Prophylactic intravesical treatment with chemotherapeutic agents or one of the different strains of the immunomodulator bacillus Calmette-Guérin (BCG) reduces tumor recurrence and may prevent progression after transurethral resection (TUR) of superficial bladder cancer. Clinical and pathological prognostic factors are used to categorize different groups at risk for disease recurrence and progression. Solitary low-grade (G1, 2A), low-stage (pTa) tumors have less than a 5% risk of progression, while pT1 G3 tumors with concomitant carcinoma in situ (CIS) have a considerably higher risk of progression and metastases. Thus, prospective clinical trials should consider the different risks associated with different prognostic groups and stratify patients accordingly. The Dutch Cooperative Trial evaluated mitomycin versus BCG-Tice versus BCG-RIVM in 469 patients with pTA/pT1 carcinoma and CIS of the urinary bladder after TUR. Of 437 evaluable patients, 50 had CIS, 254 had pTA tumors, and 133 had pT1 tumors. No statistical differences were observed in toxicity between the two strains of BCG, but local and systemic side effects were more frequent in the BCG groups versus the mitomycin group. No differences in response rate were observed between the 3 treatment groups in patients with CIS. A statistically significant difference in favor of mitomycin was seen, however, in patients with papillary tumors. Mitomycin and BCG-RIVM were equally effective, and mitomycin proved significantly more effective than BCG-Tice. No significant difference in efficacy was observed between the two strains of BCG. Disease recurrence during the study in patients with papillary tumors was seen in 43% of mitomycin-treated patients, 64% of the BCG-Tice group, and 46% of patients treated with BCG-Rivm. However, a subgroup analysis for time to first recurrence for pTa versus pT1 and for grade 1 and 2 versus grade 3 papillary tumors showed no statistically significant between-group difference. Further studies comparing identical regimens, doses, and patient groups are needed to define more clearly which patient groups and tumors are more likely to respond to intravesical therapy.
Primary prevention of prostate cancer is a relatively new concept. Through large-scale studies it is possible that we may be able to define better the risk for prostate cancer and identify those who would benefit from an intervention to lower their risk of disease. As risk for prostate cancer is better defined, a number of interventions may eventually be tested.
The Prostate cancer Intervention Versus Observation Trial (PIVOT) is a randomized trial designed to determine whether early intervention with radical prostatectomy or expectant management should be the preferred treatment for men with clinically localized prostate cancer. This trial will enroll 2000 participants younger than 75 years of age from 75 Department of Veterans Affairs and National Cancer Institute medical centers. Men will be excluded if they are judged not to be candidates for radical prostatectomy.Eligible participants will be randomized over a 3-year period and followed for a minimum of 12 years. Follow-up data will include urologic symptoms, disease- and treatment-related morbidity, and disease-specific and overall quality of life. Evidence of disease persistence, recurrence, or progression will be measured by questionnaire, physical examination, prostate specific antigen measure, and bone scan.The primary study end point will be all-cause mortality. Secondary outcomes will include prostate cancer and treatment-specific morbidity and mortality, health status, predictors of disease-specific outcomes, and cost-effectiveness.
The available data on the efficacy of cryosurgery are still too immature to recommend this as a comparable option to radical surgery in the younger patient (< 72 years old) with organ-confined disease and at least a 10- to 15-year life expectancy. The available 3-month and 1-year positive biopsy figures of 10% to 20% are inversely comparable to the 10-year 80% to 90% disease-free survivals in contemporary radical prostatectomy series. While we wait for survival data to mature, it is unlikely that 10% to 20% local recurrence rates will translate into 80% to 90% disease-free survival rates. Only the data from the Crittendon Hospital group, which reports positive biopsies at 1 year of 3% to 4%, deserves special attention. Their protocol of optimal presurgical androgen ablation, use of thermosensors, and use of 2 to 3 freeze cycles may direct the way to a better cryosurgical technique. Conversely, the 2 to 8 months of presurgical androgen deprivation may just be prolonging the appearance of cryo-resistant cells. Regarding clinical stage C disease, the data looks promising with similar results as in organ-confined disease with a 10% to 20% positive biopsy rate at 3 months. One has to be cautious about what is really a stage C lesion, and comparison of preoperative PSA values enhance the comparisons between series. Overall, if the 1-year local recurrence rate does not exceed 30%, recommending cryosurgery as a viable option seems reasonable.(ABSTRACT TRUNCATED AT 250 WORDS)
In summary, this agent is safe for administration and more accurate than any currently available imaging modality for the detection of extraprostatic metastases. This agent is still under investigation and some day may aid urologists in the evaluation of prostate cancer by improving preoperative staging and demonstration of advanced disease and postoperative localization of recurrent disease. Improved staging and localization will reduce unnecessary tests and treatment that will lead to reduced morbidity, better management, earlier detection, and intervention in advanced disease and improved cost-effectiveness.
Traumatic injuries with disruption of the posterior urethra frequently occur in patients who sustain pelvic fracture. Several endoscopic and open reconstructive techniques have been proposed for management of such urethral injuries. Treatment objectives include restoration of physiological urethral voiding with preservation of urinary continence and sexual function. This article summarizes the current recommendations for evaluation and treatment of patients with traumatic posterior urethral injuries. The various reconstructive techniques are reviewed and selection criteria and clinical outcomes are evaluated.
The treatment of major blunt renal trauma remains controversial, with opinion divided between those who favor expectant management and those who favor surgical exploration. The goals of each treatment regimen are to assure patient safety while simultaneously preserving renal function. It is our policy at Case Western Reserve, MetroHealth Medical Center (Cleveland, OH) that all hemodynamically stable patients be initially treated by observation. Renal exploration is reserved for those patients who become unstable or who develop complications. In this review, we compare our results with those in the literature in an attempt to determine whether a selective nonoperative approach to major renal trauma fulfils the goals of patient safety and renal preservation.
Erectile dysfunction (impotence) is a well-known complication of blunt pelvic and perineal trauma. The mechanism of injury is usually related to the trauma itself, via shearing of the penile blood vessels in the pelvis, or via direct trauma to the blood vessels in the perineum. The diagnostic evaluation of these patients should include evaluation of the nervous supply of the penis, the penile arterial tree and the veno-occlusive mechanism. Penile revascularization is a reasonable treatment option for this group in that many injured patients are young and show arterial injury, with minimal or no veno-occlusive dysfunction. Proper patient selection and precise operative technique should allow for restoration of erectile dysfunction in these patients.
Management of prostatomembranous urethral disruptions remains controversial. Advocates of delayed urethral reconstruction suggest that immediate repair provides inferior outcomes in terms of impotence and incontinence. However, review of the literature, provides strong evidence that the injury itself is the most important factor in determining outcome because impotence appears to be the result of injury to the corpora cavernosa. Moreover, techniques for immediate urethral realignment provide outcomes that are equivalent to delayed-repair approaches while eliminating the need for long-term suprapubic catheter drainage and multiple surgical procedures for reconstruction. Techniques for immediate urethral realignment, along with outcomes at the Vanderbilt University Medical Center (Nashville, TN) are presented. Potency and continence rates of 83% and 100% were achieved, with early realignment of complete prostatomembranous urethral disruptions. These results are comparable to or exceed those of delayed-repair approaches.
The presence of urologic injury must be considered in patients who have sustained severe lower abdominal blunt trauma and in all patients with pelvic fracture. Physical findings that suggest the possibility of a bladder rupture include gross hematuria and an inability to urinate. A properly performed cystogram is diagnostic of bladder rupture and will define whether the rupture is intraperitoneal or extraperitoneal. Selected cases of extraperitoneal bladder rupture can be safely managed by catheter drainage, antibiotics, and close clinical observation. Intraperitoneal perforations require surgical exploration and bladder closure. Complications occurring as a result of bladder injury are minimized provided the injury is identified and repaired when indicated, and provided continuous unobstructive bladder drainage is achieved.
Posterior urethral injuries are most commonly associated with pelvic fractures. Retrograde urethrogram is the study of choice for evaluation of urethral injuries. Controversy exists between advocates of various methods of initial management. Simple suprapubic cystostomy placement with delayed urethral reconstruction is best reserved for patients with life-threatening, extensive injuries or for surgeons with limited experience in the management of this injury.
Injury to the urinary tract occurs in 3% to 10% of patients suffering from blunt or penetrating trauma. Timely assessment of these patients is fundamental in minimizing associated morbidity and mortality rates. We introduce a review of the current treatment of patients with suspected injury to the urinary tract in which we focus on the appropriate diagnostic approach and current advances in the field. This review is divided into sections concentrating on injuries to the kidneys, bladder, and urethra. Pertinent anatomy, mechanism of injury, classification of injury, and indications for evaluation are addressed in each section. Illustrative case studies are also provided to complement relevant teaching points.
The management of blunt renal trauma has evolved due to advances in clinical and radiographic staging. Careful clinical evaluation and the selective use of intravenous urography (IVU) and computed tomography (CT) have allowed many patients with major renal injuries to undergo surveillance, rather than renal exploration, with low morbidity. This article reviews the current diagnosis, staging, and management of adult and pediatric blunt renal trauma and describes the technique for renal exploration and repair.
Urethral obliteration is an uncommon complication of urethral injury and is usually associated with pelvic fracture. Until recently, surgical reconstruction was the only means available to restore urethral continuity. Although formal urethroplasty may be associated with excellent success rates, impotence and incontinence are potential complications. Endoscopic urethroplasty has recently evolved into a suitable alternative to surgical reconstruction in selected cases. We review here the technique of endoscopic urethroplasty and include our initial results.
