Concomitant Prostate Cancer Research Articles

Radical cystectomy with ultrasound-guided partial prostatectomy for bladder cancer: A complication-preventing concept

Objectives Radical cystectomy has been the reference standard for the treatment of muscle-invasive bladder cancer. However, this kind of therapy does have an impact on the patient’s quality of life. For this reason, we performed prostate-sparing surgery during radical cystectomy without compromising the oncologic outcome. Methods From December 2003 to August 2005, 31 patients with a mean age of 63.6 ± 8 years (range 48 to 79) underwent apex-sparing radical cystoprostatectomy for invasive bladder cancer. All patients underwent transurethral biopsy in the prostatic urethra to exclude urothelial tumor and transrectal ultrasound-guided biopsy of the prostate to diagnose concomitant prostate cancer. Patients with a prostate-specific antigen level greater than 4 ng/mL were excluded from prostate-sparing cystectomy. The mean follow-up period was 12 months. Results The postoperative pathologic stage was pTis in 2 patients, pTa in 1, pT1 in 3, pT2 in 20, pT3 in 5, and pN+ in 4 patients. We found no prostate cancer on histopathologic evaluation. Except for 4 patients, no patient had deterioration of sexual function. Except for 2 patients, all patients were fully continent. Conclusions Radical cystectomy with prostate-sparing surgery in patients with invasive bladder cancer resulted in improved continence and improved erectile function. Additionally, with apex-sparing radical cystoprostatectomy, we were able to create a wide neovesicourethral anastomosis to prevent strictures, urinary retention, and mucous retention. It is absolutely necessary that this procedure be restricted to highly selected patients.

Retrospective study of locally advanced bladder cancer in elderly patients

18523 Background: Bladder cancer is one of the most frequent tumors in elderly patients (pts). However, guidelines have not been established yet in this age group. Methods: We analyzed retrospectively pts aged 75 years or more, with muscle invasive or metastatic bladder cancer treated between January 2000 and June 2005, in three institutions in Lyon-France: Léon Bérard Center, Saint Luc Saint Joseph Hospital and Protestant Infirmary. Results: Data from 126 pts (81% male) were available: median age was 80 years (75–94). 99 pts had disease confined to the bladder, 19 confirmed metastatic cancer and 8 at least T2aM0 disease. 42% of pts had a history of superficial bladder cancer; 96% an urothelial carcinoma, 19% an associated in situ carcinoma. Of note, 33% of male pts had a concomitant prostate cancer. Median Performance Status, American Society of Anesthesia score and Charlson Comorbidity index were 1, 2 and 2.14 respectively. Cardiovascular comorbidities were the most common (42.8%). 87% of pts were taking medications; median number of drug intake was 4. We focused on pts with muscle invasive, non metastatic bladder cancer: 55 of 99 pts underwent surgery; 48 of them had external urinary diversion. Postoperative complications occurred in 34% of pts: evisceration (15%), sepsis, hemorrhage, acute cardiac failure, acute renal failure, pulmonary embolism (3.7% each), bowel obstruction and acute arterial thrombosis of lower limbs (1.8% each), and 2 immediate postoperative deaths. 16 pts received radiotherapy with a curative intent, 6 of them had chemoradiation. Mean irradiation dose and duration were respectively 56.4 Gy and 6.5 weeks. Toxicity occurred in 5 pts: 2 discontinuations for intolerance, 1 acute cardiac failure, 1 grade 3 thrombopenia, and 1 toxic death (intestinal perforation). The last 28 pts received palliative care. After a median follow up of 14 months, 33 operated pts and 3 pts treated by radiotherapy were still alive in complete remission. Disease free survival and median survival were 11.5 and 42 months in the surgical group respectively and 12 and 12 months in the radiotherapy group respectively. Conclusions: Treatment of locally advanced bladder cancer in the elderly carries significant morbidity and mortality. Oncogeriatric assessment benefit for individual management must be studied. No significant financial relationships to disclose.

Combined radical prostatectomy and bladder augmentation for concomitant prostate cancer and detrusor instability

Objectives To determine the outcomes of a select cohort of patients with severe voiding dysfunction, refractory to medical management, and a concomitant diagnosis of prostate cancer, who were treated with radical prostatectomy and augmentation enterocystoplasty. Methods Four men with biopsy-proven prostatic adenocarcinoma, as well as a diagnosis of severe overactive bladder, underwent combined radical retropubic prostatectomy and augmentation enterocystoplasty. All patients underwent fluorourodynamic testing confirming nonobstructive detrusor instability or hyperreflexia. Three patients underwent nerve-sparing radical retropubic prostatectomy with a clamshell ileocystoplasty, and one with neurogenic hyperreflexia underwent sigmoid cystoplasty with a continent catheterizable stoma at radical retropubic prostatectomy. Results The mean follow-up was 21.5 months (range 8 to 48). All patients had an undetectable prostate-specific antigen level postoperatively. The average hospitalization was 8 days. Perioperative complications occurred in 2 patients, including a prolonged urine leak managed with catheter drainage and postoperative hematuria requiring cystoscopic clot evacuation. Erectile function was preserved in 2 patients with good preoperative erections. At last follow-up, the 3 patients who voided per urethra had minimal postvoid residual urine volumes and maintained good continence, with only 1 patient describing occasional mild stress incontinence. At last follow-up, the patient with the sigmoid cystoplasty catheterized every 4 hours with volumes of about 300 mL and complete stomal continence. No patient required anticholinergic medications postoperatively. Conclusions The concomitant diagnosis of prostate cancer and severe detrusor instability may be difficult to treat. The results of our study have shown that for those desiring surgical management for their prostate cancer, a combined bladder augmentation and radical prostatectomy may be performed with minimal added morbidity and significantly improved voiding function in the properly selected individual.

Konkomitantes Mammakarzinom und Prostatakarzinom beim Mann - ein Fallbericht

Wir berichten über einen 84-jährigen Patienten mit der zeitgleichen Diagnose eines invasiven Mammakarzinoms und eines Prostatakarzinoms. Der Patient stellte sich mit dem klinischen Befund eines exulzerierten Mammakarzinoms vor. Im Rahmen der präoperativen Abklärung wurde gleichzeitig ein Prostatakarzinom diagnostiziert.

SEMINAL SPARING CYSTECTOMY AND ILEOCAPSULOPLASTY: LONG-TERM FOLLOWUP RESULTS

The efficacy of nerve sparing techniques to save potency in cystoprostatectomy is about 50%. This radical surgery may be proposed to young men with normal sexual function. We report the results of a 13-year experience with our innovative seminal sparing cystectomy and bladder replacement to maintain sexual function in such patients. Seminal sparing cystectomy is a modification of standard radical cystectomy in which the posterior bladder dissection is anterior to the seminal vesicle plane to preserve the vasa deferens, seminal vesicles, prostatic capsule and neurovascular bundles. Ablation of the whole bladder and the prostatic urothelium with surrounding hypertrophic tissue is guaranteed, and injury to the pelvic nerve plexus that provides autonomic innervation to the corpora cavernosa is avoided. From April 1990 to December 2002 we performed 68 procedures in 63 patients (7 of whom were lost to followup) with superficial bladder cancer resistant to conservative therapies (18 patients with stage T1G2 disease, 13 TaG2, 11 T1G3 and 14 TaG3) and in 5 patients with invasive bladder cancer (T2G3) which was monofocal and away from the bladder neck. All patients had normal sexual function. A complete clinical evaluation (with prostate specific antigen [PSA], digital rectal examination and transrectal ultrasound) to exclude concomitant prostate cancer was performed. Average patient age was 49 years and mean followup was 68 months. Normal erectile function was preserved in 58 patients (95%). Complete daytime continence was reached in 58 patients (95%) and nighttime continence was reached in 19 patients (31%). The early postoperative complication rate was 18% and the delayed complication rate was 26.2%. A total of 55 patients (90.2%) are alive and 6 patients (9.8%) died, 5 of cancer progression. High grade prostatic intraepithelial neoplasia was noticed in prostatic specimens in 3 patients and prostatic cancer was noted in 1 patient. These patients had a normal PSA before operation and a serum PSA less than 0.2 ng/ml at a mean followup of 19 months. No positive margins were identified on permanent histological analysis of the specimens, nor were local pelvic recurrences observed. Our innovative technique is safe, effective and easy to perform. The oncological and functional results obtained with a long followup justify seminal sparing cystectomy as an excellent surgical procedure which can be proposed to some oncological and nononcological cases.

Expression of ezrin in prostatic intraepithelial neoplasia

Objectives To study the protein expression and gene copy number of ezrin in a set of high-grade prostatic intraepithelial neoplasia (HGPIN) samples with concomitant prostate cancer. Ezrin is a cytoskeleton linker protein that is actively involved in regulating the growth and metastatic capacity of cancer cells. Methods Nineteen HGPIN samples obtained from radical prostatectomy specimens were used for the study. Among them, 13 samples also contained invasive prostate cancer. The expression of ezrin was studied by immunohistochemistry. The same samples were also used for fluorescence in situ hybridization to study the gene copy number of ezrin. Results Immunoreactivity for ezrin was absent or weak in benign prostatic epithelial cells. Weak or moderate immunostaining was detected in 11 of 13 prostate cancer specimens. However, the immunostaining was moderate or strong in all HGPIN samples. In addition, whenever HGPIN and prostate cancer were found in the same sample, the staining was always more intense in the HGPIN cells than in the cancer cells. No alteration was found in the gene copy number detected by fluorescence in situ hybridization. Conclusions We have shown that ezrin is overexpressed in HGPIN and prostate cancer compared with adjacent benign prostatic epithelium. In addition, HGPIN has a greater expression level of ezrin compared with that of prostate cancer. Our results indicate that aberrant expression of ezrin might be involved in the pathogenesis of prostate cancer, and ezrin expression may be useful for the diagnosis of HGPIN.

Clinical Management of Premalignant Lesions of the Prostate

AbstractThe presence of high-grade prostatic intraepithelial neoplasia (PIN) in a prostate biopsy is a considerable risk factor for the presence of prostate cancer, with up to 73% of patients having cancer on rebiopsy. The risk is related to the clinical setting (screening vs urological practice) and patient factors such as prostatic serum antigen (PSA) and findings on digital rectal examination (DRE). Thus, high-grade PIN has serious clinical implications. The aim of this paper is to propose practical guidelines for the clinical management of PIN. Based on current knowledge we recommend that: Only patients considered for curative treatment of prostate cancer be further investigated for a PIN biopsy finding. A palpable nodule or tumor-suspicious transrectal ultrasonography (TRUS) finding, in conjunction with a finding of high-grade PIN on prostate biopsy, should prompt rebiopsy. An elevated PSA level or an elevated PSA density should also warrant repeat biopsy, as the most likely cause of PSA elevation is concomitant prostate cancer. The presence of high-grade PIN on biopsy without concomitant prostate cancer in patients suitable for curative treatment, notwithstanding normal DRE, TRUS or PSA, should prompt repeat biopsies, as the association with prostate cancer is significant. The presence of PIN alone on biopsy does not warrant treatment, as a substantial number of rebiopsies yield only PIN.

THE EFFECT OF HIGH GRADE PROSTATIC INTRAEPITHELIAL NEOPLASIA ON SERUM TOTAL AND PERCENTAGE OF FREE PROSTATE SPECIFIC ANTIGEN LEVELS

It is established that the percentage of free prostate specific antigen (PSA) in serum is low in patients with prostate cancer. An unanswered question is whether a low percentage of free PSA can be explained by high grade prostatic intraepithelial neoplasia alone. We compared the percentage of free PSA in men with high grade prostatic intraepithelial neoplasia alone, prostate cancer, benign prostatic hyperplasia (BPH) and a normal prostate (that is normal digital rectal examination and PSA less than or equal to 2.5 ng./ml.). From October 1994 through December 1997, 48 men were diagnosed with high grade prostatic intraepithelial neoplasia without concomitant prostate cancer. Of these men 43 with a mean age plus or minus standard deviation of 67.4 +/- 7.8 years comprised our study group. To date none has been diagnosed with cancer during followup. Serum free and total PSA levels were measured, and the percentage of free PSA was calculated. The percentage of free PSA in the 43 men was compared to that in 50 with prostate cancer (mean age 65.4 +/- 7.8 years), 50 with biopsy proved BPH (67 +/- 7) and 43 with a normal prostate (61 +/- 8). There was no significant difference in mean total serum PSA in patients with high grade prostatic intraepithelial neoplasia, prostate cancer or BPH. The percentage of free PSA was significantly lower in patients with prostate cancer (14.9 +/- 6.5%) than those with high grade prostatic intraepithelial neoplasia (20.8 +/- 7.1%), BPH (20.1 +/- 7.3%) or a normal prostate (27.7 +/- 12.2%). There was also no significant difference in the percentage of free PSA between men with high grade prostatic intraepithelial neoplasia (20.8 +/- 7.1%) and those with BPH (20.1 +/- 7.3%). Additionally, men with a normal prostate had a higher percentage of free PSA (27.7%) than those with BPH (20.1%), high grade prostatic intraepithelial neoplasia (20.8%) or prostate cancer (14.9%). The percentages of free PSA in men with high grade prostatic intraepithelial neoplasia and BPH are similar, and significantly higher than those found in men with prostate cancer.

An audit of testosterone measurement in men attending with impotence

As part of the routine assessment of 185 unselected men with undiagnosed impotence, testosterone was measured on a single serum sample to try to detect a subset of men with androgen deficiency who might benefit from testosterone replacement therapy. Those with low levels of testosterone were investigated further with repeat measurements of testosterone and luteinizing hormone (LH). In addition, prostatic specific antigen (PSA) was measured in all the men to exclude concomitant prostate cancer. Testosterone replacement therapy was offered to 20 men with consistently low levels of the hormone but few of the men continued with the therapy because of lack of benefit. It was concluded that either testosterone deficiency is rare in unselected men who actually seek help for impotence orebe our protocol of androgen assessment was not helpful for this group of men. There was correlation between PSA results and testosterone and this may have implications for the investigation of prostate cancer. The results presented here are an audit of a clinical practice and call into question the benefit of routine testosterone measurement in the investigation of all men complaining of impotence.