This Month in Adult Urology

Article Outline

• Reintervention After Sacrocolpopexy With Xenogenic Acellular Collagen Grafts
• Soft Tissue Surgical Margin Status is a Powerful Predictor of Outcomes After Radical Cystectomy
• Ketoconazole Plus Docetaxel for Metastatic Castration Resistant Prostate Cancer
• Tumor Characteristics of Urothelial Carcinoma on Multidetector Computerized Tomography Urography
• Biological Variation in the Diagnosis of Testosterone Deficiency and the Relevance of Testosterone Determinations
• Varicocele Repair in Patients With Nonobstructive Azoospermia
• Copyright

Back to Article Outline

Reintervention After Sacrocolpopexy With Xenogenic Acellular Collagen Grafts 

Synthetic mesh used for prolapse repair results in such complications as erosion, pain and infection. Alternatively, commercially available heterologous acellular grafts such as porcine small intestine submucosa, which is resorbable, or cross-linked porcine dermal collagen, have been used for sacrocolpopexies but at the cost of an increased recurrence rate. To determine whether degradation is a contributing factor, Deprest et al (page 2249) from Leuven, Belgium examined the composition of surgically removed acellular grafts used for sacrocolpopexy after failure due to prolapse or graft complications. A total of 72 patients were evaluated of whom 29 received a porcine small intestine submucosa graft and 43 received a cross-linked porcine dermal collagen graft. Failure occurred in 18% of patients at a mean of 11.5 months. Based on histopathology the submucosa grafts were completely replaced while the collagen grafts were still present. Massive polymorphonuclear infiltration occurred with the submucosa graft and, although also degraded, porcine dermal collagen materials were still recognizable. Also porcine small intestine submucosa implants were totally replaced by connective tissue. Regardless of which grafts are used, local infection and failures can occur.

Back to Article Outline

Soft Tissue Surgical Margin Status is a Powerful Predictor of Outcomes After Radical Cystectomy 

For a variety of genitourinary tumors it is unclear whether positive surgical margins affect survival or recurrence. For example, positive margins at prostatectomy or partial nephrectomy, although associated with recurrence, have not been definitively shown to reduce survival. In contrast, in this multi-institutional study Novara et al (page 2165) report that surgical margin status is a powerful predictor, regardless of the pathological stage or grade, of bladder cancer survival. The authors warn that positive margins are the result of surgical technique or high stage bladder cancer. After a 5-year interval recurrence-free and cancer specific survival rates were 62% and 69% for patients without positive margins vs 21% and 26% of those with positive margins. Soft tissue surgical margin positivity was predictive of advanced disease as well as the odds of survival.

Back to Article Outline

Ketoconazole Plus Docetaxel for Metastatic Castration Resistant Prostate Cancer 

The optimal treatment for castration resistant prostate cancer remains elusive. Recent studies suggest that immunotherapy vaccines or chemotherapy with taxol may hold promise. In an effort to determine whether suppression of steroids used by the prostate plus chemotherapy with docetaxel is effective for castration resistant prostate cancer Figg et al (page 2219) from Bethesda, Maryland administered docetaxel 3 of every 4 weeks plus daily ketoconazole in a cohort of patients. Decreases in prostate specific antigen of greater than 50% were seen in 62% of patients, and 28% of patients with measurable soft tissue disease had a partial response. Median overall survival was 22.8 months. More importantly, docetaxel naïve patients survived significantly longer (36.8 vs 10.3 months). The results of this study suggest that a combination of docetaxel and ketoconazole has significant antitumor activity, especially in patients who have not previously received docetaxel.

Back to Article Outline

Tumor Characteristics of Urothelial Carcinoma on Multidetector Computerized Tomography Urography 

Computerized tomography (CT) with contrast is often used to evaluate hematuria during followup of urothelial carcinoma (UC). Wang et al (page 2154) from Taiwan, Province of China retrospectively reviewed all consecutive patients with hematuria who underwent multidetector computerized tomography urography (MDCTU) in 23 months. Urothelial carcinoma was verified by surgical examination. A total of 87 urothelial tumors were verified in 70 patients who underwent MDCTU. Only 7% of tumors were undetected by CT. The tumor size of detectable and undetected UCs varied significantly (3 vs 0.6 cm, respectively). Tumor size greater than 1 cm, tumor location and noncarcinoma in situ tumors were significantly associated with CT detection. The authors conclude that MDCTU is useful for detecting nearly all urothelial carcinomas except for carcinoma in situ and lesions smaller than 1 cm. Surprisingly, ureteral carcinomas were detected less often than bladder tumors on MDCTU. Patients with a high risk of malignancy can still benefit from CT screening rather than ultrasound. The authors stress the importance of still performing cystoscopy to confirm the diagnosis and exclude small lesions or carcinoma in situ, and suggest the use of urine cytology for detecting carcinoma in situ.

Back to Article Outline

Biological Variation in the Diagnosis of Testosterone Deficiency and the Relevance of Testosterone Determinations 

A consensus is lacking in regard to recommendations for testosterone levels and the definition of androgen deficiency. Part of the challenge is the definition of normal, and interpreting the intra-individual variability and possible diurnal variations. Collier et al (page 2294) from Kingston, Canada examined 87 healthy men, 50 to 70 years old or older, who provided morning blood samples which were repeated 4 weeks later in the morning and afternoon. Testosterone was lower in the afternoon but varied in the morning. The variability between days was almost 19% while the same day variability was only 13%. Marked individual variability in testosterone is evident even in healthy men. Reference intervals are only of marginal usefulness since a homeostatic set point can decrease by half and still be within the reference interval. The authors suggest either prospective measurement of baseline to guide repeated measurements or reliance on symptoms regardless of testosterone concentration.

Back to Article Outline

Varicocele Repair in Patients With Nonobstructive Azoospermia 

Weedin et al (page 2309) from Houston, Texas hypothesize that men with favorable testicular histopathology on testis biopsy such as maturation arrest or hypospermatogenesis will have a higher probability of success from varicocelectomy than men with sertoli-cell-only cytology on biopsy. Of 233 patients analyzed after varicocele repair 91 (39.1%) had motile sperm in the ejaculate and 14 spontaneous pregnancies were reported. Success rates were 42% in patients with maturation arrest and 54.5% in those with hypospermatogenesis compared to 11% in the sertoli-cell only group. The authors conclude that semen analysis can improve in men with nonobstructive azoospermia and spontaneous pregnancy can be achieved especially if histology is favorable.