Showing papers in "Canadian Journal of Urology in 2008"

The Worldwide Epidemiology of Prostate Cancer: Perspectives from Autopsy Studies

Abstract: Introduction Prostate cancer is the most frequently diagnosed non-skin cancer in the United States and the third leading cause of cancer deaths International trends in the incidence, mortality and prevalence of prostate cancer are assessed Methods Databases from the Surveillance, Epidemiology and End Results (SEER) program of the National Cancer Institute and the International Agency for Research on Cancer (IARC), and the literature on autopsy studies on prostate cancer were reviewed and summarized in the article Results Prostate cancer remains an important public health concern in Western countries and an emerging malignancy in developing nations Prostate cancer incidence is dependent on efforts to detect the disease Autopsy studies provide accurate and useful information regarding comparative prevalence rates of the disease among regions of interest Conclusions Improved cancer registration is needed in developing nations The prevalence of prostate cancer must be established to predict the expected incidence of the disease and in order to plan rational detection and treatment strategies Clinically significant disease should be distinguished from insignificant disease which may pose little or no biological danger to the patient

Treatment options for metastatic renal cell carcinoma: a review.

Abstract: Metastatic renal cell carcinoma (RCC) has a poor overall survival. Localized RCC remains a surgical disease. About 20%-30% patients who present with limited disease at the time of nephrectomy develop metastasis. The median time to relapse after nephrectomy is 15-18 months. The maximum numbers of relapses are within the first 3 years. In metastatic RCC, immunotherapy is effective in a relatively small percentage of patients but is very toxic. In recent years, there has been an improved understanding of the biology of RCC. This has lead to the development of various agents that target ligands at the molecular level. The hypoxia inducible factor-alfa (HIF-)/ vascular endothelial growth factor (VEGF) pathway and mammalian target of rapamycin (mTOR) signal transduction pathway are targets for some of these novel agents. Recent randomized phase III trials have shown an improved outcome in patients with metastatic disease who received these targeted agents. This review deals with management of advanced and metastatic renal cell cancer with an emphasis on recently developed targeted therapies.

Device failures associated with patient injuries during robot-assisted laparoscopic surgeries: a comprehensive review of FDA MAUDE database.

Abstract: Introduction Robot-assisted laparoscopic surgery has increased in the areas of cardiac and urologic surgery. We sought to determine the number of reported device malfunctions leading to patient injuries. Methods We performed a review of the MAUDE database of the FDA. Adverse events (AE) were defined as potential and actual product use errors and product quality problems. All incidents involving the ZEUS and da Vinci surgical robots were analyzed. Results The MAUDE database was last accessed on August 27, 2007. A total of 189 AEs were reported from 2000 to August 27, 2007. Assuming that 50,000 robotic-assisted laparoscopic cases have been performed, this represents 0.38% overall estimated failure rate. Twenty-one malfunctions were reported for the ZEUS robotic system between 2001 and 2003, while 168 malfunctions were reported for the da Vinci robotic system between 2000 and 2007. The rate of open conversions due to device malfunction decreased from 94% in 2003 to 16% in 2007. Of the 189 reported device malfunctions, only 9 (4.8%) were associated with patient injury. Conclusions The increasing use of robotic-assisted surgery has led to an increase in the number of reported device malfunctions, albeit at a very small estimated rate of 0.38%. With experience, the rate of open conversions due to device malfunction decreased. Only a small percentage of these adverse occurrences were associated with patient injury.

Evaluation of prostate cancer characteristics in four populations worldwide.

Abstract: Introduction Prostate cancer is common around the world, but rates of advanced disease differ substantially by race and geography. Although a major health issue, little is known about prostate cancer presentation in West Africa and India compared to the United States (US). Objective The aim of this study was to compare prostate tumor characteristics in four populations of men from the US, Senegal and India. Materials and methods We recruited prostate cancer patients from four hospital-based populations. The sample included 338 African-Americans, 1265 European-Americans, 122 Asian Indians, and 72 Senegalese. Questionnaire and medical record data were collected on each participant. Results We found significant differences in age at diagnosis, BMI, and PSA levels across the groups. Senegalese and Indian men had a higher probability of high stage (T3/T4) disease compared to US men. Gleason grade was significantly higher in Asian Indians compared to other populations. African-Americans, Senegalese, and Asian Indians had a significantly higher probability of metastatic disease compared to European Americans. The odds ratios (OR) for metastasis were consistently higher in Asian Indians compared to American cases. As only 19/72 Senegalese were assessed for metastasis, OR could not be determined for metastasis. Conclusions These results suggest that there are significant geographical and ethnic differences in the presentation of prostate cancer. Men in developing countries tend to present with advanced disease compared to US men. Identifying risk factors for advanced disease may help to decrease the rate of poor prostate cancer outcomes and associated mortality worldwide.

Intermittent catheterization practices following spinal cord injury: a national survey.

Abstract: Objective To identify intermittent catheterization (IC) practices and factors associated with urinary tract infection (UTI) in community-dwelling people living with spinal cord injury (SCI) in Canada. Study design A national survey employing a 36-item self-report questionnaire that was mailed to members of the Canadian Paraplegic Association (CPA). Results There were 912 respondents with SCI of either traumatic or nontraumatic etiology. Fifty-five percent of the respondents used IC. The mean age of users (47+/-14 years) was significantly younger than non-users (53+/-13 years) and a greater percentage of males (57%) than females (50%) used IC. Of those who used IC, 26% use hydrophilic catheters either exclusively or sometimes. The mean frequency of UTIs in the past 12 months for IC users was 2.6+/-2.6. Among IC users, females had a significantly greater number of UTIs than males (p=0.003). Linear regression analysis revealed that the variables of sex, number of catheterizations per day, age, and tetraplegia versus paraplegia were individually correlated with infection rate but collectively only explained a small proportion of the variance. Time lost from social activities due to UTIs was associated with compromised quality of life more so than the actual number of UTIs or days lost from work. Conclusion The survey identifies existing IC practices and confirms previous reports of UTI rate being dependent on frequency of catheterization and reduced infection rates in individuals using hydrophilic catheters. UTI rates were significantly associated with several clinical and demographic variables but only poorly modeled by the IC practices and lifestyle variables investigated in this study.

Robot-assisted Millin's retropubic prostatectomy: case series.

Abstract: Introduction/objective Simple prostatectomy continues to be an effective surgical option for patients with symptomatic high volume benign prostatic hyperplasia. Recent trends towards minimally invasive urologic surgery, in particular for prostate cancer, have created surgical alternatives with additional potential benefits. We report on the feasibility of robot-assisted retropubic prostatectomy. Materials and methods This series consists of three cases of simple prostatectomy performed through a robot-assisted retropubic (Millin) approach at two institutions. All patients had preoperative bothersome lower urinary tract symptoms with two patients presenting in urinary retention. Average preoperative transrectal ultrasound estimated prostate volume exceeded 300 cm3. All patients were ruled out for malignancy. Results Average age for the patient group was 76.7 years with mean prostate specific antigen (PSA) of 25.1. Estimated blood loss averaged 558 ml (150-1125) and mean operative time was 211 minutes (178-230). One patient had a simultaneous inguinal hernia repair performed. The patient with the largest prostate required incision extension for removal of specimen. There were no acute intraoperative or perioperative complications. Mean hospital stay was 1.3 days and one patient required blood transfusion. Average adenoma weight was 301 grams (66-640). One patient developed bladder neck contracture several months postoperatively. Conclusions Robotic-assisted retropubic simple prostatectomy is a reasonable and safe alternative to an open technique. Faster recuperation and reduced blood loss are potential benefits to this approach. The longer operative time and extraction incision for very large prostates (>200 gms) may offset some of the advantages of the minimally invasive method.

Near-infrared spectroscopy: validation of bladder-outlet obstruction assessment using non-invasive parameters

Abstract: Introduction Near infrared spectroscopy (NIRS) is a non-invasive optical technique able to monitor changes in the concentration of oxygenated and deoxygenated hemoglobin in the bladder detrusor during bladder filling and emptying. Objective To evaluate the ability of a new NIRS instrument and algorithm to classify male patients with LUTS as obstructed or unobstructed based on comparison with classification via conventional invasive urodynamics (UDS). Method Male patients with LUTS were recruited and underwent uroflow and urodynamic pressure flow studies with simultaneous transcutaneous NIRS monitoring following measurement of post residual volume (PVR) via ultrasound. Data analysis first classified each subject as obstructed or unobstructed using the standard pressure flow data and nomogram, then compared these results with a classification derived via a customized algorithm which analyzed the pattern of change of the NIRS data plus measurements of PVR and Qmax. Results Seventy subjects enrolled: 57 data sets had all required parameters [13 incomplete sets due to: communication error between NIRS and urodynamics instruments (9); data saving error (1); damaged fiber optic cables (3)]. Two complete data sets were excluded [subjects with hematuria (2)]. Thus data from 55 subjects was analyzed. The NIRS algorithm correctly identified those diagnosed as obstructed by conventional urodynamic classification in 24 of 28 subjects (sensitivity = 85.71%) and, and those diagnosed as unobstructed in 24 of 27 subjects (specificity = 88.89%). Conclusion Scores derived from NIRS data plus PVR and Qmax are able to correctly identify > 85% of subjects classified as obstructed using UDS.

Genetic susceptibility to prostate cancer in men of African descent: implications for global disparities in incidence and outcomes.

Abstract: INTRODUCTION Disparities in prostate cancer incidence and outcomes are a hallmark of the global pattern of prostate cancer, with men of African descent suffering disproportionately from this disease. The causes of these disparities are poorly understood. METHODS A review of the literature was undertaken to evaluate the role that genetic susceptibility may play in prostate cancer etiology and outcomes, with a particular emphasis on disparities. RESULTS The genetic contribution to prostate cancer is well established, and a number of candidate prostate cancer genes have been identified. Significant differences in the frequency of risk alleles in these genes have been identified across the major races. These allele frequency differences may in part explain an increased susceptibility to prostate cancer in some populations. In addition, non-genetic factors contribute significantly to prostate cancer disparities, and the cumulative contribution of both genetic and non-genetic factors to poor-prognosis prostate cancer may explain the poorer outcomes experienced by men of African descent. CONCLUSIONS Prostate cancer disparities are a function of genetic susceptibility as well as environment, behavior, and health care factors acting in the context of this genetic susceptibility. Elimination of global prostate cancer disparities requires a full understanding of the effects of all of these factors on prostate cancer etiology and outcomes.

Prevalence and predictive factors for the development of de novo psychiatric illness in patients receiving androgen deprivation therapy for prostate cancer.

Abstract: OBJECTIVE Androgen deprivation therapy (ADT) remains a widely utilized modality for treatment of localized and advanced prostate cancer. While ADT-induced alterations in testosterone have demonstrated impacts on quality of life, the effects on mental health remain ill-defined. We investigated the prevalence of de novo psychiatric illness and predictive factors following ADT induction for prostate cancer. MATERIALS AND METHODS We retrospectively reviewed patients receiving ADT for prostate cancer at our institution between 1/1989-7/2005, excluding men receiving only neoadjuvant ADT. Variables included age, race, body mass index, prostate-specific antigen (PSA), Gleason sum, clinical stage, ADT type (medical/surgical) and schedule (continuous/intermittent), and presence of pre-ADT and newly diagnosed psychiatric illness. The cohort was divided into three groups for analysis: pre-ADT psychiatric illness, de novo psychiatric illness, and no psychiatric illness. Data analysis utilized statistical software with p < 0.05 considered significant. RESULTS Three-hundred and ninety-five patients with a mean age of 71.7 years at ADT initiation were analyzed. Thirty-four men (8.6%) were diagnosed with pre-ADT psychiatric illness. At mean follow-up of 87.4 months, 101 (27.9%) men were diagnosed with de novo psychiatric illness, most commonly including: depression (n = 57; 56.4%), dementia (n = 14; 13.9%), and anxiety (n = 9; 8.9%). On multivariate analysis, increasing pre-ADT PSA was predictive of post-ADT anxiety (p = 0.01). Overall and disease-specific survival outcomes were similar between groups. CONCLUSIONS De novo psychiatric illness was identified in 27.9% of men. While no predictive factors were identified for de novo psychiatric illness, increasing PSA was associated with de novo anxiety. Prospective investigation using validated instruments is requisite to further delineate the relationship between ADT and psychiatric health.

Urological applications of near infrared spectroscopy.

Abstract: OBJECTIVE: Near infrared spectroscopy (NIRS) uses light to monitor changes in the concentration of oxyhemoglobin and deoxyhemoglobin in living tissue non-invasively and in real time Applications of NIRS in urology research and the strengths and limitations of this technology are reviewed MATERIAL AND METHODS: A Medline and Pub-Med search using "spectroscopy" with heading terms: near infrared (NIR), near infrared spectroscopy (NIRS), urology, kidney, renal, urinary tract, bladder, prostate, testis and penis RESULTS: Research incorporating NIRS has investigated a range of urologic conditions where a hemodynamic or vascular etiology is thought to be the underlying pathophysiology: as an aid to diagnosis in cryptorchidism, testicular torsion and vasculogenic erectile dysfunction; to evaluate renal metabolism and bladder dysfunction, and to study skeletal muscle metabolism in end stage renal disease Strengths and limitations of NIRS relate primarily to the basic physics of how light in the NIR spectrum penetrates tissue and is scattered and absorbed CONCLUSIONS: NIRS is a non-invasive, portable, real time measure of changes in tissue perfusion and oxygenation In urology NIRS appears particularly applicable in ischemic conditions, and the evaluation of disorders associated with alterations in regional tissue hemodynamics (local changes in pressure, muscle contraction and urinary tract obstruction) Because the bladder detrusor can be interrogated transcutaneously NIRS may also provide a non-invasive means of evaluating patients with voiding dysfunction Studies to date warrant further research and specific refinement of instrumentation and algorithm software for urologic applications, as NIRS could provide urologists with new methods of non-invasive physiologic diagnostic evaluation

Bladder cancer in Africa.

Abstract: Accurate epidemiological data about the incidence and mortality of bladder cancer are unavailable for most African countries. Transitional cell carcinoma (TCC) of the bladder is probably less common in rural African regions than in industrialized countries, due to lower levels of exposure to carcinogenic chemicals. In areas with endemic schistosomiasis (bilharzia) caused by parasitic schistosomes (blood flukes), most bladder cancer cases are comprised of squamous cell carcinoma (SCC). However, with increased urbanization, industrialization, and cigarette smoking in many African countries, there is an increasing incidence of TCC relative to SCC of the bladder. SCC of the bladder presents in patients who are on average 10 to 20 years younger than those with TCC. In Egypt and other North African countries, SCC is more common in men (the male to female ratio ranges from 3:1 to 5:1), probably because boys and men performing agricultural work are more exposed to schistosomiasis-infested water. In some sub-Saharan countries, SCC of the bladder is equally common in men and women, probably due to equal schistosomiasis exposure of girls and boys, and because women obtain household water and perform most agricultural tasks. Although SCC of the bladder often presents at a locally advanced stage, the tumors are usually well differentiated, with a relatively low incidence of lymphatic and hematogenous metastases. Patients with localized SCC are ideal candidates for cystectomy and orthotopic neobladder construction, because they are relatively young and healthy, and there is no risk of urethral recurrence, unlike with TCC. Unfortunately, many patients in Africa still present with advanced and inoperable bladder cancer, and many do not have access to healthcare facilities that can provide a cure and a good quality of life by means of radical cystectomy and neobladder construction.

Screening for prostate cancer: an update.

Abstract: The introduction of total prostate specific antigen (tPSA) testing in serum has revolutionized the detection and management of men with prostate cancer (PCa). This review will highlight some of the exciting new developments in the field of PCa screening in general and from our SPORE research program at Memorial-Sloan Kettering Cancer Center. First, it is important to understand that the inherent variability of tPSA levels affects the interpretation of any single results. Total variation in tPSA includes both analytical (i.e., pre-analytical sample handling, laboratory processing, assay performance, and standardization) and biological variation (i.e., metabolism, renal elimination, medication, physical and sexual activity, size and integrity of the prostate). Second, recent evidence demonstrates that no single tPSA cut-off separates men at high-risk for PCa from men at low-risk or men with “significant” (high-grade, high-volume) cancer from those with low-grade, indolent cancer. Taken together with a man’s age, family history, ethnicity, and digital rectal exam results, tPSA levels add to the overall estimate of the risk of cancer, allowing men to share in the decision about a biopsy. Third, men who will eventually develop PCa have increased tPSA levels years or decades before the cancer is diagnosed. These tPSA levels may reflect the long duration of prostate carcinogenesis and raise the question about a causal role for tPSA in PCa development and progression. tPSA measurements before age 50 could help risk-stratify men for intensity of PCa screening. Fourth, enhancing the diagnostic accuracy of tPSA, especially its specificity, is of particular importance, since higher specificity translates into fewer biopsies in men not affected by PCa. While tPSA velocity has been shown to improve the specificity of tPSA, its sensitivity is too low to avoid prostate biopsy in a patient with an elevated tPSA level. Moreover, prospective screening studies have reported that tPSA velocity does not add diagnostic value beyond tPSA level. At this time, tPSA velocity appears most useful after diagnosis and after treatment, but its value in screening and prognostication remains to be shown. Finally, while free PSA molecular isoforms and human kallikrein-related peptidase 2 (hK2) hold the promise for detection, staging, prognosis, and monitoring of PCa, evidence from large prospective clinical trials remain to be reported.

Asymptomatic rectal and bladder endometriosis: a case for robotic-assisted surgery.

Abstract: OBJECTIVES To evaluate the feasibility and safety of robot-assisted laparoscopic partial cystectomy for the treatment of rectal and bladder endometriosis. MATERIALS AND METHODS A 23 year-old female with history of infertility and pelvic pain was found to have a 4 cm bladder mass and rectal nodule on pelvic ultrasonography. Patient denied any other genitourinary symptoms. Cystoscopy and bladder mass biopsy revealed endometriosis. After failure to suppressive hormonal medical therapy a partial cystectomy and resection of a rectal lesion was performed with robotic assistance (da Vinci). The procedure included excision of an ovarian cyst and several peritoneal endometrioid implants. RESULTS Robotic-assisted (da Vinci) partial cystectomy with concomitant excision of endometrial nodules from the rectum and ovarian cyst was performed in 185 min. The rectal lesion was excised and primary closure of the rectum was performed. Patient had an uneventful postoperative course and hospital stay. Oral intake was started on postoperative day 1 and follow-up imaging revealed no bladder extravasation or fistula formation. The patient became pregnant 2 years later with "in vitro" fertilization procedure. CONCLUSIONS Robotic-assisted laparoscopic partial cystectomy with excision of rectal nodules for endometriosis can be safely performed.

Development of a near-infrared spectroscopy instrument for applications in urology.

Abstract: Introduction Near infrared spectroscopy (NIRS) is an established technology using photons of light in the near infrared spectrum to monitor changes in tissue of naturally occurring chromophores, including oxygenated and deoxygenated hemoglobin. Technology and methodology have been validated for measurement of a range of physiologic parameters. NIRS has been applied successfully in urology research; however current instruments are designed principally for brain and muscle study. Objective To describe development of a NIRS instrument specifically designed for monitoring changes in chromophore concentration in the bladder detrusor in real time, to facilitate research to establish the role of this non-invasive technology in the evaluation of patients with voiding dysfunction Method The portable continuous wave NIRS instrument has a 3 laser diode light source (785, 808 and 830 nanometers), fiber optic cables for light transmission, a self adhesive patient interface patch with an emitter and sensor, and software to detect the difference between the light transmitted and received by the instrument. Software incorporated auto-attenuates the optical signals and converts raw optical data into chromophore concentrations displayed graphically. Results The prototype was designed, tested, and iteratively developed to achieve optimal suprapubic transcutaneous monitoring of the detrusor in human subjects during bladder filling and emptying. Evaluation with simultaneous invasive urodynamic measurement in men and women indicates good specificity and sensitivity of NIRS chromophore concentration changes by receiver operator curve analysis, and correlation between NIRS data and urodynamic pressures. Conclusion Urological monitoring with this NIRS instrument is feasible and generates data of potential diagnostic value.

Treatment of refractory interstitial cystitis/painful bladder syndrome with CystoProtek--an oral multi-agent natural supplement.

Abstract: Objectives Interstitial cystitis/Painful bladder syndrome (IC/PBS) is a chronic bladder condition of unknown etiology and pathogenesis. However, there is evidence of bladder surface mucosal and glycosaminoglycans (GAG) dysfunction in IC/PBS and GAG replacement therapy has been used to treat the condition. The results of an open label, uncontrolled study of a dietary supplement designed to improve GAG mucopolysaccharides integrity (glucosamine sulfate, sodium hyaluronate and chondroitin sulfate) and reduce bladder wall inflammation (quercetin, rutin) are presented herein. Methods Two hundred fifty two IC/PBS patients (25 men, 227 women; 18-69 years old), who had failed other treatments, took four CystoProtek capsules /day (mg/capsule: glucosamine sulfate, 120; chondroitin sulfate, 150; hyaluronate sodium, 10; quercetin, 150; rutin, 20). Symptoms were evaluated using a visual analogue scale (VAS) (severity range from 1-10) before and after treatment ( 12 months). The women were divided into two severity groups--a more severe A group with a baseline mean VAS score greater than or equal to 5 and a less severe B group with a mean score Results Male patients (55.72 +/- 9.53 years, n = 25) had a mean VAS score at baseline of 7.6 +/- 1.63 which fell 51.8% to 3.94 +/- 2.46 (p 12 months), A2, B2 (6-12 months) and A3, B3 ( Conclusions Dietary supplements targeting the bladder GAGs (chondroitin, glucosamine, hyaluronate) and bladder inflammation (quercetin, rutin) are useful in the treatment of refractory IC/PBS. Prospective randomized trials of such supplements are warranted in both treatment refractory and treatment naive patients.

Radiofrequency ablation for T1a tumors in a solitary kidney: promising intermediate oncologic and renal function outcomes.

Abstract: OBJECTIVE The experience with radiofrequency ablation (RFA) in solitary kidneys is limited in numbers and follow-up. Therefore, we report our oncologic and renal function outcomes of RFA for T1a tumors in patients with a solitary kidney. METHODS From April 2000 to August 2007, 242 patients were treated with RFA for renal cortical masses. Sixteen patients with localized tumors < or = 4 cm in a solitary kidney were identified. Clinical and radiographic data were reviewed to assess indications, complications, disease recurrence, and renal function. RESULTS Twenty-one renal masses were ablated in 16 patients with a solitary kidney. The mean patient age was 66.1 years, and the mean tumor size was 2.6 cm (range, 1.1-4.0). Preoperative biopsy was diagnostic of renal cell carcinoma (RCC) in 75% of cases. At a mean follow-up of 30.7 months (range, 1.5-66.0), 14/16 (88%) patients had no radiographic evidence of disease recurrence. One patient with three masses in a solitary kidney had a local recurrence managed by salvage RFA. The other patient with a local failure also had severe baseline renal insufficiency with progression to end stage renal disease 2.5 years following RFA and underwent a radical nephrectomy. Mean glomerular filtration rate (GFR) decreased from 54.2 ml/min/1.73m2 preoperatively to 47.5 ml/min/1.73m2 at last follow-up (p = 0.015). There were no major complications, and four patients had minor complications which resolved without intervention. CONCLUSION Radiofrequency ablation is an attractive alternative for the management of patients with T1a renal cortical tumors in a solitary kidney. Renal function appears to be adequately maintained with promising oncologic outcomes at 2.5 years.

Management of advanced prostate cancer in Africa.

Abstract: Background Carcinoma of the prostate (CaP) is the most common male malignancy in developed and developing countries and has been termed the "malignant epidemic of blacks." Despite this, clinicians managing men with advanced CaP in Africa have to contend with significant limitations in the healthcare systems. This article reviews the current and future options for the management of these patients on the African continent. Methods We searched PubMed and Google for articles on CaP with an emphasis on those focusing on subpopulation differences. Information was also obtained from ongoing studies and interviews with urologists and other specialists and executives in hospitals in our locality. Results In Africa, most patients with CaP present with advanced disease, and surgical castration is the most common treatment option, as most modern treatment strategies for the disease are unavailable or unaffordable. Unfortunately, a significant proportion of these men progress to hormone-resistant disease shortly after first-line hormonal treatment, and a majority die within 2 years. Problems that are peculiar to the African continent include poor health facilities, scarcity of expert care, high cost of treatment, lack of data, low level of awareness of the disease, absence of early detection and treatment programs, cultural limitations, and the prominence of alternative medical practice. Conclusion Most Africans with CaP present with advanced disease, and treatment is mostly limited to bilateral orchiectomy, but the results are poor. The care of these patients can be improved by increased funding of healthcare institutions and projects directed at prevention, early detection, and treatment.

Hydrodissection for preservation of neurovascular bundle during robot-assisted radical prostatectomy.

Abstract: Introduction To describe a technique that may facilitate neurovascular bundle preservation during robot-assisted radical prostatectomy. Materials and methods From December 2007 to January 2008, 10 patients underwent robot-assisted radical prostatectomy with bilateral nerve preservation. Hydrodissection of the neurovascular bundle was performed by injecting a 1:10000 epinephrine solution diluted in 0.9% normal saline into the lateral prostatic pedicle with an injection cannula needle (Wolf). Operative time, blood loss and margin status were assessed when this new technique was utilized. Erectile function status will be analyzed in the future. Results Ten potent patients underwent bilateral nerve-sparing robot-assisted radical prostatectomy with hydrodissection. Mean patient age was 54 years old. Mean preoperative Gleason score was 6.5 and mean pretreatment PSA was 7.0. Six patients were clinical stage T1c and four patients were T2a. The mean operative time was 182 minutes, with a range of 148 minutes to 230 minutes. Mean blood loss was 297 cc. Hemodynamic changes were not seen during hydrodissection or after hydrodissection. No intraoperative or postoperative complications developed. None of the ten patients developed delayed postoperative bleeding. Final pathologic stage was pT2 in eight patients, pT3 in one patient and pT4 in one patient. All surgical margins were negative, except in the patient with bladder neck invasion. Conclusions We describe an athermal technique which may facilitate neurovascular bundle preservation. While intraoperative parameters were favorable with hydrodissection, long term sexual function results need to be analyzed.

What is the significance of the HPV epidemic

Abstract: Human papillomavirus (HPV) is the most common sexually transmitted infection. The incidence of this infection has been on the rise in recent times. It is estimated that approximately 6 million new HPV infections are acquired each year in the United States alone, and prevalence data suggest that as many as 24 million American adults--that is, 1 in 5--may be infected with HPV. Unfortunately, there is little public awareness and knowledge about the infection and its sequelae. It is well known that more than 90% of cases of anogenital warts are caused by HPV. HPV has been implicated in cancers of the cervix, vulva, vagina, penis, anus, and oropharynx. The virus is a necessary cause of cervical cancer. HPV DNA is detected in almost 100% of cases of cervical cancer. There have been major strides in recent years in the prevention of this infection and consequently, of diseases related to it. Vaccines are available and licensed in some countries. Two HPV vaccines are available: a quadrivalent (HPV types 6, 11, 16, and 18) vaccine and a bivalent (HPV types 16 and 18) vaccine. Both vaccines show a more than 90% protection against persistent HPV infection for up to 5 years after vaccination. The role of the vaccine in males is still controversial. The vaccination cost, however, is beyond the reach of many individuals in developing countries where 80% of cervical cancer cases of are found. Many countries in Africa are battling with HIV, malaria, tuberculosis, maternal mortality, and childhood illness. Nevertheless, with increased awareness, political will, and engagement by pharmaceutical countries, HPV vaccines may become affordable in these countries.

The addition of robotic surgery to an established laparoscopic radical prostatectomy program: effect on positive surgical margins.

Abstract: Purpose The addition of robotic assistance with the da Vinci surgical system for performing laparoscopic radical prostatectomy has been reported to improve surgical outcomes. In order to evaluate the benefit of robotic assistance to improve cancer control in a center with an established laparoscopic radical prostatectomy program, we evaluated the incidence of positive surgical margins in both transperitoneal laparoscopic (LRP) and robotically assisted laparoscopic radical prostatectomy (RALP). Materials and methods We performed an Institutional Review Board (IRB) approved, retrospective review of 247 men with clinically localized prostate cancer treated with either a LRP or a RALP from March 2000 to August 2006. Pathology reports were reviewed for both preoperative and postoperative Gleason score as well as clinical and pathological stage. Surgical pathology specimens were evaluated using a whole mount, step section technique. Extracapsular extension, seminal vesicle invasion and positive margins were noted when present in the final surgical pathologic specimens. Results One hundred ninety seven patients underwent LRP, and 50 patients underwent RALP. Seven of the 197 LRP required open conversion to retropubic radical prostatectomy, and were excluded. None of the RALP were converted. The overall positive surgical margin rate for LRP and RALP was 18% (35/190) and 6% (3/50), respectively (p = 0.032). When examining pathologically organ confined specimens (pT2), the positive surgical margin rate was 12% (20/161) and 4.7% (2/43) for the LRP and RALP cohorts, respectively (p = 0.181). For pathologic disease that has spread outside the capsule (pT3/T4), the positive surgical margin rate was 54% (15/28) and 14% (1/7) for LRP and RALP, respectively (p = 0.062). Patient age, race and prostate volume were not significant factors in the incidence of positive surgical margins. Conclusion The addition of robotic assistance to an established laparoscopic radical prostatectomy program appears to reduce the incidence of positive surgical margins. Data is maturing to determine whether this will lead to improved functional and oncologic outcomes.

The importance of determining the aggressiveness of prostate cancer using serum and tissue molecular markers

Abstract: Incidental prostate cancer (PCa) has been demonstrated at autopsy in about 80% of men aged 80 years and above and also in 10%-15% of younger men aged 30-50 years in the United States. These data imply a wide variation in aggressiveness of prostate cancer, from indolent tumors to aggressive cancers that kill the patients. The use of prostate specific antigen (PSA) in screening for PCa may detect even indolent disease for which radical prostatectomy may not be necessary. Currently available criteria such as histological grade, PSA level, stage of the disease do not always predict outcome. Furthermore, only about 80% of men with metastatic PCa will respond to first line hormone manipulation and once the patient develops hormone resistant prostate cancer (HRPCa), survival remains poor. Recent genomic and proteomic studies have provided many novel molecular markers that may help to redefine prognostic parameters. This paper is a review of studies using these novel markers in order to determine whether prostate cancer patients with the following characteristics have more aggressive cancer than those without: a) high serum levels of cathepsin B, survivin, Her - 2 / neu, IGFBP-2; b) low serum stefin A, IGFBP-3, c) positive immuno-staining of primary tumors for Her-2/neu, survivin and cathepsin B / stefin A ratio > 1 and d) gene expression of AMACR, HER-2/neu, high Bcl-2: Bax ratio and EZH2 in cancer cells. These markers have been chosen for review because they are among the most promising markers emerging currently.

Hematuria: etiology and evaluation for the primary care physician.

Abstract: Asymptomatic microscopic and gross hematuria are common problems for the primary care physician. The exact definition of microscopic hematuria is debated, but is defined by one group as > 3 red blood cells/high power microscopic field. While the causes of hematuria are extensive, the most common differential diagnosis for both microscopic and gross hematuria in adults includes infection, malignancy, and urolithiasis. Clinical evaluation of these patients often involves urological consultation with urine cytology, urine culture, imaging studies, and cystoscopy. Patients who have no identifiable cause after an extensive workup should be monitored for early detection of malignancy or occult renal disease.

Signet-ring cell carcinoma arising from the urinary bladder.

Abstract: Introduction Signet-ring cell carcinoma of the urinary bladder can be primary - arising from the bladder wall or urachus remnants - or metastatic from tumors originating in the stomach, colon, or breast. Saphir first described primary signet-ring cell cancer of the urinary bladder in 1955. Less than 100 cases have been reported in the literature since then. Case report We report a case of a 45-year-old woman who was admitted with gross hematuria. Cystoscopy revealed a necrotic tumor on the left bladder wall. A transurethral biopsy showed signet-ring cell carcinoma. The bladder tumor was diagnosed as the primary one. Radical cystectomy was performed with ureterosigmoidostomy (Mainz pouch II). Histological examination showed a primary signet-ring cell carcinoma of the bladder (pT3bN0M0). Following surgery, the patient received adjuvant chemotherapy with cisplatin and fluorouracil. Conclusions Primary signet-ring cell carcinoma of the urinary bladder is an extremely rare tumor, accounting for approximately 0.24% of all bladder malignances. Patients with this type of cancer generally have a poor prognosis. However, our patient is free of disease 5 years after radical cystectomy.

Update on the diagnosis and management of prostate cancer.

Abstract: Early detection of prostate adenocarcinoma (prostate cancer) through screening tests such as a serum prostate-specific antigen (PSA) test and a digital rectal examination (DRE) enables primary care physicians and urologists to offer patients a broader choice of treatments that are also more likely to provide a cure. Whether men are being over treated or over diagnosed through the widespread use of screening tests remains controversial. This review aims to provide general practitioners with a better understanding of different prostate cancer tests that can be performed and to help them decide which patients should be referred to a urologist for an ultrasound-guided biopsy.

Tubeless percutaneous nephrolithotomy for complex renal stone disease: single center experience.

Abstract: OBJECTIVE Tubeless percutaneous nephrolithotomy (PCNL) has become an option for treatment of renal stone disease, though no clearly defined algorithm exists for selection of patients suitable to tubeless PCNL. We investigated our experience with tubeless PCNL to evaluate its safety and efficacy for cases of complex renal calculi. PATIENTS AND METHODS Retrospective review of all tubeless PCNLs performed for complex renal calculus disease (bilateral stones, partial/complete staghorn, infundibular stenosis/calyceal diverticulum, pre-existing renal insufficiency) between January 2001 and January 2006. All patients had a ureteral stent placed in an antegrade fashion following stone treatment, and a foley catheter remained in place overnight. No patient received nephrostomy tube (NT). Imaging (CT or KUB) was obtained at the first outpatient follow-up visit. Patient demographics, incidence of complications, clinical outcomes and stone-free rates were noted and analyzed. "Stone free" was defined as negative imaging (CT or KUB). RESULTS Forty-two patients (47 renal units) were treated with tubeless PCNL for complex renal stone disease (5 bilateral, 25 total/partial staghorn, 12 renal insufficiency, and 10 infundibular stenosis or calyceal diverticulum). Mean age was 58.2+/-9.4 years. Mean length of hospital stay was 2.1 days. Mean preoperative and postoperative hematocrit were 40.5+/-4.5 and 37.2+/-5.8, respectively (p=0.001). Single-procedure stone free rate was 74.5%, and the two-procedure stone free rate was 91.5%. One patient (2.4%) required a blood transfusion and one patient (2.4%) developed urosepsis. CONCLUSIONS Tubeless PCNL is safe and effective and can be utilized in cases of complex renal stone disease.

Androgen deprivation therapy for advanced prostate cancer: why does it fail and can its effects be prolonged?

Abstract: Androgen deprivation therapy (ADT) has been the cornerstone of treatment for advanced prostate cancer for over 65 years. Although there can be worrisome side effects, data will be presented that for men with metastatic prostate cancer, immediate ADT can reduce the likelihood of developing the rare but catastrophic sequellae of metastatic disease, although it is unlikely to prolong survival compared with waiting for symptoms before initiating ADT. Additionally, for patients with extremely high risk prostate cancer that is not distantly metastatic (e.g. have a life expectancy from prostate cancer less than 10 years with all other available treatments except immediate ADT) and, whose life expectancy from non-prostate cancer diseases is excellent during this period, early ADT both alone and in conjunction with definitive local treatment prolongs survival. Moreover, ADT seems to be most effective when the cancer volume is low. However, eventually most men receiving ADT experience disease progression. The biological mechanisms explaining how prostate cancer escapes from ADT's control include: 1) Alterations in the androgen receptor (AR) and in the AR co-factors (which modify the responsiveness of the AR to androgens) allow molecules and medications which are not normally AR agonists to act as agonists. 2) The human prostate gland, and particularly prostate cancer, may be able to synthesize androgens from both cholesterol and adrenal androgens. This may occur because prostate cancer tissue has higher concentrations of androgens than does the serum in patients receiving ADT. Thus, castrated men may not be starving their prostate cancers of androgens. 3) The AR in prostatic stroma far more strongly stimulates both malignant and benign prostatic epithelial growth than the epithelial AR does. Indeed, the epithelial AR, particularly in advanced prostate cancer, may have anti-proliferative and anti-tumor progression properties. That is, the AR in the prostatic epithelial cells, particularly malignant ones, may act as a tumor suppressor. Thus, by inhibiting the epithelial AR, its protective effects may be abrogated. The controversial nature of these concepts, as well as the clinical and experimental data which support and question them, will be presented. Additionally, strategies for addressing each of these escape mechanisms, which may be able to prolong responsiveness to ADT, will be discussed.

Erectile function following unilateral cavernosal nerve replacement.

Abstract: INTRODUCTION With nerve-sparing techniques, patients undergoing a radical prostatectomy may avoid the morbidity of erectile dysfunction. Certain patients who are not candidates for nerve-sparing procedures may be eligible for nerve interposition grafts. While bilateral cavernosal nerve grafting after radical prostatectomy has shown efficacy, the effect of unilateral nerve grafting following prostatectomy remains unclear. We evaluate a large group of patients who underwent a unilateral cavernosal nerve replacement. METHODS Forty patients underwent unilateral nerve sparing surgery with concomitant contralateral cavernosal nerve replacement. Patients were selected for this procedure based upon preoperative nomogram risk assessment, endorectal MRI evidence of extra capsular disease (ECE) or intraoperative histology demonstrating margin positivity. Age, demographic data, Gleason score, clinical and pathologic stage and pre and post operative IIEF data was collected and prospectively analyzed. RESULTS Median follow-up was 19 months. Median change in IIEF scores was 7.5. Twenty-one of 29 patients (72%) report being able to penetrate after prostatectomy. Sixteen of those 21 (76%) continue to require PDE-5 inhibitors to facilitate penetration. Four of the 6 patients (67%) who were unable to have intercourse following cavernosal nerve replacement received adjuvant hormonal and/or radiation therapy. Twenty-eight patients (97%) reported numbness at the graft harvest site. One patient experienced a graft site infection. Two of 29 (7%) patients reported pain at the harvest site. CONCLUSION Unilateral sural nerve grafting is a feasible and well-tolerated approach for patients who must undergo wide resection of a NVB. While men do show a decrease in their IIEF score, 76% are able to achieve penetration following surgery. The majority of men continue to require PDE-5 inhibitors to facilitate intercourse.

Radiofrequency ablation of renal tumors in the solitary kidney.

Abstract: Objectives Radiofrequency ablation (RFA) is a minimally invasive therapy aimed at maximal preservation of renal function in the nonsurgical renal mass patient. We evaluate our experience with RFA of renal tumors in the solitary kidney. Patients and methods A retrospective review of all patients with a solitary kidney treated with RFA for renal mass was performed. Two radiologists reviewed all images. From December 2001 to June 2006, 55 renal tumors were treated with RFA in 30 patients with a solitary kidney. Percutaneous approach was used in 44 tumors (26 patients) and intraoperative open approach in 11 tumors (4 patients). Average mass size was 2.0 cm (1.2-5.4). Biopsy performed prior to ablation in 14 tumors showed renal cell carcinoma in 12 (86%) and was non diagnostic in 2 (14%). Results There were no major post procedural complications. Initial technical success was noted in 98% of tumors in 97% of patients. Average follow-up with contrast enhanced CT or MRI was 25 months (3-47) in 26 patients (50 tumors) and showed local tumor control in 100%. No difference in preoperative and postoperative calculated creatinine clearance was noted (p = 0.072). There was no difference in systolic (p = 0.102) and diastolic (p = 0.790) blood pressure pre and post ablation. Conclusions RFA of renal masses in the solitary kidney appears to be a safe, minimally invasive alternative to open surgical resection in properly selected patients. Local tumor control was achieved with no adverse effects on renal function and blood pressure in this series.

Challenges of anticancer chemotherapy in Africa.

Abstract: Background Cancer patients in Africa face unique challenges beyond the issues of disease pathology and treatment. Most patients present in advance stages beyond hopes of a cure and their management is confounded by complex socioeconomic and cultural issues unique to underdeveloped countries. Methods Critical assessment of the state of cancer care in Africa with focus on the management of advanced stages of the disease. The impact of a shortage of resources, difficulty with access to care and cultural attitudes that impact on the ability to provide state-of-the-art therapies are reviewed. Results In contrast to AIDS, malaria, and tuberculosis, malignancies kill more patients than all three of these high profile infectious diseases combined. The lack of adequate social and economic resources results in direct limitation on the effectiveness of care in many African nations. Conclusions Effective cancer treatment strategies in Africa need to focus on providing basic care, making efforts to diagnose cancers earlier, making treatments more accessible and affordable, promoting research that is more applicable to local conditions in an African setting, and striving for public health initiatives that will benefit the vast majority of patients with advanced-stage disease.

Management of benign prostatic hyperplasia by the primary care physician in the 21st century: the new paradigm.

Abstract: Benign prostatic hyperplasia (BPH) is one of the commonest causes of lower urinary tract symptoms (LUTS) in men over age 50. Fifty percent of men over age 50 will require some type of management for BPH/LUTS symptoms. Until about 15 years ago, the most common management for BPH was a transurethral resection of the prostate (TURP) operation. Initially, once a diagnosis of BPH has been made, most men are treated medically. One must first rule out other serious causes of these symptoms, such as prostate cancer, bladder cancer, and other obstructions. For men with an enlarged prostate, there is a good chance that therapy with a 5-alpha-reductase inhibitor (5-ARI) can prevent disease progression and the need for surgery. There has been a lot of recent work on different combination therapies for the treatment of BPH/LUTS. If a patient's serum prostate-specific antigen (PSA) level is greater than 1.5 ng/ml and his prostate volume is greater than 30 cc and he has significant LUTS, then combination medical therapy of an alpha blocker with a 5-ARI is the most effective therapy. After a careful workup, it is quite reasonable and appropriate for the primary care physician to initiate this therapy for a patient with BPH/LUTS.