Adherence to AUA Guidelines for Periprocedural Antibiotics for In-Office Cystoscopy after Implementation of a Simple Quality Improvement Protocol.

INTRODUCTION: AUA guidelines recommend periprocedural antibacterial prophylaxis for high risk patients undergoing in-office cystoscopy. We sought to determine if implementation of a simple quality improvement protocol could increase guideline compliance. METHODS: As part of a quality improvement initiative, 4 simple changes were incorporated into our practice for in-office cystoscopy, including creation of a "yes/no" checklist to identify high risk patients, checklist review and electronic antibiotics order placed by urology provider, immediate nurse directed administration of single doses of the most common recommended antibiotics, and review of the checklist and antibiotic administration during the preprocedural time-out. We retrospectively compared antibiotic adherence in patients 3 months before and 3 months after implementation of the intervention. Data collected included age, gender, indication for procedure, type of procedure and high risk status. RESULTS: A total of 307 patients were included in the study (157 before implementation and 150 after implementation of the protocol). In the pre-intervention group 120 patients (76.4%) were considered high risk and should have been administered antibiotic prophylaxis, although only 38 (31.7%) actually received it. In the post-intervention group 104 patients (69.3%) were considered high risk and should have been given antibiotic prophylaxis, and 84 (80.8%) actually received it. Overall, this quality improvement initiative resulted in a 49.1% increase in appropriate antibiotic administration (p <0.0001). CONCLUSIONS: Implementation of a simple 4-step quality improvement initiative resulted in a significant increase in the administration of appropriate antibiotics for in-office cystoscopy.

A review of urologic cancer patients with multiple primary malignancies.

Much has been written on the treatment of solitary or multiple metastatic nodules that sometimes present in patients with urological malignancies. However, relatively little has been published regarding those patients with urological cancer who have another concomitant primary non-urologic tumor. We describe several cases of patients who presented with a urologic malignancy and a secondary non-urologic tumor. We also reviewed the literature using MEDLINE to gather information concerning this rare occurrence. We found that secondary malignancies, although not very common, are being increasingly reported. They are usually detected during the preoperative work-up of the primary tumor, usually by CT scan, ultrasound, or chest X-ray. Most authors suggest that treatment should be directed at the more aggressive lesion first, which would improve the overall status of the patient, and thus allow a better response from therapy for the secondary lesion. While patients with multiple primary malignancies are rare, the urologist should be alerted to this possibility when evaluating the patient for the initially presenting or detected tumor.

Partial cystectomy during radical surgery for nonurological malignancy.

PURPOSE: It is not uncommon for a locally advanced, nonurological malignancy to invade the bladder. Partial cystectomy may be required to ensure complete tumor eradication. To our knowledge the true benefit of this procedure is unknown. MATERIALS AND METHODS: A total of 45 patients underwent partial cystectomy as part of radical surgery for a nonurological malignancy. We retrospectively reviewed these cases to determine which malignancies are prone to invade the bladder, the incidence of malignant invasion, the complication rate and the prognosis after wide en bloc resection. RESULTS: Colorectal adenocarcinoma accounted for the majority of cases. Tumor invaded only 11 bladder specimens (21.5%). Radical surgery was performed with curative intent in 30 patients, of whom 23 had negative surgical margins. At a mean followup of 30.7 months 16 of these 23 patients (69.6%) were free of disease or died of other disease processes. Disease progression and/or cancer related death occurred in 14 of the 15 patients (93.3%) who underwent surgery for palliation and in 16 of the 17 (94.1%) with positive margins at a mean of 21.7 months. Overall disease specific survival in those with malignant invasion was 27.3% compared to 41.2% when the bladder was fixed by a dense fibrous reaction only. No reported complications were related to partial cystectomy at followup. CONCLUSIONS: Advanced primary and recurrent nonurological malignancies often involve the bladder. Partial cystectomy may be necessary due to a dense fibrous reaction or direct tumor extension. While this distinction is made only after formal pathological results are reviewed, wide en bloc resection is necessary to ensure complete excision. When radical surgery is performed with curative intent and negative surgical margins are achieved, patients are likely to experience prolonged disease-free survival.

Radical transurethral resection in the management of muscle-invasive bladder cancer.

The morbidity of radical cystectomy and early reports of good results have stimulated interest in radical transurethral resection of bladder tumors (TURBT) for muscle-invasive transitional-cell carcinoma of the bladder. Various investigators have used surgery alone or with adjuvant or neoadjuvant chemotherapy or radiation. Further research is necessary to define the indications, but at present, radical TURBT for muscle-invasive cancer appears to be appropriate for patients too ill to undergo radical cystectomy, those who decline the open operation, and those enrolled in clinical trials of this approach to bladder cancer.

Squamous cell carcinoma at the prostatectomy site: squamous differentiation of recurrent prostate carcinoma.

Adenosquamous carcinoma of the prostate is rare. Even rarer is the subsequent squamous metastasis or recurrence in which only the malignant squamous component is observed in some sites, with the adenocarcinoma present in other sites. We describe a case of squamous cell carcinoma presenting at the prostatic bed 6 years after radical retropubic prostatectomy was performed for adenocarcinoma. Even though the primary tumor showed adenocarcinoma with foci of squamous differentiation, there was no morphologic evidence of adenocarcinoma in the current tissue examined. The suspected origin of the squamous tumor from a recurrence of the prostate tumor is discussed.

Upregulation of prostate-specific membrane antigen after androgen-deprivation therapy.

OBJECTIVES: To determine the expression of prostate-specific membrane antigen (PSMA) before and after androgen-deprivation therapy and to compare PSMA expression with prostate-specific antigen (PSA) expression. METHODS: We studied specimens from 20 patients with prostate cancer undergoing medical or surgical castration or combination androgen-deprivation therapy in whom matched pretreatment and post-treatment tissue specimens were available and 16 patients in whom only a post-treatment specimen was available. The expression of PSMA and PSA in the tissue specimens was determined by immunoperoxidase staining. The extent of staining was calculated by multiplying the percent of antigen-positive tumor cells by the staining intensity to arrive at a stain index for each biomarker. An in vitro study assessed the concentration of PSMA and PSA in extracts of LNCaP cells cultured in the presence or absence of androgen as determined by immunoassays and Western blot analysis. RESULTS: PSMA reactivity was found to be increased in 55% (11 of 20) of post-treatment primary tissues and 100% (4 of 4) of post-treatment metastatic specimens. In contrast, PSA expression was found to be decreased in 70% (14 of 20) of post-treatment primary and 100% (4 of 4) of post-treatment metastatic specimens. Neither type of androgen-deprivation treatment nor tissue sensitivity to androgen deprivation appeared to influence degree of biomarker expression. PSMA was found to be downregulated and PSA upregulated when LNCaP cells were cultured in the presence of testosterone or dihydrotestosterone. CONCLUSIONS: The enhanced expression of PSMA in tissues and LNCaP cells after androgen deprivation suggests that PSMA is upregulated in the majority of prostate carcinomas after androgen treatment. The high expression in metastatic tissues strongly suggests that PSMA may be a clinically useful target for antibody-and genetic-directed therapy of prostate cancer that recurs after androgen deprivation. The mechanism whereby androgens suppress the expression of PSMA, and the association of PSMA with the development of hormone-independent prostate cancers, will require further study.

Changes in immunohistochemical staining of PSA, PAP, and TURP-27 following irradiation therapy for clinically localized prostate cancer.

OBJECTIVES: To determine if tissue expression of prostate-specific antigen (PSA), prostatic acid phosphatase (PAP), and a prostate-associated monoclonal antibody (TURP-27) is retained after irradiation therapy and to compare these results with serum levels. METHODS: Immunohistochemical tests were performed on prostatic tissue obtained by needle biopsy or transurethral resection prior to and following definitive irradiation therapy for clinically localized prostatic carcinoma. PSA, PAP, and TURP-27 were studied. Results were compared with serum PSA and PAP values. RESULTS: All 20 preirradiation specimens stained positively for PSA and PAP; 19 of 20 stained for TURP-27. All 5 of the initial post-treatment biopsy specimens that showed recurrent tumor stained for all 3 markers. In 2 cases, staining for the 3 markers was greatly diminished. Only 8 of 15 post-treatment biopsy-negative specimens stained for all 3 markers. Six of 15 demonstrated loss of tissue expression for all 3 antigens. One specimen stained for PAP and TURP-27 but failed to stain for PSA. Serum PSA levels paralleled tissue expression in recurrent tumor specimens. However, 3 of the post-treatment biopsy-positive cases with PAP expressing tissue had normal serum PAP levels. CONCLUSIONS: No cases of recurrent tumor with marker-negative tissue were identified. However, benign epithelial prostate cells appear to sustain sufficient damage from irradiation to lose the capacity to produce certain proteins. Diminished contribution of benign glands to circulating PSA, in addition to decreased expression in malignant tissues, may explain the lower than anticipated serum PSA levels in patients who progress after irradiation therapy.

The detection of prostate specific antigen, MHS-5, and other markers in invasive prostate cancer and seminal vesicle.

Prostate specific antigen (PSA) is the most useful serum marker for following the disease status of prostate cancer patients after therapy. While PSA is felt to be an organ specific marker, lack of PSA expression in the seminal vesicles has not been adequately established. MHS-5 is a monoclonal antibody which recognizes an epitope on seminal vesicle specific antigen. Our objectives were to define PSA expression by the seminal vesicles, to determine whether MHS-5 could serve as an adjunct in the diagnosis of seminal vesicles invasion by carcinoma of the prostate, and to determine whether carcinoma, having invaded seminal vesicles would retain its expression of PSA and other prostate markers. Using an immunoperoxidase procedure, we studied thirteen seminal vesicles without histologic evidence of prostate cancer invasion and five seminal vesicles with locally invasive cancer. No seminal vesicles expressed PSA, whereas prostate cancer invading the seminal vesicles expressed PSA in all cases. MHS-5 expression was more variable. Only two of five cases of locally invasive tumor demonstrated seminal vesicles expression for MHS-5. Our findings further support the specificity of PSA. While MHS-5 may be helpful in delineating seminal vesicles in some instances, it is not a consistently reliable marker.