Radical Prostatectomy Results After Active Surveillance Fails
The criteria, safety and advisability of active surveillance for prostate cancer are controversial. To shed light on possible risks of this approach to localized prostate cancer, outcomes for 48 of 470 men in an active surveillance program were evaluated by Duffield et al (page 2274) from Baltimore, Maryland. Stringent criteria were used to enroll patients in active surveillance, including stage T1c, prostate specific antigen (PSA) density less than 0.15 ng/ml/cm, no Gleason pattern grade 4/5, and 2 or fewer cores involved with cancer. An annual repeat needle biopsy was performed as part of the surveillance. The authors defined progression as any Gleason pattern grade 4/5 or cancer in more than 2 cores. Of the patients 31 (65%) had organ confined disease, 25 (52%) had a Gleason score of 6 and 17 (35%) had extraprostatic extension. Only 3 (7%) patients had seminal vesicle or lymph node involvement. More extensive disease was found in the surveillance biopsies within the first 2 years, suggesting a sampling error that missed worse disease. Fortunately even with progression on repeat biopsy, most tumors had favorable pathology including 27% that were potentially insignificant.
Perceptions of Quality of Life for Patients With Prostate Cancer
Patients ultimately assess the impact of a health care intervention on quality of life. Yet surgeons must explain the potential impact of an intervention based on their personal experience and the literature. Unfortunately, physicians often underestimate the impact of their actions, particularly in regard to radical prostatectomy. Sonn et al (page 2296) from Stanford, California compared selected health related quality of life instruments completed by patients to impressions by their treating physicians. They postulated that physicians would understate the impact of prostate cancer treatment on quality of life. The authors assumed that quality of life would be more accurately assessed in short-term followup but less accurately assessed by physicians than patients in long-term followup. Although urologists did a respectable job estimating impacts of urinary incontinence and impotence, they underestimated the impact for the domains of pain, fatigue and bowel problems by a wide margin. For example in 2001 to 2007 there was a 16% difference for sexual function and 22% for incontinence reporting between patients and physicians. However, for fatigue, pain and bowel problems the difference was nearly 50%. This is even more profound since even if the physician rated the impact as mild and the patient rated it as severe, this would have been noted as agreement in the present study.
Impact of Patient Age on the Early and Late PSA Eras
Men older than 70 years have the greatest chance of dying of prostate cancer, and yet studies often show increased disease specific survival for treatment in this age group. Therefore, recent studies in Europe and the United States to assess the value of PSA screening have excluded men older than 75 years. Disease risk in this age group was studied by Sun et al (page 2242) from Durham, North Carolina, particularly the effect of age on the change in Gleason sum and survival during the early and late PSA eras. To evaluate the role of age in disease risk, race, body mass index, PSA, prostate weight, Gleason sum, tumor volume, pathological stage, extracapsular extension, seminal vesicle invasion and surgical margin status were compared against stratified age groups. The authors were able to show that age was an independent predictor of disease specific death on univariate analysis but it was not statistically significant on multivariate analysis. Thus physicians need to exercise caution when excluding older patients from therapy.
Expression of Thrombospondin-1 and p53 in Clear Cell Renal Carcinoma
Thrombospondin-1 (TSP-1) is one of the most anti-angiogenic substances known. This glycoprotein is regulated by p53, and inhibits angiogenesis by inhibiting endothelial cell migration and inducing apoptosis. Zubac et al (page 2144) from Bergen, Norway postulated that a reduction in TSP-1 in clear cell renal carcinoma tumor specimens would be associated with greater adverse pathological characteristics. In a retrospective analysis of tumor specimens 41% were TSP-1 positive with 35% showing strong TSP-1 staining. The risk of tumor progression in TSP-1 negative tumors was high (HR 2.78, p = 0.006). The authors conclude that TSP-1 correlated with p53 and was inversely related to tumor proliferation. They speculate that TSP-1 has an impact on angiogenesis in clear cell renal carcinoma.
Partial Nephrectomy After Previous Radio Frequency Ablation
Anecdotally, surgeons report that partial nephrectomy after minimally invasive procedures can be more technically difficult than nontreated renal masses and associated with greater morbidity. A retrospective chart review of 13 patients after 16 attempted partial nephrectomies following radio frequency ablation (RFA) was performed by Kowalczyk et al (page 2158) from the National Cancer Institute. Published studies of similar patient populations were used as historic controls for comparison. There was a modest but significant decline in renal function after partial nephrectomy following RFA and a higher reoperation rate compared to other series of primary or repeat partial nephrectomies but a lower rate of vascular or visceral injuries. Thus, while partial nephrectomy after RFA is feasible, it can be technically challenging with potentially a greater chance of reoperation. These findings should be considered during planning and discussions with patients.
Different Approaches to Initial Management of Benign Prostatic Hyperplasia
In the current health care debate a greater emphasis is being placed on primary care and potentially diverting patients from specialists to reduce health care costs. In this timely report Hollingsworth et al (page 2410) from Ann Arbor, Michigan performed a retrospective cohort review using a medical claims database from a nonprofit managed care organization. Using cohort analysis, they examined differences in the use of medical therapy between primary care physicians (PCPs) and urologists. All patients seen by urologists were referred from PCPs. Fewer than a third of the patients received initial care from a urologist. However, when patients did see a urologist the odds of having a laboratory study doubled (OR 2.03, 95% CI 1.51–2.74) and urology patients were more than 6 times as likely to undergo diagnostic imaging. Men seen by a urologist were also more likely to receive medical therapy than those seen by the PCP (36.6% vs 17.4% respectively, p <0.01). Increased testing of patients seen by a urologist was noted even after the clinical characteristics of the disease had stabilized. One might expect less financial incentives for testing in the managed care environment. Therefore, differences in training and knowledge of disease may help account for the differences in care. Alternatively, specialists such as urologists could be attempting to justify the appropriateness of the consultation from the PCP to reaffirm the value of the consultation.
Use of TachoSil® for the Prevention of Lymphoceles After Lymphadenectomy for Prostate Cancer
Pelvic lymphadenectomy can cause increased morbidity, primarily through the development of a lymphocele. A prospective randomized trial of TachoSil, an equine collagen glue patch coated with fibrin glue components, human fibrinogen and human thrombin, was conducted by Simonato et al (page 2285) from Genoa, Italy. A total of 60 patients were randomized to receive TachoSil plus standard surgical lymphadenectomy using electocautery and hemoclips vs lymphadenectomy alone. The TachoSil group had less wound drainage (64 vs 190 cc) immediately postoperatively. Lymphoceles developed in 5 (drainage required in 1) of the 30 patients receiving the sealant and in 19 (drainage required in 4) of the 30 treated with the standard technique. The authors conclude that TachoSil provides a useful prophylaxis for lymphocele.
Primary Tumor Location Does Not Predict Cancer Specific Mortality
The prognostic significance of urothelial cell carcinoma in the renal calix vs the upper ureter is not fully known but differences in anatomy, lymphatic and vascular drainage, and urine dwell times could alter disease expression. Isbarn et al (page 2177) from Montreal, Quebec, Canada examined 2,824 patients from the SEER (Surveillance, Epidemiology and End Results) registry between 1988 and 2004, and found that renal pelvic tumors were of higher stage than ureteral tumors (34% vs 57.9%) and had a higher rate of lymph node metastases (9.8% vs 6%). Disease-free survival estimates were roughly the same (81% vs 75.5%). In this large cohort it appears that despite differences in stage and grade, tumor location did not predict cancer specific mortality. One wonders if the difference in stage and grade could also be related to the time of diagnosis since ureteral tumors may be more symptomatic.
Psychological Profiles of Men With Chronic Prostatitis/Chronic Pelvic Pain Syndrome
There is a growing realization that patients with chronic pelvic pain syndrome may have an altered hypothalamus-pituitary-adrenal (HPA) axis and different stress profiles. Anderson et al (page 2319) from Stanford, California found that patients with chronic pelvic pain scored in the 94th percentile in the Trier Social Stress Test compared to the 49th percentile for asymptomatic controls. Patients with chronic pelvic pain had blunted plasma adrenocorticotropin hormone responses, approximately 30% less than that of controls. However, there were no differences in cortisol responses. The authors conclude that similar to patients with fibromyalgia and interstitial cystitis, there may be chronic down-regulation of the HPA axis in patients with chronic pelvic pain syndromes and that, although there is a stress response, it is different from that of asymptomatic controls.
Outcome of Laparoscopic Sacrocolpopexy With Xenografts Vs Synthetic Grafts
The records of 50 consecutive patients who underwent laparoscopic sacrocolpopexy with porcine grafts were compared to those of 100 consecutive patients in whom polypropylene mesh was used by Deprest et al (page 2362) from Leuven, Belgium. The primary outcome measure was anatomical cure (stage 1 or less at any compartment). Of the 104 cases available for anatomical comparison the overall failure rates were comparable (49% xenograft vs 34% polypropylene) but those in the xenograft group had more apical failures and reoperations than those in the polypropylene group. Moreover, xenografts did not reduce graft related complications, suggesting that greater efficacy without the price of increased morbidity could be achieved by using polypropylene grafts for sacrocolpopexy.
Cytoreductive Nephrectomy for Kidney Cancer With Sarcomatoid Histology
Shuch et al (page 2164) from Los Angeles, California examined 62 tumors with sarcomatoid histology, accounting for 14.9% of 417 patients undergoing cytoreductive nephrectomy. As might be expected, patients with sarcomatoid features had higher T stage and increased nonclear cell cytology. Most importantly, mean survival of patients with sarcomatoid features was 4.9 months vs 17.7 for those with tumors of nonsarcomatoid histology. Use of postoperative therapy was significantly worse for patients with sarcomatoid histology. The question arises whether patients with sarcomatoid histology receive any benefit from cytoreductive surgery since the prognosis is so poor and life expectancy is so short.
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