This Month in Adult Urology

Article Outline

• Can Epirubicin Improve BCG Efficacy for Invasive Bladder Cancer in High Risk Patients?
• Safety and Side Effects of Apaziquone After Transurethral Resection of Nonmuscle Invasive Bladder Cancer
• Feasibility and Outcomes of Repeat Partial Nephrectomy
• Residual Urinary Volume and Urinary Tract Infection
• Detrusor Contractility Test as Exclusion Criterion for Sacral Neurostimulation
• Impaired Renal Function in Newly Spinal Cord Injured Patients Improves With Time
• Surgical Salvage of Renal Cell Carcinoma Recurrence After Thermal Ablative Therapy
• Surgical Morbidity Associated With Preoperative Targeted Molecular Therapies for Locally Recurrent Renal Cell Carcinoma
• Urethral Reconstruction in Patients With Neurogenic Bladder Dysfunction
• Prostatic Urethral Biopsy as a Predictor of Urethral Margin Status
• Lower Urinary Tract Symptoms and Depression
• Copyright

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Can Epirubicin Improve BCG Efficacy for Invasive Bladder Cancer in High Risk Patients? 

Single dose intravesical instillation of a chemotherapeutic agent after transurethral resection of a bladder tumor is now recommended in many bladder cancer guidelines. Most studies reveal a significant reduction in recurrences. Cai et al (page 110) from Florence, Italy studied the efficacy of a single dose of epirubicin in patients with a high risk of recurrences in a placebo controlled randomized trial. The study population had greater than 2 recurrences or higher grade (2 to 3) tumors, or had undergone multiple resections. Patients were followed after resection and epirubicin before given a course of bacillus Calmette-Guerin (BCG). The authors reported that a single dose of epirubicin before a full course of BCG did not confer a benefit with regard to progression, disease-free interval, tumor progression or eradication of carcinoma in situ. Because of the lack of efficacy and the risk of toxicity they recommend that this regimen be followed only in low risk patients only.

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Safety and Side Effects of Apaziquone After Transurethral Resection of Nonmuscle Invasive Bladder Cancer 

Up to 70% of transitional carcinomas initially present as nonmuscle invasive cancer. As part of a phase II multi-institutional trial of safety, tolerability and pharmacokinetics, Hendricksen et al (page 116) administered a single instillation of the novel synthetic bioreductive alkylating indoloquinone apaziquone after initial resection. Apaziquone was administered transurethrally and retained for an hour in 20 patients. No patients suffered serious adverse events directly attributed to the drug. At 85 days postoperatively cystoscopy in 10 patients revealed no tumor recurrences and complete mucosal healing. Of these patients 6 had Gleason grade 1 Ta disease, 2 had grade 2 Ta disease and 1 had grade T1 disease. The relative safety, tolerability and efficacy of this agent encourage further study of apaziquone.

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Feasibility and Outcomes of Repeat Partial Nephrectomy 

Repeat partial nephrectomy in patients with recurrent kidney tumors is a surgical challenge. Johnson et al (page 89) at the National Cancer Institute presented the outcomes of repeat partial nephrectomy in 47 patients predominantly with recurrent kidney tumors from von Hippel-Lindau disease. Although morbidity was significant, with 1 death, a mean decrease in creatinine clearance from 95 to 84 ml per minute and dialysis for renal failure (5.8%) in 3 patients, dialysis was avoided in 92% of patients. Two patients required a third operation. The authors conclude that repeat partial nephrectomy is feasible and can help retain sufficient renal function to avoid renal replacement therapy.

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Residual Urinary Volume and Urinary Tract Infection 

Although previous investigators have studied the risk of urinary tract infections in children, diabetics or women with large post-void residual urines, no data exist on clinical symptoms of large post-void residuals in men with presumed benign prostatic hyperplasia. Truzzi et al (page 182) from Sao Paulo, Brazil examined post-void residual urine in men with urinary tract infections presenting with lower urinary tract complaints. Urine culture was positive in 27% of the men, and no patients with residual urine less than 150 cc had documented bacteriuria (greater than 10⁵ CFU) at presentation. In a multivariate analysis patient age, International Prostate Symptom Score and post-void urine greater than 180 cc were found to be predictors of urinary tract infection. The authors believe that clinically asymptomatic men with post-void residuals greater than 180 cc are at significant risk for bacteriuria and may require early therapy.

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Detrusor Contractility Test as Exclusion Criterion for Sacral Neurostimulation 

Sacral nerve stimulation is accepted therapy for overactive bladder and has also been used for urinary retention. However, results for retention are less predictable. Bertapelle et al (page 215) from Turin, Italy monitored cystometrograms while stimulating the sacral nerve roots at parameters normally exceeding those during normal sacral modulation. An increase in detrusor contraction exceeding 25 cm H₂O followed by a decrease at the end of the stimulation was considered indicative of a bladder contraction. Of 96 patients 72 (65%) did not demonstrate a contraction and, therefore, did not receive a sacral nerve stimulation device, while 12 with a positive detrusor contraction test as defined by the authors received the device. Three patients still required 1 clean intermittent catheterization a day and explantation was necessary in 1. Assuming that implantation of a nerve stimulation device will fail in all patients with a negative detrusor contraction test, the authors suggest that this test be used as an exclusion criterion before implantation of sacral nerve stimulators.

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Impaired Renal Function in Newly Spinal Cord Injured Patients Improves With Time 

Pettersson-Hammerstad et al (page 187) from Göteborg, Sweden compared creatinine ethylenediaminetetraacetic acid clearance in spinal cord injured patients soon after injury and 3 to 5 years later. Patients were stratified by spinal level of injury, completeness of injury and methods of bladder management. Interestingly, newly cervical spine injured patients had 86% of the predicted glomerular filtration rate (GFR) for age at the time of injury overall. At 3 to 5 years after injury patients treated with clean intermittent catheterization versus those treated with indwelling catheterization had a higher GRF. The age corrected GFR value had increased by 7%. This study documents that patients with cervical injury may initially present with lower GFR rates but intermittent catheterization may produce GFR rates near normal values. The study also provides evidence that indwelling catheterization can lead to deteriorating renal function, although it is not clear whether this is due to lower urinary tract infections.

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Surgical Salvage of Renal Cell Carcinoma Recurrence After Thermal Ablative Therapy 

High recurrence rates after cryosurgery and radio frequency ablation of small renal cell carcinomas indicate that salvage therapy will be necessary in a significant number of these patients. Nguyen et al (page 104) from Cleveland, Ohio reported repeat surgical salvage radical nephrectomy in 7 patients and partial nephrectomy in 2. One patient refused surgery because of fear of dialysis. Cryosurgery was associated with more significant scarring than radio frequency ablation. The authors note that regardless of the initial thermal management, primary thermal ablation can make subsequent surgical salvage difficult including open surgery.

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Surgical Morbidity Associated With Preoperative Targeted Molecular Therapies for Locally Recurrent Renal Cell Carcinoma 

Administration of targeted molecular therapies such as bevacizumab, sunitinib and sorafenib before surgical resection may become standard care for renal cell carcinoma. Margulis et al (page 94) from Houston, Texas evaluated the feasibility of tumor targeted therapies before cytoreductive surgery. Cohorts of patients underwent surgery with and without targeted molecular therapy and were then compared for complications. A total of 39 complications occurred in 17 of 44 patients (39%) given preoperative targeted therapy and 16 of 58 patients (28%) treated initially with surgery. There were no significant differences in surgical parameters, perioperative morbidity, thromboembolic events or toxicity in these patients. Patients given preoperative targeted molecular therapy had a shorter interval to initiation of postoperative systemic therapy than those treated with surgery alone. The authors note the possibility of increased surgical morbidity and postoperative complications taking into account the serum half-life of these agents. However, when bevacizumab was discontinued at least 4 weeks before surgery and sorafenib or sunitinib were discontinued at least 24 hours before surgery, there was no increase in surgical or perioperative complications. The authors conclude that the strategies integrating surgical resection with systemic molecular therapy may hold promise for patients with metastatic or locally recurrent renal cell carcinoma.

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Urethral Reconstruction in Patients With Neurogenic Bladder Dysfunction 

Casey et al (page 197) from Chicago, Illinois report the 24-month followup results of a heterogeneous series of 23 patients who underwent urethral reconstruction for urethral erosion (10), stricture (7), diverticula (3), urethrocutaneous fistula (2) and a combination of diverticula and stricture (1). Success rates varied by pathological condition. Urethral reconstruction was successful in 16 patients overall, with rates of 60% for urethral erosion, 85.7% for urethral stricture, and 66.6% for urethral diverticula and fistula. Disease recurred in 4 of 7 patients (57%) after repair of urethral erosion. Although this is a small series and followup is too short for stricture, the study suggests that urethral reconstruction is a reasonable alternative to diversion in this population of patients.

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Prostatic Urethral Biopsy as a Predictor of Urethral Margin Status 

Predictors of negative urethral margins would be beneficial when planning methods of urinary diversion for men undergoing radical cystectomy. Kassouf et al (page 164) from Houston, Texas evaluated the usefulness of preoperative transurethral prostatic urethral biopsy for predicting urethral margin status at the time of radical cystectomy in 252 patients. The incidence was 1.1% (3 of 252) for positive distal urethral margins on final pathological examination and 0.7% (2 of 252) for urethral recurrence. The correlation between transurethral resection findings and frozen section margins was only 68%, and 16 patients with positive resection findings had negative frozen section margins. The authors conclude that while the absence of tumor on biopsy correlates with a high likelihood of negative margins, a positive transurethral resection specimen does not correlate with final margin status.

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Lower Urinary Tract Symptoms and Depression 

A growing body of evidence is suggesting a correlation between lower urinary tract symptoms and depressive symptoms. However, information on causality remains incomplete. Among 3,291 patients being interviewed as part of the Male Attitudes Regarding Sexual Health study (page 233) the odds of lower urinary tract symptoms were increased among men who reported depressive symptoms (OR 2.68, 95% CI 1.60–4.47, p <0.01), especially for white and Hispanic men. Conversely, the odds that depression was increased in men reporting lower urinary symptoms were similarly increased (OR 2.64, 95% CI 1.39–4.85, p <0.01), especially in Hispanic and black men. The authors confirm that depression and lower urinary tract symptoms are strongly associated.