Use of DHEA in a patient with advanced prostate cancer: a case report and review.

Dehydroepiandrosterone (DHEA) is being evaluated in the basic science laboratories as a potential treatment for adenocarcinomas, with some initial promise for success. However DHEA can be metabolically converted to androgenic compounds, possessing unwanted side effects. A patient with advanced prostate cancer with progressive symptomatology was treated with DHEA after other treatment regimens failed. Many of his symptoms improved on DHEA therapy, but his cancer also flared dramatically during treatment. His previous hormonally unresponsive cancer subsequently responded transiently to third-line hormonal therapy with diethylstilbestrol (DES). Adrenal precursor molecules such as DHEA may have significant therapeutic benefits in a number of diseases of the elderly, however their utility may be limited by potential androgenic side effects including endocrine epithelial cell growth. The development of analogue compounds with less conversion to androgenic metabolites should be considered, as molecules such as DHEA are more widely tested and utilized clinically.

Transurethral evaporation of the prostate for treatment of benign prostatic hyperplasia: results in 168 patients with up to 12 months of followup.

PURPOSE: We assessed the safety and efficacy of transurethral evaporation of the prostate for the treatment of symptomatic benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: A total of 168 patients with symptomatic BPH underwent transurethral evaporation of the prostate. Peak flow rate, American Urological Association symptom index and post-void residual were assessed at baseline, and at 3, 6 and 12 months of followup. RESULTS: We found a statistically significant decrease in mean American Urological Association symptom index from 20.6 at baseline to 7.2 at 12 months (mean difference 13.4, 65% reduction, p < 0.0001). We also found a statistically significant improvement in mean peak flow rate from 8.2 to 18.2 cc per second, respectively (mean difference 10, 122% increase, p < 0.0001). The most frequent complications were irritative voiding symptoms in 22.6% of patients and urinary tract infections in 4.8%. There were no additional major complications. CONCLUSIONS: From these results transurethral evaporation of the prostate appears to be safe and effective for treatment of BPH at 12 months of followup.

The potential for reintroduction of tumor cells during intraoperative blood salvage: reduction of risk with use of the RC-400 leukocyte depletion filter.

OBJECTIVES: Intraoperative autotransfusion of shed blood is widely utilized in surgery. However, several studies have raised concern about the transmission of tumor cells during oncologic procedures. We compared the ability of a leukocyte depletion filter (RC-400; LDF) to a standard red blood cell filter (SBF) to remove tumor cells derived from urologic malignancies. METHODS: Cells were suspended in media and passed through a SBF or a LDF. The filtrate was evaluated for the presence of viable cells utilizing the trypan blue exclusion method as well as cell culture. In a second experiment, cells were suspended in fresh bovine blood and processed through a cell saver apparatus followed by filtration with either a SBF or a LDF. Aliquots were cultured after admixture with blood, after processing, and after filtration. RESULTS: The LDF was able to remove tumor cells completely, as demonstrated by both counting with the trypan blue exclusion test and by cell culture. In contrast, admixture with blood processing through the cell saver apparatus nor a standard red blood cell filter removed these cells. CONCLUSIONS: Tumor cells derived from urologic malignancies are easily removed with a LDF but not with a SBF. Filtration of blood salvaged at the time of uro-oncologic surgery with a LDF but not with a SBF reduces the potential for reinfusion of viable tumor cells.

Adenocarcinoma of the prostate metastatic to the choroid of the eye.

We report an unusual case of bilateral choroidal masses developing in a patient with metastatic prostate cancer. Visual symptoms resolved and ocular mass lesions regressed after initiating total androgen deprivation. The natural history and management of choroidal metastatis originating from prostate cancer is discussed.

The role of transrectal ultrasound-guided biopsy-based staging, preoperative serum prostate-specific antigen, and biopsy Gleason score in prediction of final pathologic diagnosis in prostate cancer.

OBJECTIVES: To evaluate the role of ultra sound-guided systematic and lesion-directed biopsies, biopsy gleason score, preoperative serum prostate-specific antigen (PSA) as three objective and reproducible variables to provide a reliable combination in preoperative identification of risk of extraprostatic extension in patients with clinically localized prostate cancer. METHODS: The case records of 813 patients who underwent radical prostatectomy for clinically localized prostate cancer were analyzed. All had multiple systematic biopsies, two to three from each lobe, in addition to lesion-directed biopsies. Additionally, biopsies were done on seminal vesicles (SVs), if abnormal. Based on biopsy results, patients were classified as having stage B1 (T2a-T2b) or B2 (T2c) disease, depending on whether biopsies from one or both lobes were positive and stage C (T3) if there was evidence of SV involvement by biopsy of biopsies from areas of extracapsular extension as seen on transrectal ultrasound (TRUS) were positive. Logistic regression analyses with log likelihood chi-square test was used to define the correlation between individual as well as combination of preoperative variables and pathologic stage. RESULTS: On final pathologic examination, 473 (58%) patients had organ-confined disease, 188 (23%) had extracapsular extension (ECE), with or without positive surgical margins, and 72 (9%) had SV involvement. Eighty (10%) patients had pelvic lymph node metastases. Biopsy-based staging was superior to clinical staging in predicting final pathologic diagnosis. Logistic regression analyses revealed that the combination of biopsy-based stage, preoperative serum PSA, and biopsy Gleason score provided the best prediction of final pathologic stage. Probability plots constructed with these data can provide significant information on risk of extraprostatic extension in individual patients. CONCLUSIONS: This study demonstrates that TRUS-guided systematic biopsy in combination with preoperative serum PSA and biopsy Gleason score may provide a cost-effective approach for management decisions and prognostication in patients with prostate cancer.

Utility of preoperative serum prostate-specific antigen concentration and biopsy Gleason score in predicting risk of pelvic lymph node metastases in prostate cancer.

OBJECTIVES: To determine the accuracy of the preoperative serum concentration of prostate-specific antigen (PSA) plus the Gleason pathology score of biopsy specimens in predicting the presence of disease in the pelvic lymph nodes in patients with prostate cancer. METHODS: The medical records of all patients treated for prostate cancer at eight medical centers from January 1988 to June 1993 were reviewed. There were 932 patients with newly diagnosed prostate cancer for whom all relevant data were available who had undergone pelvic lymphadenectomy with (n = 912) or without (n = 20) radical prostatectomy. The rate of false-negative predictions of metastases based on combined preoperative biopsy Gleason score and serum PSA concentration was analyzed. A multivariate logistic regression analysis was performed to assess the value of preoperative serum PSA and biopsy Gleason scores individually and in combination in predicting pelvic lymph node metastases. RESULTS: The false-negative rate of metastases was 0% for preoperative PSA concentrations < or = 6 ng/mL and biopsy Gleason scores < or = 5 (n = 142) and 1.0% for PSA concentrations < or = 10 ng/mL and Gleason scores < or = 6 (n = 388). The 95% upper confidence limit for the rate of false negativity at this PSA cut-off level was 2.0%. A combination of preoperative serum PSA levels and biopsy Gleason scores provided the best prediction for the false-negative rates. CONCLUSIONS: For patients with newly diagnosed prostate cancer who have biopsy Gleason scores < or = 6 and preoperative PSA concentrations < or = 10 ng/mL (42% of our series), a staging pelvic lymphadenectomy appears to be unnecessary. The substantial cost associated with both cross-sectional imaging and staging lymphadenectomy may therefore be avoidable in this group of patients.

Transurethral evaporation of prostate (TUEP) with Nd:YAG laser using a contact free beam technique: results in 61 patients with benign prostatic hyperplasia.

OBJECTIVE: This prospective study was undertaken to evaluate the safety and efficacy of neodymium:yttrium-aluminium-garnet (Nd:YAG) laser for treatment of symptomatic benign prostatic hyperplasia (BPH). METHODS: A total of 61 patients at a mean age of 71.6 years with symptomatic bladder outlet obstruction due to BPH underwent transurethral evaporation of prostate (TUEP) using Nd:YAG laser. Twelve of the patients were experiencing acute retention. Pre- and postoperative evaluation consisted of American Urological Association (AUA) symptom questionnaire and a sexual function questionnaire, uroflowmetry, postvoid residual urine, electrolytes, blood urea nitrogen, creatinine, hematocrit, and prostate volume estimation by transrectal ultrasound. TUEP was achieved by employing a side-firing Nd:YAG laser fiber with a durable quartz reflector and high-power density (Ultraline, Heraeus LaserSonics, Milpitas, CA) that was used in a contact mode. RESULTS: All patients have been evaluated for three months, 26 for six months, and 7 for twelve months. Mean prostatic size was 41.1 g. The mean improvement in symptom scores at one, three, six, and twelve months was 69.8 percent, 70.9 percent, 76.0 percent, and 70.9 percent, respectively (P = < 0.0001). The mean increase in maximum uroflow at one, three, six, and twelve months was 63.4 percent, 66.7 percent, 41.94 percent, and 164.52 percent, respectively (P = < 0.0001). There was no instance of significant fluid absorption or bleeding. The duration of postoperative catheterization was two days in 43 patients, three to seven days in 16 patients, and two to three weeks in 2 patients. There were no deaths. All patients evaluated by TRUS at six months had open channeling defects. Videocystoscopy performed in 16 patients at two to three months postoperatively revealed tissue slough. At repeat cystoscopy in these patients at six months, the prostatic fossa was completely healed with no evidence of tissue slough. CONCLUSIONS: It is concluded that the technique of TUEP using Nd:YAG laser is safe and, in preliminary results, appears apparently effective in the management of BPH.

Iatrogenic urinary tract infection with Pseudomonas cepacia after transrectal ultrasound guided needle biopsy of the prostate.

In response to an unexplained development of Pseudomonas cepacia cystoprostatitis after transrectal ultrasound guided prostate biopsy, a retrospective review of records and biopsy protocol was performed at our institution. Between June 5, 1990 and January 9, 1991 no documented infections occurred in 272 patients undergoing transrectal ultrasound and prostate biopsy. During the next 6 months, however, 9 of 110 patients (8.2%) presented again with infectious symptomatology after transrectal ultrasound guided needle biopsy of the prostate. Culture of a majority of the specimens (67%) yielded P. cepacia. Two additional asymptomatic patients became colonized with P. cepacia. Environmental investigations revealed the ultrasound transmission gel as the source of the contamination. The proposed mechanism of infection was direct prostate or bladder seeding of contaminated transmission gel used to prepare the ultrasound transducer probe. Infections developed in immunocompetent patients despite adequate antimicrobial prophylaxis most likely secondary to underlying bladder outlet obstruction and significant direct inoculum of organisms. We currently recommend use of individualized sterile packets of transmission gel in addition to appropriate antimicrobial prophylaxis and povidone-iodine cleansing enemas when performing transrectal sonographic guided biopsies of the prostate.

Genitourinary involvement of systemic sarcoidosis confined to testicle.

We report on a patient with systemic sarcoidosis who presented with a lesion of the genitourinary tract confined to the testicle. Clinically evident sarcoidosis of the testicle has been identified in few instances. Several recommendations in evaluating such lesions have been offered. A consensus on treatment is not yet defined. The therapeutic options are presented and the literature is reviewed.

Postoperative urinary retention. Guidelines and an algorithm.

Postoperative urinary retention is a common problem after surgery. Prevention includes obtaining a preoperative history and physical, having the patient void just before surgery, avoiding overhydration, and encouraging micturition soon after surgery. Management requires sterile catheterization, when indicated, to drain the urinary bladder completely. Urine cultures must be done when indwelling catheters are used. Antibiotics may be necessary.

Mature teratoma of the testis metastasizing as mature teratoma.

We report an unusual case of mature teratoma of the testis with retroperitoneal metastasis of mature teratoma. Mature teratoma of the testis should be considered a low grade malignant neoplasm.

Small bowel perforation secondary to metastatic lung carcinoma.

Since 1961, there have been a total of seven patients with small bowel perforation caused by metastatic lung carcinoma reported in the literature. Perforation of the small bowel to metastatic lung carcinoma must be considered when evaluating older patients who have histories of heavy cigarette smoking and signs and symptoms suggestive of pulmonary neoplasia. Primary resection and end-to-end anastomosis of the perforated bowel is the treatment of choice. No patient with small bowel perforation secondary to lung carcinoma has survived more than four months.