithiasis. In order to evaluate if ureteroscopy is a valuable alternative to ESWL in the treatment of ureteric lithiasis, an analysis of all the ureteroscopies performed in our institution was made and these results were compared with results (both ESWL and URS) described in literature. PATIENTS AND METHODS: During the period 1990 till 1997, 292 patients underwent in our institution in total 354 ureteroscopies for ureteric lithiasis. In all procedures a rigid 9 Fr. ureteroscope was used, together with laser lithotripsy or pneumatic lithotripsy as fragmentation device. RESULTS: Overall success rate in our series was 90.1%, with distal and middle ureteric stone location being more favorable (94% and 95%) than proximal location (73%). Overall complication rate was 7.6% (including minor complications, such as ureteral mucosal tear), for which open surgical intervention had to be performed in 2.3% of cases. CONCLUSIONS: Although invasive, ureteroscopy proved to be a very competitive alternative to ESWL, when treating ureteric lithiasis. Success rates are equal, if not better, using ureteroscopy when compared to ESWL. Complications of ureteroscopy are infrequent, but do exist. Therefore ureteroscopy should be performed by experienced urologists.

Radical prostatectomy and prognostic factors.

OBJECTIVES: Prognosis of patients who have been treated by radical prostatectomy, because of prostatic carcinoma, is dependent on a number of factors. In this study we try to determine these factors, their relationship with each other, their relationship with progression of disease and the prognostic value of this relationship. METHODS: "Progression" (or relapse) of disease is defined as clinical evidence of local or general recurrence and/or isolated elevation of postoperative PSA level more than 0.2 ng/ml (Hybritech) at two consecutive outpatient visits. In our institution, 62 radical retropubic prostatectomies were performed over a period of 66 months. Without any exclusion, these patients were included in the analysis (with respect to "progression"), which consisted of bi- and multivariate analyses, Kaplan-Meier estimations and multivariate survival analyses using the "Cox proportional hazards model". Median follow-up time was 32 months. RESULTS: "Progression" was seen in 24.5% of cases, after a median progression-free interval of 13 months. Overall survival and freedom from "progression" (FFP) after 32 months were respectively 98.11% and 81.11%. Significant relations can be demonstrated between on one side preoperative PSA level, and on the other side "progression". FFP after 32 months for pathological T3-T4NO-1 tumors is 67.12% compared to 100% for pathological T2 tumors; FFP after 32 months is 88.98% for Gleason score of resection specimen < 7 and 73.86% for Gleason score > or = 7. Age, preoperative PSA level, Gleason score of resection specimen, surgical margin and 1-month-postoperative PSA level have in our analysis significant value (p < 0.05) in predicting "progression". CONCLUSIONS: Most in the literature described predictive factors for "progression" are fairly well reproduced in our analysis. Elimination of bias from applied (neo-)adjuvant therapy and less heterogeneity of the study group would most certainly improve this reproducibility.

PSA evolution: a prognostic factor during treatment of advanced prostatic carcinoma with total androgen blockade. Data from a Belgian multicentric study of 546 patients.

OBJECTIVES: To study the prognostic value of the prostate-specific antigen (PSA) response and its relationship with other initial prognostic factors during the treatment of advanced prostatic carcinoma with total androgen blockade. METHODS: Five hundred forty-six patients with advanced loco-regional (M0) or distant metastatic (M1) prostatic carcinoma treated with flutamide combined with either orchiectomy or LHRH analogues were included in this analysis. Initial patients characteristics and the PSA response were evaluated in relation to progression-free survival using a univariate and multivariate (Cox regression) analysis. RESULTS: The following prognostic factors were indicative of a decrease in progression-free survival: the absence of PSA normalization (< 4 ng/ml) after 3 or 6 months, M1 stage, high G grade, ECOG performance status > 1, presence of pain and absence of dysuria. In M1 patients the combination of PSA normalization after 3 or 6 months with initial G grade and ECOG performance status had the strongest predictive value. CONCLUSIONS: This study demonstrates that PSA normalization after 3 or 6 months along with initial tumor stage, grade and health status of the patient are the most important prognostic factors related to progression-free survival in the hormonal treatment of advanced prostatic carcinoma.

Tolerability and safety of flutamide in monotherapy, with orchiectomy or with LHRH-a in advanced prostate cancer patients. A Belgian multicenter study of 905 patients.

OBJECTIVE: In a multicenter study, 905 patients with newly diagnosed advanced prostate cancer treated with flutamide were followed for safety and side effects. METHODS: Flutamide was administered in monotherapy (75 patients (8%)) or as part of total androgen blockade (TAB groups): the latter group had orchiectomy (196 patients (22%)) or an LHRH (634 patients (70%)). RESULTS: The incidence of gastrointestinal complaints such as loss of appetite, vomiting/nausea and diarrhea (+/- 15%) was similar in the TAB and the monotherapy groups. Eighteen patients (2%) were withdrawn because of severe diarrhea. Hot flushes was the most frequently reported adverse event in TAB groups (40% of patients), leading to withdrawal in 4 patients (0.4%). Breast tenderness occurred most frequently in the monotherapy group (49%) and was reported as severe in 7% of the patients. Only 0.8% of the patients were withdrawn because of liver function changes. No unexpected potentially dangerous adverse events were reported. CONCLUSION: Flutamide alone or in combination therapy appears to be safe and well tolerated.

Prognostic factors in advanced prostatic carcinoma treated with total androgen blockade. Flutamide with orchiectomy or with LHRH analogues. A Belgian multicentric study of 546 patients.

Prognostic factors were evaluated in advanced loco-regional (M0) or distant metastatic (M1) prostatic carcinoma treated with total androgen blockade (flutamide with either orchiectomy of LHRH-analogues), in 546 patients from a Belgian multicentric study. After a mean follow-up of 16.5 months (maximum 37 months) 113 (21%) patients had progressed (90 were patients with M1 disease (31%)). The estimated median progression-free survival exceeded 37.5 months. The results of a univariate analysis show that the following parameters are important prognostic factors with respect to progression-free survival in these patients: M stage, G grade, ECOG performance status, weight loss, concomitant disease, pain, dysuria and haemoglobin (Lee-Desu test, p < or = 0.01). From a multivariate analysis (Cox regression) the following prognostic factors were indicative of a decrease in progression-free survival: M1 stage, high initial G grade, ECOG performance status > I, high serum PSA, presence of concomitant disease, presence of pain and absence of dysuria. Age did not appear to be a statistically significant prognostic factor.

Endocrine profiles during administration of the new non-steroidal anti-androgen Casodex in prostate cancer.

OBJECTIVE: Casodex (Zeneca) is a new potent, long-acting non-steroidal anti-androgen, which produces androgen deprivation by blocking the androgen receptor. We evaluated the endocrine effects of Casodex 150 mg daily given in monotherapy as primary treatment for patients with prostate cancer. DESIGN: As part of a large, multicentre study comparing the therapeutic effects of surgical castration with 150 mg/day Casodex in monotherapy for patients with prostate cancer, a subgroup of 23 patients on Casodex were studied in detail for changes in endocrine parameters. Serum levels of LH, FSH, testosterone, DHT, oestradiol, prolactin, sex hormone binding globulin and free testosterone were measured at the start of therapy and after 1, 4, 8, 12 and 24 weeks. Effects on libido, sexual activity and the appearance of hot flushes, breast pain and gynaecomastia were recorded. RESULTS: Administration of Casodex resulted in a rise in LH levels in all patients with a mean increase after 24 weeks of 102% (P < 0.001). Mean FSH levels showed a limited increase (7%) after 24 weeks, which was significant only after 1 week (P < 0.001). As a result of the high LH levels, total testosterone levels increased after 24 weeks by 66% (P < 0.001), free testosterone by 57% (P < 0.001) and dihydrotestosterone by 24% (P = 0.0112). Parallel to testosterone, oestradiol levels rose by a mean of 66% (P < 0.001). Mean sex hormone binding globulin and prolactin levels rose by respectively 8% (P = NS) and 65% (P < 0.01). Despite an increase in testosterone levels, excellent androgen blockade was obtained, as shown by a decrease in prostate specific antigen levels in 22/23 patients. Libido was maintained in 8/11 patients, and sexual activity in 5/6. No patient complained of hot flushes. However, mild gynaecomastia and/or breast tenderness were seen in 48 and 30% of cases respectively. CONCLUSION: Casodex 150 mg/day monotherapy resembles surgical castration in achieving androgen deprivation, despite an increase in LH and testosterone levels. In contrast to castration, libido and sexual activity are usually maintained and hot flushes are rare. However, mild gynaecomastia and/or breast tenderness were noted in 48 and 30% of patients.

Adenoid cystic carcinoma of the prostate.

A case of a patient with this extremely rare tumor is described. Adenoid cystic carcinoma of the prostate should be considered as a subtype of prostate adenocarcinoma. Since this tumor can be associated with a prostatic adenocarcinoma, it should be regarded as malignant.

Endopyelotomy. Evaluation of a limited experience.

Endopyelotomy is a recently developed endo-urological technique which gets to be standardised and gradually may replace the open pyeloplasty. Our technique is described and the early results are presented.