Androgen deprivation prior to radical prostatectomy for T2b and T3 prostate cancer.

OBJECTIVE: In an effort to improve on the results of radical prostatectomy for clinical stages T2b and T3 prostate cancer, a selected group of patients received androgen deprivation for three to sixteen months prior to surgery. METHODS: Fifteen men with clinical T2b and 22 with small T3 tumors received a luteinizing hormone-releasing hormone analog (n = 34) or a bilateral orchiectomy (n = 3) three to sixteen months prior to radical retropubic prostatectomy. The prostate was evaluated with particular attention to tumor grade, presence of extracapsular extension, tumor at the inked margin, seminal vesicle invasion, and tumor in the lymph nodes. RESULTS: No patient had clinical or chemical (prostate-specific antigen [PSA]) progression during androgen deprivation. The PSA level declined a mean 90 percent and remained above 4 ng/mL in only two patients. The prostate volume decreased an estimated 30-50 percent. Prostate cancer at the inked margin was found in 15 (41%) and seminal vesicle involvement in 11 (30%) patients. Five (14%) had tumor in regional lymph nodes. There was no difference in regard to positive margins or lymph node metastases between those clinically staged as T2b and those preoperatively staged as T3. Fourteen patients have received adjuvant therapy (13 androgen deprivation, one radiation therapy). None has progressed (mean follow-up, 38.4 months). Of 23 who did not receive immediate additional therapy, six (26%) had progression, as was evident from an increase in PSA and have since been treated. Only one continued to progress. Thirty-five of the 37 patients are alive. Seventeen (46%) are tumor free (PSA < 0.4 ng/mL) without further androgen deprivation. CONCLUSIONS: Only a prospective randomized trial can determine whether androgen deprivation prior to radical prostatectomy has a role. The results from this trial are encouraging for several reasons. The prostate is much smaller as a result of androgen deprivation and this may facilitate surgery. Although the great majority of these patients were expected to be margin positive, 60 percent had negative margins and only 14 percent had positive lymph nodes.

Use of oral ketoconazole to prevent postoperative erections following penile surgery.

Analgesics and topical agents ineffectively inhibit painful erections after penile and urethral surgery. Oral ketoconazole reversibly inhibits testosterone production and has been used empirically at our institution to decrease postoperative erections. We performed a retrospective review of 38 patients who had undergone penile and urethral reconstructive surgery. In all, 31 patients received 400 mg of ketoconazole three times daily for 10-14 days postoperatively (the study group) and seven patients did not receive ketoconazole (the control group). The incidence of postoperative erections, pain, side effects, surgical outcomes and patient satisfaction in each group were compared. Of the control group, 71% reported erections in the immediate postoperative period, and all these patients reported the erections were painful. Only 23% of the patient taking ketoconazole reported postoperative erections, and only 16% reported the erections were painful. We conclude that ketoconazole effectively prevents painful postoperative erections with minimal side effects.

Vasovasostomy: Macroscopic approach and retrospective review.

The objective of this study was to review our 5-year experience with macroscopic vasovasostomy. A series of 160 consecutive patients who underwent macroscopic vasovasostomies between 1991 and 1996 at Madigan Army Medical Center were studied. A modified one-layer anastomotic technique using 7-0 or 8-0 Prolene sutures was utilized. Results showed that 87% of patients who underwent bilateral vasectomy reversal showed return of sperm to the ejaculate with a mean progressive sperm motility of 32.2%. Clinical success was measured by successful pregnancies in 50% of patients in whom <5 years had elapsed since vasectomy. The average operative time was 1 hour 15 minutes. Although slightly better results have been obtained using the microscopic approach, vasovasostomy performed under loupe magnification has the advantage of reduced cost, decreased operative time, and a lower operator skill level.

Outcomes of varicocele ligation done for pain.

PURPOSE: Surgical ligation is an option in the management of patients with painful varicocele. Little objective data exist addressing the effectiveness of this treatment. We reviewed records from 58 patients who underwent varicocele ligation at our institution from January 1985 to May 1996 to establish success of surgical ligation of the painful varicocele. MATERIALS AND METHODS: ICD-9 billing codes were used to identify all patients who had undergone varicocele ligation for pain since 1985. We documented patient age, grade and location of varicocele, duration and quality of pain, response to conservative therapy and surgical approach to ligation. Telephone interviews and chart reviews were conducted to determine resolution of pain, complications of the procedure and if the patient would choose surgery again. RESULTS: We obtained followup on 35 of the 58 painful varicocele patients (60%). Average patient age was 25.7 years (range 15 to 65). The varicocele was on the left side in 30 men and bilateral in 5. Of the patients 31 described the pain as a dull throbbing ache, 2 as sharp and 2 as a pulling sensation. Initial conservative therapy failed in all 35 men. Varicocele was grade III in 18 cases, grade II in 16 and grade I in 1. The inguinal or subinguinal approach was used in 24 patients, high ligation in 10 and laparoscopic repair in 1. In 30 patients there was (86%) complete resolution of pain postoperatively and 1 had partial resolution. Only 4 patients (11%) had persistent or worse symptoms. CONCLUSIONS: This retrospective review supports the conclusion that varicocele ligation is an effective treatment for painful varicocele in properly selected patients.

Significance of androgen deprivation prior to radical prostatectomy, with special reference to prostate-specific antigen.

A total of 37 selected patients with clinical stage T2b or T3 prostate cancer received androgen deprivation prior to radical retropubic prostatectomy. A luteinizing hormone-releasing hormone (LHRH) analog alone was given to 15 individuals; 19 received an LHRH analog with flutamide. Three underwent bilateral orchiectomy instead of chemical castration. The duration of androgen deprivation prior to radical prostatectomy varied from 3 to 16 months, with 31 individuals undergoing induction therapy for 3-6 months. Three received androgen deprivation for more than 1 year. In all, 15 patients had clinical stage T2b disease and 22, stage T3 prostate cancer. The prostate size decreased approximately 30%-50% following induction therapy. Prostate-specific antigen (PSA) values decreased in all 19 instances where this was obtained. In all, 6 of 15 (40%) patients with clinical T2b lesions and 9 of 22 (41%) with clinical T3 tumors had a positive surgical margin; 5 (13%) had 1 or more positive lymph nodes. Androgen deprivation was continued following surgery in 13 cases. Only one patient received postoperative radiation therapy. After a mean follow-up period of 33 months, 35 (95%) patients are alive. Two patients died, one of poorly differentiated prostate cancer with subsequent metastasis and one of a myocardial infarction 33 months after surgery without showing any evidence of disease. Of 23 patients without postoperative adjuvant therapy, 6 (26.1%) progressed (PSA level, > 0.4 ng/ml). None of the patients who underwent adjuvant therapy progressed over a follow-up period of 6-75 months (mean, 38 months).(ABSTRACT TRUNCATED AT 250 WORDS)

Randomized trial of safety and efficacy of transurethral resection of the prostate using contact laser versus electrocautery.

The aim of this study was to prospectively evaluate the safety and efficacy of contact laser ablation of the prostate (CLAP) vs. transurethral resection of the prostate (TURP) in symptomatic benign prostatic hypertrophy (BPH). During a 1-year period (1995-1996), 37 males 50 years of age or older were randomized to either CLAP using Nd:YAG laser treatment or TURP. Patients with Qmax <15 mL/s, American Urological Association (AUA) symptom score >12, and postvoid residual (PVR) >125 mL were enrolled. Patients were excluded if they had prior surgical treatment for BPH or known conditions that could affect bladder function. Comparisons of preoperative and postoperative symptom scores, Qmax, PVR, total catheter time, hospital stay, complications, and hematocrit changes were performed. A 2:1 randomization was used, which resulted in 26 CLAP and 12 TURP patients. One-year follow-up data were available for 21 CLAP and 7 TURP patients. The mean prostate volume, age, AUA symptom score, and Qmax were not significantly different between the two arms. Significant differences in favor of CLAP were shorter catheter time (27.2 vs. 40.4 hours; p < .05) and shorter hospital stays (28.5 vs. 60.0 hours; p < .05). The only other significant difference between the two arms was a lower AUA symptom score in favor of TURP at 1 year (4.7 vs. 8.4; p < .05). Qmax, PVR, and postoperative hematocrit were similar between the groups. The only complications included recatheterizations, which occurred more frequently in the TURP patients (25% vs. 14%). CLAP appears to be slightly less effective in AUA symptom score reduction; however, it is equally safe and is superior for shortening catheter time and hospital stay compared to TURP.