Re: Health Related Quality of Life in Men With Prostate Cancer

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LETTERS TO THE EDITOR renal vessels during radical nephrectomy is unnecessary, whether the operation is laparoscopic or open. In addition, while the stapler can be placed through any trocar (at least 12 mm) according to the authors, this flexibility is unnecessary. During pure laparoscopic nephrectomy the port at the apex of the L-shaped (left side) or reverse L-shaped (right side) configuration has always provided an excellent angle to the hilum in more than 300 and more than 190 cases of donor and radical nephrectomy, respectively. Advantages of the hand port are not apparent in the reported operative time and duration of hospitalization. We believe that pure laparoscopy provides the greatest opportunity for resident education. With the described approach only 1 surgeon can perform the operation, while the assistant manipulates the camera. If the procedure becomes so difficult that the resident cannot progress, the attending surgeon must intervene and occupy the 2 working ports. In a 4-port pure laparoscopic approach the trainee can continue to manipulate 2 instruments as the attending assists and guides via the third working port. Even if the trainee is relegated to the camera and assisting port, s/he acquires skills in laparoscopic assisting, which is often as crucial as the primary working sites. Although intact specimen extraction is essential for accurate pathological staging, accurate pathological staging is not essential for oncological outcomes. In the 3 largest series with long-term cancer outcomes after laparoscopic radical nephrectomy the specimen was removed piecemeal in a significant number of cases.1–3 This approach did not appear to compromise cure. While the described hand site may mimic a common site of intact specimen removal, the low Pfannenstiel site is an alternative that does not cut muscle, with improved cosmesis. Whether this approach affects postoperative pain and recovery is unclear. The authors also assume, based on skin incision length, that the morbidity from an extraction incision is equivalent to a hand port through which the tissues have been manipulated for several hours. We believe that the hand may be advantageous in only a limited number of cases. Modern renal cancer surgery has evolved—laparoscopic radical nephrectomy is used for larger tumors and partial nephrectomy for smaller lesions away from the renal hilum. With larger renal masses the relative working space is limited and the presence of a hand may hinder, rather than aid, dissection. A major premise of their approach is that conversion to an open operation can be avoided by the mere presence of the hand. During pure laparoscopy a site for the hand can be added if necessary. If the bleeding is such that the time required for placement of the hand port is too long, then the prudent decision may be to convert to an open operation rather than persist with laparoscopy in any form, especially in the hands of a novice laparoscopist. Ultimately the question becomes how and when does one move away from the hybrid technique and select either pure laparoscopy or hand assisted laparoscopy. At some point the choice must be made regarding whether one requires the hand to perform urological laparoscopy or develops sufficient skills to perform pure laparoscopy. Respectfully, Maxwell V. Meng and Marshall L. Stoller Department of Urology University of California San Francisco San Francisco, California 94143-1695 1. Chan, D. Y., Cadeddu, J. A., Jarrett, T. W., Marshall, F. F. and Kavoussi, L. R.: Laparoscopic radical nephrectomy: cancer control for renal cell carcinoma. J Urol, 166: 2095, 2001 2. Portis, A. J., Yan, Y., Landman, J., Chen, C., Barrett, P. H., Fentie, D. D. et al: Long-term followup after laparoscopic radical nephrectomy. J Urol, 167: 1257, 2002 3. Ono, Y., Kinukawa, T., Hattori, R., Gotoh, M., Kamihira, O. and Ohshima, S.: The long-term outcome of laparoscopic radical nephrectomy for small renal cell carcinoma. J Urol, 165: 1867, 2001

Reply by Authors. We appreciate the comments of Meng and Stoller on our recently published article. They state, “We agree that the best method of disseminating laparoscopic skills is an important consideration and remains a topic of debate.” We did not intend nor are we currently attempting (nor do we want) to enter this debate. However, we are presenting what we believe is an opportunity for those urologists who are entering the world of laparoscopy to provide a safe and efficacious approach for their patients, while allowing the

surgeon to decide for himself or herself which approach is the best for them. Not all urologists are going to be as accomplished as Meng and Stoller, nor will they necessarily have the volume of cases to tolerate the learning curve needed to refine their techniques. Many experts have described that the hand provides a sense of security for the surgeon, while opponents have claimed it to be unnecessary, both of which may be true. However, it is our responsibility to continue to look for “the best method of disseminating laparoscopic skills.” Thus, it is important to describe an approach to laparoscopic nephrectomy that will allow a rookie or a veteran urologist the opportunity to be secure with the hand assist, if they desire, while also allowing the use of the standard approach, without forcing commitment to either one. The surgeons can then decide for themselves what approach they prefer, instead of trying to figure it out from the debates between the competing camps. We would like to indicate an inaccuracy that was implied by Meng and Stoller regarding our hand port/extraction site. This incision is made in a muscle splitting fashion, and does not cut muscle, similar to the Pfannenstiel approach that they describe. As the hand assist and standard laparoscopic camps continue to debate over millimeters, milliliters and minutes, one thing we believe in strongly, about which we respectfully disagree with Meng and Stoller, is intact specimen extraction. Morcellation does not allow for accurate pathological staging, nor does it follow sound oncological principles. Although Meng and Stoller have described a mathematical model to provide a pathological diagnosis for morcellated specimens, their model “does not address the questions of staging.” Tumor stage is an important factor in determining the type and extent of followup necessary. There are also a number of promising adjuvant therapies for patients with locally advanced disease currently under development, and their rational use requires complete and accurate pathological staging, which can only be achieved by pathological examination of an intact specimen to determine the degree of local invasiveness. DOI: 10.1097/01.ju.0000095231.65451.8e

RE: PERMANENT INTERSTITIAL BRACHYTHERAPY FOR THE MANAGEMENT OF CARCINOMA OF THE PROSTATE GLAND G. S. Merrick, K. E. Wallner and W. M. Butler J Urol, 169: 1643–1652, 2003

RE: HEALTH RELATED QUALITY OF LIFE IN MEN WITH PROSTATE CANCER D. F. Penson, M. S. Litwin and N. K. Aaronson J Urol, 169: 1653–1661, 2003 To the Editor. These articles review aspects of adenocarcinoma of the prostate, namely the use of interstitial brachytherapy for management and health related quality of life issues. In a practice dedicated to pelvic pain we find that a major quality of life issue that neither article discussed is the development of debilitating pain often causing suicidal ideation. The pain meets the characteristics of pudendal neuralgia and appears to be due to radiation neuritis of the pudendal nerve. The pain characteristics include penile, scrotal, rectal and coccygeal pain that is aggravated by sitting, decreased by standing and decreased when recumbent.1 Associated sexual, voiding and rectal dysfunction are components of pudendal neuralgia. Direct radiation of the base of the bladder, the corpora or the rectal wall could also produce these dysfunctional symptoms. Radiation neuritis occurs at approximately 54 Gy or less.2 This level is well below the attempted therapeutic levels, especially when radiation dose is calculated for local spread up to 5 mm from the prostate capsule. Radiation neuritis responds to self-care, perineural injections of corticosteroids and bupivacaine.3, 4 One of our patients required bilateral neurolysis and nerve decompression with fasciotomy of Alcock’s canal to achieve good relief.5

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We have treated 7 men with radiation neuritis, all with distinct benefit (approximately 1.0% of total men seen with pudendal neuralgia). The National Institutes of Health Chronic Prostatitis Symptom Index is used in all men to measure pain, voiding and quality of life scores before, during and after therapy. This validated pain score includes pain questions that are not a component of any of the scores mentioned in these review articles. Only “crampy abdominal pain” is discussed in those pain scores. Our patient group includes 2 men with external beam therapy only, 4 with brachytherapy only, and 1 with combined brachytherapy and external beam radiotherapy. We have computerized tomography images that show seeds misplaced into Alcock’s canal and the pelvic wall. Seeds at the apex are commonly in position to give greater than therapeutic doses of radiation therapy to the neurovascular bundle. Two additional men with “prostatitis-like pains” had necrotic sloughing prostate tissue. They responded briefly to conservative therapy but required prostatocystectomy and urinary diversion for pain relief.6 Onset of symptoms may occur 1 to several months after completing brachytherapy. In men receiving combined therapy usually the symptom onset is late in the course of the external beam therapy component. Brachytherapy for carcinoma of the prostate is a scientific endeavor with uncertain physical outcomes. Pudendal neuralgia (the chronic pelvic pain syndrome) is a serious complication of pelvic radiation therapy and has been recognized in patients with gynecological and colorectal cancer. Urologists need to be aware of this problem and use appropriate questionnaires in addition to the ones discussed in these review articles. Respectfully, Stanley J. Antolak, Jr. Department of Urology Mayo Clinic 200 First St., SW Rochester, Minnesota 55905

Reply by Merrick et al. Antolak’s insight and suggestions regarding this phenomenon are appreciated.3 In our group the development of chronic pelvic pain following permanent prostate brachytherapy has occurred in 3 of an approximate 2,500 implants (incidence 0.12%). Each of these 3 patients described deep pelvic pain that was worse with urination and was exacerbated by prolonged sitting or walking, with all remaining clinically functional without suicidal ideation. Neither cystoscopy, computerized tomography nor magnetic resonance imaging identified any physical or radiographic abnormality. Treatment with ␣-blockers, anti-inflammatories, steroids and/or pentoxyphylline/vitamin E failed to help. However, detailed dosimetric evaluation demonstrated higher central prostate radiation doses compared to our general brachytherapy population.7 Our group will continue intense evaluation of potential predisposing factors and management of brachytherapy related morbidity, including chronic pelvic pain.8 1. Robert, R., Prat-Pradal, D., Labat, J. J., Bensignor, M., Raoul, S., Rebai, R. et al: Anatomic basis of chronic perineal pain: role of the pudendal nerve. Surg Radiol Anat, 20: 93, 1998 2. Fajardo, L.-G. L. F., Berthrong, M. and Anderson, R. E.: Nervous system; peripheral nerves. In: Radiation Pathology. New York: Oxford University Press, chapt. 23, p. 362, 2001 3. Antolak, S. J., Hough, D. M. and Pawlina, W.: The chronic pelvic pain syndrome after brachytherapy for carcinoma of the prostate. J Urol, 167: 2525, 2002 4. Hough, D. M., Wittenberg, K. H., Pawlina, W., Maus, T. P., King, B. F., Vrtiska, T. J. et al: Chronic perineal pain caused by pudendal nerve entrapment: anatomy and CT-guided perineural injection technique. AJR Am J Roentgenol, 181: 561, 2003 5. Spinner, R.: Personal communication, April 2003 6. Zincke, H.: Personal communication, March 2003 7. Wallner, K., Elliot, K., Merrick, G., Ghaly, M. and Maki, J.: Chronic pelvic pain following prostate brachytherapy. Unpublished data 8. Merrick, G. S., Wallner, K. E. and Butler, W. M.: Minimizing prostate brachytherapy-related morbidity. Unpublished data DOI: 10.1097/01.ju.0000095266.31942.84

RE: PRETREATMENT TOTAL TESTOSTERONE LEVEL PREDICTS PATHOLOGICAL STAGE IN PATIENTS WITH LOCALIZED PROSTATE CANCER TREATED WITH RADICAL PROSTATECTOMY J. C. Massengill, L. Sun, J. W. Moul, H. Wu, D. G. McLeod, C. Amling, R. Lance, J. Foley, W. Sexton, L. Kusuda, A. Chung, D. Soderdahl and T. Donahue J Urol, 169: 1670 –1675, 2003 To the Editor. The authors tested pretreatment total serum testosterone level as a potential staging and prognostic marker in a cohort of 879 patients with localized prostate cancer. They concluded, after multivariate analysis, that pretreatment total testosterone is an independent predictor of extraprostatic disease in patients with localized prostate cancer treated with radical prostatectomy. The authors state that they used the 1992 TNM classification for staging the extent of disease in their patients with prostate cancer. They also state in the methods section that they defined organ confined disease as pT1 and pT2 tumors. Similarly, table 3 in the article shows that 514 patients had “pT2 or lower” disease. The TNM classification is a dual system with a pretreatment clinical classification (cTNM or TNM) and a postoperative pathological classification (pTNM).1–3 To our knowledge pT1 tumors do not exist in the TNM classification system for prostate cancer. Given this fact, we wonder whether the statistical correlation between preoperative serum testosterone and prostate cancer stage is valid. Respectfully, Rabi Tiguert and Brant A. Inman Division of Urology Centre de Recherche L’Hoˆ tel Dieu Que´ bec Centre Hospitalier universitaire de Que´ bec 11, Coˆ te du Palais Que´ bec, Canada G1R2J6 1. Beahrs, O. H.: Handbook for staging of cancer. In: AJCC Manual for Staging of Cancer, 4th ed. Philadelphia: J. B. Lippincott Co., p. 189, 1992 2. Sobin, L. H. and Wittekind, C.: TNM Classification of Malignant Tumours, 5th ed. New York: Wiley-Liss, p. 172, 1997 3. Sobin, L. H. and Wittekind, C.: TNM Classification of Malignant Tumours, 6th ed. New York: Wiley-Liss, p. 184, 2002

Reply by Authors. We appreciate the letter from Tiguert and Inman and their careful reading of our article. It is always gratifying to know that others in the field are reading one’s work. They are correct in noting the error in our use of the 1992 TNM classification. There is, in fact, no “pT1” in this system. On reviewing our data none of our 879 cases were staged as pT1, but we did find 1 case that was pT0, with no tumor found in the radical prostatectomy specimen even though review of the preoperative biopsy showed prostate cancer. The remaining 878 cases were stage pT2 or higher. The classification “pT2 or lower” in table 3 referred to this single pT0 case. In retrospect this would have been better noted in a footnote stating that the dataset contained 1 pT0 case. This single case of pT0 does not change the results of the study—that a low pretreatment total serum testosterone level was an independent predictor of pT3 or greater prostate cancer. We apologize for any confusion this may have caused and again thank the correspondents for their attention to detail. DOI: 10.1097/01.ju.0000095148.84868.ba

RE: RANDOMIZED CONTROLLED TRIAL OF ZOLEDRONIC ACID TO PREVENT BONE LOSS IN MEN RECEIVING ANDROGEN DEPRIVATION THERAPY FOR NONMETASTATIC PROSTATE CANCER M. R. Smith, J. Eastham, D. M. Gleason, D. Shasha, S. Tchekmedyian and N. Zinner J Urol, 169: 2008 –2012, 2003 To the Editor. Mineralization of bone in males and females is mediated by estrogen from embryonic development onward.1 Estrogen is a metabolite of testosterone in males and females. Therefore,