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While 80% of transitional cell carcinomas (TCC) present as Ta Tl lesions, they account for only 15% of deaths caused by TCC. We have evaluated the ability of DNA ploidy analysis to predict outcome in 228 patients with Ta Tl TCC. All patients were judged to be at increased risk for tumor recurrence due to having two occurrences of Stage TI tumor within 56 weeks, or three or more tumors presenting simultaneously within 16 weeks of registration. Concurrent carcinoma in situ was acceptable. All patients were treated with either bacillus Calmette Guerin (BCG) immunotherapy or mitomycin-C (MMC) intravesical chemotherapy. Patients with nondiploid tumors had higher hazard rates for both tumor progression and death (p = 0.007 and p = 0.016, respectively); however, the prognostic information of DNA ploidy was not additive to tumor grade.

Purpose: The safety, efficacy and pharmacokinetics of bicalutamide were investigated in 150 patients with stage D2 prostate cancer., Materials and Methods: Patients received 50 mg. bicalutamide daily in an open label multicenter North American trial., Results: The objective response rate (modified European Organization for Research in Cancer Therapy criteria) was 70%. Of 150 patients 59 (39%) met prostate specific antigen criteria for partial response, and 88 (59%) reached treatment failure end points and withdrew. Extent of disease was a significant predictor of response but baseline testosterone was not. Breast pain and gynecomastia developed in 76% and 60% of patients, respectively. Mean drug plasma concentration was 8,528 +/- 2,928 ng/ml., Conclusions: Bicalutamide (50 mg.) daily was well tolerated and efficacious. However, suboptimal effects on prostate specific antigen have led to additional trials to evaluate monotherapy at higher doses.

Purpose: We report the results of a collaborative care program that has been developed for radical cystectomy and urinary reconstruction., Materials and Methods: All patients undergoing surgery after July 1993 were placed on a collaborative care pathway and were compared to patients undergoing the same procedure before this period., Results: Total adjusted hospital charges decreased from $31,174 to $19,479. Hospital stay decreased from 12.7 to 10.3 days. There were also decreases in duration of surgery, blood loss, intensive care unit use and postoperative morbidity rates., Conclusions: Collaborative care pathways favorably affect the cost efficiency of care and provide favorable surgical outcomes.

Objectives: To compare the efficacy and safety of goserelin and orchiectomy in patients with stage D2 prostate cancer., Methods: A randomized, open, multicenter study was conducted in 283 patients. Patients were allocated to goserelin, 3.6 mg every 28 days or to orchiectomy. Study end points were endocrine response, objective response, time to treatment failure, survival, and tolerability. Objective response was based on modified criteria of the National Prostate Cancer Project., Results: Serum testosterone decreased from baseline to castrate levels by week 4 in each group and remained below castrate levels thereafter. Acid phosphatase and alkaline phosphatase concentrations also decreased in each group. The goserelin and orchiectomy groups had similar results for objective response (82% versus 77%) and had similar medial times to treatment failure (52 versus 53 weeks) and survival (119 versus 136 weeks). No significant interactions between treatments and prognostic factors were observed. Adjusting for baseline testosterone concentration had no effect on survival outcome. Race had no influence on outcome or efficacy end points. Common adverse events in both groups were pain, hot flushes, and lower urinary tract symptoms., Conclusions: Goserelin is well tolerated and as effective as orchiectomy in patients with Stage D2 prostate cancer.

Nonpalpable prostate cancer, detected on a biopsy sample and prompted by an elevated prostate-specific antigen level, has become one of the most common presentations of the disease. The clinical significance of these cancers has been debated, but pathologic examination has shown a substantial tumor volume in most patients. On the other hand, a tumor is confined within the surgical margins in some 80% of men undergoing radical prostatectomy for T1c cancers. Overall, then, most T1c prostate cancers meet the desired selection criteria for radical prostatectomy, which include a tumor of clinical significance, yet one which can be totally excised surgically.

Objective: To develop and analyse a cost-containment programme for radical retropubic prostatectomy., Patients and Methods: An in-depth analysis of the hospital charges associated with radical retropubic prostatectomy was conducted and a standard programme developed to control patient costs using a collaborative pathway method. The development of this programme and the outcomes of the first 50 patients who underwent radical retropubic prostatectomy while on the collaborative care pathway system are summarized., Results: The programme reduced both overall hospital charges per patient and the duration of hospital stay by 44%. In addition, there was a significant reduction in the duration of surgery, intra-operative blood loss and the need for transfusion. Implementation of this programme had no apparent adverse effects on the rates of major or minor complications or hospital readmissions, and was accepted well by the patients., Conclusion: The collaborative care pathway developed for radical prostatectomy provides a system to deliver high quality, cost-efficient care in an environment which is highly acceptable to patients and which allows continued refinements in the care delivered.

To compare the toxicity and efficacy of intravesical bacillus Calmette-Guérin (BCG) immunotherapy and mitomycin C (MMC) chemotherapy in the prophylaxis of recurrent transitional cell carcinoma, 469 patients with completely resected stage Ta or TI transitional cell carcinoma were enrolled in a randomized Southwest Oncology Group Phase III study. All patients were judged to be at increased risk for tumor recurrence due to having had two occurrences of tumor within 56 weeks, stage T I tumor or three or more tumors within 16 weeks, or concurrent carcinoma in situ. Three hundred and seventy-seven evaluable patients received either 50 mg of Tice BCG in 50 cc saline or 20 mg MMC in 20 cc water weekly for 6 weeks and then monthly to one year. Local and systemic grade I and 2 toxicity was seen significantly more frequently following BCG treatment (P = 0.003), but no life threatening toxicity was seen with either treatment. Recurrence-free survival was significantly prolonged (P = 0.017, proportional hazard regression) in patients randomized to the BCG arm compared to the MMC arm, but there were no statistically significant differences at this analysis for worsening-free survival and overall survival, although the number of these events is too low for a definitive analysis of these long-term outcomes. Therefore, when compared to MMC chemotherapy, BCG immunotherapy is associated with a significantly higher frequency of grade 1 and 2 adverse reactions and a significantly lower first recurrence hazard rate.

Laser systems used for prostatectomy may be right-angle (sidefiring) devices, which are either refractive or reflective, or contact devices. The tissue physics of these systems differ, and as a result, there are very real differences in the optimal exposure techniques. An understanding of the device being used is essential for producing a satisfactory result.

We report on 3 cases of femoral neuropathy following radical surgery for urologic malignancy. The defect was bilateral in 2 patients. Compression from self-retaining retractors was the presumed mechanism of injury in all patients. Spontaneous improvement was observed in each case although the symptoms did not resolve completely. The pathophysiology contributing to this operative complication as well as measures for prevention and treatment are discussed.

Given the excellent local control rates achieved with partial penectomy, it is important to consider laser treatment or radiation therapy of squamous cell carcinoma of the penis cautiously. Emotional issues surrounding preservation of a functional penis should not be allowed to compromise adequate therapy. On the other hand, some penile cancers undoubtedly can be managed adequately by techniques other than partial penectomy. The fundamental question is, then, how great a compromise laser treatment or radiation therapy introduces. In patients who present with bulky, long-neglected penile cancers, the point is moot: Partial or even total penectomy is indicated. However, other treatments are feasible in many patients, and an attempt at functional organ preservation should not be restricted simply to the rare small tumor. Lesions up to 2 cm in size can be controlled adequately without amputation. Because tumor grade correlates highly with depth of invasion, the presence of nodal metastasis, and survival, most poorly differentiated squamous cell tumors of the penis probably should be treated by amputation. As mentioned above, it may be several months after laser treatment or radiation therapy before local treatment failure is recognized. Although this is a concern, it probably does not ultimately result in therapeutic compromise in most patients. With most urologic cancers, local recurrence equates with the inability to cure the patient and, ultimately, death. With locally recurrent carcinoma of the penis, however, the situation can be salvaged by converting to partial penectomy. Thus, the patient compromises his chances for cure only if tumor dissemination occurs during the few months between the end of treatment and recognition of failure.

We reviewed 109 consecutive patients undergoing radical retropubic prostatectomy to determine the effect of intermittent pneumatic compression devices on intraoperative blood loss. Sequential compression devices were used intraoperatively and perioperatively in 86 patients, while 23 underwent surgery without these devices. There were no identifiable selection factors between the 2 groups. Median intraoperative blood loss was 885 cc without sequential compression devices and 800 cc when they were used. These results are at odds with previous reports in the urological literature and suggest that anatomical control of the dorsal vein complex negates any potential influence of sequential compression devices on blood loss during radical prostatectomy.

Objectives: We designed and implemented a broad-based program to decrease costs while maintaining quality of care in patients undergoing radical retropubic prostatectomy., Methods: This program initially involved identification of factors that contribute to patient costs after radical prostatectomy and elimination or control of items that were deemed unnecessary. Patient care was standardized with a collaborative care pathway coordinated by a clinical nurse specialist and that served as a goal for each case., Results: Length of total hospital stay was reduced from a mean of 5.7 days to 3.6 days after full implementation of the program (p < 0.0001). A reduction in operating room time, material utilization, antibiotic use, routine laboratory studies, and refinements in postoperative pain management contributed significantly to cost savings. Overall, the average adjusted total hospital charges were reduced from $13,783 to $7741 (p < 0.0001) by the implementation of this program, with no discernible adverse effect on morbidity rates., Conclusions: Careful analysis of the critical components of medical care and implementation of a standardized pathway with emphasis on a collaborative approach can substantially increase the cost efficiency of medical care.

From July 1988 to August 1991, 174 stone treatments were attempted on 112 stones in 86 patients using a Therasonics lithotriptor. Mean stone diameter was 13 mm. (range 4 to 60). The success rate (defined as no debris or fragments less than 4 mm. in an asymptomatic patient) was 49% and the retreatment rate was 63%. Subjects reported moderate to severe pain during 70 treatment sessions (42%) despite sedation with parenteral narcotics (50 to 100 mg. meperidine and 50 mg. hydroxyzine intramuscularly). One patient had perirenal bleeding requiring a 7-unit blood transfusion. Of the treatments 24 (13%) were aborted, 10 due to pain and 13 because of inability of the operator to position the patient or localize the stone. These results appear to be inferior to those reported with alternative lithotriptors. Modifications that have been made in the Therasonics system may improve stone localization and treatment results.

In a prospective, comparative study 68 men were treated for hot flushes after androgen deprivation therapy for prostate cancer. Complete responses (elimination of hot flushes) were rare in patients receiving either combined phenobarbital plus ergotamine or clonidine. Of the men receiving either diethylstilbestrol or megestrol acetate 70% had a complete response, while another 20% had a greater than 50% decrease in the severity of hot flushes. Based upon a lower incidence of side effects, oral megestrol acetate was the preferred treatment for hot flushes in this study.

We reviewed the surgical specimen from 142 men undergoing radical prostatectomy for prostate cancer detected because of an elevation in serum prostate specific antigen alone. No patient had a palpable abnormality suggestive of cancer. One patient had no identifiable tumor in the radical prostatectomy specimen, 8 (6%) had only a few high power microscopic fields showing cancer, 40 (28%) had an estimated tumor volume of less than 1 cc and 93 (65%) had a tumor volume of greater than 1 cc. Surgical margins were positive in 37 patients (26%) and negative in 105 (73%). Most patients with cancer detected because of modest elevation in prostate specific antigen, even without palpable abnormalities, have a clinically significant tumor volume and are good candidates for radical prostatectomy.

Variceal bleeding from an ileal conduit stoma is an uncommon complication of portal venous hypertension. We report on a 59-year-old man who experienced frequent and severe bleeding episodes from the parastomal skin and mucosa of an ileal conduit requiring multiple blood transfusions. A mesenteric angiogram showed portal hypertension and large varices around the ileal conduit. Resolution of the dilated cutaneous veins occurred after a portosystemic shunt and he has had no further bleeding episodes. Recognition of this unusual complication of ileostomy formation is important for urological surgeons who may encounter patients with liver disease requiring urinary diversion.

This article assesses the likely role of PSA in the future management of patients with carcinoma of the prostate, taking into consideration new methods for measurement and assessment. In addition, novel tumor markers are discussed that may complement, or even perhaps replace, PSA.

The tissue effects of a laser are responsible for the therapeutic value as well as the potential for complications. Within certain constraints, the type and depth of energy effect can be controlled by the selection of the wavelength as well as of appropriate energy parameters. In a clinical endoscopic setting, however, precise prediction of tissue penetration is not feasible, and proper use relies on the experience and knowledge of the operating surgeon. Considering this, it is important for surgeons to understand laser tissue effects and the various parameters that influence them.

In a study of the familial risk of prostate cancer 17 sets of 2 brothers with prostate cancer were identified. A total of 34 first-degree relatives of these probands (sons and brothers, 55 to 80 years old) underwent an intensive screening examination that included prostate specific antigen, digital rectal examination, transrectal ultrasound and systematic as well as clinically directed core needle biopsies. Previously unsuspected and clinically relevant cancers were found in 8 men (24%), compared to the approximately 1 expected (p less than 0.01). Of these cancers 2 were detected by the systematic biopsies. This study emphasizes the importance of thorough screening in first-degree relatives of prostate cancer patients.

Lasers generate a unique form of energy with specific tissue effects different from those of either unipolar or bipolar electrocautery. A noncontact coagulation necrosis of superficial transitional-cell carcinoma of the bladder can be achieved. There are insufficient data to support the contention that the recurrence rate of transitional-cell carcinoma is decreased by laser therapy. However, there is abundant evidence that laser treatment of superficial bladder cancer is effective in eradicating grossly visible tumors. Bleeding does not occur during laser application, a clear advantage over electrocautery resection. Additionally, the treatment can sometimes be performed without anesthesia, and the energy can be transmitted via flexible fibers, facilitating the use of flexible cystoscopes. Bladder perforation is unlikely, obturator nerve stimulation does not occur, and postoperative Foley catheter drainage of the bladder is unnecessary. Tumors within bladder diverticula can be treated endoscopically with lasers, and stenosis of the ureteral orifice is rare. There is experimental evidence that laser treatment does not increase the absorption of intravesical chemotherapy, possibly allowing earlier adjuvant use of intravesical treatment postoperatively. On the other hand, there are limitations of laser treatment. Lasers are less familiar to both surgeons and operating room personnel. Appropriate eye protection during treatment is mandatory. Tumor staging is suboptimal, because tissue from the base of the lesion is not routinely available for histologic examination. Accordingly, appropriate patient selection is a paramount consideration. Finally, bowel injury without bladder perforation is a unique, though rare, complication of laser surgery. Simultaneous laparoscopy may be of benefit in some patients but is not indicated routinely. Although laser treatment has not revolutionized the management of superficial bladder cancer, it has an established and enduring role. Future changes in surgical instruments seem likely to increase the usefulness of lasers in managing patients with transitional-cell carcinoma of the bladder.

Background: Given the variable natural history of prostate cancer, prognostic parameters are needed to help guide treatment decisions in individual patients. In some series, analysis of DNA ploidy has correlated well with prognosis. This review was performed to determine whether flow cytometry could be used to help guide treatment decisions in patients with localized carcinoma of the prostate., Methods: Two hundred consecutive patients were observed for a minimum of 10 years after radical prostatectomy. Follow-up information was incomplete in 14 patients, leaving 186 for analysis. Clinically, there were 72% Stage B tumors and 28% Stage A., Results: Sixty percent of patients were alive with a minimum of 10 years of follow-up, and 47% apparently were tumor free. Twenty-two percent died of carcinoma of the prostate and 18% of other causes. The median time until death from prostate cancer was 6.5 years. Seventy-four percent of tumors were diploid on flow cytometry. Fifty-three percent of patients with diploid tumors survived 10 years without recurrence, whereas 20% died of carcinoma of the prostate. Aneuploid tumors were identified in 16% of the total group; 47% of these patients were alive at 10 years, whereas 24% had died of prostate cancer., Conclusions: Aneuploid tumors have a worse overall prognosis than diploid lesions. However, the correlation is not strong enough to allow treatment decisions on an individual patient basis. Analysis of DNA ploidy was no more accurate than Gleason histologic grading.

The toxicity of intravesical drugs used for the treatment of bladder cancer is increased by systemic absorption. Therefore, treatment is often delayed several weeks after transurethral resection until sufficient healing occurs. Since a neodymium:YAG laser causes tissue injury by thermal coagulation, we investigated differences in bladder permeability after laser treatment compared to TUR. Comparable 2.5 cm in diameter areas of tissue injury were created in the bladder of mongrel dogs either by Nd:YAG laser coagulation or transurethral electrocautery resection (TUR). Subsequently, 30 mg. of adriamycin were instilled intravesically. A control group consisted of animals receiving adriamycin alone. Blood was taken at 10, 30, 60, and 120 minutes after instillation and the serum concentration of adriamycin measured quantitatively by high performance liquid chromatography (HPLC) with fluorescence detection. The maximum serum ADM concentration during 120 minutes for the control group was 28.0 +/- 12.9 ng/ml compared to 38.9 +/- 4.8 for the laser group and 102.9 +/- 29.9 for TUR. The area under the curve was 35.1 +/- 10.2 ng x hours/ml for control, 43.5 +/- 3.9 for laser and 127.7 +/- 49.9 for TUR. Using a two-tailed Student's t test, the difference between the TUR and the laser group was significant (p less than 0.01). There was no difference between laser and control. These results suggest that laser treatment has minimal effect on the absorption of drugs from the bladder. The clinical practice of delaying intravesical therapy after TUR is verified but a similar policy may not be necessary after laser treatment.

This study was designed to evaluate the interaction of photodynamic therapy (PDT) and intravesical drugs (thiotepa, adriamycin, mitomycin C and BCG) in a murine transitional cell carcinoma (MBT-2) model. C3H/He mice with implanted MBT-2 flank tumors were treated with either thiotepa (TT), adriamycin (ADM), mitomycin C, Bacillus Calmette-Guerin (BCG), photodynamic therapy (PDT) or a combination of the drug and PDT. The MBT-2 tumor showed sensitivity to adriamycin, MMC or PDT compared to control. PDT combined with either adriamycin, MMC or BCG, produced a greater retardation in the growth of the MBT-2 tumor than monotherapy with adriamycin, MMC, BCG or PDT. PDT combined with the anticancer agents currently used in intravesical therapy for bladder cancer is well tolerated. The combination of PDT and intravesical drugs may enhance the tumoricidal effect of either treatment used alone.

Background: In carcinoma of the bladder, both intravesical chemotherapy and immunotherapy can induce tumor regression and reduce the rate of recurrence, but the relative merits of these two therapies are unclear. We conducted a multi-institutional study to address this question., Methods: Patients with rapidly recurrent (stage Ta and T1) or in situ transitional-cell carcinoma of the bladder were randomly assigned to receive either doxorubicin administered intravesically or bacille Calmette-Guérin (BCG) administered both intravesically and percutaneously. The 262 eligible patients were followed for a median of 65 months. Complete responses to treatment of carcinoma in situ were confirmed by biopsy and cytologic analysis of the urine., Results: For patients with Ta and T1 tumors without carcinoma in situ, the estimated probability of being disease free at five years was 17 percent after doxorubicin, as compared with 37 percent after immunotherapy with BCG (P = 0.015). The median times to treatment failure (termination of treatment, due to persistence, recurrence, or progression of disease) were 10.4 and 22.5 months, respectively. For patients with carcinoma in situ the complete-response probability estimates (i.e., the estimated probability of documented disappearance of disease) were 34 percent for doxorubicin (23 of 67 patients) and 70 percent for BCG (45 of 64 patients) (P less than 0.001); the median times to treatment failure were 5.1 and 39 months, respectively. The probability of being disease-free at five years survival among the patients with carcinoma in situ was 18 percent after treatment with doxorubicin and 45 percent after BCG therapy. Patients treated with BCG had a higher incidence of toxic systemic effects and a larger number of local irritative symptoms than patients treated with doxorubicin, but few of these adverse reactions were severe., Conclusions: As compared with intravesical doxorubicin, immunotherapy with BCG provides improved protection against the recurrence of superficial bladder cancer.

We report one of the largest series of patients treated by radical prostatectomy followed for a minimum of 10 years. The tumor-free survival rate at 10 years seems superior to that achieved with alternative methods of treatment. Pathologic stage, DNA histograms, and tumor grade all correlate with prognosis but none is sufficiently powerful as an independent factor to allow selection of patients for surgery. Although a survival benefit has not been demonstrated, adjuvant treatment such as postoperative irradiation or early hormonal therapy may be indicated in patients with established poor prognostic factors.

For most applications in the urethra, lasers simply represent an alternative to existing technology. Most studies conducted to date can be considered "feasibility studies," ie, they demonstrate that the technique can be performed without clearly showing whether it holds any clear advantages or indications. We have found laser treatment of condyloma acuminata of the urethral meatus as well as more proximal portions of the urethra to be easy and to provide cosmetic results that appear to be superior to those obtained with alternative techniques. In more proximal portions of the urethra, scarring is less than that with an electrocautery and the incidence of treatment induced urethral strictures may be lower with laser. The recurrence rate remains high and is probably unrelated to the device or technique used in treating gross lesions.

During a 2-year period, 884 extracorporeal piezoelectric lithotripsy treatments have been performed on stones in 388 renal units (kidney and upper ureter) using a Wolf Piezolith device.* Lithotripsy routinely was performed on an outpatient basis without use of anesthesia or premedication. Often, the maximum number of pulses allowable by a Food and Drug Administration protocol (4,000) was delivered and retreatments frequently occurred on successive days. Of the patients 75% were stone-free 3 months after treatment, while another 20% had only residual small fragments. No intrarenal or perinephric hematomas were observed and only 1 patient has had hypertension requiring medication. Renal colic from passage of stone fragments occurred in only 10% of the patients. An aggressive treatment policy using repeat treatments as necessary provides for superior results with this device without an incision or complication.

We report preliminary results for the first 164 patients enrolled in a multicenter study comparing the endocrine effects, efficacy, and safety of 3.6 mg of goserelin acetate (Zoladex) and orchiectomy in patients with Stage D2 prostate cancer. Eighty-one patients were randomly allocated to receive Zoladex and 83 to orchiectomy. The median follow-up time for all patients was two hundred ten days. Median serum levels of testosterone were reduced to castrate levels (less than 50 ng/dL) within four weeks in both groups and remained suppressed for up to sixty weeks. An objective response according to modified criteria of the National Prostatic Cancer Project was observed in 81 percent and 78 percent of patients in the Zoladex and orchiectomy groups, respectively. There were no statistically significant differences between treatment groups in the distributions of time to treatment failure or time to disease progression. The most commonly reported adverse events in both treatment groups were hot flashes, cancer-related pain, unspecified pain, and urinary symptoms. These results suggest that Zoladex may offer an alternative to orchiectomy in the treatment of advanced prostate cancer.

A total of 12 men from a sperm donor bank underwent transrectal ultrasonography before and after ejaculation to investigate possible changes that could influence interpretation of seminal vesicle ultrasonography. The mean length of the seminal vesicles was 2.98 cm. before and 2.95 cm. after ejaculation. The anteroposterior diameter decreased only from 0.59 to 0.52 cm. Minimal differences were noted between the right and left seminal vesicles, and the greatest variation in size in an individual was only 3 mm. These results indicate that interpretation of seminal vesicle anatomy as seen by ultrasonography does not depend upon the temporal relationship to ejaculation.

Available epidemiologic data do not allow targeting of specific populations for prostate cancer screening or early detection programs. Although certain strong factors have been identified (age, race, location), none sufficiently defines high-risk groups in whom recommendations should differ from those of other age-matched patients. Certainly, a strong familial tendency has been identified, but the relative contribution of genetic and environmental factors in these patients remains unclear. Some hypotheses on the pathogenesis of prostate cancer are possible based on the available data. Genetic factors appear to be permissive, as are hormonal influences, which are partially regulated by genetics. Environmental factors appear to be promotional in genetically susceptible men. Dietary fat may also be an important promotional factor in genetically susceptible men. Dietary factors appear to exert some influence by modulating sex hormone concentration. Several factors demand more investigation and understanding of the epidemiology of prostate cancer. The relative frequency of the disease and the increasing death rate from prostate cancer are of concern. The similarities in the incidence of latent prostate cancer among various groups with strong differences in the rate of clinically apparent disease raise significant issues regarding potential lifestyle or environmental promotional factors. Further understanding of the pathogenesis of prostate cancer may allow a refinement and definition of programs for prevention and early detection of the disease.

Transrectal ultrasonography has defined a new category of stage A disease, namely nonpalpable lesions diagnosed by needle biopsy. How this type relates to classic stage A disease is unclear. Stage A1 carcinoma becomes clinically significant only in a distinct minority of patients, and even in this group, progression does not necessarily mean significant morbidity or death from prostate cancer. An aggressive approach is not justified. In contrast, stage A2 cancer is usually virulent, and aggressive therapy with curative intent is justified in patients of appropriate age and health. Both radical prostatectomy and external irradiation appear to provide long-term survival rates superior to those obtained with observation alone, but nearly 20% of these patients will die of cancer despite therapy. Unfortunately, forecasting the outcome in an individual case is still not possible, and efforts to identify prognostic features must continue. In the meantime, emotional arguments in favor of the treatment of all discovered cancers must be suppressed by an informed and objective understanding of the natural history of nonpalpable prostate cancer and the potential impact of treatment.

Relatively recent changes and improvements in equipment have vastly increased image resolution for transrectal ultrasonography of the prostate. The expanded use of transrectal ultrasonography has greatly furthered knowledge of prostate zonal anatomy and permitted clinical evaluation of internal prostate architecture. The technique is operator dependent, as the quality of the results is related directly to that person's knowledge and experience. The significant majority of prostate cancers originate from the peripheral zone. Palpable stage B nodules characteristically have a hypoechoic appearance. There is disagreement about the tumor characteristics that cause hypoechogenicity, but large tumors may obscure the normal prostate anatomy and appear isoechoic because of the lack of contrast with surrounding prostate tissue. The transition zone of the prostate is the origin of benign prostatic hyperplasia and almost 20 per cent of prostate cancers. These tumors probably correspond to most stage A lesions. Transrectal ultrasonography is less accurate in identifying transition zone tumors because of the mixed echogenicity of the transition zone, interference from prostatic calculi or calcified corpora amylacea, and poorer image resolution in this area. Studies evaluating the use of transrectal ultrasonography for early detection of prostate cancer generally have shown a twofold increase in the detection rate compared with digital rectal examination. However, the decreased morbidity and expense of transrectal prostate biopsy using an automatic gun device have increased the frequency of biopsy in ultrasound-examined patients compared with those historically evaluated by digital rectal examination. The increased detection rate may in part be a function of the increased use of biopsies, independent of other factors. Transrectal ultrasonography rarely detects cancer in patient with normal digital rectal examination and a normal serum prostate-specific antigen level. Transrectal ultrasonography may be capable of identifying early capsular penetration or seminal vesicle invasion in some patients with known prostate cancer. However, its superiority to digital rectal examination for this purpose has not been demonstrated unequivocally. Ultrasonography does allow directed biopsies of the seminal vesicles or other suspect areas, and this may be helpful in staging the disease. The use of transrectal ultrasonography in prostate cancer has evolved rapidly, and changes in technology antiquate reports within a few years.(ABSTRACT TRUNCATED AT 400 WORDS)

An argon beam coagulator was evaluated in 25 canine partial nephrectomies to determine its hemostatic capabilities, safety and degree of thermal injury to renal parenchyma. Comparison was made with a control group of seven partial nephrectomies performed by standard technique. In both groups the procedure was performed without renal cooling or clamping of the renal artery. The argon beam coagulator was operated with a power output of 130 watts. Mean operative time for partial nephrectomy was 22 minutes in the control group versus 10 minutes when the argon coagulator was used (p less than 0.001). Mean blood loss was 276 cc by standard technique but only 135 cc with the argon coagulator (p less than 0.001). A regular eschar with a mean depth of tissue necrosis of 2.4 mm. was observed with the argon coagulator.

Bladder hemangiomas may occur singly or in association with systemic arteriovenous malformations. A total of 13 patients with bladder hemangiomas underwent treatment at this university. All patients had recurrent bleeding and neodymium:YAG laser energy was delivered endoscopically to the hemangioma. No treatment-related bleeding occurred in any patient, and all had a significant decrease in the frequency and intensity of bleeding episodes. Followup cystoscopic examinations have shown either complete eradication of the hemangioma or a marked decrease in size. Neodymium:YAG laser irradiation provides results superior to alternative therapy and is the preferred treatment for most patients with bladder hemangioma.

The classification of patients with incidental carcinoma of the prostate into focal (Stage A1) or diffuse (Stage A2) subgroups depends primarily on the microscopic findings on tissue removed from transurethral resection (TUR) or open enucleation. However, these procedures sample only a portion of the entire prostate, and some patients staged A1 may have residual diffuse cancer that should properly be classified as Stage A2. This study is a review of 86 patients with Stage A1 cancer of the prostate in whom additional prostatic tissue was available because of repeat transurethral resection or radical prostatectomy. Only six patients (7%) were found to have diffuse cancer in the remaining prostatic tissue. Therefore, it appears that the classification of patients into Stage A1 or Stage A2 is generally accurate when based on the findings from initial TUR alone and that the incidence of understaging in this group is low. Repeat transurethral resection does not appear to contribute significantly to the accuracy of staging.

Sixty-four patients with adenocarcinoma of the prostate and histologic evidence of pelvic nodal metastasis have been followed for at least 5 years after pelvic lymphadenectomy only. Forty-seven patients were treated with extended field irradiation, while 17 did not receive any irradiation. Only 17 per cent of the patients receiving irradiation survived free of disease for 5 years, while 40 per cent died of prostatic cancer, compared to 29 and 35 per cent, respectively, of those who did not receive irradiation. Symptomatic manifestations of local disease occurred within 5 years in 65 per cent of the patients not treated with irradiation, compared to 51 per cent of those who received pelvic irradiation. External radiation therapy imparted no discernible benefit in terms of survival free of disease in our patients. Furthermore, the impact of irradiation in preventing local symptoms in these patients seems to be slight.

Selected patients in whom definitive external irradiation fails to control bladder cancer can potentially be salvaged by cystectomy. Before 1974, 189 patients at our cancer center underwent salvage cystectomy. The over-all 5-year survival rate was 37 per cent and the postoperative hospital mortality rate was 5 per cent. Infectious complications developed in a third of the patients and ureteroileal urine leak developed in 8 per cent but the incidence of other complications was not dissimilar to that after radical cystectomy without prior large dose irradiation.

Between 1971 and 1974, 101 patients at Memorial Sloan-Kettering Cancer Center underwent planned integrated treatment for bladder cancer with 2000 rads by megavoltage delivered to the whole pelvis over five consecutive days followed by radical cystectomy within a week. The overall five-year survival rate was 39%; the hospital mortality rate was 2%. In the pelvis alone tumor recurred in 9% of the patients. These results support other studies demonstrating the efficacy of this and other regimens of preoperative irradiation and cystectomy.

The goal of hormonal treatment of prostate cancer is to deprive the prostatic cancer cell of androgen. This may be achieved by orchiectomy, a simple and safe procedure (but one which may have adverse psychological consequences), or by the administration of estrogens--particularly diethylstilbestrol (with its attendant risk of thromboembolic complications), synthetic analogs of luteinizing hormone-releasing hormone (which seem to be effective and free of side effects), or antiandrogens (whose effectiveness and safety are being tested). All treatments that deprive the cancer cell of androgen seem to be equally effective. Selection of treatment thus depends on patient preference, potential side effects, and cost.

Sodium etidronate is a diphosphonate compound that inhibits bone resorption and mineralization. The drug has been reported to be highly effective for the palliation of painful bone metastasis from prostatic cancer. Fifty-seven patients were entered into a randomized, prospective, double-blind, placebo-controlled study of sodium etidronate. All patients had hormone refractory metastatic prostatic cancer and bone pain requiring analgesics. No difference was seen in the symptomatic response rate or analgesic requirement between patients treated with sodium etidronate and placebo. With the dose scheme used in this study sodium etidronate was ineffective for palliation of bone pain from prostatic cancer.

Fifteen consecutive patients with progressive metastatic prostate cancer who had failed primary endocrine therapy underwent surgical pituitary ablation by transphenoidal hypophysectomy. Eleven patients showed subjective improvement with reduced pain postoperatively. No patient had any evidence of an objective response although duration of survival was longer in subjective responders (15 months) than nonresponders (4 months). Neither the quality nor the duration of the initial endocrine-induced remission predicted the subsequent response to hypophysectomy. The lack of objective improvement in these patients suggests that the subjective responses seen in prostate cancer patients after hypophysectomy may be due to alterations in pain receptive mechanisms rather than to a favorable impact on the disease process itself.

A technique for partial nephrectomy using a combination of an Ultrasonic Surgical Aspirator and a neodymium:YAG laser provided better hemostasis and decreased total operative time compared to standard methods. Delayed hemorrhage was not seen, and thermal damage to the remaining renal parenchyma was minimal.