Comorbidity and survival of patients selected for radical prostatectomy at an age of 75 years or older

Radical prostatectomy in elderly patients is controversial. To identify very old candidates for radical prostatectomy with the highest probability of long-term survival, we studied 47 consecutive men who underwent radical prostatectomy between 1992 and 2005 at an age of 75 years or older. A heuristic approach was used to search for subgroups with particularly high long-term survival. Several two-sided comorbidity measures and combinations of these measures were investigated to find classifications best identifying healthy, long-living elderly candidates for radical prostatectomy. Four of the 25 two-sided comorbidity classifications or combinations reached the significance level with hazard ratios between 4.00 and 4.80. After 10 years, patients identified as healthy patients according to these comorbidity measurements had exhibited relative survival rates between 129% and 137% and overall survival rates between 86% and 95%, whereas those with comorbidities had exhibited relative survival rates of only 66%-84% and overall survival rates of 44%-58%. In conclusion, classifying comorbidity may identify a meaningful proportion of men selected for radical prostatectomy at an age of 75 years or older with an excellent long-term survival probability superseding that of the general population.

Enhanced inhibition of bladder cancer cell growth by simultaneous knockdown of antiapoptotic Bcl-xL and survivin in combination with chemotherapy

The overexpression of antiapoptotic genes, such as Bcl-xL and survivin, contributes to the increased survival of tumor cells and to the development of treatment resistances. In the bladder cancer cell lines EJ28 and J82, the siRNA-mediated knockdown of survivin reduces cell proliferation and the inhibition of Bcl-xL sensitizes these cells towards subsequent chemotherapy with mitomycin C and cisplatin. Therefore, the aim of this study was to analyze if the simultaneous knockdown of Bcl-xL and survivin might represent a more powerful treatment option for bladder cancer than the single inhibition of one of these target genes. At 96 h after transfection, reduction in cell viability was stronger after simultaneous inhibition of Bcl-xL and survivin (decrease of 40%-48%) in comparison to the single target treatments (decrease of 29% at best). Furthermore, simultaneous knockdown of Bcl-xL and survivin considerably increased the efficacy of subsequent chemotherapy. For example, cellular viability of EJ28 cells decreased to 6% in consequence of Bcl-xL and survivin inhibition plus cisplatin treatment whereas single target siRNA plus chemotherapy treatments mediated reductions down to 15%-36% only. In conclusion, the combination of simultaneous siRNA-mediated knockdown of antiapoptotic Bcl-xL and survivin-a multitarget molecular-based therapy-and conventional chemotherapy shows great potential for improving bladder cancer treatment.

Prostate-specific antigen-negative prostate cancer recurrence?

We describe a patient with bone metastases occurring shortly after radical prostatectomy for organ-confined prostate cancer. The medical history and immunohistochemical findings suggested prostate cancer recurrence to the skeleton. Undetectable serum prostate-specific antigen levels, however, raised doubts about this diagnosis. A whole body (18)F-fluorodeoxyglucose positron emission tomography-computed tomography scan was obtained and revealed a right-sided breast cancer as the primary site of metastatic spread.

Systematic assessment of complications and outcome of radical cystectomy undertaken with curative intent in patients with comorbidity and over 75 years of age

OBJECTIVE

To evaluate the complications, survival and oncological outcome of patients ≥75 years of age after radical cystectomy for muscle-invasive bladder cancer.

PATIENTS AND METHODS

Between April 1993 and August 2010, 765 patients with muscle-invasive bladder cancer underwent radical cystectomy at one high-volume center. Of these, 70 patients were ≥75 years of age. All 70 patients had at least one severe systemic comorbidity with an American Society of Anesthesiologists score of 3. Primary endpoints of this retrospective study were overall and recurrence-free survival with a mean follow-up of 22 months (1-159). Perioperative parameters such as need for blood transfusions, hospital stay, mortality, short- and long-term complications were also assessed. Complications were graded according to the Clavien-Dindo classification.

RESULTS

Perioperative complications occurred in 23/70 patients (33%) with a 30-day mortality rate of 1.4%. 16/70 patients (23%) developed late complications requiring hospitalization. Within 30 days of surgery, according to the Clavien-Dindo grading, 27% had no complications, 3% grade 1, 49% grade 2, 14% grade 3, 6% grade 4 and 1.4% grade 5 complications. Within 31-90 days after surgery, 76% had grade 1 complications, 3% grade 2, 6% grade 3, 9% grade 4 and 6% grade 4 complications. The calculated 5- and 8-year overall survival rates were 30 and 25%, respectively, with a recurrence-free survival rate of 52% at 5 and 42% at 8 years.

CONCLUSIONS

Radical cystectomy is an appropriate and effective treatment for comorbid elderly patients. The oncological long-term outcome is the same as in younger patients while overall survival is comparatively lower. Mortality and complication-related morbidity are comparable to those in younger patients with modern perioperative management.

Perioperative Complications after Radical Prostatectomy: Open versus Robot-Assisted Laparoscopic Approach

<b><i>Background:</i></b> The best technique of radical prostatectomy - open versus robot-assisted approach - is controversially discussed. In this study, we compared the complication rates of open and robot-assisted radical prostatectomy during the introduction and subsequent routine use of a da Vinci® robotic device while open surgery remained the standard approach. <b><i>Patients and Methods:</i></b> Between January 1st, 2006, and June 4th, 2012, 2,754 men underwent radical prostatectomy at our department. Among them, 317 received robot-assisted and 2,438 open surgery. According to the requirements for prostate cancer centers certified by the Deutsche Krebsgesellschaft (German Cancer Society), a prospective database recording perioperative complications was built up. The complication rates of open and robot-assisted radical prostatectomy were compared with the &#x03C7;² or Fisher exact test. The distributions of quantitative variables were compared with U tests. <b><i>Results:</i></b> Whereas the demographic factors favored patients selected for robot-assisted radical prostatectomy, there were no differences between open and robot-assisted surgery concerning length of stay, autologous blood transfusion rates and the incidence of perioperative complications. <b><i>Conclusions:</i></b> Open and robot-assisted radical prostatectomy had comparable complication rates. With better patient- and tumor-related parameters as well as decreasing transfusion rates in the robot-assisted subgroup, this observation might reflect the learning curves of the involved robotic surgeons.

Urinary tract-related quality of life after radical prostatectomy: open retropubic versus robot-assisted laparoscopic approach

BACKGROUND

The best technique of radical prostatectomy--open retropubic versus robot-assisted surgery--is a subject of controversy.

PATIENTS AND METHODS

Between January 1st, 2007 and December 31st, 2011, 2,177 men underwent radical prostatectomy at our department. 252 (12%) cases were laparoscopic robot-assisted, the remainder open retropubic procedures. In Germany, certified prostate cancer centers are required to collect urinary tract-related outcome data after radical prostatectomy using the International Consultation of Incontinence Questionnaire Male Lower Urinary Tract Symptoms. The questionnaire data were used to compare both surgical approaches concerning the urinary tract-related outcome 1, 2 and 3 years postoperatively.

RESULTS

Neither the voiding score nor the incontinence score or the bother scale sum differed between the two cohorts at any of the measurement times.

CONCLUSIONS

Concerning continence recovery, in this series, there were no detectable differences between robot-assisted and open radical prostatectomy.

siRNA-mediated inhibition of antiapoptotic genes enhances chemotherapy efficacy in bladder cancer cells

BACKGROUND

The up-regulation of antiapoptotic B-cell CLL/lymphoma 2 (BCL2), BCL2-like 1 (BCLXL), X-linked inhibitor of apoptosis (XIAP) and survivin is one mechanism by which cancer cells develop resistance towards chemotherapeutics. Therefore, the knockdown of these four genes could sensitise bladder cancer (BCa) cells towards chemotherapy.

MATERIALS AND METHODS

BCL2, BCLXL, XIAP and survivin were inhibited using siRNAs--either one target-alone or all four targets simultaneously--in EJ28 and J82 BCa cells. After 24 h, cells were treated with mitomycin C or cisplatin. Treatment effects were analysed regarding cell viability, cell count and apoptosis induction.

RESULTS

Knockdown of BCLXL and survivin, as well as the simultaneous inhibition of all four antiapoptotic genes, sensitised EJ28 and J82 cells towards mitomycin C and cisplatin.

CONCLUSION

Since the contribution of one antiapoptotic gene to chemotherapy response can vary between BCa cell lines, the simultaneous knockdown of multiple inhibitors of apoptosis might represent a more promising option for enhancing chemotherapy efficacy in BCa treatment.

Simultaneous siRNA-mediated knockdown of antiapoptotic BCL2, Bcl-xL, XIAP and survivin in bladder cancer cells

Bladder cancer (BCa) represents the ninth most common malignancy worldwide. Despite intensive treatment with surgery and chemotherapy the prognosis for BCa patients particularly at advanced stages is poor. The ability to evade apoptosis is a hallmark of cancer cells. Since the antiapoptotic genes BCL2, Bcl-xL, XIAP and survivin are frequently upregulated in BCa tissues, their combined siRNA-mediated knockdown might be more potent in decreasing BCa growth than the single inhibition of one target. Against each target two siRNAs were selected that specifically reduced the mRNA and protein levels of their appropriate target in EJ28 and J82 BCa cells. Inhibition of survivin provoked the strongest antiproliferative effect of all single target treatments, for example cell counts decreased by 50%. Simultaneous targeting of all four antiapoptotic genes downregulated expression levels of all targets and mediated significant reductions in cell viability and cell counts as well as induction of apoptosis. In EJ28 cells, combined knockdown of BCL2, Bcl-xL, XIAP and survivin caused a 2.5-fold enhancement in apoptosis rate and reduced cellular viability by 40%. Therefore, simultaneous knockdown of antiapoptotic BCL2, Bcl-xL, XIAP and survivin may represent a promising treatment option for bladder cancer.

Retroperitoneal Leiomyosarcoma Associated with an Elevated beta-HCG Serum Level Mimicking Extragonadal Germ Cell Tumor

Patient. A 65-year-old man was admitted with a large primary retroperitoneal tumor and an increased β-human chorionic gonadotropin (β-HCG) serum level. A germ cell tumor was suspected; however, a computed tomography-guided biopsy failed to enable tumor classification. After two courses of chemotherapy, the β-HCG serum level had returned to the normal level and a diagnostic laparotomy with incisional biopsy was performed. The immunohistochemical examination of the specimen identified the tumor as a retroperitoneal pleomorphic leiomyosarcoma.

Discussion. Tumor markers play only a marginal role in the work-up of patients with soft tissue sarcomas. In men with suspected retroperitoneal sarcomas, however, the determination of germ cell tumor markers occasionally enables a preoperative distinguishing of primary retroperitoneal germ cell tumors with considerable consequences for management. In this setting, a retroperitoneal tumor associated with a moderately elevated β-HCG is a diagnostic dilemma, and surgeons should be aware of the pitfall of a β-HCG-producing leiomyosarcoma in the differential diagnosis.

Biology and natural history of prostate cancer and the role of chemoprevention

Androgens not only play an important role in the development and function of the prostate but they are also intimately involved in the development and progression of prostate cancer (PCa). Within the prostate, testosterone is converted to the more potent androgen dihydrotestosterone (DHT) via the action of 5α-reductase enzymes. DHT is the primary prostatic androgen and promotes the growth and survival of normal, hyperplastic and malignant prostate tissues. Throughout the different stages of PCa [prostatic intraepithelial neoplasia (PIN), localised, recurrent, and metastatic] there is an increase in expression of 5α-reductase enzymes, particularly in localised high-grade carcinoma. Specifically inhibiting 5α-reductase may reduce the production of DHT in the prostate while maintaining other endogenous hormone levels. Clinical studies have shown significant PCa risk reduction by blocking this pathway with 5α-reductase inhibitors (5ARIs). However, this comes at a risk, albeit low, with sexual side effects, gynaecomastia and cardiac failure. In addition, one study has shown a slight, but significant, risk of high-grade PCa. The currently available evidence does not support the routine use of 5α-reductase inhibitors to prevent PCa in the general population. It could, however, be considered as an individual option for high-risk or concerned patients with appropriate education from the prescribing provider.

Importance of erythrocyte band III anion transporter (SLC4A1) on oxalate clearance of calcium oxalate monohydrate stone-formering patients vs. normal controls

OBJECTIVES

To examine erythrocyte band III transport protein (SLC4A1), erythrocyte oxalate flux, and plasmatic, cellular, and urine oxalate concentrations and blood gas analyses in calcium oxalate monohydrate stone-forming patients (COM) in comparison with normal controls (NC).

METHODS

Isolated red cells from 51 NC and 25 COM cases were divided for cellular oxalate measurement and for measurement of transcellular erythrocyte oxalate flux (pH 7.48-8.24). SLC4A1 protein levels were determined by Western blot analyses. Plasmatic and urinary oxalate levels and the venous blood gas analysis were measured simultaneously.

RESULTS

SLC4A1 protein levels were significantly higher in COM (8.76 ± 2.12) than in NC (4.17 ± 0.61; P < .02). Cellular oxalate and venous HCO(3)(-) were significantly lower in COM (2.35 ± 0.26 μmol/L) and (24.06 ± 0.24 mmo/l) than in NC (4.03 ± 0.49 μmol/L; P < .05) and (24.93 ± 0.17 mmol/L; P < .01). Urinary oxalate was significantly higher in COM (0.31 ± 0.02 mmol/L) than in NC (0.25 ± 0.01 mmol/L; P < .04). The erythrocyte transmembrane oxalate flux correlated with the pH value and with the urinary oxalate in both groups (r = .25-.55; P = .01). With increased pH values, the oxalate flux showed inverse effects in both groups.

CONCLUSIONS

SLC4A1 associated changes of HCO(3)(-) and pH levels influenced the cellular oxalate levels and urinary oxalate clearance. Under normal conditions (pH 7.55) the oxalate efflux in COM was comparable with the acid stimulated oxalate efflux in NC. The addition of HCO(3)(-) compensated the flux of COM stone formers to the levels of normal controls.

Complications following radical cystectomy for bladder cancer in the elderly

CONTEXT

The incidence of bladder cancer increases with advancing age. Considering the increasing life expectancy and the increasing proportion of elderly people in the general population, radical cystectomy will be considered for a growing number of elderly patients who suffer from muscle-invasive or recurrent bladder cancer.

OBJECTIVE

This article reviews contemporary complication and mortality rates after radical cystectomy in elderly patients and the relationship between age and short-term outcome after this procedure.

EVIDENCE ACQUISITION

A literature review was performed using the PubMed database with combinations of the following keywords cystectomy, elderly, complications, and comorbidity. English-language articles published in the year 2000 or later were reviewed. Papers were included in this review if the authors investigated any relationship between age and complication rates with radical cystectomy for bladder cancer or if they reported complication rates stratified by age groups.

EVIDENCE SYNTHESIS

Perioperative morbidity and mortality are increased and continence rates after orthotopic urinary diversion are impaired in elderly patients undergoing radical cystectomy. Complications are frequent in this population, particularly when an extended postoperative period (90 d instead of 30 d) is considered.

CONCLUSIONS

Although age alone does not preclude radical cystectomy for muscle-invasive or recurrent bladder cancer or for certain types of urinary diversion, careful surveillance is required, even after the first 30 d after surgery. Excellent perioperative management may contribute to the prevention of morbidity and mortality of radical cystectomy, supplementary to the skills of the surgeon, and is probably a reason for the better perioperative results obtained in high-volume centers.

Extraperitoneal inguinoscrotal herniation of the ureter: a rare case of recurrence after hernia repair

Inguinoscrotal herniation of the ureter is a rare finding with the potential for serious surgical complications. Two anatomic forms are defined. In the more common paraperitoneal variant, the herniating peritoneal sac drags the ureter and sometimes other abdominal structures with it. The uncommon variant--extraperitoneal inguinal herniais without a peritoneal sac and consists of the ureter and fat tissue. We report a case of extraperitoneal inguinoscrotal hernia possibly due to a prior inguinal hernia repair.

Second cancers as competing causes of death after radical prostatectomy

PURPOSE

We analyzed the risk of dying of a second cancer after radical prostatectomy for clinically localized prostate cancer.

MATERIALS AND METHODS

We studied 1,910 patients who consecutively underwent radical prostatectomy between 1992 and 2004. These patients had a median age of 65 years, a median prostate specific antigen of 7.6 ng/ml and a median followup of 5.9 years. Overall disease specific, comorbid, second cancer specific and other mortality data were used as study end points in competing risk analyses. Fatal second cancers were subdivided into 10 categories. The numbers of observed deaths from second cancers were compared with expected rates using cancer registry data.

RESULTS

The risk of dying of a second cancer within 10 years after radical prostatectomy was 4.1%. This death rate was lower than that of comorbidity (5.8%) and prostate cancer (5.4%). Among second cancers colorectal cancer (0.74%), lung cancer (0.69%) and lymphoma, myeloma or leukemia (0.66%) were the most common causes of death after 10 years. Whereas the mortality rates from the other second cancers were within the expected range, fatal lung cancer occurred significantly less frequently than expected.

CONCLUSIONS

The low probability of dying of a second malignancy within 10 years after surgery (about 4%) and the nevertheless relatively large contribution of second cancers to competing mortality (about 40%) reflect the good general health status of men selected for radical prostatectomy.

Incidence, risk profile and morphological pattern of venous thromboembolism after prostate cancer surgery

BACKGROUND

Venous thromboembolism (VTE) is the most common non-surgical complication after major pelvic surgery. Little is known about the risk factors or the time of development of postoperative venous thrombosis.

METHODS

A cohort of 523 consecutive patients undergoing radical prostatectomy with lymphadenectomy was prospectively assessed by complete compression ultrasound at days -1, +8 and +21.

RESULTS

Complete data were available in 415 patients, while four patients had VTE before surgery and were excluded from the analysis. In the remaining 411 patients, 71 VTE events were found in 69 patients (16.8%). Most were limited to calf muscle veins (56.5%), followed by deep calf vein thrombosis (23.2%), proximal deep vein thrombosis (DVT, 14.5%) and pulmonary embolism (PE, 5.8%). Of the 14 patients with proximal DVT/PE, 11 patients (78.6%) developed VTE between days 8 and 21. Risk factors for VTE were a personal history of VTE (OR 3.0), pelvic lymphoceles (LCs) impairing venous flow (OR 2.8) and necessity of more than two units of red blood cells (OR 2.6).

CONCLUSION

Venous thromboembolism is common after radical prostatectomy. A significant proportion develops after day 8, suggesting that prolonged heparin prophylaxis should be considered. Since LCs with venous flow reduction result in higher rates of VTE, hemodynamically relevant lymphoceles should be surgically treated.