New Orleans is also known as the "Big Easy", the city of "laisser le bon temps rouler". This holds true for this meeting of the AUA. There is a lot of work to do and so many different sessions, making it hard to come to a choice. The organizing committee is overwhelmed by the number of people, while the plenary sessions cannot seat them all. All social events were sold out even before the meeting started. A new record has been reached; the high number of on-site registrants brought the total count to 16.000.
Monday is the traditional 'oncology-day'. Montie started off with the treatment of advanced bladder cancer. "Smart people don't take dangerous risks", i.e. don't wait until it's too late. The elderly patient belongs to the bad-prognosis group and should be eligible for radical cystectomy. External radiotherapy will reach cure in only 20% and therefore is not a viable alternative. Chemotherapy is often too toxic for this group of people. The urinary diversion should be some type of pouch. Women can also be treated in this way, if the bladder neck does not contain tumor. In 16% this is, however, not the case (924). In everyone of these cases, the extent of the tumor was estimated wrongly, preoperatively; per-operative pathology is therefore mandatory. A lot of the women (20-30%) need self-catherization after surgery; only 5% of the men do. The 'chemotherapists' are awaiting less toxic and more effective medication, like perhaps taxol and gemcitabine. Different preliminary studies show 75% total response with less toxicity - in the past also MVAC gave preliminary results in this range, but now barely reaches 30-40% total response.
Superficial bladder cancer is one of the more important issues today. Van der Meijden showed the results of several EORTC studies indicating that random biopsies of normal-looking bladder epithelium does not add anything to the treatment. Patients with pTa bladder tumors benefit from a single dose of Mitomycin within 24 hours after TUR. The best treatment scheme for BCG bladder instillations is: initially 6 weekly instillations, followed by 3-weekly instillations at 3 months and 6 months, if histologicall proven effective; thereafter every half year (838). Biological markers like p53 and KI-67 seem to become important to decide on the type of treatment in the near future.
The more bladder augmentationsare being done, the more complications of these procedures are reported. In 7% of 319 patients a spontaneous perforation was seen; 2% when cecum was used, 15% in case of small bowel. The patient may present with a tumor next to the bladder or septic shock (6).
1997 seems to mark the end of Complete Androgen Block. Walsh quoted older DES studies in which an optimal hormonal treatment did not require castration levels of testosterone. He also added his advice to believe the well-prepared SWOG study. The only remaining reason to give anti androgens is to diminish flare-up at the start of LhRh therapy. Possibly, as shown in older EORTC studies, there may be an indication for CAB in patients with extensive metastasis in the first few months.
Hormonal treatment preceding radical prostatectomy causes an unacceptable delay, false-negative margins and lymphnodes, according to Scardino. Hormonal pre-treatment can, in 30% of cases, lead to a reduction of prostate volume, which may add to the benefit of external radiotherapy (of which the effect is dependant on volume). Randomized studies ar still ongoing.
DeKernion added to the discussion about cost. In Belgium the hormonal treatment of Pca through orchiectomy would cost $ 1200, while CAB would cost $ 28.000 per patient. DeKernion predicts that the urologist will be budgeted per patient, which will include the price of medication. In that case, the American urologist would lose $ 18.000 if LhRh is used, while the loss rises to $ 34.000 in CAB.
It all went too fast for most people in the audience. At the end of the session, 20% out of 1000 urologists-with-a-voting-button were still prepared to give neo-adjuvant hormonal therapy, while 30% still prescribed CAB in metastasis.
Richie gave some hints on how to prevent positive margins in a radical prostatectomy. Good preoperative staging remains a problem. Schröder (463) found in the Rotterdam screening study (n=8627, 1882 biopsies, 4,7% carcinoma) that, if PSA is below 8, TRUS and DRE can not predict the outcome of one of the sextant biopsies.
If the prostate has a middle lobe, then Richie opens the bladder to clear the prostate from the bladder from the inside. He advises not to do a nerve-sparing resection at that side if more than one biopsy is positive, or if the apex biopsy was tumor-positive or in case of higher Gleason scores. Diagnosis is reached by sextant biopsies from both sides of the apex, lateral sides and prostate base. In PIN (prostatic intra-epithelial neoplasia) another set of biopsies should be done, since there is cancer somewhere in 50-95%.
The presentation of the Association of Urologic Oncology showed a lot of PSA, free PSA et cetera. Low free PSA (below 25% of total) could yield a sensitivity of 95% for cancer detection, while 20% of unnecessary biopsies can be prevented. But it all depends on age, prostate volume, Total PSA and a lot of other factors. The 25% proposition depends on total PSA of 4-10 and age 50-75.
"Impotence or loss of sexuality is not a signal of aging, but of attitude to sexuality". Tom Lue summarized male impotence and the current status of intracavernous therapy. Serum testosterone decreases at a rate of about one percent per year, so we'll all be impotent at the age of 300. He cited Newsweek that the angle of erections decreases in time; therefore, the lesion of the suspensory ligament in penile lengthening really causes early aging. Hindus used baked goat' testicles with pepper to better potency; the recipe guarantees that 100 women can be satisfied using it. Testosterone suppletion only works when testosterone is low. In hypogonadism with low testosterone, 65% of men end up having erections. Lue starts with 1-5 mg PGE1 in cases of neurogenic or psychogenic impotence. The pain predominantly arises in patients with diabetes or neuropathy, but also after radical prostatectomy. Regular treatment also improves arterial flow as measured by Doppler, while 30% of patients report better spontaneous erections. (Rutchik does not agree with that (710)).
MUSE (medicated intra-urethral system for erection) may signify a major breakthrough for men with erectile dysfunction. Intraurethral application of 250-1000 mg PGE1 using a miniature suppository will allow a sufficient erection for intromission in 46% of men. Placebo only leads to 18% success. Adverse effects include, as with intracavernous application, pain in 10%, causing 2% of patients to discontinue its use. There was no priapism. The response may even be better when a small rubber band is used around the base of the penis. MUSE is expected to be FDA approved before the year is over. Pelvic floor exercises may also be of help to extent erection time.
"Take that pill and call me in the morning if it doesn't work". Will this be the very first option in patients with erectile dysfunction? Yohimbine supposedly works synergistic with trazodin. The future drug will possibly be Sildenafil, a phosphodiesterase inhibitor causing smooth muscle relaxation. It is a potent pill with only few adverse effects and 87% response and may be used in any type of erectile dysfunction. Warnings apply to the prescription of the drug to all patients, since a lot of patients suffer from sexual problems as well; these will not surface without an attempt to diagnose them. The podium session had a very big audience, much bigger than the organizers had anticipated, despite the fact that the drug will probably not be approved by the FDA before the end of 1998. It was speculated that even more patients than doctors were to be found among the audience, or were they interchangeable?
The sessions on medical treatment of BPH failed to show any news. Difference between different alfa-blockers do not seem to be that great. Tamsulosin can be used together with antihypertensive medication without too much problems. The indication for the use of finasteride only include large prostates (more than 40 grams), but it also seems effective in patients with hematuria caused by BPH.
"To see we must stand on the shoulders of those who saw before us".
The History of Urology Forum showed several predecessors, like the primitive medieval 'stonecutters' of modern day urology. Moderator Lichtwardt showed his respect for the risks that our colleagues dared to take in the pre-antibiotic era. Probably numerous patients will have paid the price.
Dr Boon presented a poster compiled by Vroege (771) about the sexual function in meningomyelocele patients. There is ever more interest in adolescent urology in patients with inborn diseases, with its own sexual and incontinence problems.
Over 4300 abstracts were presented to the scientific committee of the AUA; 1809 were accepted. We have now reached number 978.
Part of the urologic crowd closed todays sessions with a visit to David Copperfields illusion show. For most of us, it turned out to be an illusion: 'old dog, new tricks'. Police protection made sure that nothing untoward happened, proving that New Orleans is not so violent after all.
More of this tomorrow.
| ENGLISH version | | DUTCH version 12 April 199713 April 199714 April 199715 April 199716 April 1997 |