Treatment of high-grade low-stage prostate cancer by high-dose-rate brachytherapy.

BACKGROUND AND PURPOSE: The best management of patients with low-stage, high-grade prostate cancer remains unclear. In an attempt to improve the outcomes of this high-risk group, we have offered those with Gleason > or =7 cancers removable-source high-dose-rate (HDR) brachytherapy in combination with external-beam radiation. PATIENTS AND METHODS: We reviewed the clinical histories of 61 consecutive patients with high-grade clinical stage T1-T2 lesions who received the combination radiation therapy between March 1997 and November 1998. The average Gleason score was 7.5. The HDR brachytherapy was given in three sessions with removable-source afterloaded (192)Ir to a minimum peripheral dose of 6 Gy. Conformal external-beam radiation in 25 fractions to a dose of 50 Gy was given beginning 1 week later. Patients with prostate volumes >40 cc received a luteinizing hormone-releasing hormone analog before brachytherapy. RESULTS: Among the 52 patients available for follow-up (average duration 11.8 months), there has been one death from prostate cancer. After treatment, only one patient had an initial rise in serum prostate specific antigen (PSA) concentration. In addition to the patient who died, there have been three confirmed treatment failures. Toxicity was mild, with only two patients having RTOG grade 3 or 4 effects. Neither of them required surgery. CONCLUSION: Although long-term results are not available, available data suggest that HDR brachytherapy plus external-beam radiation is at least as effective as any single therapy for high-risk, low-stage prostate cancer. The toxicity is acceptable.

Dramatic rise in prostate-specific antigen after androgen replacement in a hypogonadal man with occult adenocarcinoma of the prostate.

We present the case of a hypogonadal patient in whom a 20-fold increase in prostate-specific antigen and a palpable prostatic nodule developed 6 months into the administration of intramuscular testosterone.

Retroperitoneoscopic technique for treating symptomatic caliceal diverticula.

Calculous disease in a caliceal diverticulum is a rare entity. The standard treatment currently is endoscopic surgery with marsupialization or fulguration or both with dilatation of the neck of the diverticulum. We present the fifth reported case of retroperitoneoscopic management of a caliceal diverticulum in a patient with a long history of flank pain and suggest that this treatment offers a stone-free rate comparable to that of open surgery with less morbidity than is associated with endoscopic treatments.

Oral bropirimine immunotherapy of bladder carcinoma in situ after prior intravesical bacille Calmette-Guérin.

OBJECTIVES: Bropirimine is an oral immunomodulator that has demonstrated anticancer activity in transitional cell carcinoma in situ (CIS) in both the bladder and upper urinary tract. Activity also has been documented in patients after prior therapy with bacille Calmette-Guérin (BCG). To more accurately estimate bropirimine's efficacy in BCG-resistant bladder CIS, a Phase II trial was performed. A separate analysis was performed in additional patients intolerant of BCG toxicity. METHODS: Patients received bropirimine 3.0 g/day by mouth for 3 consecutive days, weekly, for up to 1 year. Bladder biopsies and cytologic examination were performed quarterly. Complete response (CR) required negative biopsy and cytology results. RESULTS: Twenty-one of 86 patients entered were not evaluable. CR was seen in 21 (32%; 95th percentile confidence interval [CI], 21% to 44%) of 65 evaluable patients, including 14 (30%, CI 17% to 43%) of 47 BCG-resistant, and 7 (39%, CI 16% to 61%) of 18 BCG-intolerant patients. Overall, by intent-to-treat analysis, CR was thus seen in 21 (24%) of 86 subjects. Most BCG-resistant patients were failures to BCG without relapse, and had received 12 to 36 (median 12) BCG treatments; intolerant patients had received 4 to 11 treatments (median 6). Response duration ranged from 65 to 810 days, with median not yet reached (but greater than 12 months). Thirteen (15%) of 86 stopped bropirimine due to toxicity. Progression to invasive or metastatic disease during or immediately after therapy was documented in only 4 patients (6%), all nonresponders. CONCLUSIONS: Bropirimine may be an alternative to cystectomy for some patients with bladder CIS who have failed or have not tolerated BCG. Further evaluation to improve responses and durability is warranted.

Endoscopic injection of glutaraldehyde cross-linked collagen for efferent limb incompetence in the Indiana reservoir.

PURPOSE: We determined the clinical applicability, safety and efficacy of endoscopically injected glutaraldehyde cross-linked collagen for the treatment of efferent limb incompetence in the incontinent Indiana urinary reservoir. MATERIALS AND METHODS: Six patients were diagnosed with incompetence of the efferent limb of the Indiana reservoir by video urodynamics. Glutaraldehyde cross-linked collagen was injected through the efferent limb at the level of the ileocecal valve. Outcome was assessed by evaluation of dryness and pouchograms. RESULTS: With a mean followup time of 26 months (range 6 to 36) after the last injection 5 of the 6 patients were cured. The remaining patient, although improved, had a small capacity and subsequently underwent ileal patch augmentation. No patient failed to improve. The mean volume of collagen was 16 ml. (range, 5 to 26). Reservoir volume increased from 150 to 400 ml. CONCLUSIONS: The use of glutaraldehyde cross-linked collagen in the treatment of the incontinent Indiana reservoir is safe and effective.

Ileocecal valve resistance augmentation using glutaraldehyde cross-linked collagen: a canine model for endoscopic salvage of the leaking Indiana reservoir.

PURPOSE: Periurethral injection of glutaraldehyde cross-linked collagen is a well-established modality for the treatment of patients with incontinence caused by structural defects at the bladder outlet. Little is known about the potential usefulness of this approach to the nonfunctioning continence mechanism of a leaking continent urinary reservoir. An animal model of an incontinent Indiana reservoir was created using the naturally incompetent canine ileocecal valve. The effectiveness and feasibility of endoscopic submucosal injection of glutaraldehyde cross-linked collagen into the ileocecal valve to increase resistance were examined. MATERIALS AND METHODS: Seven beagle dogs underwent isolation of the ileocecal segment. The right colon and ileum were brought to the skin as 2 stomas. Baseline leak point pressures of the ileocecal valve were determined while infusing contrast material into the right colon. The leak point was observed fluoroscopically, and the pressure at which contrast material crossed the valve was measured. Glutaraldehyde cross-linked collagen, 4 to 10 ml., was injected endoscopically into the valve in a circumferential pattern. Leak point pressures were measured immediately, 1 month after injection and 3 months after injection. RESULTS: An average of 7.1 gm. (range, 4.1 to 10.1 gm.) was required to create an endoscopically "closed" ileocecal valve. Leak point pressure increased from a mean 3.8 mm. water (range, 2.5 to 6.0 mm. water) at baseline to mean 35.7 mm. water after injection (range, 22.0 to 57.0 mm. water). At 1 month, mean leak point pressure decreased slightly to 26.7 mm. water. This pressure stabilized at 3 months at 29.5 mm. water. CONCLUSIONS: Endoscopic delivery of glutaraldehyde cross-linked collagen into the ileocecal valve consistently enhanced resistance as measured by leak point pressure. This effect was durable over a 3-month period of observation. Admittedly, this period of observation is relatively short. Longer followup may have demonstrated significant diminution of collagen migration or resorption. However, this feasibility study demonstrates that collagen injections may provide a minimally invasive means of treating the incontinent continent urinary reservoir.

Primary skeletal metastasis of a nonseminomatous germ cell tumor.

Bony metastasis is common in patients with germ cell tumor of the testicle; however, it is usually seen late in the disease process and is associated with lymph node or other visceral involvement. We present a case of isolated bony metastasis in a patient with a nonseminomatous germ cell tumor of the testis and normal retroperitoneal lymph nodes as determined by surgical resection.

Corticosteroid-associated fatal mycobacterial sepsis occurring 3 years after instillation of intravesical bacillus Calmette-Guerin.

A case is reported of systemic Mycobacterium bovis infection that occurred 3 years after uneventful instillation of intravesical bacillus Calmette-Guerin (BCG) and after several months of oral prednisone therapy. The literature on delayed BCG infection and the systemic persistence of BCG after intravesical instillation is reviewed. We propose that rarely a reservoir of dormant M. bovis may become established after intravesical therapy. Reactivation infection may later develop in a manner that parallels the natural history of secondary tuberculosis.

Laparoscopic marsupialization of massive renal cyst.

Laparoscopic approaches to urological problems continue to increase. We describe laparoscopic marsupialization and fulguration of a symptomatic giant renal cyst. Transient obstruction at the marsupialized window illustrated the importance of using omental or epiploic fat to maintain patency. Complete resolution of the cyst and hydronephrosis ensued.

Is the neodymium:YAG laser effective therapy for invasive bladder cancer?

The neodymium:YAG (yttrium-aluminum-garnet) laser can cause transmural coagulation necrosis of bladder tumor or bladder wall. Pathologic specimens of 18 patients prospectively treated with the neodymium:YAG laser before radical cystectomy were reviewed to compare the initial clinical stage of bladder tumor with the final pathologic stage and to assess the destructive tissue effects of neodymium:YAG laser therapy. Eleven of 18 patients were unchanged pathologically in stage of tumor or had tumor progression. Seven patients had a lower pathologic tumor stage; 3 of these patients had pathologic Stage T0 with no residual tumor, with the remainder of patients showing superficial disease. One asymptomatic small bowel injury was discovered at operation. Healing lesions showed marked granulation tissue, coagulation necrosis, and persistent ulceration.

Ureteroscopic removal of retained ureteral Double-J stents.

At the Lahey Clinic Medical Center, Double-J stents are placed primarily for management of patients with calculi. They are used before extracorporeal shock-wave lithotripsy (ESWL) of large renal calculi or bilateral ESWL treatments and after ureteroscopic instrumentation or removal of calculi. They are also used for palliative urinary diversion for patients with ureteral obstruction secondary to pelvic cancer. Fluoroscopy with C-arm guidance is the standard radiologic technique employed for manipulation of all calculi and insertion of stents. Results have been good with the use of these stents, but in 3 patients the rigid ureteroscope was required to remove a retained Double-J stent.

Complications of retropubic bladder neck suspension.

Seven women who underwent the Stamey endoscopic bladder neck suspension performed by different urologists at a variety of institutions were evaluated at the Lahey Clinic Medical Center. Two to 36 months after operation, each woman sought medical attention because of complaints of pain in the lower abdomen, pelvis, or groin with or without urinary frequency and urgency. Endoscopic examination revealed an acute mucosal inflammatory reaction, perforating sutures or Dacron pledgets, and formation of calculi around a suture. In each patient, sutures or pledgets were removed endoscopically with resolution of presenting complaints.

Dilation of benign ureteral strictures.

Balloon dilation of benign ureteral strictures was performed in 33 patients in a percutaneous antegrade (25 patients) or retrograde (eight patients) fashion followed by placement of a 7-10-F stent for 4-8 weeks. Dilation was possible in all patients. During the follow-up period of 1-40 months the overall success rate was 76%. The success rate in primary strictures at the ureteropelvic junction was 86%. Among 10 patients with postsurgical (pyeloplasty, ureteroenterostomy, and ureteroneocystostomy) anastomotic strictures, dilation was successful in 50%. Of six patients with postoperative strictures after calculus removal by ureterolithotomy or pyelolithotomy, four (67%) had good results. All patients with iatrogenic postureteroscopic strictures (five patients) or accidental ureteral ligation (two patients) had a normal pyelogram at follow-up. The success rate in acute strictures of less than 3 months duration was 88%; in strictures of more than 3 months duration the success rate was 67%. Cause, length, and duration of stricture are the prime determinants of success. Early intervention with balloon dilation is suggested.

Percutaneous balloon dilatation in treatment of infected pyelocaliceal diverticulum.

Abscess formation is a known complication of pyelocaliceal diverticulum. Although successful management of stones complicating pyelocaliceal diverticulum has been described utilizing percutaneous techniques, this is the first report to our knowledge of a percutaneous technique that simultaneously manages an acute abscess and provides for ablation of the diverticular cavity thus preventing future recurrences. The method involves placement of single or multiple stents spanning the diverticulum and the collecting system proper following percutaneous dilatation of the narrow isthmus that usually provides the communication with the main collecting system. The procedure offers an economical and tissue-sparing approach, which obviates the need for major abdominal or retroperitoneal operation.