The merits of cytology in the workup for upper tract urothelial carcinoma - a contemporary review of a perplexing issue.

INTRODUCTION: The importance of upper tract cytology for evaluating tumors is unclear. We correlated upper tract cytology with histologic findings in patients who underwent nephroureterectomy for upper tract urothelial carcinoma (UTUC) at a single tertiary care referral center. MATERIALS AND METHODS: 137 patients underwent nephroureterectomy between 2004 and 2012. 18 patients were excluded (benign tumors, atrophic kidneys with the remaining 119 patients serving as our study population). Upper tract cytology from the renal pelvis and/or ureter were retrospectively reviewed and analyzed with final pathology data in the remaining patients with UTUC. RESULTS: 57% (68/119) had preoperative upper tract cytology collected. 73% (50/68) patients had abnormal cytology (positive, suspicious) with a sensitivity of 74% (which increased to 90% if atypical included), specificity of 50% and a positive predictive value of 98%. High grade tumors were more common than expected (77% high grade vs. 20% low grade). Abnormal cytology did not predict T stage or tumor grade. Interestingly, positive upper tract cytology was found in all of the UTUC CIS specimen. CONCLUSIONS: Upper tract cytology has been utilized to support the diagnosis of upper tract urothelial carcinoma. Our data demonstrates that abnormal cytology correlates well with the presence of disease but does not predict staging or grading in these respective patients.

The merits of cytology in the workup for upper tract urothelial carcinoma - a contemporary review of a perplexing issue

Introduction The importance of upper tract cytology for evaluating tumors is unclear. We correlated upper tract cytology with histologic findings in patients who underwent nephroureterectomy for upper tract urothelial carcinoma (UTUC) at a single tertiary care referral center. Materials and Methods 137 patients underwent nephroureterectomy between 2004 and 2012. 18 patients were excluded (benign tumors, atrophic kidneys with the remaining 119 patients serving as our study population). Upper tract cytology from the renal pelvis and/or ureter were retrospectively reviewed and analyzed with final pathology data in the remaining patients with UTUC. Results 57% (68/119) had preoperative upper tract cytology collected. 73% (50/68) patients had abnormal cytology (positive, suspicious) with a sensitivity of 74% (which increased to 90% if atypical included), specificity of 50% and a positive predictive value of 98%. High grade tumors were more common than expected (77% high grade vs. 20% low grade). Abnormal cytology did not predict T stage or tumor grade. Interestingly, positive upper tract cytology was found in all of the UTUC CIS specimen. Conclusions Upper tract cytology has been utilized to support the diagnosis of upper tract urothelial carcinoma. Our data demonstrates that abnormal cytology correlates well with the presence of disease but does not predict staging or grading in these respective patients. .

Primary cryosurgery for clinically localized prostate cancer--do perioperative tumor characteristics correlate with post-treatment biopsy results?

OBJECTIVE: To investigate the rate and predictive factors of positive post-treatment biopsy in men treated with primary cryosurgery for localized prostate cancer. METHODS: A retrospective review was performed of all patients treated with primary cryosurgery at a single institution between 1999 and 2012. Perioperative prostate-specific antigen (PSA) levels, Gleason score, and number of positive preoperative biopsy cores were obtained and correlated with postoperative biopsy results. Patients were stratified according to the risk classification system of D'Amico to low-, intermediate-, or high-risk groups. RESULTS: Sixty-five men were treated with primary cryosurgery, and 57 of 65 (88%) of them underwent postoperative biopsy on average 9 months after the treatment. Eleven of 57 patients (19%) were found to have persistent tumor on post-treatment biopsy. Men who had positive biopsy had significantly higher perioperative PSA levels than men who had negative biopsy (preoperative PSA 12.5 vs 6.2, P = .002; post-operative PSA nadir 4.3 vs 0.71, P = .005); however, no independent predictor was found on a multivariate analysis. Gleason score and number of positive preoperative biopsy cores did not predict tumor persistence. Positive biopsy results were found more often in the intermediate- and high-risk patients, although this was not statistically significant (low risk 9%, intermediate risk 20%, and high risk 27%). CONCLUSION: Perioperative PSA levels, Gleason score, or number of positive pretreatment biopsy cores do not predict failure after primary cryosurgery for clinically localized prostate cancer. Our findings suggest that physicians, who offer primary cryosurgery to patients with localized prostate cancer, should consider offering post-treatment biopsy to patients to assure adequate cancer control.

Devastating complications after brachytherapy in the treatment of prostate adenocarcinoma.

OBJECTIVE: To report a retrospective chart review of patients who developed recto-urethral fistula (RUF) or several bladder neck contracture (BNC) recurrences after brachytherapy for treating localized prostate cancer. PATIENTS AND METHODS: In the past 3 years 18 patients with devastating complications after prostate brachytherapy were referred to our centre (RUF in 11, BNC in seven; mean age 63 years, range 60-81). All patients with RUF initially underwent diverting colostomy (six cystoprostatectomy with closure of the fistula, omental interposition and urinary diversion; one prostatectomy, bladder neck closure, fistula closure with omentum flap and continent vesicostomy). Three patients had the fistula closed with gracilis muscle flap using the York-Mason approach (one had a bladder neck closure and suprapubic tube; one elected to have no treatment). All patients with BNC had received three or more procedures to resect or incise their contracture. Four had diversion with a catheterizable segment, two used an indwelling Foley catheter and one uses intermittent catheterization. RESULTS: All six patients who had cystoprostatectomy with urinary diversion have had no recurrence of their RUF. All three treated with the York-Mason procedure healed well. One developed recurrent prostate adenocarcinoma and two a secondary neoplasia in the prostate or rectum (leiomyosarcoma and neuroendocrine, respectively). The enterocystoplasty patient developed sepsis after colostomy reversal and subsequently died. In those patients with BNC, the four who underwent urinary diversion fared well; two tolerate the indwelling catheter poorly, and the seventh uses intermittent catheterization with occasional difficulty. CONCLUSIONS: Brachytherapy with or without external irradiation can be associated with severe complications. RUF managed with aggressive anterior pelvic exenteration and urinary diversion can be associated with excellent results. The York-Mason procedure in patients with an adequate urinary continence mechanism and bladder dynamics may provide good functional results. The presence of a secondary malignancy in patients deserves further investigation. Many recurrences of a BNC tend be refractory to transurethral resection/incision; indwelling catheters are then poorly tolerated and patients may require a major reconstructive procedure.

Radical prostatectomy in the management of clinically localized prostate cancer.

BACKGROUND: Several management options are available when prostate cancer is diagnosed at an early stage. However, the optimal treatment for localized prostate cancer is unknown, and reports in the literature are controversial regarding the best treatment modality for this early presentation. METHODS: The authors review improvements in surgical technique that have decreased complications, and they address long-term outcomes of surgery related to cancer control. RESULTS: Improvements in surgical techniques allow for decreased intraoperative complications. The incidence of long-term complications such as incontinence and impotency is also reduced. The 5- and 10-year progression-free survival with radical prostatectomy has improved. CONCLUSIONS: Surgery today is safer with improvements in techniques. The long-term outcomes with surgery are excellent and, in several series, better than outcomes achieved with other treatment modalities.

Contemporary management of superficial bladder cancer.

BACKGROUND: Bladder cancer is the second most common urologic malignancy after prostate cancer. Superficial bladder cancer presents as a heterogeneous group of tumors with variable biological potential. A significant percentage of patients diagnosed with superficial cancer will have multiple recurrences, and some will progress to invasive disease. METHODS: Patients are stratified into low- or high-risk for recurrence and progression. We review the most recent literature regarding intravesical therapy for superficial bladder cancer, and we summarize indications for the use of intravesical agents as well as their efficacy, toxicity, and cost. RESULTS: Several intravesical agents are available for the treatment of superficial bladder cancer. Patients may be identified as low- or high-risk for recurrence and progression. High-risk patients benefit from intravesical therapy. CONCLUSIONS: Superficial bladder cancer is a heterogeneous group of diseases. Treatment is effective in preventing recurrences and progression in the high-risk group.

NCCN Practice Guidelines for Prostate Cancer.

Systemic therapies for prostate cancer are likely to improve, and as they do, they will have enormous impact on the treatment of high-risk and locally advanced cancers. Further technical improvements in radiotherapy and alternative local modalities, such as cryoablation, are also likely, and will bring even more options for local control. It is certain these guidelines will continue to evolve.

Needle imaging during ultrasound-guided permanent prostate implants.

As demonstrated by water phantom experiments and clinical observations, the reverberation artifact associated with the ultrasound needle image during permanent prostate implants is extremely useful in determining precise radioactive seed positioning. It also serves as an independent quality assurance check of the number of seeds in the strand.

Predictability of PSA failure in prostate cancer by computerized cytometric assessment of tumoral cell proliferation.

OBJECTIVES: To evaluate the relationship of DNA ploidy and cell proliferation (CP) with Gleason score (GS) and clinical outcome in prostate cancer. METHODS: Sixteen patients with benign prostatic hyperplasia (BPH) and 65 patients with prostate cancer classified by GS (four groups: 2 to 4, 5 to 6, 7, and 8 to 10) were studied. All patients with carcinoma underwent prostatectomy and were separated into prostate-specific antigen (PSA) failure and nonfailure groups (failure if PSA 0.1 ng/mL or more three times after surgery). Tumoral CP (Ki-67 inmunostaining and SG2M phase) and DNA ploidy were evaluated by computerized cytometry. RESULTS: BPH were diploid with low CP (8% SG2M cells or less). Carcinomas were either diploid with high CP (greater than 8% SG2M cells) or aneuploid. CP was significantly higher (P <0.001) in tumors with GS 7 or greater than in tumors with GS less than 7 (mean percent Ki-67 cells 18.3% versus 7.8%, respectively). PSA failure increased with GS (7.1% in GS 2 to 4, 21% in GS 5 to 6, 28.6% in GS 7, and 50% in GS 8 to 10), as well as with aneuploidy (18.5% in diploid tumors versus 72.7% in aneuploid tumors). Those experiencing PSA failure had significantly higher (P <0.001) CP than those not failing (mean percent Ki-67 cells 24% and mean percent SG2M 30.4% versus 8.7% and 13.5%, respectively). Cox regression analysis showed GS, DNA ploidy, Ki-67, and SG2M to each be univariately prognostic for time to PSA failure; however, Ki-67 and SG2M were more highly significant (P <0.0001 for both) than GS (P = 0.007) or DNA ploidy (P = 0.002). After adjusting for either SG2M or Ki-67 measures of CP, neither ploidy nor GS contained additional prognostic value. CONCLUSIONS: Tumor CP and DNA ploidy can be reliably determined in prostate cancer by computerized cytometry. On the basis of our preliminary results, CP correlates well with GS and predicts PSA failure better than DNA ploidy or GS.

Evaluation of flap valve as an alternative continence mechanism in the Florida pouch.

OBJECTIVES: To evaluate urodynamic findings in a successful flap valve (FV) continence mechanism in association with a continent colonic urinary reservoir (Florida pouch) and to compare the urodynamic findings of the FV mechanism with the doubly plicated (PI) standard anti-incontinence segment in the same reservoir. METHODS: Thirteen patients who successfully received the Florida pouch between 1988 and 1996 agreed to undergo urodynamic evaluation as part of a pilot study. Eight patients had a PI continence mechanism and a mean time from surgery of 51 months; 5 had a FV continence mechanism and a mean time from surgery of 14 months. Enterocystometry was performed with a trans-stomal Bard triple channel 7F catheter. Volume and pressure at first desire to empty (VFDE, PFDE), as well as maximal enterocystometric capacity and pressure (VMEC, PMEC), were recorded. Maximal outlet pressure (MOP) was recorded using the catheter withdrawal technique. RESULTS: PI and FV groups demonstrated the following mean values respectively: VFDE, 692.7 and 403 mL; PFDE, 19.5 and 19.2 cm H2O; VMEC, 876.5 and 515 mL; PMEC, 25.9 and 24.6 cm H2O; MOP, 57.5 and 51.2 cm H2O (reservoir empty) and 50.5 and 52.6 cm H2O (reservoir full); and functional length of outlet, 24.3 and 24.6 cm. MOP measurement demonstrated greater variability in the PI than in the FV group. CONCLUSIONS: Urodynamic comparison of these mechanisms reveals that MOP measurement was closer to the mean among FV than PI patients. In addition, the mean VFDE (692.7 mL for PI versus 403 mL for FV, P < 0.05) and the mean VMEC (876.5 mL for PI versus 515 mL for FV, P < 0.05) were significantly less in the FV group. Lower VMEC and less variability in MOP indicate that continence may be more dependent on MOP in the FV mechanism. A longer follow-up time and a larger number of patients will be of assistance in clarifying these findings.

Estimated Blood Loss in Group O as Compared to Non-group O Radical Prostatectomy Patients.

BACKGROUND AND OBJECTIVES: Blood group O individuals have been shown to have lower levels of von Willebrand factor (vWF). It is not known if these differences are associated with an increased bleeding risk. We retrospectively assessed estimated blood loss (EBL) in group O and non-group O men undergoing radical prostatectomy. MATERIALS AND METHODS: All patients undergoing radical retropubic prostatectomy from October 1986 through January 1997 were evaluated for ABO type, EBL in the operating room and red blood cell (RBC) transfusion requirements. RESULTS: Complete data were available for 138 group O and 168 non-group O men. Average intraoperative blood loss was 1996 mLs for all men and there was no significant difference in the EBL or transfusion requirements for group O patients. Substantial blood loss (EBL of at least 3 liters) did occur in 20.3% of group O and 13.1% of non-group O patients (P = 0.12). There were no significant differences between the two groups in the number of autologous, allogeneic or total RBCs transfused either intraoperatively or within 48 hours of surgery. CONCLUSION: There was no difference in blood loss or RBC transfusion requirements between group O and non-group O patients undergoing radical prostatectomy. The lower levels of vWF that have been found in group O individuals do not appear to put group O men at significant risk for greater operative blood loss or transfusion requirements during radical prostatectomy. SUMMARY: Group O men undergoing radical prostatectomy do not have greater estimated blood loss or transfusion requirements as compared to non-group O men.

Ancillary techniques in the followup of transitional cell carcinoma: a comparison of cytology, histology and deoxyribonucleic acid image analysis cytometry in 91 patients.

PURPOSE: Voided urine and bladder washing cytology are used frequently in the evaluation of transitional cell carcinoma of the bladder. As part of an ongoing investigation we report on the role of deoxyribonucleic acid (DNA) image analysis cytometry as an adjunct to cytology in the followup of patients with transitional cell carcinoma. MATERIALS AND METHODS: Urine cytology and image analysis cytometry were performed independently on aliquots of voided urine, catheterized urine or bladder washings from 91 patients with previous or active transitional cell carcinoma of the bladder, and the results were compared to those of concurrent biopsy and clinical followup. RESULTS: Of 75 recurrent transitional cell carcinomas 42 were detected by cytology, while 63 and 64 were identified by image analysis cytometry and biopsy, respectively, for a sensitivity of 57, 84 and 85%, respectively. Combined cytology and image analysis cytometry detected 67 recurrences, for an overall sensitivity of 89%. Of 11 cases undetected by concurrent biopsy 9 had abnormal DNA histograms with transitional cell carcinoma at followup and 2 were DNA diploid but with grade 1 transitional cell carcinoma at followup. Of 12 cases undetected by image analysis cytometry 8 were grade 1 and 4 were grade 2 transitional cell carcinoma. CONCLUSIONS: Urine cytology and image analysis cytometry detect most recurrent tumors. Their combined use is indicated in the followup of patients with bladder transitional cell carcinoma.

Improvement in dosimetry of ultrasound-guided prostate implants with the use of multiple stabilization needles.

The use of three stabilization needles for ultrasound-guided permanent prostate implants results in better dosimetric coverage of the prostate, all other variables being equal. This technique prevents rocking motion of the prostate when anterior needles are inserted and thus improves accuracy of seed placement and shortens the length of the procedure. On post-implant CT-based dosimetric evaluation, the three stabilization needles technique provides better coverage, with the prescription isodose line encompassing 95% of the target volume compared to 90% for the implant utilizing two stabilization needles. Further improvements in the technique are currently under investigation, with the goal of consistently achieving truly "conformal anatomical prostate brachyradiotherapy."

Role of DNA image cytometry in the follow-up of patients with urinary tract transitional cell carcinoma.

Detection of recurrent urinary tract transitional cell carcinoma (TCC) is a frequent diagnostic challenge in exfoliative cytology because of the difficulty in distinguishing reactive changes from low grade tumors. This study evaluated the role of DNA analysis by image cytometry (ICM) as a diagnostic aid to cytology. Eighty-seven urine samples from patients with a known history of transitional cell carcinoma were examined by both cytology and ICM, and the results were compared with concurrent surgical biopsy specimens and patients' follow-up data. Twenty-seven patients were also examined by cystoscopy, and the results were compared to those of DNA analysis, cytology and biopsy. Urine samples were cytocentrifuged and stained with Papanicolaou stain for general cytology and Feulgen stain for ICM. DNA ploidy and the proliferating cell fraction (SG2M) were measured using the CAS 200 image analyzer. Among the 87 specimens included in the study, 59 were from patients considered to have recurrent disease when urine was obtained. Of the 59 recurrences, 33 were detected by cytology, 50 by ICM and 50 by biopsy, resulting in 55%, 85% and 85% sensitivity, respectively. When combined, cytology and ICM detected 53 recurrences and achieved 90% sensitivity. Nine cases originally undetected by biopsy had abnormal DNA histograms and were found to have TCC on follow-up examination. All cases undetected by ICM were low grade lesions with DNA diploidy and low proliferation. Among the 27 patients examined by cystoscopy, 14 had recurrent disease; 5, 13 and 6 of those cases were detected by cystoscopy, DNA analysis and cytology, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Antisense DNA inhibition of tumor growth induced by c-Ha-ras oncogene in nude mice.

Antisense DNA has shown an ability to target specific oncogene transcripts and inhibit their expression in cells, but the degree to which sustained treatment can suppress total levels of an oncogenic product and alter tumorigenesis in vivo remains to be determined. In this study, NIH-3T3 cells transformed by the activated c-Ha-ras oncogene from T24 human bladder cancer cells were treated for 3 consecutive days in vitro with an antisense DNA pentadecamer complementary to a target in the 5'-flanking region of the c-Ha-ras RNA transcript. Following antisense DNA treatment, a portion of the cells was lysed for measurement of RAS p21 while the remaining cells were evaluated for tumorigeneity by injection s.c. into athymic nude mice at a dose of 5 x 10(5) cells/mouse. The 3 days of treatment with the anti-c-Ha-ras DNA reduced RAS p21 cellular levels by more than 90% while a nonspecific control DNA reduced p21 levels by approximately 20%. Tumor growth of cells treated with anti-c-Ha-ras DNA was significantly reduced for up to 14 days following the end of treatment and implantation into the mice whereas the nonspecific control DNA had no significant effect. These effects on tumor growth were evident in two different strains of nude mice and in both males and females. It is suggested that the pronounced decrease in RAS p21 levels produced by anti-c-Ha-ras DNA resulted in a reversal of the transformed phenotype, and it is this reversal which accounts for the prolonged inhibition of tumorigenesis following antisense DNA treatment.

[Continent urinary diversion with the Florida pouch]. / Dérivation urinaire continente à l'aide de la poche de Floride.

Continent urinary diversion (Florida Pouch) has been performed on 151 patients. The surgical technique utilizes a detubularized extended right colon segment, a doubly-plicated segment of ileum and a non-tunneled uretero-intestinal anastomosis. Mortality rate was 1.3%. Early and late complication rates have been minimal. 2.8% were incontinent. No radiographic renal damage has been noted and electrolyte abnormalities have not been a problem. The procedure is highly recommended to those surgeons performing continent urinary diversions.