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Urology

Volume 12, No 1 - Winter 2010

Volume 12, No 1 - Winter 2010

Table of Contents

Intermittent Androgen Deprivation Therapy: Redefining the Standard of Care? Management Update
As a clinical strategy, intermittent androgen deprivation therapy (IADT) has the potential to minimize adverse events associated with continuous androgen deprivation therapy while providing comparable efficacy for patients with advanced prostate cancer. Because most studies supporting IADT to date have been somewhat small and underpowered, additional large, randomized, controlled trials are needed before this strategy becomes the standard of care.However, the potential advantages of IADT, which include improved quality of life, the theoretical possibility of delaying hormone resistance, and possible reduction in expenses to the patient and health care payers, suggest it is a strategy worth further exploration.[Rev Urol. 2010;12(1):1-11 doi: 10.3909/riu0490]
A Comparative Review of Oxybutynin Chloride Formulations: Pharmacokinetics and Therapeutic Efficacy in Overactive Bladder Treatment Update
Antimuscarinic agents remain the mainstay of treatment of overactive bladder. However, the utility of some of these agents is limited due to tolerability concerns, multiple daily dosage regimens, lack of formulary coverage, and high cost. This can lead to problems with long-term compliance and may preclude optimal management. Oxybutynin has been the most widely prescribed antimuscarinic agent for more than 30 years. To meet the needs of tolerability and compliance, oxybutynin has evolved from an immediate-release pill to a once-daily oral dose and is now available as a topical gel. This review compares the various oxybutynin formulations in terms of pharmacokinetics, efficacy, and tolerability issues.[Rev Urol. 2010;12(1):12-19 doi: 10.3909/riu0484]
Complications of Pelvic Lymphadenectomy: Do the Risks Outweigh the Benefits? Treatment Review
The American Urological Association Best Practice Policy states that although pelvic lymph node dissection (PLND) is commonly done with radical prostatectomy, its morbidity must be considered, particularly in cases in which it offers little additional information. The benefits of PLND include more accurate staging and reassurance for the patient. In addition, PLND may be therapeutic for men with lymph node metastases and may result in long-term biochemical cure for selected node-positive patients. However, the incidence of node positivity is declining, and accordingly a greater number of lymphadenectomies must be performed to benefit 1 patient. In addition to the associated cost, PLND has the potential for morbidity, including lymphoceles, thromboembolic events, ureteral injury, and neurovascular injury. Patients and physicians should therefore assess the risk/benefit ratio associated with PLND on an individual basis to permit informed treatment decisions.[Rev Urol. 2010;12(1):20-24 doi:10.3909/riu0422]
Emerging Vaccine Therapy Approaches for Prostate Cancer Treatment Update
Prostate cancer vaccines attempt to induce clinically relevant, cancer-specific systemic immune responses in patients with prostate cancer and represent a new class of targeted, nontoxic therapies. With a growing array of vaccine technologies in preclinical or clinical development, autologous antigen-presenting cell vaccines loaded with the antigen, prostate acid phosphatase, and poxvirus vaccines targeting prostate-specific antigen have recently demonstrated a significant survival benefit in randomized trials of patients with metastatic castration-resistant prostate cancer, whereas others have failed to demonstrate any benefit. The combination of vaccines with chemotherapy, radiotherapy, and other biologic agents is also being evaluated. Efforts to optimize vaccine approaches and select ideal patient populations need to continue to build on these early successes.[Rev Urol. 2010;12(1):25-34 doi:10.3909/riu0437]
Open Versus Laparoscopic Versus Robot-Assisted Laparoscopic Prostatectomy: The European and US Experience Treatment Update
Open radical prostatectomy (ORP) is the reference standard for the surgical management of localized prostate cancer. With wider availability of minimally invasive radical prostatectomy techniques, there is a debate regarding the standard treatment of the management of localized prostate cancer. Therefore, we reviewed the current status of laparoscopic radical prostatectomy (LRP) and robotic-assisted laparoscopic radical prostatectomy (RALRP) as compared with ORP. Because no prospective, randomized trials comparing the different techniques have been performed, outcomes must be assessed from published series by centers that focus on ORP, LRP, and RALRP. Aside from reducing the amount of blood loss, current data suggest that the most significant outcomes (cure, continence, and potency) are no better with LRP or RALRP than with conventional ORP. Therefore, in experienced hands, ORP remains the gold standard procedure. However, there is a trend toward consistently better outcomes following RALRP in comparison with LRP. In the end, individual patient outcomes can be maximized by choosing the best modality based on the patient’s comorbid medical conditions, cancer characteristics, and surgeon experience. Future studies are needed to further investigate long-term cancer control as well as functional outcomes for RALRP series.[Rev Urol. 2010;12(1):35-43 doi: 10.3909/riu0470]
Emerging Therapies for Incontinence Meeting Review
Highlights From the International Continence Society 39th Annual Meeting, September 29-October 3, 2009, San Francisco, CA[Rev Urol. 2010;12(1):44-51 doi: 10.3909/riu0488]
Transitional Cell Carcinoma Within a Calyceal Diverticulum Associated With Stone Disease Case Review
We report a case of transitional cell carcinoma (TCC) discovered within a calyceal diverticulum at the time of percutaneous nephrolithotomy. The stones and tumor were endoscopically removed and the diverticular cavity fulgurated. Pathologic analysis demonstrated low-grade TCC. A subsequent laparoscopic radical nephroureterectomy was performed and high-grade TCC invading the parenchyma was found. This case demonstrates the potential for TCC to develop in stone-containing calyceal diverticula and also the potential for coexistence of different grades of TCC within the involved renal unit.[Rev Urol. 2010;12(1):52-55 doi: 10.3909/riu0446]
Diagnostic and Therapeutic Options for the Management of Ischemic and Nonischemic Priapism Case Review
Priapism is defined as persistent penile erection continuing beyond, or unrelated to, sexual stimulation. Proper diagnosis encompasses at least 2 very different pathophysiologic processes. Ischemic priapism (“low flow”) is a disorder of venous outflow and/or stasis. Nonischemic priapism (“high flow”) is a disorder of arterial flow. We present 2 cases that review each condition. The first case highlights a 32-year-old man with a medical history of sickle cell disease who presented to the emergency department complaining of a persistent, painful erection that had continued for 18 hours. The second case describes a 24-year-old man with no significant medical history who sustained trauma to his pelvis while skateboarding. Although the initial evaluation of both types of priapism is similar, pathophysiology and resulting interventions differ for each, underscoring the importance of proper diagnosis.[Rev Urol. 2010;12(1):56-63 doi: 10.3909/riu0457]