European urology
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Chronic testicular pain (orchialgia, orchidynia or chronic scrotal pain) is common and well recognized but its pathophysiology is poorly understood. Currently treatment is largely empirical. This article aims to present an overview of its prevalence, possible aetiology and the available treatment options. ⋯ The importance of the sympathetic nervous system and the role of a possible alteration of the adrenergic receptors of the vas deferens in patients with chronic testicular pain are discussed. For patients failing to respond to conservative treatment, microsurgical denervation of the spermatic cord, epididymectomy and vasovasostomy have all shown a degree of relief. Unfortunately a small number of patients fail to respond to both conservative and more invasive treatment methods and for them the only available therapeutic option is inguinal orchiectomy.
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Review
Rational selection of a control arm for randomised trials in metastatic renal cell carcinoma.
Immunotherapy, and only immunotherapy, has reproducible, albeit limited efficacy in metastatic renal cell cancer (MRCC). Further improvement is warranted and progress will have to be investigated in randomised clinical trials, because the variable natural history of this disease precludes firm conclusions outside the context of controlled clinical studies. Currently, there is no general accepted standard arm to compare for those randomised clinical protocols. This needs to be established, which is the goal of this project. ⋯ An appealing safety profile, the applicability in an outpatient regimen, the possibility of less stringent selection criteria, and the proven life prolonging effect will make adjuvant monotherapy, in particular IFN-alpha monotherapy, after a tumournephrectomy currently the control-arm of choice in randomised trials for MRCC.
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Review
Treatment of superficial bladder tumors: achievements and needs. The EORTC Genitourinary Group.
The therapeutic objectives in the initial treatment of superficial tumors are to remove completely the tumor, to assess the need for further therapy and to plan the follow-up. ⋯ Investigation of the concept of chemoimmunotherapy up to now lacked evidence of advantages for this approach. Preventive regulatory measures directed to decrease tobacco smoking and some occupational exposures to aromatic amines may contribute to the reduction of bladder cancer. Bladder cancer is a multistep process making this tumor a candidate for chemoprevention. To date, retinoids are the best-studied chemopreventive agents achieving mixed clinical results in superficial bladder tumors. The potent apoptosis-inducing retinoid fenretinide is currently in the phase III trials. The follow-up of patients with all types of superficial tumors must be lifelong; unfortunately cystoscopy cannot be replaced yet by the control of any markers present or not in the urine. There is hope this may change in the near future.
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Intermittent hormonal treatment of prostate cancer was first developed based upon experimental study results. Using the Shionogi mouse breast cancer model, it was shown that the tumor grows rapidly in the presence of androgens, then undergoes apoptotic regression when androgens are removed. This apoptotic potential can be reinduced several times by cyclic replacement and withdrawal of androgens. These results led to the concept being evaluated in clinical trials. ⋯ These studies demonstrated that the androgen-dependent state of prostate cancer can be maintained during a course of intermittent androgen suppression, supporting the possibility of multiple apoptotic regressions under well-regulated conditions. Oliver et al. in 1997, conducted a retrospective study of 20 patients and concluded that intermittent androgen deprivation reduced induction of hormone-resistant prostate cancer, with no acute or major risk associated with the use of intermittent androgen suppression. More clinical studies are required to clarify the indication for intermittent hormone therapy and evaluate improvement in quality of life and survival. In the future, approaches to the improvement of therapeutic apoptosis could include intermittent hormone therapy, associated with additive cytotoxic therapeutic strategies.
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There is no debate that both the earlier diagnosis and the treatment of men with cancer of the prostate (CaP) are having an impact on patients with this disease. In many practices there are fewer and fewer patients presenting with the classic diagnosis of 'advanced disease', i.e., stage M (D2). Only a few years ago, a large percentage of men with CaP had bony metastases when they presented to a physician. ⋯ Newer advances, including 3-month depot formulations of luteinizing hormone-releasing hormone analogues, the reversibility of medical castration, the preference of most patients to have medical castration, and the approval of other antiandrogens in the United States, all have further strengthened the use of combined androgen blockade. Hormonal therapy in adjuvant settings, when there is a high likelihood of disease recurrence, is also being used in many clinical situations. In addition, there appears to be a role for certain types of hormonal therapy in chemoprevention.