Localized prostatic adenocarcinoma: role of pelvic radiotherapy following radical prostatectomy

Although single photon emission tomographic (SPET) imaging has been shown to be more sensitive than planar imaging in the diagnosis of pulmonary embolism, it has yet to be used routinely in clinical practice. The aims of this study were (1) to compare a new three-dimensional surface-shaded version of SPET (3-D SPET) with conventional planar imaging and coronal SPET slices, and (2) to evaluate observer agreement among these three modalities in the assessment of regional pulmonary perfusion. Compared with a consensus score (based on revised PIOPED criteria) of 29 cases, including nine with a clinical diagnosis of pulmonary embolism, 3-D SPET showed the highest number of normal scans, suggesting better specificity than planar or coronal SPET images. Five observers evaluated the three image sets twice within a 3-6 month period. Agreement with the consensus score was slightly better for the second reading and the average perfect agreement was 71-76%. No one image set was superior to any other in this respect. In conclusion, the number of normal scans using 3-D SPET is significantly greater relative to planar and coronal SPET scans as defined by the consensus view. Observer agreement rates are very similar with all three modalities.     

Transrectal ultrasonography to assess local extent of prostatic cancer before radical prostatectomy

BACKGROUND: The safety and efficacy of operations for gastrointestinal diseases in very elderly patients has been a matter of debate in recent years. STUDY DESIGN: One hundred seventy-seven instances of carcinoma of the colon and rectum in patients more than 80 years of age who wee surgically treated between 1961 and 1987 were reviewed. They were compared with 623 similar instances in patients younger than 80 years of age who were treated during the same time period. RESULTS: Octogenarians and nonagenarians significantly more often displayed obstruction or perforation, elevated preoperative carcinoembryonic antigen, right-sided lesions, and solitary hepatic metastases, when present. Patients more than 80 years of age received adjuvant chemotherapy or radiotherapy less often. Carcinoma recurrence in very elderly patients implied a very poor prognosis, with only a 4 percent salvage rate. The actuarial five year survival rate was 32 percent for the older patients and 48 percent in the younger group (p < 0.05). There was no significant difference in operative mortality between the two groups. CONCLUSIONS: In general, age alone should not alter treatment strategy in patients with carcinoma of the colon and rectum.     

The contemporary value of pretreatment prostatic acid phosphatase to predict pathological stage and recurrence in radical prostatectomy cases

PURPOSE: We examine the clinical prognostic value of the currently available simple and inexpensive immunoenzymatic prostatic acid phosphatase (PAP) assay for the staging and prognosis of radical prostatectomy cases. MATERIALS AND METHODS: Between February 1, 1990 and May 3, 1996 pretreatment PAP was measured in 295 patients who underwent radical prostatectomy. From February 1, 1990 to May 17, 1992 the Hybritech Tandem-E assay was used in 75 cases, from May 18, 1992 to February 28, 1993 the Abbott EIA assay was used in 49 and from March 1, 1993 to May 3, 1996 the Abbott IMx assay was used in 171. PAP assays were analyzed individually and the results were combined with pretreatment prostate specific antigen (PSA) values to assess the ability to predict organ confined prostate cancer and serological recurrence after radical prostatectomy. RESULTS: PAP testing was not of value for predicting organ confined disease or positive margins. However, this test was useful for predicting the first serological PSA recurrence in the 3 periods (77 to 85% correct) and overall (82% correct, p < 0.001, odds ratio 6.06). The Kaplan-Meier disease-free survival rate at 4 years was 78.8% for men with PAP less than 3 ng./ml. and 38.8% for those with PAP 3 ng./ml. or greater, which was significant when pretreatment PSA was less than 10 ng./ml. (p = 0.047), 10 ng./ml. or greater (p = 0.012) and overall (p < 0.001). PAP testing added prognostic information to pretreatment PSA values and it was an independent predictor of recurrence. CONCLUSIONS: The widely available and inexpensive PAP assays of the 1990s are predictors of recurrence after radical prostatectomy. They should be included in future studies of prostate cancer recurrence modeling. However, they do not predict pathological stage or margin status.     

Immediate radical prostatectomy for incidentally found prostate cancer after open prostatectomy for benign prostatic hyperplasia

In Algeria, Human myiasis, essentially ophtalmomyiasis, are known for a long time. Most of cases are due to Oestrus ovis. In this papers the authors report, in a shepherd, the first case of otomyiasis due to Chrysomya bezziana larvae, a species still unknown in North Africa. This observation which indicates the presence of the species in a Northern part of Algeria is also the first report of the insect outside of its endemic traditional area.     

Adjuvant treatment after radical prostatectomy in prostatic carcinoma (pT3 or pTxN+): prognostic factors and results

Adjuvant therapy after radical prostatectomy should ideally be limited to those patients at greatest risk for cancer recurrence, but identification of these patients remains a challenge. The local control rate in a group of 7494 patients undergoing radical prostatectomy for patients with pT2a disease of 76% is not different to pN+ disease of 80%. 95% of the pT3 patients were pN+ .90% of them received adjuvant treatment but only few patients with organ-confined cancer. A prognostic scoring system was created using the regression coefficients from the Cox multivariate model to classify patients with pathologically organ-confined prostate cancer according to risk of progression. Although tumor volume has traditionally been regarded as the most important prognostic factor in patients with localized prostate cancer, a recent multivariate analysis has shown that tumor volume is not an independent predictor. Moreover, accurate measurement of tumor volume is extremely difficult. Preoperative serum PSA levels, clinical stage, pathological grade and stage, and deoxyribonucleic acid (DNA) ploidy were evaluated by multivariate analysis to determine relative value in predicting treatment failure. Patients with the lowest score had a 92% progression free survival rate at 5 years, compared to only 39% of those with the highest scores. Patients believed to be at higher risk for cancer progression despite having organ confined disease might be targeted for adjuvant therapy and closer surveillance, while those at low risk may be followed less often.     

Pain and quality of life following radical retropubic prostatectomy

PURPOSE: We assess pain and quality of life following radical retropubic prostatectomy and determine whether intraoperative anesthetic management has any long-term effects on outcomes. MATERIALS AND METHODS: A total of 110 patients undergoing radical retropubic prostatectomy were randomly assigned to receive epidural and/or general anesthesia. Patients responded to a questionnaire mailed 3 and 6 months following surgery that assessed prostate symptoms, pain related to surgery, quality of life and mood. RESULTS: No long-term effects of anesthesia were observed. Of the 103 respondents (94%) at 3 months 49% had some pain related to surgery. Although pain was not related to anesthesic technique, patients who had it at 3 months used significantly more pain medication on postoperative day 3. Pain at 3 months was mild, averaging 1.5 on a scale of 0 to 10, and associated with poor perceptions of overall health (p <0.02), and reduced physical (p <0.01) and social (p <0.01) functioning. Pain at 3 months was associated with higher levels of preoperative anxiety (p <0.05). At 6 months 36 of 90 patients (35%) had some pain related to surgery and the impact was similar. CONCLUSIONS: Long-term effects of intraoperative anesthesic technique were not apparent. Mild pain following radical retropubic prostatectomy was common and associated with reduced quality of life, particularly social functioning. Affective distress, particularly anxiety, before surgery and use of pain medications following surgery may be predictors of chronic pain following radical retropubic prostatectomy.     

Radical prostatectomy for localized prostatic carcinoma in a renal transplant patient

A case of multiple pyogenic granuloma affecting the penis of a 28 year old man is reported. The lesions were arranged in a floret-like fashion around the inner aspect of the prepuce and developed after circumcision for congenital phimosis. Histopathological examination of sections from a biopsy specimen of the papillomatous growths revealed the findings of pyogenic granuloma. In this patient, the pathogenesis of the lesions is probably related to the failure in surgical wound repair that followed circumcision. Problems of clinical and histopathological differential diagnosis are discussed.     

Incontinence and vesical neck strictures following radical retropubic prostatectomy

OBJECTIVES: To evaluate the incidence and severity of vesical neck strictures and urinary incontinence after radical retropubic prostatectomy (RRP) for prostate cancer. METHODS: Between August 1983 and December 1991, 481 consecutive patients underwent RRP by 1 of 2 senior surgeons. Strictures were treated by passing a urethral sound. Incontinence was measured by asking patients for a daily "pad count" of pads required to control urinary leakage. Results were compared to patient age, tumor volume, number of neurovascular bundles spared, preoperative urinary complaints, and previous transurethral resection of the prostate. RESULTS: Of 456 patients with adequate follow-up to determine stricture formation, 82.5% had no strictures, 6.8% required a single dilation, 3.7% required 2 dilations, 3.1% required 3 dilations, and 3.9% required more than 3 dilations. Risk of stricture formation was unrelated to every variable studied. Of 458 patients with adequate follow-up to determine recovery of continence, 80.1% required no pads, 8.1% required 1 to 2 pads a day, 6.6% required 3 to 5 pads a day, and 5.2% were totally incontinent 1 year or more after surgery. Incontinence was closely associated with postoperative urinary urgency. CONCLUSIONS: Strictures are a common but easily managed complication of RRP for prostate cancer. Despite substantial surgical experience, we report a somewhat higher rate of postoperative incontinence than other recently reported series. Our experience is more closely matched by published surveys of patient-reported complications after RRP.     

Radiation enteritis following radiotherapy for prostatic carcinoma

Two cases of radiation enteritis and small bowel obstruction are reported following supervoltage radiation therapy for carcinoma of the prostate. The mechanisms of radiation injury to the small bowel and contributing factors are discussed. It is suggested that lymph node staging procedures for carcinoma of the prostate be done extraperitoneally in order to avoid the enhanced sensitivity of small bowel to radiation injury following transperitoneal procedures.     

Disease progression following radical prostatectomy in men with Gleason score 7 tumor

PURPOSE: The long-term prognosis of men with Gleason score 7 adenocarcinoma of the prostate is uncertain. MATERIALS AND METHODS: We studied 488 men whose radical prostatectomy specimen showed Gleason score 7 tumor without involvement of the seminal vesicles or lymph nodes. Of the 400 men without progression 318 had been followed for 2 years or more and 93 for 7 years or more. RESULTS: Cases of organ confined disease and negative margins regardless of extent of extraprostatic extension had roughly similar and better prognoses than cases of focal and established extraprostatic extension with positive margins. The greater influence of margin status on progression (p <0.0001) compared to extent of extraprostatic extension (p = 0.023) was evidenced in the multivariate analysis. Of 30 men with established extraprostatic extension and positive margins 6 (20%) had progression to distant metastases, which was similar to 14 of 58 (24%) without established extraprostatic extension and positive margins. There was no difference in response to radiotherapy between men with established extraprostatic extension and positive margins compared to the other cases. CONCLUSIONS: Margins status greatly influences the risk of progression in men with Gleason score 7 tumors. Among men with Gleason score 7 tumors, except for those with established extraprostatic extension and positive margins, more than 50% appear to be cured at long-term followup. Because of the high risk of progression in patients with positive margins, clinical studies of adjuvant therapy in this population appear warranted.     

Preoperative assessment of advanced gastric carcinoma using computed tomography

OBJECTIVES: The role of computed tomography (CT) for the staging of gastric carcinoma is controversial. The purpose of this study was to evaluate the utility of CT in assessing the perigastric spread of advanced gastric carcinoma. METHODS: The study included 56 patients who underwent dynamic CT and laparotomy for the treatment of node-positive gastric adenocarcinoma. Preoperative CT findings were compared with surgical findings, and diagnostic accuracy was estimated. RESULTS: Sensitivity, specificity, and accuracy of preoperative CT in determining the perigastric tumor spreads were 33, 97, and 73% in pancreatic invasion, 36, 97, and 70% in level III lymph node involvement, and 89, 98, and 96% in liver metastasis. Peritoneal dissemination was not detected in 15 of 56 patients (27%), and stage IV disease was not diagnosed correctly in 18 of 40 patients (45%). CONCLUSIONS: Radiologists and surgeons must remember that pancreatic invasion, extended lymph node metastasis, and peritoneal dissemination are sometimes overlooked in CT examination in patients with advanced gastric carcinoma.     

Splenunculus mimicking late local recurrence of renal cell carcinoma

We report on a case of a splenunculus found in the renal fossa 14 years after left transperitoneal radical nephrectomy and splenectomy for renal cell carcinoma. The significance of splenunculi in differential diagnosis of space occupying lesions in the left renal bed is discussed.     

Return of erections and urinary continence following nerve sparing radical retropubic prostatectomy

We evaluated recovery of erections and urinary continence following anatomical radical retropubic prostatectomy in a series of 784 consecutive patients with clinical stage A or B prostate cancer. Nerve sparing radical prostatectomy was performed in men deemed appropriate candidates. Recovery of erections sufficient for intercourse and urinary continence were analyzed controlling for patient age, pathological tumor stage and the performance of unilateral or bilateral nerve sparing surgery in men followed for a minimum of 18 months. Erections were regained in 149 of 236 preoperatively potent men (63%) treated with bilateral and 24 of 59 (41%) treated with unilateral nerve sparing surgery. Recovery of erections correlated with patient age and pathological tumor stage in patients treated with bilateral nerve sparing surgery. Continence was regained in 409 of 435 patients (94%) and did not correlate with patient age, tumor stage or nerve sparing surgery. Anatomical radical retropubic prostatectomy can be performed with favorable results in preserving potency and urinary continence. Better results are achieved in younger men with organ confined cancer.     

Hepatocellular carcinoma presenting as extrahepatic mass on computed tomography

Carbogen and nicotinamide have been evaluated in a phase II study as hypoxia-modifying agents during radical radiotherapy for bladder cancer using a standard daily 20-fraction schedule. Three groups of patients have received (a) nicotinamide alone, given orally in a dose of 80 mg kg(-1) daily with 52.5 Gy in 20 fractions over 4 weeks, (b) carbogen alone, with 50 Gy in 20 fractions over 4 weeks, and (c) carbogen and nicotinamide, with 50-52.5 Gy in 20 fractions over 4 weeks. Ten patients were treated in each group. All patients completed carbogen and radiotherapy as prescribed, but only 45% completed daily nicotinamide over the 4-week treatment period. The end points of this study were acute bowel and bladder morbidity and local control at cystoscopy 6 months after treatment. An expected level of acute bowel and bladder morbidity was seen that reverted to normal in most patients by 12 weeks with no difference between the three treatment groups. Complete response rates at 6 months were seven out of ten (100%) in the nicotinamide alone group, nine out of ten (90%) in the carbogen alone group and seven out of ten (70%) in the carbogen and nicotinamide group. It is concluded that carbogen and nicotinamide may improve the results of daily fractionated radiotherapy in bladder cancer and that further evaluation is required.     

Obliterative vesicourethral strictures following radical prostatectomy for prostate cancer: reconstructive armamentarium

PURPOSE: We report the reconstructive techniques used to correct obliterative vesicourethral strictures related to prostate cancer surgery. MATERIALS AND METHODS: Four men with anastomotic obliteration after radical prostatectomy underwent primary excision with end-to-end anastomosis, penile fasciocutaneous flap, free-graft urethroplasty with rectus muscle flap or anterior bladder tube with omental pedicle flap procedure. RESULTS: At mean followup of 33.8 months all patients had urethral patency but none was continent. CONCLUSIONS: Single stage reconstruction of the obliterated vesicourethral anastomosis after prostatectomy successfully restored urethral patency. No technique was applicable in all cases. Sphincteric function is likely to be compromised after the primary procedure, resulting in incontinence after successful urethral reconstruction. Subsequent artificial sphincter placement appears to be safe and helpful in restoring continence.     

Efficacy and safety of transurethral alprostadil in patients with erectile dysfunction following radical prostatectomy

PURPOSE: A retrospective analysis of the MUSE clinical trial was performed to evaluate the efficacy and safety of transurethral alprostadil in patients with erectile dysfunction after radical prostatectomy. MATERIALS AND METHODS: Patients received doses of transurethral alprostadil in the clinic and those for whom a suitable dose was determined were treated at home with active drug or placebo for 3 months. Patients had undergone radical prostatectomy no less than 3 months before study entry. RESULTS: Of the 384 patients in whom radical prostatectomy was identified as a cause of erectile dysfunction 70.3% had an erection believed sufficient for intercourse in the clinic and 57.1% on active medication had sexual intercourse at least once at home. The product of clinic and home success rates (70.3 x 57.1%) was an overall success rate (the likelihood of active treatment to lead to intercourse at home) of 40.1%. The frequency of most adverse effects of radical prostatectomy was comparable to that of other organic etiologies of erectile dysfunction (1,127 patients). The percentage of patients with hypotension in the clinic was lower after radical prostatectomy compared to other erectile dysfunction etiologies (0.8 versus 4.2%, p < 0.001) but the percentage of patients with urethral pain/burning was higher (18.3 versus 10.4%, p = 0.027). No urinary tract infection, fibrosis or priapism occurred in the post-radical prostatectomy patients. CONCLUSIONS: Transurethral alprostadil is a well tolerated and efficacious method of treating erectile dysfunction after radical prostatectomy, although psychological changes associated with cancer and surgery may limit home response. The severe neurovascular deficit associated with prostatectomy neither limits the efficacy of transurethral alprostadil nor increases the risks.     

Sexuality and intimacy following radical prostatectomy: Patient and partner perspectives.

Most research on adjustment following radical prostatectomy has focused on limited assessments of urinary and erectile functioning. In this study, the authors provided a more comprehensive assessment of sexuality from 134 radical prostatectomy patients and their partners and determined the extent to which various components of sexuality are associated with psychosocial adjustment. Measures of sexuality and intimacy modestly predicted patients' emotional distress and quality of life (QoL), with body image and dyadic adjustment playing the most important roles after controlling for medical variables, general physical functioning, and optimistic outlook. Urinary incontinence and other sexuality variables were not unique predictors. In contrast, partner ratings of sexual satisfaction played a more important role in predicting their QoL. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Value of cardiac ultrafast computed tomography for detecting right atrial thrombi in chronic atrial fibrillation

We evaluated the accuracy of cardiac ultrafast computed tomography in diagnosing atrial thrombi in 70 patients with chronic atrial fibrillation, and identified the predictors of atrial thrombi from among clinical, echocardiographic, and ultrafast computed tomographic features. Ultrafast computed tomography identified 11 atrial thrombi in 9 patients: 4 patients had thrombi in the left atrium, 3 in the right, and 2 in both. Transthoracic echocardiography detected only 4 left atrial thrombi, and enlargement of the left or right atrium was associated with atrial thrombi (p <0.05).