Laparoscopic extraperitoneal radical prostatectomy--learning curve of a laparoscopy-naive urologist in a community hospital.

OBJECTIVES: To describe the training approach that a laparoscopy-naive general urologist working in a nonteaching hospital used to successfully learn to perform laparoscopic extraperitoneal radical prostatectomy and describe the results obtained in the first 114 cases performed. METHODS: The urologist assisted an experienced laparoscopic surgeon for 20 extraperitoneal radical prostatectomies. During this time, he modified his technique of performing open radical retropubic prostatectomy to facilitate the acquisition of the laparoscopic techniques. Intracorporeal suturing was learned with the aid of a pelvic trainer. The clinical records of the first consecutive 114 cases were examined to evaluate the outcomes in terms of morbidity and oncological and functional concerns. A similar analysis was performed on a subgroup of 15 patients who had undergone laparoscopic extraperitoneal radical prostatectomy after previous transurethral resection of the prostate. RESULTS: The operating time progressively decreased during the learning curve. The mean duration of surgery was 160 minutes. Two conversions to open surgery were required owing to failure to progress. Of the 114 patients, 14% experienced complications, most of which were minor. The positive surgical margin rate was 17%. The average follow-up was 16 months. Undetectable serum prostate-specific antigen levels were observed in 82%, 87%, and 79% at 6, 12, and 18 months, respectively; 96% of patients used 0 to 1 pad per day for incontinence at 6 months of follow-up. The results in the transurethral resection subgroup were similar. CONCLUSIONS: Laparoscopic extraperitoneal radical prostatectomy can be successfully learned by a general urologist with no prior laparoscopic experience.

Antiandrogen withdrawal in the treatment of hormone-relapsed prostate cancer: single institutional experience.

OBJECTIVES: Locally advanced and metastatic prostate cancer eventually progresses in spite of complete androgen blockade. Second-line therapy is usually disappointing, and further progression is the rule. Laboratory and clinical data have indicated that antiandrogen withdrawal may be a valuable strategy in the treatment of these patients. However, after antiandrogen withdrawal, controversial clinical results have been reported. Therefore every contribution to this therapeutic strategy is useful. METHODS: Herein we present our experience with antiandrogen discontinuation in a series of 44 patients with locally advanced or metastatic prostate cancer treated with complete androgen blockade (CAB). RESULTS: Prostate-specific antigen (PSA) decline was observed in 13 of 44 (29%) and in 11 of these patients the reduction was greater than 50%. No response or further progression after antiandrogen withdrawal was observed in 31 of the 44 patients (71%). Among these patients 14 died due to prostate cancer after a mean period of 5.6 months. No patient in the responding group has died. CONCLUSIONS: Our data indicate that approximately 30% of patients with advanced prostate cancer treated with CAB respond to antiandrogen withdrawal with a reduction in serum PSA levels. Even though it is not clear whether this PSA reduction produces a benefit in terms of survival, we feel that antiandrogen withdrawal must be the first therapeutic maneuver in patients with advanced prostate cancer who progress after CAB. If there is no PSA response within 4 months, second-line treatment is necessary.

Transurethral resection and sequential chemo-immunoprophylaxis in primary T1G3 bladder cancer.

OBJECTIVES: T1G3 superficial bladder cancer is considered to be at high risk for progression, and in some institutions early cystectomy is advocated. Other authors and personal experience suggest that conservative treatment, such as TURBT followed by intravesical prophylaxis, may be adequate in the majority of cases. The purpose of the present phase II study was to assess the tolerability and efficacy of sequential intravesical administration of a chemotherapeutic agent, epirubicin, followed by BCG, after TURBT. MATERIALS AND METHODS: 81 patients with primary T1G3 superficial bladder cancer, without evidence of Tis or upper tract tumor, underwent TURBT and intravesical prophylaxis with weekly epirubicin 50 mg for 8 weeks followed by weekly BCG Connaught 120 mg for 6 weeks. A control cystoscopy with bladder mapping and/or TUR of suspicious areas was performed at 15-17 weeks. Then patients were followed-up with 3-month urinary cytology and cystoscopy. RESULTS: The sequential chemo-immunoprophylaxis was generally well tolerated. After a mean follow-up of 48 months recurrent tumors were found in 19 patients (23.4%) and progressive disease in 6 cases (7.4%). Of 6 progressions, 4 patients died (5%) of the disease. CONCLUSION: Sequential chemo-immunoprophylaxis with epirubicin followed by BCG is well tolerated and seems to be efficacious in primary T1G3 bladder cancer. The recurrence progression and disease-specific mortality rates were acceptable so that this study seems to confirm previous data which show that TURBT and intravesical prophylaxis are appropriate treatment for the majority T1G3 tumors.

Results of a clinical care pathway for radical prostatectomy patients in an open hospital - multiphysician system.

OBJECTIVES: The object of this study was to evaluate the results of a comprehensive clinical care pathway (CCP) aimed at reducing the length of hospitalization and overall cost for patients undergoing radical prostatectomy in a setting including both academic and private physicians. METHODS: The clinical records of 1,129 consecutive patients who underwent radical prostatectomy by 24 urologists between July 1, 1990, and December 31, 1996, were reviewed. The factors considered were length of stay, morbidity and mortality, readmission rates, and average cost. The CCP was implemented on January 1, 1994. Its scope was to minimize preoperative evaluation, eliminate the preoperative hospital stay, standardize postoperative care and provide intensive patient education. RESULTS: The average length of stay decreased significantly after implementation of the CCP (8.1 vs. 4.9 days, p = 0.0001). In 1990, there was a large difference in length of stay between academic and private physicians (8.3 vs. 12.6 days) (p = 0. 02) but by 1 year after implementation of the CCP there was virtually no difference (4.69 vs. 4.71 days) (p > 0.05). Complication rates were similar before and after implementation of the CCP. Using the average 1993 cost/case as the baseline preCCP figure, the average cost of radical prostatectomy decreased by 16% in 1994 and by 22% in 1995. CONCLUSIONS: It is possible to successfully implement a CCP in a multi-physician system to reduce length of stay and cost of radical prostatectomy without subjecting the patient to a greater risk of complication.

Renal cell carcinoma--diagnosis and treatment: state of the art.

The authors update the current status of diagnostic and staging work-up and therapy of renal cell carcinoma (RCC). They first point out that the disease is increasingly discovered incidentally (about 30% of cases) when symptoms are absent. This, on average, has not led to a clear variation in stage distribution at first observation. It is not rare, however, to find very small lesions, for which differential diagnosis and particular therapeutic strategy are needed, because in some instances small lesions can give distant metastases. Hematuria remains the onset symptom in about 60% of cases where in about 20% of cases systemic symptoms or paraneoplastic syndromes are present. Distant metastases at presentation are still not rare, being observed in about 6-15% of patients. A review of diagnostic tools is then made, concluding that CT scan should be considered the most sensitive examination. The differential diagnosis with oncocytoma, angiomyolipoma and the so-called 'pseudo-tumors' is discussed in detail because these are the most frequently observed renal lesions out of RCC. Special attention is reserved for the diagnostic problems of renal cysts, suggesting that the Bosniak classification should be generally followed, and to the indications for fine-needle aspiration and biopsy which should be performed only in very selected cases. Minimal requirements for staging are indicated after a survey of the most common diagnostic methods. In treatment issues, the efficacy of lymph node dissection and adrenalectomy are discussed, concluding that the present body of data is still unable to clearly indicate that there is an absolute indication for extensive lymph node dissection whereas in selected cases partial nephrectomy may be a valid therapeutic option. Results of immunotherapy, cytotoxic therapy and their association are finally summarized as well as future prospects.

Chemoresection in Ta-T1 bladder cancer. Members of the EORTC Genito-Urinary Group.

OBJECTIVES: The authors present the results of two parallel phase II trials, instituted by the EORTC Genito-Urinary Group in 1986, whose aims were to assess the tolerability and ablative capacity of mitomycin C (study 30864) and epirubicin (study 30869) in patients with multiple primary or recurrent Ta-T1 bladder cancer. METHODS: A well-defined tumour (marker lesion) was left in the bladder after transurethral resection (TUR). All patients received 8 weekly instillations, after which cystoscopy with bladder biopsies +/- TUR was performed. Responses were rated as follows: (1) complete-no visible or microscopic bladder cancer; (2) no change-persistence of the marker lesion; (3) progression-increased marker lesion size, new tumour(s) or presence of muscle-invasive disease at any site. RESULTS: Ninety-six evaluable patients were treated with mitomycin and 36 with epirubicin. The overall bladder response in the former group was complete in 50%, no change in 30% and progression in 20% of patients, while the marker lesion response was complete in 57%, no change in 39% and progression in 4%. In the epirubicin group, 56% of the patients achieved a complete overall response, while there was no change in 22% and progression in 22%. The marker lesion response in this group was complete in 67%, no change in 31% and progression in 3%. Only 2 cases of progression were due to the presence of muscle-invasive disease. Both of these were in the mitomycin group; 1 was at the marker lesion site, and 1 was at a remote site. CONCLUSIONS: The present studies confirm the feasibility and safety of the marker lesion model for the objective evaluation of the antitumoural activity of intravesically administered drugs.

Results of transurethral resection and intravesical doxorubicin prophylaxis in patients with T1G3 bladder cancer.

OBJECTIVES: This retrospective study evaluates the outcome of patients with T1G3 bladder cancer treated by transurethral resection (TUR) and intravesical doxorubicin prophylaxis and identifies clinically useful prognostic factors. METHODS: One hundred twenty-eight consecutive patients with primary T1G3 bladder cancer were treated by TUR followed by 1-year intravesical prophylaxis with doxorubicin. Sex, age, number, size, and morphology of the tumors, exfoliative cytology, presence of dysplasia at first observation, pathologic findings of the first recurrence, and number of recurrences were the parameters considered in a multivariate analysis whose object was to identify specific risk factors for recurrence and progression. RESULTS: The recurrence rate was 56.3% and progression of disease was seen in 23.4% of cases with a disease-specific mortality rate of 7.8%. The disease-free survival in patients who had cystectomy was 37.7 months and the disease-specific mortality rate for this group was 35.7%. The recurrence rate was found to be significantly higher for multiple tumors, solid morphology, size greater than 3 cm, positive exfoliative cytology, and concurrent dysplasia. The reappearance of Stage 1, grade 3 tumor on first recurrence was the only factor found to be correlated with progression. CONCLUSIONS: Up front therapy consisting of TUR and intravesical doxorubicin prophylaxis is appropriate for T1G3 bladder cancer. Patients with unfavorable prognostic factors should be kept under strict control; and if a T1G3 tumor is identified on first recurrence, immediate cystectomy should be considered.

Performance evaluation of a hand-held gamma detector probe used for radioimmunoguided surgery.

The success of radioimmunoguided surgery (RIGS) is dependent on the performance parameters of the apparatus, its correct handling, and the employment of a suitable radioactive compound. In the present study the authors examined the performance of the Neoprobe 1000 device with respect to the radioisotope 99mTc. Detecting efficiency was evaluated experimentally using a phantom containing a radioactive point source which could be moved both vertically and horizontally with respect to the central axis of the probe. In this way curves representing the variations in efficiency as a function of the vertical and horizontal distances of the source from the probe were constructed. Furthermore, values of minimum detectable activity as a function of source depth, counting time and background radioactivity were calculated. These results were compared to those previously obtained using 125I, the radioisotope most frequently employed in RIGS. The graphs and tables included could serve as a practical aid to help the operator obtain the best possible measuring conditions, thereby maximizing his/her results.