This Month in Adult Urology

Article Outline

• Salvage Prostate Cryoablation
• Combined Neoadjuvant Docetaxel and Hormone Therapy Before Radical Prostatectomy for Localized Prostate Cancer
• [-2]proPSA for Prostate Cancer Detection: An NCI Early Detection Research Network Validation Study
• Nephrostomy Placement Versus Tubeless Percutaneous Nephrolithotomy
• Percutaneous and Laparoscopic Cryoablation of Small Renal Masses
• Percent Tumor Involvement and Risk of Biochemical Progression After Prostatectomy
• Single Port Transumbilical Donor Nephrectomy
• Prognostic Impact of Postoperative C-Reactive Protein Level in Patients With Metastatic Renal Cell Carcinoma
• PSA Testing After a Negative Prostate Biopsy to Predict Prostate Cancer
• Copyright

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Salvage Prostate Cryoablation 

Cancer registries have demonstrated a biochemical failure rate as high as 63% and positive prostate biopsy rates of 25% to 94% following definitive radiotherapy. Salvage prostatectomy can be curative in these patients but it is associated with substantial morbidity. Salvage cryotherapy has been advocated in an attempt to control persistent prostate cancer after radiotherapy. In a large series of patients Pisters et al (page 559) present 5-year actuarial data from the Cryo On-Line Data Registry. Biochemical failure was defined using the ASTRO and Phoenix criteria. Although 83% of patients had a detectable prostate specific antigen (PSA) of 0.2 ng/ml or greater at 5 years, the biochemical disease-free rate was 59% by ASTRO criteria and 55% by Phoenix criteria. The incontinence rate requiring pads was only 4%. Rectal fistulas occurred in 1.2% of patients, and 3.2% required transurethral resection of the prostate to remove sloughed tissue. These findings indicate that biochemical control can be achieved with local cryoablation with minimal morbidity after failure of radiotherapy for prostate cancer.

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Combined Neoadjuvant Docetaxel and Hormone Therapy Before Radical Prostatectomy for Localized Prostate Cancer 

In vitro animal studies suggest that a combination of androgen ablation and chemotherapy with docetaxel provides therapeutic benefit in the treatment of prostate cancer. Chi et al (page 565) from Vancouver BC Canada demonstrate that docetaxel plus androgen ablation can be administered safely to and is well tolerated by patients at high risk for recurrence. Although the final end point of a 20% pathological complete response rate was not achieved in their study of 64 patients, it was encouraging that 2 patients did achieve a complete response and 16 had less than 5% prostate cancer detected on the prostatectomy specimens. Patients were followed for a median of 43 months during which time 30% had PSA progression compared to slightly more than 50% of historical controls. These results provide a rationale for further studies to assess this combination of neoadjuvant chemotherapy/androgen ablation for patients at high risk for prostate cancer recurrence after radical prostatectomy.

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[-2]proPSA for Prostate Cancer Detection: An NCI Early Detection Research Network Validation Study 

The use of percent free PSA has enhanced the ability to predict cancer on biopsy or re-biopsy of the prostate in patients. Sokoll et al (page 539) from multiple centers exploited the fact that percent free PSA exists in a proPSA (cancer) form and a BPSA (benign) form to examine the use of a serum percent [-2]proPSA to enhance sensitivity and specificity, rather than using free PSA alone. Results confirmed that the sensitivity and specificity of percent [-2]proPSA was superior to those of percent free PSA. These authors performed a retrospective analysis of banked sera from a random selection of equal numbers of cancer and noncancer specimens from men with an indication for prostate biopsy. If percent [-2]proPSA had been used, 20% of the patients would have been spared biopsies.

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Nephrostomy Placement Versus Tubeless Percutaneous Nephrolithotomy 

Significant morbidity exists with protracted drainage using a nephrostomy tube following nephrolithotripsy. A randomized controlled trial of nephrostomy placement (25 patients) versus tubeless percutaneous nephrolithotomy (25) was performed by Crook et al (page 612) from Hants, United Kingdom in a select group of patients with renal stone disease. The primary outcome measure was length of stay, and secondary outcome measures were analgesic requirements and postoperative complications including bleeding, infection or ureteral obstruction. Mean stone size was 21.6 mm in the nephrostomy group and 17.5 mm in the tubeless group. No transfusions were needed in either group and there was no difference in hemorrhage or infection rates. This study demonstrates that in select patients with limited stone burden percutaneous nephrolithotomy without a nephrostomy tube or placement of a stent is safe and fairly well tolerated. The length of stay was reduced and no major complications occurred. However, adoption of this technique should go slowly until a larger number of patients with a greater variety of stone sizes have been analyzed.

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Percutaneous and Laparoscopic Cryoablation of Small Renal Masses 

Laparoscopic nephrectomy is associated with substantial morbidity, especially early in the learning curve. The results of the first 4 years of percutaneous versus laparoscopic cryoablation for small renal masses were compared by Finley et al (page 492) from Orange, California. The percutaneous cryoablation group had a lower transfusion rate, shorter hospital stay and less narcotic use than the laparoscopic group. Of the patients with biopsy proven renal cell carcinoma treatment failures were modest in both groups at 5.3% in the percutaneous group and 4.2% in the laparoscopic group. The authors detail the approaches used to perform percutaneous and laparoscopic cryoablation. They believe the percutaneous approach is superior to the laparoscopic approach in this group of patients. However, it should be noted that the followup is short and the issue of recurrence remains for both groups.

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Percent Tumor Involvement and Risk of Biochemical Progression After Prostatectomy 

The percent of tumor involvement has been associated with biochemical progression in organ confined prostate cancer. Rampersaud et al (page 571) from Durham, North Carolina hypothesized that tumor involvement may correlate with outcome in all stages of prostate cancer regardless of pathological diagnosis. On multivariate analysis they showed that percent tumor involvement was highly predictive of the risk of positive surgical margins, extracapsular extension, seminal vesicle invasion and biochemical progression (HR 1.1, 95% CI 1.01–1.33, p = 0.035). Percent tumor cutoff points of 5% or less, 6% to 20%, 21% to 50% and greater than 50% significantly separated groups of men with differing biochemical progression risks. The authors conclude that percent tumor involvement was a significant predictor of biochemical progression which could be used to stratify patients who were already assigned to rather narrowly defined pathological groups. If confirmed this may help identify patients who would benefit from adjuvant therapy.

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Single Port Transumbilical Donor Nephrectomy 

Significant publicity has been garnered by a new approach using natural orifices to perform laparoscopic surgery. In an effort to avoid scarring, abdominal surgery via natural orifices (called natural orifice translumenal endoscopic surgery or NOTES™) is increasingly being attempted. The umbilicus, an embryonic natural orifice and thus referred to as eNOTES, permits abdominal access and offers concealment of scarring. Gill et al (page 637) from Cleveland, Ohio were able to perform donor nephrectomy through a transumbilical single access tri-lumen R-port. While some may argue whether the umbilicus is truly a natural orifice, the results of this study suggest that this modification can make abdominal surgery more scar-free and less uncomfortable.

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Prognostic Impact of Postoperative C-Reactive Protein Level in Patients With Metastatic Renal Cell Carcinoma 

The search continues for a molecular marker than can accurately predict metastatic disease in patients with renal cell carcinoma. C-reactive protein (CRP) status was examined by Tatokoro et al (page 515) from Tokyo, Japan in 40 patients with metastatic renal carcinoma who underwent cytoreductive nephrectomy. CRP was not preoperatively increased in 17 of the 40 patients. Of the remaining 23 patients increased preoperative CRP levels normalized after cytoreductive nephrectomy in 17 and remained high in 6. The latter 6 patients died of disease within 1 year. The overall survival rate in the normalized group and the nonelevated group was significantly better. The authors conclude that CRP may be a useful prognostic indicator in patients with renal cell carcinoma after cytoreductive surgery.

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PSA Testing After a Negative Prostate Biopsy to Predict Prostate Cancer 

There are those who believe that a PSA test after performing a negative biopsy is of little use in patients at risk for prostate cancer. In a multicenter study Thompson et al (page 544) reviewed the results of more than 18,000 cases in the Prostate Cancer Prevention Trial to determine the significance of PSA testing after a negative biopsy. Using receiver operating curves the authors confirmed that PSA retains predictive value for the detection of prostate cancer even after a negative first biopsy.