Medical versus surgical androgen suppression therapy for prostate cancer: a 10-year longitudinal cost study.

PURPOSE: We provide a relative cost comparison of medical versus surgical androgen suppressive therapy for prostate cancer. MATERIALS AND METHODS: Comparison is based on a cohort of 96 patients who began androgen suppressive therapy for prostate cancer between 1988 and 1990. Patients were followed until death or the end point of study in June 2000 at which time 15% were alive. Current Medicare orchiectomy reimbursements were compared to 1999 wholesale drug costs. RESULTS: For an individual patient the cost of luteinizing hormone releasing hormone (LH-RH) agonist treatment surpassed the cost of surgery at less than 4.2 to 5.3 months, and for combined androgen blockade (LH-RH agonists and nonsteroidal antiandrogens) at less than 2.7 to 3.4 months. For 5 (5.2%) patients on combined androgen blockade and 6 (6.3%) on LH-RH agonists alone, medical therapy would have had a cost advantage over bilateral orchiectomy. For the androgen suppression cohort the cost of LH-RH agonist treatment was 10.7 to 13.5 times and combined androgen blockade was 17.3 to 20.9 times the cost of bilateral orchiectomy. Urology resource use comparisons are provided. These findings significantly underestimate the cost advantage of surgery. A seventh of the patients were alive at study end point, and prostate specific antigen induced stage shifting and changes in practice patterns resulted in earlier and more frequent androgen suppressive treatment. CONCLUSIONS: Except for patients with short anticipated survivals current medical androgen suppressive treatment options are more costly than bilateral orchiectomy. There is a need for a cost comparable medical option to orchiectomy.

Primary intratesticular sarcoma. Immunohistochemical ultrastructural and DNA flow cytometric study of three cases with a review of the literature.

BACKGROUND: Fourteen cases of testicular sarcoma have been reported in the contemporary era. These included 7 cases of rhabdomyosarcoma, 2 spindle cell sarcoma, 2 osteosarcoma, 1 leiomyosarcoma, 1 fibrosarcoma, and 1 chondrosarcoma coma. METHODS: In this report, immunohistochemical stains, electron microscopy, and DNA flow cytometric analysis were performed on primary testicular sarcomas from three patients. RESULTS: The patients were age 47, 40, and 33 years. Each presented initially with a testicular mass. The tumors measured 4.8, 4.0, and 4.0 cm in greatest dimension. There was no associated germ cell elements nor elevated alpha-fetoprotein or beta-human chorionic gonadotropin. Case 1 was positive for actin, vimentin, and alpha-1-chymotrypsin. Case 2 was positive for vimentin but not desmin. Case 3 was positive for desmin and S-100. Smooth muscle differentiation was identified by electron microscopy. Flow cytometric analysis revealed DNA aneuploidy in all cases: 1.27, 1.29, and 1.71. The 3 patients were alive and well without recurrent disease at 7, 6, and 4 years after diagnosis. Inguinal orchiectomy was the initial treatment in all 17 patients, there was 1 death from metastatic disease and 2 patients with distant metastases. CONCLUSION: Primary testicular sarcoma is a rare indolent tumor with potential for distant metastases. Two cases of primary testicular leiomyosarcoma and one of unclassified sarcoma of the testis are reported.

The significance of adult hematuria: 1,000 hematuria evaluations including a risk-benefit and cost-effectiveness analysis.

Between March 1976 and June 1985, 1,000 consecutive adults with asymptomatic gross or microscopic hematuria in the absence of proteinuria were evaluated urologically. Lesions that could account for the hematuria were detected in 88.3 per cent of the patients. Life-threatening lesions were diagnosed in 9.1 per cent of the patients, while lesions requiring at least observation were present in 22.8 per cent. The incidence of life-threatening lesions increased with age, with a sharp increase after age 50 years. Life-threatening lesions were more common in men (13.6 per cent) than in women (4.9 per cent). In general, as the degree of hematuria increased so did the yield of life-threatening lesions; however, there was no "safe" lower limit of hematuria. Of the patients with life-threatening lesions 18.6 per cent had at least 1 urinalysis with less than 3 red blood cells per high power field within 6 months of the diagnosis. The direct medical cost of a hematuria evaluation was $777. The difference in direct medical costs to diagnose and treat localized versus metastatic genitourinary cancer was $48,070 in 3 matched pairs of patients. In this study group 77 of 84 patients (92 per cent) diagnosed with genitourinary cancer had localized disease. A hematuria evaluation was cost-effective for all groups studied. A literature-based estimate of the life-threatening risks of diagnostic studies applied to the study data resulted in a 1.1 per cent life-threatening risk per hematuria evaluation. For all categories studied, except for women less than 40 years old with microscopic hematuria, the risk of a hematuria evaluation was less than the incidence of life-threatening lesions discovered as a result of the evaluation. Asymptomatic hematuria, whether gross or microscopic, is a significant finding and warrants evaluation from a risk-benefit and cost-effectiveness standpoint.

Dipstick chemical urinalysis: an accurate cost-effective screening test.

In a double-blind prospective study of 200 sequential urine specimens the sediment count of leukocytes in the centrifuged urine (white blood cells per high power field) was compared to a chamber count of leukocytes in uncentrifuged urine (white blood cells per microliter.). There was good correlation (coefficient of correlation 0.783, sensitivity 91.9 per cent, specificity 97.6 per cent and efficiency 96.6 per cent) between the more precise chamber count and the more commonly performed sediment count if the methodology of the sediment count was standardized. In a double-blind prospective study the results of the sediment count for leukocytes and erythrocytes were compared to the leukocyte esterase and hemoglobin dipstick results of urine specimens from 1,346 adults who underwent multiphasic screening. The dipsticks were found to be sensitive to physiologic limits for leukocytes and erythrocytes, with only 0.9 per cent false negative results for each. Formed elements in the urine not detectable by dipstick, such as casts and crystals, were present in 3 per cent of the specimens. Among patients who had significant pyuria, hematuria or formed elements not detectable by dipstick chemical urinalysis, no significant pathological condition was detected upon retrospective review. Because the chemical dipstick is not quantitative and because the sensitivity of the dipsticks resulted in many false positive findings compared to the sediment count (red and white blood cells 16.4 and 13.2 per cent, respectively) a protocol is offered in which results of screening urine specimens that are positive on dipstick culture would be confirmed by a properly performed microscopic urinalysis. This protocol as applied to an adult screening population would be an accurate, cost-effective method of urine testing.

Urine screening strategy employing dipstick analysis and selective culture: an evaluation.

A cost-effective urinalysis test strategy, employing screening dipstick analysis with sediment microscopy performed on urines positive for leukocyte esterase, nitrite, protein, or blood, is evaluated. Screening urine culture is done when greater than or equal to 5 WBC/HPF, greater than 10 bacteria/HPF, or yeasts are found on sediment microscopy. Predictive value, sensitivity, and specificity of the test strategy in predicting significant bacteriuria is compared with sediment microscopy, Gram staining of uncentrifuged urine and leukocyte chamber counting. Employment of the test protocol for routine urine specimens would decrease sediment microscopy by 49%, while effectively screening for significant bacteriuria with a sensitivity of 88.9% and predictive value of a negative result of 98.8%.

Emphysematous prostatic abscess: diagnosis and treatment.

We report an unusual case of an emphysematous prostatic abscess. Prostatic abscess is a difficult clinical diagnosis associated with lower urinary tract symptomatology and frequently diabetes mellitus. Computerized axial tomography and transrectal or transurethral ultrasonography can assist in making a specific diagnosis. Definitive treatment is complete surgical drainage, which is achieved by transurethral resection of the prostate. Wide spectrum, adjuvant antibiotic therapy should be given to assure coverage of anaerobic bacteria.

Sacral agenesis: an analysis of 11 cases and review of the literature.

Sacral agenesis is an uncommon condition associated with familial diabetes mellitus and complicated pregnancy. The condition is characterized by gluteal skin dimpling, loss of gluteal fold, myelomeningocele, sacral lipoma, as well as numerous orthopedic, anorectal and other widespread anomalies. The motor nerve deficit, for example poor anal sphincter tone, is more pronounced than the sensory nerve deficit, for example perianal anesthesia. Diagnosis is made by anteroposterior and lateral spinal x-rays. All of our patients had bladder or external sphincter dysfunction, while 91 per cent had vesicoureteral reflux. Early diagnosis and conservative management with intermittent catheterization and uropharmacological agents are now advocated.

Bilateral localized amyloidosis of the ureter presenting with anuria.

A patient with bilateral localized amyloidosis of the ureters is described. This is the first case to be reported in which anuria was the presenting symptom, the second case with bilateral involvement and the thirteenth case of amyloidosis localized to the ureter. Careful urologic and hematologic followup is indicated.