Search

The contribution of LHRH analogs is enormous in prostate cancer management at nearly all stages of the disease, the Leading cancer in males over 50 years of age. They make it possible to use hormone therapy reliably, with Little morbidity, and can be reversed. Their use can be immediate or delayed, continuous or intermittent, whether or not they are associated with an antiandrogen, and can be associated with chemotherapy for patients who have reached the stage of hormone-refractory prostate cancer.

Rising PSA after radical prostatectomy corresponds to a biochemical recurrence, i.e., a new rise in PSA levels. Several definitions of biochemical recurrence exist. Predictive factors can differentiate Local recurrence and distant metastasis. Depending on the case, the therapeutic options for managing these recurrences are radiotherapy, hormone therapy, and chemotherapy.

Difficult clinical cases of locally advanced prostate cancer at high-risk of progression should be discussed during a collegial decision-making process with different clinical specialists (surgeon, radiotherapist, oncologist, chemotherapist). Scientific consensus exists to give an adjuvant therapy after initial curative local treatment in patients with unfavourable prognostic features. For patients with locally advanced prostate cancer extending beyond the capsule (pT3) or with positive surgical margins, studies have shown that immediate postoperative radiotherapy is to eradicate the microscopic disease left in the surgical bed. Studies have shown the potential benefit of cytotoxic chemotherapy in terms of overall survival and median time to progression in patients with metastatic hormone-refractory prostate cancer. Active clinical research is underway to study neoadjuvant systemic chemotherapy before radical prostatectomy. There are also currently several clinical trials that are investigating the addition of chemotherapy in patients at high-risk of progression in the postprostatectomy setting. Antiandrogen therapy after radical prostatectomy has been shown in randomised studies to significantly reduce the risk of objective clinical progression in patients with high-risk localized prostate cancer. Immediate hormonal therapy with bicalutamide is a valuable therapeutic option in men having prostate cancer with such clinicopathological features.

The presence of positive surgical margins on radical prostatectomy specimen is an adverse prognostic factor. Parameters supposed to influence surgical margin status includes pathology method analysis, surgical technique, tumoral and non tumoral patient parameters, and neoadjuvant hormonal therapy. Regarding the surgical technique, surgeon's experience and neuro-vascular bundles preservation are the most important factors of margin status, whereas surgical approach, bladder neck conservation, intraoperative frozen analysis, and bleeding are minor factors. Non tumoural patient parameters influencing surgical margin status include patient's age and weight, and prostate gland weight. For tumoural parameters, pathological stage and tumour volume are more important factors than the tumor grade and PSA. Five preoperative tumoral risk factors of positive surgical margins are particularly important, including abnormal digital rectal examination, preoperative PSA 10 ng/mL, biopsy Gleason score >7, number of positive biopsy cores > or = 2, and suspicion of extraprostatic extension on radical prostatectomy specimen.

Prostate cancer is currently the main indication of LH-RH analogs. This class, which in recent years has replaced diethylstilbestrol and surgical castration, now plays a major role at all stages of the disease. Numerous studies with contradictory results have compared total hormonal blockage, an alog combined with an anti-androgen, with analog alone in locally advanced prostate cancer. A recent metaanalysis showed a slight though globally non-significant advantage in favour of total blockage, but with a significant advantage in the case of a nonsteroidal anti-androgen. In stage T3 cancers, adjuvant hormone therapy over three years in combination with radiotherapy versus external radiotherapy alone was more effective in terms of local or metastatic progression and survival. Institution during radiotherapy and a prolonged duration of treatment gives a greater benefit though this was only significant for the subgroup of patients with a Gleason score > or = 8. For localized stages but at high risk (PSA > 15 ng / ml and\or Gleason score > 7), adjuvant hormone therapy after prostatectomy improved recurrence-free survival in comparison with prostatectomy followed-up by simple monitoring. On the other hand, the administration of analogs two or three months before radical prostatectomy did not seem to provide any additional benefit. Medical castration prolonged by LH-RH analogs engenders multiple side effects which become all the more worrying as patient survival is prolonged by this hormone therapy. In phase I-II studies, intermittent treatment is equivalent to continuous treatment for "hormone sensitive" patients (PSA nadir at six months < 0.5 ng). Phase III studies are in progress to confirm this equivalence. This intermittent hormone therapy may be a useful solution for elderly patients (> 78 years old) with a biologically highly active cancer and remains to be evaluated in relatively young subjects after radical prostatectomy or radiotherapy. Combination of analogs with chemotherapy has been used very recently for patients who have reached hormonal escape and may be a useful immediate option for patients with cancers with a high risk of progression.

Intermittent hormone therapy in prostate cancer consists in disrupting treatment after the nadir PSA has been reached, and reinitiating treatment when the PSA increases over a certain threshold. Theoretical advantages of intermittent hormone therapy are to delay the occurrence of hormone-independence and to decrease treatment-related side effects. Some phase II trials have demonstrated the feasibility of intermittent hormone therapy. The percent time without treatment varies between 40 and 50%. Oncologic results of intermittent hormone therapy are, at least, equivalent to those of continuous therapy. Moreover, the side effects of treatment are decreased and the quality of life is improved during off treatment phases. Due to the lack of comparative studies, the superiority of intermittent upon continuous treatment has not been established at long-term follow-up. Prospective comparative trials are ongoing; they will determine the true benefit of intermittent hormone therapy in prostate cancer.

Radiation therapy is commonly used to treat pelvic or retroperitoneal cancers but has some impact on genito-urinary system: short-term side effects are frequent with usually a completed regression. However, the incidence of major complications is about 12% and is probably underestimated due to a long delay between radiation therapy and diagnosis of some adverse events such as ureteral strictures or fistula. Clinical follow-up must absolutely include an early diagnosis and treatment of radiation therapy complications such as renal dysfunction, ureteral stricture, ureteral fistula, chronic bladder injury, bladder fistula, urethral stricture, infertility or erectile dysfunction.

Seven patients with renal failure secondary to bilateral ureteric obstruction by pelvic carcinoma underwent palliative urinary diversion. In 3 cases, an autostatic ureteric stent was inserted after endoscopic resection of the trigone invaded by the tumour in the presumed zone of the ureteric meatus, and retrograde catheterisation of the ureter. This method has very limited indications, but may improve the comfort of survival of certain patients.

Endometriosis, initially believed to be a gynecologic disease, occasionally involves the urinary bladder, and less frequently the ureters. Use of ureteral stents with an appropriate hormonal treatment can obviate the need for open surgery.

Thirty patients with traumatic rupture of the urethra were treated in the Urology Department of Cochin Hospital between 1975 and 1985: 11 as an emergency procedure, 7 for an early complication and 12 for a late complication. In the patients treated early, urethrorrhaphy or one-stage urethroplasty gave the best results. Two stage urethroplasty constituted best treatment for patients with a complication of earlier treatment. In patients with late complications, endoscopic urethrotomy is rarely sufficient on its own and two-stage urethroplasty is generally indicated.

The LDMWH (Promeditech 2000), a hyperthermia apparatus emitting microwaves with a frequency of 915 MHz, has been used since July 1988 in the Urology Department of Hôpital Cochin and the Polyclinic of Montreuil for the treatment of prostatic obstructions. Patients are selected on the basis of objective criteria (flowmetry, post-micturating residue) and subjective criteria (standard clinical history). Only patients with objective obstruction are treated by localized hyperthermia, which constitutes a real alternative to surgery. Treatment is performed as an outpatient procedure without anaesthesia as one one-hour session per week for a period of six weeks. The results are evaluated one and three months after completion of treatment by assessing the same objective and subjective criteria as before treatment. The results of the first 26 patients with sufficient follow-up reveals 45% good objective results and 65% good subjective results.

In order to assess the potential benefits of radical cystectomy in bladder cancer associated with pelvic lymph node metastasis, a retrospective study compared 2 groups of patients with T2-T3 N+ bladder cancer: 10 treated by radical cystectomy and 14 treated conservatively once the diagnosis of nodal metastasis had been established by fine needle node aspiration or lymphadenectomy. The survival rates were identical in both groups: 80% of the patients died within 2 years, 60% during the first year after diagnosis, mainly due to distant metastasis. No patient in the conservative arm required salvage cystectomy because of local progression. It is concluded that radical cystectomy is of little benefit in T2-T3 N+ bladder cancer, a disease which is no longer amenable to purely local treatment.

The tissue effects of pulsed dye laser (Pulsolith) were studied in 10 dog ureters. The results show the absence of ureteric perforation or damage to adjacent organs by the laser irradiation. The only lesions observed were focal hyperplasia of the urothelium and chorion with extremely limited abrasions of the urothelium. The absence of tissue damage of the pulsed dye laser allows it to be used in human clinical practice.

Intracorporeal lithotripsy of urinary calculi by pulsed dye laser has recently enriched the urologist's therapeutic arsenal. We recall the in vitro studies and animal experimentations which demonstrated the feasibility of laser lithotripsy and the absence of harmful tissue damage. The ideal indications for intracorporeal lithotripsy are ureteral stones accessible by rigid and, more especially, flexible ureteroscopy. The results of the first published series using this technique are very encouraging.

Extracorporeal shock wave lithotripsy (ESWL) as primary treatment for large renal stones has been evaluated in this clinical study of 55 patients. Patients were treated using the Dornier HM-3 lithotripter. Twenty-one (38%) patients presented with a stone burden greater than 4 centimeters. Nineteen patients had "steinstrasse", of which 8 had to undergo a secondary procedure. Sixteen (29%) patients had no residual stone, 5 had clinically non significant stones and 34 had clinically significant stones. Out of the 15 patients who underwent a second ESWL, only 2 were rendered stone-free. In this study, ESWL was not found to be a satisfactory treatment for large renal stones.

Among one hundred consecutive patients submitted to radical cysto-prostatectomy for invasive transitional cell carcinoma of the bladder, 26 also exhibited adenocarcinoma of the prostate on histological specimens: 17 microscopic foci and 9 larger prostate carcinomas. In 3 cases, the tumor was found in the apex of the prostate gland. Pelvic lymphadenectomy was positive in 4 cases but always corresponded to a urothelial metastasis. Follow-up was never marked by a metastatic development of this adenocarcinoma. This frequency of latent prostatic adenocarcinoma is not different from its observed incidence in the general population on autopsy studies. The high incidence of this association makes removal of the whole prostatic tissue during total cystectomy necessary.

The prone position is often used in urologic surgery: posterior approach for pyeloureteral procedures, repair of vesicovaginal fistulas... Positioning of the patient and intraoperative ventilation are facilitated by use of an antistatic, fitted mattress.

In order to more clearly define the risk of infection of prostatic biopsy, the authors conducted an analysis of the morbidity of each method. The risk of infection, the possible forms of prophylaxis and the best indications are presented for each method.

Sarcomas of the retroperitoneal soft tissues and of the cord are rare and serious tumours. However, a better histological understanding, determination of the histological and prognostic grades and progress in chemotherapy have led to an improvement in the overall prognosis of these tumours.

Several teams over recent years have proposed deep transurethral incision of the prostate as treatment for obstructive symptoms secondary to primary bladder neck sclerosis or to a small prostatic adenoma. We have performed this technique in 16 patients over a period of 9 months: 9 cases of primary bladder neck sclerosis and 7 prostatic adenomas weighing less than 20 grams. There were no post-operative complications. This technique was definitely effective on the dysuria with 93% good results at 6 months. The preservation of post-operative anterograde ejaculation was less certain; 27% of our patients developed post-operative retrograde ejaculation. The indication for TUI amongst the other available surgical techniques depends on a rigorous pre-operative assessment evaluating the size and the nature of the obstruction. It is a remarkably simple technique which effectively cures the dysuria. It also markedly decreases the risk of retrograde ejaculation. As this complication is difficult to predict, the patients should be informed of the risks prior to the operation.

Four patients with solid genito-urinary tumors and HIV 1 infection have been treated in our institution over the last 2 years, including 2 with seminoma, 1 with renal adenocarcinoma and 1 with renal angiosarcoma. All had severely impaired immunity with a low CD4 level. Three had or developed a true AIDS syndrome according to the WHO and CDC criteria (1988). The remaining patient was seropositive and died less than 3 months following the diagnosis of renal angiosarcoma, he is the first reported case of renal sarcoma in a patient infected with HIV 1. Two patients were homosexuals and the other 2 were drug addicts. Along with other reported cases, our cases may underline the association between depression of immunity due to HIV and onset of solid genito-urinary tumors.

In order to define the prognosis of pure squamous carcinomas of the bladder, on the one hand (group I), and the possible aggravating role of the presence of squamous tissue in an invasive renal cell tumour, on the other hand (group II), 46 cases files of patients treated between 1975 and 1984 were analysed retrospectively. Group I consisted of 18 cases of pure squamous carcinoma (11 men with a mean age of 71 years and 7 women with a mean age of 74 years). 66% of cases presented with haematuria, but urinary cytology was of little help. The diagnosis was established by transurethral resection with 18 grade 3 tumours: stage A in 4 cases and stage B in 14 cases. 10 patients had unilateral (8 cases) or bilateral (2 cases) complications of the upper urinary tract. The presence of lymph node and/or haematogenous metastases was investigated by bone scan, hepatic ultrasonography, pulmonary tomography and, most importantly, by bipedal lymphography combined with percutaneous cyto-aspiration of suspicious nodes. 4 patients presented with invasion of the obturator lymph nodes (2 cases) and iliac lymph nodes (2 cases). 9 patients were treated by total cysto-prostatectomy, 6 patients by radiotherapy (60 Grays) and 3 patients did not receive any treatment. The overall survival was 12.5% after 2 years. None of the patients treated by radiotherapy were alive after 2 years. 29% of the patients treated by surgery survived for 2 years, but none of them were alive after 5 years, essentially as a result of local recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective study was conducted on the sexual function of 70 patients undergoing transurethral (48 cases) or transvesical (22 cases) prostatectomy for benign prostatic hypertrophy. 22 patients with no sexual activity before operation, remained sexually inactive after surgery. Frequency of intercourse and penile erection remained generally unchanged after operation. Retrograde ejaculation was observed in 33 patients (69%). Only one patient complained of total loss of potency after operation. Orgasm was maintained in all other patients; however 25 patients considered it to be "different". 4 of the sexually active operated patients (8%) and 7 of their partners complained of lack of sexual satisfaction after operation.

One case of intra-abdominal seminoma with persistent müllerian duct syndrome is reported. Literature is reviewed and guidelines for management of such are suggested.

Complicated pyelo-ureteral duplication in the adult may be revealed by recurrent pyelonephritis or urinary leakage. The diagnosis can be performed by combined urography and ultrasound scan. The management is rarely conservative. In most cases, it consists in hemonephrectomy. The ureterectomy is partial, extending up to the pelvic brim in the case of a fine ureter. If the ureter is dilated, however, the ureterectomy must be subtotal, in order to avoid postoperative infectious recurrence.

Prostatic specific antigen has become an essential laboratory parameter in prostatic cancer; it may rise transiently after various manipulations of prostatic tissue. We decided to investigate a possible modification in PSA after rectal examination. The PSA level, studied before and after rectal examination in 40 patients, confirmed the almost constant rise in PSA after thorough rectal examination. The biokinetic features of PSA are also discussed as they are important to determine the time of PSA assay after a transient rise.