Ureterolysis with ureterotomy and omental sleeve wrap in patients with radiation induced pelvic retroperitoneal fibrosis.

INTRODUCTION: Secondary retroperitoneal fibrosis (RPF) due to pelvic radiation alone or together with pelvic surgery is one of the causes of obstructive renal failure. Ureteral obstruction is caused by ischemic stricture and encasement by fibrotic tissue. Endo-ureterotomy alone, without vascular supply, is not successful in these cases. MATERIAL AND METHODS: We present eleven cases of ureteral obstruction due to radiation and surgery induced RPF. Seven patients had radiation therapy with or without radical hysterectomy and three patients had anterior resection of the rectum with pre-emptive radiation and one patient had anal cancer treated with local excision and radiation therapy. Nine of the eleven patients had bilateral ureteral obstruction. Open ('intubated') stented ureterotomy and omental sleeve wrap was performed. In one patient, Boari flap ureteroneocystostomy was necessary. RESULTS: Of the eleven patients (twenty renal units) we succeeded in nine patients (eighteen renal units). In two patients with bilateral ureteral obstruction, we were able to reestablish ureteral patency in only one renal unit each. CONCLUSIONS: Ureterolysis with ureterotomy and omental sleeve wrap is a valid surgical approach for alleviation of ureteral ischemic obstruction due to secondary retroperitoneal fibrosis caused by radiation alone or together with pelvic surgery.

The impact of dyadic social support on self-efficacy and depression after radical prostatectomy.

OBJECTIVE: To assess the effect of one-on-one peer support at enhancing self-efficacy and decreasing depression in older men treated by radical prostatectomy for prostate cancer. METHODS: Six weeks after surgery, 72 men (M(age) = 60) were randomly assigned to a treatment (n = 37) or control group ( n = 35). Treatment group participants were paired to form dyads with a trained support partner who had similar treatment and related side effects; control group participants received usual health care. Dyads met 8 times over 8 weeks to discuss concerns and coping strategies. RESULTS: At posttest, the treatment group had significantly higher self-efficacy than the controls (M = 328.89 and M = 304.54, respectively) and significantly less depression (M = 0.92 and M = 2.49, respectively). Depression outcomes remained significant when controlling baseline self-efficacy and social support (F = 4.845, p = .032). DISCUSSION: Findings confirm pilot study results and are theoretically consistent with the self-efficacy enhancing nature of vicarious experience described by Bandura in self-efficacy theory.

Radical prostatectomy and postoperative radiation in patients with adenocarcinoma of prostate of intermediate and high risk for recurrence.

OBJECTIVE: To report on the outcome of patients with intermediate and high risk of recurrence who underwent radical prostatectomy (RP). METHODS: Eighty-five consecutive patients categorized as intermediate (17.5%) and high risk (82.5%) of failure after definitive therapy for carcinoma of prostate according to the National Comprehensive Cancer Network (NCCN) underwent RP between 1989 and 1997. Median preoperative PSA was 26 ng/ml (range 15 ng/ml-91 ng/ml). Fifty-nine patients (70%) received three months neoadjuvant hormone therapy. Thirty-six patients (42%) underwent early (three to four months after RP) adjuvant radiation for pT3 disease and/or positive surgical margins. RESULTS: The median follow-up was 58 months (range 12-104 months). There was no difference in the biochemical recurrence rate between the intermediate and high-risk group of patients. The overall relapse rate was 33%. Cancer-specific mortality was 3.5%. Patients with T1c tumors had a significantly lower biochemical recurrence rate (bRR) (7%) compared to palpable tumors (p = 0.03). Age above 65 was a significant negative prognostic factor with respect to biochemical recurrence (p = 0.01). Adjuvant radiation was associated with biochemical recurrence rates of 25% vs. 40% in patients who were not radiated (p = 0.05). CONCLUSIONS: In the intermediate and high-risk groups of patients with nonpalpable prostate cancer, RP and adjuvant RT may provide a biochemical recurrence-free rate (bRFR) comparable to that reported in other series with RP alone on patients in the low-risk groups. We encourage the multimodality treatment approach incorporating adjuvant postoperative radiation in these patients.

Small lymphocytic lymphoma involving an enlarging complex renal cyst.

A 47-year-old white man presented for evaluation of a complex right renal mass. He had a history of human immunodeficiency virus. Cervical lymph node biopsy had revealed small lymphocytic lymphoma. Computed tomographic scan disclosed diffuse mesenteric and retroperitoneal adenopathy consistent with chronic lymphocytic leukemia, as well as a 4.5-cm complex cystic right renal mass, which 17 months later enlarged to 6.2 cm. The mass resembled multiloculated cystic nephroma. Partial nephrectomy revealed infiltration of the cyst wall by small lymphocytic lymphoma. To our knowledge, this is the first reported case of lymphoma arising in or colonizing a renal cyst.

Postoperative adjuvant and salvage radiotherapy for prostate cancer: impact on freedom from biochemical relapse and survival.

OBJECTIVES: To determine the therapeutic outcomes in patients with high-risk prostate cancer treated with adjuvant or salvage radiotherapy (RT) after radical prostatectomy. METHODS: Between 1982 and 2000, 163 patients were treated with RT after radical prostatectomy. Adjuvant therapy was administered to 107 consecutive node-negative patients (T2-T4N0) referred to our institution less than 1 year after surgery for postoperative RT. Salvage treatment was delivered to 56 patients for a persistently elevated prostate-specific antigen level, biochemical relapse after surgery, or local recurrence. RESULTS: The median follow-up was 70 months (range 2 to 167) from the initiation of RT. Patients treated with adjuvant RT were less likely than those treated with salvage RT to experience biochemical relapse. At 5 and 10 years, the rate of freedom from biochemical relapse was 80% and 66% in the adjuvant cohort compared with 39% and 22% for patients treated with salvage intent, respectively (P <0.0001). This did not translate into a statistically significant improvement in absolute survival (72% versus 70%) or cause-specific survival (93% versus 86%) at 10 years. On multivariate analysis, neoadjuvant hormonal therapy (P = 0.0187), presence of seminal vesicle involvement (P = 0.0002), and referral indication for postoperative RT (salvage versus adjuvant RT; P <0.001) were predictors of biochemical relapse. CONCLUSIONS: In this single-institution experience, patients at high risk of disease recurrence after radical prostatectomy realized a greater biochemical relapse-free survival benefit when treated with adjuvant RT than with salvage RT. Neoadjuvant hormonal therapy and seminal vesicle involvement predicted for inferior treatment outcome.

Comparison of adjuvant versus salvage radiotherapy policies for postprostatectomy radiotherapy.

PURPOSE: We compared the long-term results of postprostatectomy radiotherapy (RT) from two institutions, one adapting a prospective policy of adjuvant RT and the other salvage RT. METHODS AND MATERIALS: Between 1989 and 1997, 69 patients were referred for adjuvant RT to the institution using adjuvant RT and 88 patients with evidence of recurrence were treated in the institution using salvage RT. The salvage group underwent RT after longer postoperative intervals (median, 40.3 vs. 2.9 months; p <0.0001) and had higher prostate-specific antigen (PSA) values before starting RT (4.5 vs. 0.86 ng/mL; p = 0.003). Both groups were routinely treated to a minimal total dose of 60 Gy. The treatment groups were analyzed for overall survival, disease-specific survival, distant metastasis-free survival, and biochemical recurrence-free survival (BRFS) using Cox proportional hazards modeling. RESULTS: Of the 69 patients referred for adjuvant RT, 22 (32%) had nonzero PSA values before RT. Multivariable modeling of BRFS found only the PSA value before RT to be statistically significant (p <0.0001). RT after prostatectomy was equally effective in either setting when the pre-RT PSA level was <1 ng/mL. When the PSA value before RT was >or=1 ng/mL, the 5-year BRFS for each group was inferior. CONCLUSION: Although the adjuvant treatment policy was associated with significantly improved BRFS, this was attributable to low pre-RT PSA values. When the treatment groups were stratified for pre-RT PSA level, the differences in BRFS were not statistically significant. Patients with a rising PSA level after prostatectomy, regardless of their initial risk, should receive prompt referral for RT.

RTOG 97-06: initial report of a phase I-II trial of selective bladder conservation using TURBT, twice-daily accelerated irradiation sensitized with cisplatin, and adjuvant MCV combination chemotherapy.

To examine combination cisplatin and twice-daily accelerated irradiation (RT) after aggressive transurethral resection of bladder tumor (TURBT) in an attempt to preserve the bladder and to determine the likelihood that patients who complete this regimen could then complete three cycles of methotrexate, cisplatin, vinblastine (MCV) chemotherapy. Between 1998 and 2000, 52 patients with Stage T2-T4aN0M0 disease, from 17 institutions, were entered into the trial. Forty-seven patients were deemed eligible; the planned accrual was 40. Of the 46 patients, 68% were >60 years old, 70% were men, and 96% had a Karnofsky score >/=90. The clinical T stage was T2 in 66%, T3a in 25%, and T3b in 9%. The median follow-up at the time of analysis was 26 months. The protocol required TURBT within 6 weeks of the initiation of induction therapy. Induction treatment involved 13 days of concomitant boost RT, 1.8 Gy to the pelvis in the morning followed by 1.6 Gy to the tumor 4-6 h later. For sensitization, cisplatin (20 mg/m(2)) was given on the first 3 days of each treatment week. Three to four weeks after induction, patients were evaluated cystoscopically for residual disease. Patients whose biopsies and cytologic evaluations showed no disease completed consolidation chemoirradiation. Patients with residual tumor went on to cystectomy. After either consolidation or cystectomy, patients were to complete three cycles of MCV chemotherapy. Of the 47 patients, 45% completed all phases of the protocol treatment with minor, or no, deviations. Five patients refused either the postinduction evaluation or cystectomy and 6 refused adjuvant chemotherapy. The CR rate after induction therapy was 74%. For 2 patients, residual disease after induction was limited to positive cytologic findings, and for 8 patients, biopsy of the primary site revealed persistence. Of the 8 cystectomy patients, 2 had no evidence of disease in the bladder at pathologic review of the surgery specimen. Grade 3 toxicity related to chemotherapy was observed in 11% of patients during both induction and consolidation, and in 41% during adjuvant chemotherapy. A total of 8 patients (36% of those receiving adjuvant chemotherapy) went on to develop Grade 4 neutropenia or thrombocytopenia during additional adjuvant chemotherapy. Grade 3 toxicity due to RT was seen in 4% and 0% of patients during induction and consolidation, respectively. One patient developed Grade 4 hydronephrosis during consolidation. The projected 36-month value for locoregional failure, distant metastasis, overall survival, and bladder-intact survival was 27%, 29%, 61%, and 48%, respectively. After aggressive TURBT, twice-daily accelerated RT initiated in concomitant-boost format is well tolerated and results in a rate of complete response (74%) similar to that in previous bladder-sparing trials. The projected 2-year values for locoregional control, bladder-intact survival, and overall survival were also consistent with previously reported trials of bladder-sparing treatment. With only 45% of patients completing three cycles of MCV, this form of adjuvant chemotherapy appears to be poorly tolerated by most patients.

Attitudes and use of complementary medicine in men with prostate cancer.

PURPOSE: Patients with cancer are increasingly incorporating complementary therapies into the overall treatment. We determine the prevalence and patterns of use of complementary therapies among patients with prostate cancer. MATERIALS AND METHODS: Patients attending 6 urology institutions for prostate cancer management completed a self-administered questionnaire on complementary therapy. All men diagnosed with prostate cancer were eligible, regardless of age, stage of disease or treatment. RESULTS: A total of 1,099 patients returned the questionnaire. The overall response rate was 78.5%. Complementary therapies had previously been or were currently being used by 23.5% (258) and 18.2% (200) of patients, respectively. Higher levels of education and income were associated with greater use of complementary therapy (p <0.002 by logistic regression). Patients with progressive disease or those primarily treated with hormones were most likely to use complementary therapy. Among the patients using complementary therapy 90% believed that it would help them live longer and improve quality of life, 60% believed it would relieve symptoms and 47% expected it to cure disease. CONCLUSIONS: Complementary therapies are used by a large number of patients with prostate cancer, particularly those with progressive disease or who have undergone multiple treatments. Health care providers need to recognize this growing pattern of use of complementary therapy. Among patients who use complementary therapy the perception of benefit is much greater than that supported by scientific data. Future research should aim to unravel the complex psychosocial dynamics that influence the decision to use complementary therapy by men with prostate cancer and to educate patients about the efficacy of such therapies.

The role of chemotherapy and radiation in organ-preservation strategies for muscle-invasive bladder cancer.

Radical cystectomy with pelvic lymph node dissection has been accepted as the standard treatment for muscle-invasive bladder cancer. Radiation therapy and chemotherapy are increasingly being implemented in bladder-preservation protocols to provide an alternative treatment to cystectomy. We review experience with radiation and chemotherapy in treating bladder cancer and their use in bladder-preservation protocols. Multimodality organ-sparing treatment strategies offer overall survival rates comparable to radical cystectomy and pelvic lymph node dissection in selected cases. However, bladder-preservation techniques risk local recurrence of potentially aggressive tumors whose long-term effect on cancer-specific survival has not been fully characterized. No improvement in quality of life has clearly been demonstrated with bladder-preservation regimens. Bladder-preservation protocols are costly and require precise coordination of multiple specialists as well as strict, life-long patient compliance. Bladder-preservation protocols should only be performed at tertiary care centers with experience in their administration and be limited to patients desiring an alternative cystectomy or who are not surgical candidates.

Neoadjuvant androgen ablation before radical prostatectomy in cT2bNxMo prostate cancer: 5-year results.

PURPOSE: In the initial report of the Lupron Depot Neoadjuvant Prostate Cancer Study Group patients who received 3 months of androgen deprivation had a significant decrease in the positive margin rate. We monitored these patients for 5 years and to our knowledge present the longest followup of any neoadjuvant trial. MATERIALS AND METHODS: A multi-institutional prospective randomized trial was performed between February 1992 and April 1994 involving patients with stage cT2b prostate cancer, including 138 who received 3 months of leuprolide plus flutamide before radical prostatectomy and 144 who underwent radical prostatectomy only. Patients were followed every 6 months with serum prostate specific antigen (PSA) testing for 5 years. Biochemical recurrence was defined as PSA greater than 0.4 ng./ml. RESULTS: At 5 years there was no difference in the biochemical recurrence rate. PSA was less than 0.4 ng./ml. in 64.8% of the patients in the neoadjuvant androgen ablation plus prostatectomy and 67.6% in the prostatectomy only group (p = 0.663). CONCLUSIONS: Although 3 months of androgen deprivation before radical prostatectomy resulted in an apparently significant decrease in positive surgical margins, a 5-year followup does not indicate any difference in the recurrence rate. Until studies document improvement in biochemical or clinical recurrence with longer periods of treatment, induction androgen deprivation before radical prostatectomy is not indicated.