Highlights of the Society of Urologic Oncology meeting, June 2, 2001.

The Society of Urologic Oncology held its annual spring meeting in conjunction with the annual meeting of the American Urological Association in Anaheim, California on June 2, 2001. The program was organized by Dr. Charles Brendler, Professor and Chief of Urology, University of Chicago and 3 colleagues at the University of Chicago, namely Drs. Gary Steinberg, Carrie Rinker-Schaeffer and Mitchell Sokoloff. The first session of the meeting was open to all American Urological Association meeting registrants and was devoted to a discussion of surgical challenges in urologic oncology. This session was chaired by Dr. Gary Steinberg, Associate Professor of Urology, University of Chicago and it included a series of presentations of controversial issues in the surgical management of prostate, bladder and testicular cancer. The second session of the meeting was open only to members of the Society of Urologic Oncology and it was divided into 2 parts. Part 1 was chaired by Carrie Rinker-Schaeffer, Ph. D., Associate Professor of Urology and Director of Urologic Research, University of Chicago. This part was devoted to prostate cancer metastasis and it included several talks regarding the basic principles of prostate cancer metastasis and clinical research regarding factors that influence metastatic dormancy. Part 2 of the closed meeting session was chaired by Mitchell Sokoloff, M. D., Assistant Professor of Urology, University of Chicago. This session dealt with novel therapies for prostate cancer and it included discussions of angiogenesis, immunotherapy, gene therapy and anti-sense therapy. The highlights of these 3 sessions are reviewed. Radiation therapy. Patients with biochemical recurrence after radical prostatectomy should be considered for salvage radiotherapy if they are believed to have locally recurrent disease only. While the value of salvage radiotherapy remains controversial, it seems clear that the lower the prostate specific antigen (PSA) at the time of radiation, the greater the probability of benefit. Patients with a PSA of less than 1.5 ng./ml. are more likely to benefit from treatment than those with a PSA of greater than 1.5 ng./ml., who are more likely to have systemic disease. In addition, salvage radiation is less likely to be beneficial in patients who have relapse within 1 year postoperatively (suggesting that they already have systemic disease), those with Gleason 8 to 10 tumors and those with a PSA doubling time of less than 6 months.1 Alternative adjuvant treatments. New treatments for hormone resistant prostate cancer are under development. Several nomograms exist to help identify patients at high risk for failure. Phase II and phase III trials are being done in this group to determine if chemotherapy with or without hormonal therapy would increase survival and/or disease-free survival. For example, Southwest Oncology Group 9,925 randomizes men to 6 cycles of mitoxantrone and prednisone plus 2 years of hormonal therapy versus 2 years of hormonal therapy alone. Currently several phase II trials of experimental therapies are being performed in this population and these studies generally use an increase in serum PSA as an end point to determine efficacy.2 There are now more than 20 vaccine trials ongoing for hormone refractory prostate cancer. These studies generally show a 10% to 20% response rate with relatively few side effects.3 Other therapies that are being studied in this population include matrix metalloproteinase inhibitors, angiogenesis inhibitors, bisphosphonates and complementary medicine approaches. It is worth noting that many patients in this population are already using alternative medicines, such as PC-SPES, low fat diets, green tea, vitamin E, selenium and soy, and these nutritional supplements must be considered as these patients are being treated.4 Mitchell Steiner, M. D., Professor and Chairman of Urology, University of Tennessee discussed surgical modifications to improve the recovery of urinary continence after radical prostatectomy. He reported that continence is improved by avoiding injury to the anterolateral pubourethral sphincteric complex and the posterior median fibrous raphe. It is accomplished by sharp transection of the pubourethral ligaments and by not using a right angle clamp to dissect and spread posterior to the urethra. In addition, the muscular integrity of the dorsal venous complex of the penis and posterior rectourethralis muscle should be preserved. In addition, the intrapelvic branch of the pudendal nerve enters the urethral rhabdosphincter at the 5 and 7 o’clock positions, and anastomotic sutures should not be placed in these areas. Using these modifications results in improved time to urinary continence and overall improved continence rates. Briefly, preserving the fascial attachments, muscular integrity, and autonomic and somatic innervation of the membranous urethra leads to improved recovery of urinary continence after radical prostatectomy.5 Peter T. Scardino, M. D., Chairman of the Department of Urology, Memorial Sloan-Kettering Cancer Center and Patrick Walsh, M. D., Professor and Director of Urology, The Johns Hopkins Hospital, debated the role of sural nerve grafts to preserve sexual function in men requiring excision of the neurovascular bundles to the penis during radical prostatectomy. Scardino reported that bilateral sural nerve grafts in men in whom the 2 neurovascular bundles are widely resected can be accomplished with minimal morbidity. Intraoperative use of a nerve stimulator and optical magnification improves identification of the resected ends of the neurovascular bundles. Of 12 patients in whom the 2 neurovascular bundles were resected and replaced with sural nerve grafts 4 recovered spontaneous erection, 3 were functional on sildenafil and 2 achieved partial erection. In men who received unilateral sural nerve grafts 79% recovered potency, although 65% recovered potency without a nerve graft. Because it is sometimes difficult to determine intraoperatively extraprostatic extension of tumor posterolateral in the region of the neurovascular bundles, nerve grafts may allow surgeons to dissect widely with improved surgical margins, while still being able to preserve sexual function.6 Accepted for publication March 1, 2002. * Equal study contribution. † Financial interest and/or other relationship with Searle, Baxter and Cook Urological. ‡ Requests for reprints: University of Chicago Medical Center, 5841 South Maryland Ave., MC 6038, Chicago, Illinois 60637. 0022-5347/02/1682-0653/0 THE JOURNAL OF UROLOGY Vol. 168, 653–659, August 2002 Copyright © 2002 by AMERICAN UROLOGICAL ASSOCIATION, INC. Printed in U.S.A.