Controversial cases in endourology.
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Calcium Oxalate↗
Biomedical subjects
C J Kane
Publications and source records attributed to C J Kane.
Is there a difference in outcome after radical prostatectomy between patients with biopsy Gleason sums 4, 5, and 6? Results from the SEARCH database.
PURPOSE: Fewer patients newly diagnosed with prostate cancer today have biopsy Gleason sums <6 compared to several years ago. Several tables and nomograms for predicting disease recurrence after definitive therapy provide little or no discrimination between biopsy Gleason sums 4, 5, and 6. We sought to examine the significance of biopsy Gleason sum for predicting biochemical failure following radical prostatectomy (RP) for men with biopsy Gleason sums of 4, 5, and 6. MATERIALS AND METHODS: We examined data from 988 men treated with RP between 1988 and 2002 who had biopsy Gleason sums of 4-6. Clinical and pathological variables as well as outcome information were compared between men with biopsy Gleason sums of 4-6. The log-rank and Cox proportional hazards analysis were used to determine whether biopsy Gleason sum provided unique prognostic information for men with low biopsy Gleason sums undergoing RP. RESULTS: There was statistically significant, but overall weak correlation between biopsy Gleason sum and Gleason sum of the RP specimen (Spearman's r=0.277, P<0.001). As biopsy Gleason sum increased from 4 to 5 to 6, there was a steady rise (HR=1.31 for each one point increase in Gleason sum, Cox's model) in the risk of PSA failure (P=0.025, log-rank). On multivariate analysis comparing biopsy Gleason sum, preoperative PSA, clinical stage, year of surgery, percent of biopsy cores positive, and age for their ability to predict time to biochemical recurrence, only PSA (HR 2.09, CI 1.56-2.80, P<0.001) and biopsy Gleason sum (HR 1.33, CI 1.05-1.70, P=0.019) were significant independent predictors of PSA failure. CONCLUSIONS: Despite weak correlation between biopsy and pathologic Gleason sum among men with biopsy Gleason sum 4-6 tumors, grade was a significant independent predictor of PSA failure following RP. In the range of 4-6, biopsy Gleason sum acted as a continuous variable for predicting PSA failure. The routine use of Gleason sums 4 and 5 to grade prostate needle biopsy specimens should not be abandoned.
Biopsy, Needle↗
Effects of body mass on nicotine-induced thermogenesis and catecholamine release in male smokers.
The aims of this study were to examine the effects of nicotine on resting energy expenditure (REE) and plasma catecholamine release following ad libitum smoking in fasted, middle-aged males; and, to determine if the acute responses in REE and catecholamine release to smoking differ between normal weight (< or = 25 kg/m(2)) and overweight (> 25 kg/m(2)) smoker groups. REE was measured by indirect calorimetry in 32 fasted male smokers prior to, and 30 minutes after, consuming either two 0.16 mg nicotine (low yield) or two 1.74 mg nicotine (high yield) cigarettes. Plasma nicotine and norepinephrine levels were simultaneously measured. There was no thermic effect of nicotine or catecholamine response after smoking low yield cigarettes in both groups, nor after smoking high yield cigarettes in the overweight group. In contrast, REE increased 7.2%, which was accompanied by an increase in plasma norepinephrine release, after smoking high yield cigarettes in the normal weight group. Controlling plasma nicotine level ablated these increases. In conclusion, body mass interacts with the thermic effect of nicotine and neuroendocrine function in male smokers. Smoking-induced increase in the plasma nicotine level accounts for the observed responses, which are blunted in overweight smokers. This finding may have implications for potential weight gain following smoking cessation by normal weight individuals, related to lost smoking-induced thermogenesis.
Adult↗
Initiation of salvage therapy for prostate cancer.
Physicians and patients have variable and individual levels of comfort regarding when to begin salvage therapy for rising prostate specific antigen (PSA) after definitive treatment of prostate cancer. The decision to start salvage therapy is a multifactorial process for which few rigorous data or guidelines exist. A questionnaire survey of urologists of the Department of Defense (DoD) Center for Prostate Disease Research (CPDR) was undertaken to obtain current perspectives on when to begin salvage therapy for biochemical failure after definitive therapy. Variables of age, grade, T-stage, nodal status, performance status, latency since prior therapy, PSA velocity, and ploidy were prioritized in four clinical situations; subsequent questions assessed consensus PSA cut-offs for beginning adjuvant therapy in 84 clinical scenarios. Consensus on PSA cut-off points was limited to postoperative radiotherapy (RT), where values of 1.0-1.5 were the mean cut-off points. CPDR urologists consider salvage prostatectomy post-RT only for patients <70-y-old with node negative, grade 2-7 disease and excellent performance status. Ploidy was not generally considered useful in any scenario. Many variables in addition to PSA level are involved in the decision of when to commence adjuvant therapy for initial biochemical failure. These are strikingly interdependent, and few clear absolutes are evident from this questionnaire. This is a point of necessary further research and continued discussion among physicians caring for these patients.
Adult↗
Ureteral stenting after ureteroscopy for distal ureteral calculi: a multi-institutional prospective randomized controlled study assessing pain, outcomes and complications.
PURPOSE: We compare postoperative pain, stone-free rates and complications after ureteroscopic treatment of distal ureteral calculi with or without the use of ureteral stents. MATERIALS AND METHODS: A total of 113 patients with distal ureteral calculi amenable to ureteroscopic treatment were prospectively randomized into stented (53) and unstented (60) groups. Stones were managed with semirigid ureteroscopes with or without distal ureteral dilation and/or intracorporeal lithotripsy. Preoperative and postoperative pain questionnaires were obtained from each patient. Patients with stents had them removed 3 to 10 days postoperatively. Radiographic followup was performed postoperatively to assess stone-free rates and evidence of obstruction. RESULTS: Six patients randomized to the unstented group were withdrawn from the study after significant intraoperative ureteral trauma was recognized, including 3 ureteral perforations, that required ureteral stent placement, leaving 53 with stents and 54 without for analysis. Patients with stents had statistically significantly more postoperative flank pain (p = 0.005), bladder pain (p <0.001), urinary symptoms (p = 0.002), overall pain (p <0.001) and total narcotic use (p <0.001) compared to the unstented group. Intraoperative ureteral dilation or intracorporeal lithotripsy did not statistically significantly affect postoperative pain or narcotic use in either group (p >0.05 in all cases). Overall mean stone size in our study was 6.6 mm. There were 4 (7.4%) patients without stents who required postoperative readmission to the hospital secondary to flank pain. All patients (85%) who underwent imaging postoperatively were without evidence of obstruction or ureteral stricture on followup imaging (mean followup plus or minus standard deviation 1.8 +/- 1.5 months), and the stone-free rate was 99.1%. CONCLUSIONS: Uncomplicated ureteroscopy for distal ureteral calculi with or without intraoperative ureteral dilation can safely be performed without placement of a ureteral stent. Patients without stents had significantly less pain, fewer urinary symptoms and decreased narcotic use postoperatively.
Humans↗
Intraoperative cell salvage in radical retropubic prostatectomy.
OBJECTIVES: To investigate the efficacy and safety of intraoperative cell salvage with autotransfusion using leukocyte reduction filters in patients undergoing radical retropubic prostatectomy (RRP). METHODS: Between September 1996 and March 1999, 62 patients (age range 48 to 70 years) with clinically localized prostate cancer underwent RRP with intraoperative cell salvage as the sole blood management technique. Salvaged blood was passed through a leukocyte reduction filter before autotransfusion. The 62 cell salvage patients were compared with a cohort who predonated 1 to 3 U autologous blood (n = 101). The estimated blood loss, preoperative and postoperative hematocrit, need for homologous transfusion, and biochemical recurrence rates were compared between the two groups. The progression-free survival rates were compared using the Kaplan-Meier method. RESULTS: No difference was found in preoperative prostate-specific antigen level, pathologic stage, or estimated blood loss between the cell salvage and autologous predonation groups. The preoperative and postoperative hematocrit levels were higher in the cell salvage group (42.7% versus 39.6% and 31.3% versus 27.9%, respectively; P <0.001 for each). The homologous transfusion rates were lower in the cell salvage group (3% versus 14%, P = 0.04). The incidence of progression-free survival (prostate-specific antigen level 0.4 ng/mL or greater) was no different between the groups (P = 0.41). CONCLUSIONS: Intraoperative cell salvage with autotransfusion using leukocyte reduction filters in RRP results in higher perioperative hematocrit levels and low homologous transfusion rates and eliminates the need for autologous predonation. Cell salvage does not appear to be associated with an increased risk of early biochemical progression after RRP.
Blood Loss, Surgical↗
Relationship between obesity and race in predicting adverse pathologic variables in patients undergoing radical prostatectomy.
OBJECTIVES: To determine whether obesity is associated with more advanced prostate cancer (PCa) in radical prostatectomy patients and to explore the ethnic variability in body mass index (BMI) as a potential explanation for racial differences in PCa risk. METHODS: A multi-institutional retrospective analysis of the clinical and pathologic parameters was performed on data from 860 patients with PCa undergoing radical prostatectomy between 1992 and 1998. Patient height and weight was used to calculate the BMI, which categorized patients into obese (BMI 30 kg/m(2) or greater), overweight (BMI 25 to 30 kg/m(2)), and normal (BMI 25 kg/m(2) or less) groups. Age, serum prostate-specific antigen level, pathologic stage, and Gleason score for each group were compared. The distribution of the BMI in each of four ethnic groups was also determined. RESULTS: Of 860 patients, 171 (20%) were obese, 425 (49%) overweight, and 264 (31%) normal. The obese patients presented at a younger mean age (62 years, P = 0.001), had higher mean Gleason scores (6.7, P = 0.002), had a higher likelihood of Gleason score 7 or greater cancer (71%, P = 0.003), and had a lower chance of organ-confined cancer (46%, P = 0.050). The BMI was highest in blacks, followed by whites and Asians, and blacks had significantly higher grade cancers (P = 0.045). In multiple logistic regression analysis of the BMI and race, only BMI remained an independent predictor of Gleason grade. CONCLUSIONS: Obese patients with PCa present for radical prostatectomy at a younger age with higher grade and more pathologically advanced cancers. Blacks have higher grade cancers than other ethnic groups and, at the same time, have significantly higher BMIs. These findings suggest that obesity may in part account for the racial variability in PCa risk.
Age Factors↗
The role of imaging studies and molecular markers for selecting candidates for radical prostatectomy.
For the typical patient who has newly diagnosed prostate cancer, clinically organ-confined disease of moderate grade, and a PSA less than 10 ng/mL, the current role of imaging studies and molecular biomarkers is limited. Bone scans are not necessary for newly diagnosed men with a PSA less than 10 ng/mL in the absence of bone pain. Similarly, abdominal and pelvic CT scanning rarely provides any useful diagnostic or staging information when the PSA is less the 20 ng/mL and is indicated rarely. Endorectal coil MR imaging adds staging information for patients with a PSA between 10 and 20 ng/mL, a Gleason score of 7 or less, and 50% or more positive biopsies on a sextant sampling. Indium 111 capromab pendetide scanning (ProstaScint) is FDA-approved to evaluate newly diagnosed patients at high risk for metastases. These patients have a Gleason score of 7 or greater and a PSA greater than 20 ng/mL, a Gleason score of 8 to 10 regardless of the PSA value, or clinical stage T3 disease and a Gleason score of 6 or greater. RT-PCR testing of blood or bone marrow for prostate-specific or prostate cancer-specific gene expression, or "molecular staging," is a promising technique whose current use is still investigational. Much useful information may be gained by careful study of prostate needle biopsy material. Aside from current Gleason grading and the number or percentage of cores involved with cancer, no molecular biomarker is approved for clinical use. p27, p53, bcl-2, Ki-67 (MIB-1), and the assessment of neovascularity hold promise, but prospective multicenter studies are needed. In the long-term, multiple gene expression profiling of biopsy material using gene chips may revolutionize the care of patients with prostate cancer and those who elect radical prostatectomy.
Antibodies, Monoclonal↗
Impact of socioeconomic status and race on clinical parameters of patients undergoing radical prostatectomy in an equal access health care system.
OBJECTIVES: To analyze the relationships among socioeconomic status (SES), race, and the clinical parameters of patients undergoing radical prostatectomy (RP) in an equal access health care system. METHODS: The Department of Defense Center for Prostate Disease Research longitudinal prostate cancer database from multiple military institutions was used to analyze the clinical, pathologic, and outcome data of 1058 patients with localized (Stage T2c or lower) prostate cancer and a preoperative prostate-specific antigen (PSA) level of 20 ng/mL or less who underwent RP between January 1987 and December 1997. Military rank (officer versus enlisted) was used as a surrogate measure of SES. RESULTS: The percentage of patients with pathologic Gleason grade 7 or greater prostate cancer was higher in enlisted (45%) than in officer (37%) patients (P = 0. 021). However, no difference was found between these groups with respect to pathologic stage or biochemical recurrence rates. African Americans presented at a younger age (P = 0.003), with a higher pretreatment PSA level (P = 0.001), and demonstrated higher biochemical recurrence rates than other ethnic groups (P = 0.037). The Cox proportional hazards analysis showed that a lower SES (P = 0.010) but not African American race (P = 0.696) was an independent predictor of a higher grade (Gleason grade 7 or higher) cancer. However, biochemical progression was more common in African American men (P = 0.035) and was not related to SES (P = 0.883). CONCLUSIONS: In an equal access health care system, patients of lower SES presented with higher grade prostate cancer at the time of RP. However, only African American race predicted biochemical progression after RP.
Age Factors↗
Sildenafil citrate-associated priapism.
We report the first case of priapism associated with the use of sildenafil citrate. The patient was a 28-year-old man with mild erectile dysfunction after penile trauma who self-treated with a 100-mg dose of sildenafil citrate, resulting in low-flow priapism. After aspiration and intracorporal injection of alpha-agonists, the priapism resolved. The patient's erectile function returned to his prepriapism baseline.
3',5'-Cyclic-GMP Phosphodiesterases↗
Current management of severely encrusted ureteral stents with a large associated stone burden.
PURPOSE: We review our recent experience with encrusted retained ureteral stents associated with a large stone burden as well as current endoscopic options available for management. MATERIALS AND METHODS: One man and 3 women presented to our department between May 1998 and April 1999 for treatment of an encrusted retained ureteral stent. One patient had a history of 3 episodes of ureteral stent encrustation during the last 6 years. We reviewed the management of these stents and the associated stone burden. RESULTS: Average patient age was 32.5 years (range 25 to 41). Average interval that the encrusted stent remained in place was 7 months (range 3 to 12). In the 3 women pregnancy was associated with the retained stent. All patients required 2 to 6 endourological approaches (average 4.2) performed at 1 or multiple sessions to render them stone-free and stent-free. Postoperatively sepsis in 1 case necessitated a prolonged intensive care unit stay with eventual recovery. CONCLUSIONS: Successful management of a retained encrusted stent requires combined endourological approaches. Percutaneous nephrostolithotomy and ureteroscopy are often necessary for treating a severely encrusted stent and the associated stone burden.
Adult↗
Unenhanced helical computed tomography in the evaluation of acute flank pain.
Noncontrast helical computed tomography has rapidly replaced other imaging modalities in the evaluation of patients with acute flank pain. New studies from multiple centers have compared helical computed tomography directly with intravenous urography in large numbers of patients, confirming the value of the former. It is highly sensitive and specific for the diagnosis of ureterolithiasis, including the visualization of ureteral calculi and secondary signs of obstruction. It can evaluate alternate diagnoses, improving the utility of noncontrast helical computed tomography as a diagnostic tool in the evaluation of acute flank pain.
Acute Disease↗
Free-to-total prostate-specific antigen ratios 18-24 months following external beam radiation for adenocarcinoma of the prostate.
BACKGROUND AND OBJECTIVES: The purpose of this study was to evaluate free-to-total prostate-specific antigen (PSA) ratios after definitive external beam radiation therapy for men with adenocarcinoma of the prostate (CaP). METHODS: A prospective evaluation of percent free PSA in men following definitive external beam radiation therapy for CaP was compared to men with untreated CaP and men at very low risk for CaP. Statistical comparison of clinical and pathologic parameters was performed. RESULTS: There was no statistically significant difference in free-to-total PSA ratios for men with newly diagnosed CaP and men with detectable PSA who were treated with external beam radiation therapy. CONCLUSIONS: Free-to-total PSA ratios after definitive external beam radiation therapy for CaP are consistent with percent free PSA in patients with newly diagnosed CaP. This supports the theory that PSA from in situ prostate tissue following external beam radiation therapy is produced by malignant cells.
Adenocarcinoma↗
Drug-seeking behavior in urolithiasis in the noncontrast computed tomography era: 2 cases.
Symptomatic urolithiasis is usually treated with narcotic pain management. This leads to the potential for use of its symptoms for personal gain. Historically, the typical presentation of a narcotic-seeking "stone patient" was a history of radiolucent stones and an intravenous contrast allergy. With the increased use of non-contrast-enhanced computed tomography to evaluate patients suspected of having acute urolithiasis, we have seen a change in the strategy of narcotic-seeking patients. We report 2 patients with pelvic calcifications on non-contrast-enhanced computed tomography feigning symptoms of urolithiasis to receive narcotic drugs.
Adult↗
Holmium:YAG laser lithotripsy of intrahepatic biliary calculi.
The holmium:YAG laser has been used effectively for a wide variety of urinary calculi. No cases have been reported of its in vivo use in the biliary system. In this report, we describe its utility in intracorporeal lithotripsy of intrahepatic biliary stones and the urologist's role in providing expertise in small-caliber endoscopy and lithotripsy to other disciplines.
Adult↗
Time to stone passage for observed ureteral calculi: a guide for patient education.
PURPOSE: We analyze the natural history of stone passage in patients with ureterolithiasis, and define factors predictive of spontaneous passage. MATERIALS AND METHODS: A total of 75 patients with ureteral calculi were prospectively followed for stone passage. Clinical data included patient gender and age, stone size and location, pain medication requirements and interval to stone passage. Of the 75 patients 13 (17%) required intervention and 62 (83%) were followed until spontaneous stone passage. Stones requiring intervention were not included in the time to passage analysis. RESULTS: Of the 75 patients 41 (55%) had ureteral stones 2 mm. or smaller with an average time to stone passage of 8.2 days and only 2 (4.8%) required intervention, 18 (24%) had stones between 2 and 4 mm. with an average time to stone passage of 12.2 days and 3 (17%) required intervention, and 16 had stones 4 mm. or greater with an average time to stone passage of 22.1 days and 8 required intervention. For 95% of stones to pass it took 31 days for those 2 mm, or less, 40 days for those 2 to 4 mm. and 39 days for those 4 to 6 mm. Multivariate analysis revealed that size, location and side were statistically related to stone passage interval (p = 0.012). Stones that were smaller, more distal and on the right side were more likely to pass spontaneously and required fewer interventions. CONCLUSIONS: Interval to stone passage is highly variable and dependent on stone size, location and side. Degree of pain, and patient gender and age had no bearing on the time to stone passage. Of ureteral stones 95% 2 to 4 mm. pass spontaneously but passage may take as long as 40 days. Intervention may be required in 50% of ureteral calculi greater than 5 mm.
Adult↗
Re: Metastatic adenocarcinoma of the prostate to the choroid with loss of visual acuity as a presenting symptom.
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Adenocarcinoma↗
Immediate and postoperative complications of transurethral prostatectomy in the 1990s.
PURPOSE: We compare the morbidity, mortality, hospitalization and urethral catheter time of contemporary transurethral prostatectomy to historical series, and evaluate recent trends in hospitalization and urethral catheter time during the last 8 years. MATERIALS AND METHODS: A retrospective chart review of 520 consecutive patients who underwent transurethral prostatectomy between 1991 and 1998 at a single institution for symptomatic benign prostatic hyperplasia was performed. Inpatient and outpatient charts, clinic records, operative reports and discharge summaries were reviewed. For each patient 43 data points were collected. Telephone followup was performed when data were lacking. All retrieved data were compiled in a computer database. Perioperative and late postoperative morbidity and mortality, hospitalization and urethral catheter time were analyzed. RESULTS: A total of 520 patients were identified with an average age of 67 years (range 44 to 89). Significant co-morbidity (2 or more co-morbid disease processes) was identified preoperatively in 30.3% of the patients. The most common indications for transurethral prostatectomy were lower urinary tract symptoms (80.9%) and urinary retention (15.2%). Average preoperative International Prostate Symptom Score was 23.8. Average weight of resected tissue was 18.8 gm. There was no perioperative patient mortality. Blood transfusion rate was 0.4%. The rate of intraoperative and immediate postoperative complications was 2.5% and 10.8%, respectively. Average hospital stay was 2.4 days, and 1.1 from 1997 through 1998. The rate of late postoperative complication was 8.5% and the average postoperative symptom score was 6.4 with an average followup of 42 months (range 6 to 84). CONCLUSIONS: Contemporary perioperative and postoperative complications of transurethral prostatectomy are significantly lower than rates in historical series. The average hospital stay and urethral catheter time have steadily decreased during the last 8 years.
Adult↗