Deceased donor kidney procurement: Systematic review of the surgical technique.

INTRODUCTION: Kidney procurement procedure must be carried out following a standardized technique in order to optimize kidney grafts for their subsequent implantation. OBJECTIVES: Review of the available literature on kidney procurement procedure. MATERIAL AND METHODS: Narrative review of the available evidence on deceased donor kidney procurement technique after a search of relevant manuscripts indexed in PubMed, EMBASE and Scielo written in English and Spanish. RESULTS: Deceased donor kidney procurement can be divided into two groups, donation after brain death (DBD) and donation after circulatory death (DCD). Kidney procurement in DBD frequently includes other chest and/or abdominal organs, requiring multidisciplinary surgical coordination. During the harvesting procedure, the renal vascular pedicle must remain intact for subsequent implantation and reduced ischemia time. CONCLUSIONS: Adequate execution and perfect knowledge of the technique for surgical removal and anatomy reduces the rate of graft losses associated to inadequate harvesting techniques.

[Urinary calculi in myelomeningocele adults]. / Litiasis urinaria en adultos con mielomeningocele.

INTRODUCTION AND OBJECTIVES: The improvements in the management of newborns with myelomeningocele (MMC) have obtained a big increase in survival, allowing them to get longevity like never before, but data regarding urologic diseases during adult age are still missing. We herein evaluate the features of urinary lithiasis in adults born with MMC and the therapies used for its treatment. MATERIAL AND METHOD: We review 52 patients diagnosed at birth of MMC, between 18 and 40 years old, treated in our institution, with a mean follow-up of 6.7 years. RESULTS: 10 patients (19.2%) were diagnosed of urolithiasis. Three developed kidney calculi and one of them, with 7 more patients, developed bladder calculi (15.3%). The neurological level was < or = L2 in 3 cases, L2-S1 in 5, and > or = S1 in the other two. The type of neurogenic dysfunction of inferior urinary tract was multiple lesion of lower motor neurone in 6 cases, upper motor neurone in 1 case, multiple mixed lesion in 1 case and in case it was impossible to determine. Two patients had a bladder augmentation procedure and one of these with other 3 patients had a non-functional AMS-800 artificial urinary sphincter. Bladder stones were treated endoscopically in 14 procedures and by suprapubic cystolithotomy in 4 procedures, combined with removal of AMS-800 in 3 of them. One patient spontaneously passed a small stone. In one case, 2 ESWL and 2 percutaneous nephrolithotomies were needed. Three patients developed multiple recurrences during follow-up. CONCLUSIONS: Urinary lithiasis is common in adults with MMC. Some distinct features of these patients, together with their anatomical configuration and some therapies used in them, cause diagnostic, therapeutic and prophylaxis issues for the calculi they may develop.

[Primary seminal vesicle abscess: diagnosis and treatment by transrectal ultrasound]. / Absceso primario de vesicula seminal: diagnóstico y tratamiento mediante ecografía transrectal.

A 38 years old man with the only past medical history of bilateral orchiopexy 15 years ago is diagnosed of left primary seminal vesicle abscess. The patient is sent to our emergency service with an ultrasound finding of either dilated vas deferent or seminal vesicle abscess with hiperecogenic material inside it. The examination was performed after a 5 month history of purulent ejaculation. The diagnose of seminal vesicle abscess is confirmed by TRUS and, in the same procedure, drainage of the abscess was completed by needle-aspiration puncture. After this treatment the patient stay 12 hours at the observation room with intravenous antibiotics and is discharged home with oral antibiotics. We are interested in this case because of the low incidence of this pathology and the easy diagnosis and treatment by TRUS.

[Nutcracker's syndrome: demostration with helicoidal TC with volumetric reconstruction "3D"]. / Síndrome "Nutcracker" o Cascanueces: demostración mediante TAC Helicoidal con reconstrucción "3D" (VR).

The nutcracker's syndrome or phenomenom is defined as the left renal vein compression between the aorta and the superior mesenteric artery. Diagnosis is uncommon, not only due to its low frequency but for the dificulty to be suspected in usual findings as lumbar pain or hematuria. We present the case of a patient to whom we were able to show mentioned pathology with the helicoidal TC with volumetric reconstruction "3D" (VR).

[Incidence and significance of "atypical acinar proliferation" in transrectal prostatic biopsies]. / Incidencia y significación de la "proliferación acinar atípica" en las biopsias transrectales de próstata.

OBJECTIVE: To determine the incidence of atypical acini in our series, the percentage of prostate cancer and other suspicious or preneoplastic lesions in the successive biopsies and to establish a follow up strategy in these patients. MATERIAL AND METHOD: A total of 117 patients diagnosed with isolated atypical acini or associated with high grade PIN were obtained from our database, 75 (64%) of these were submitted to at least a second biopsy of the gland. The age, PSA, digital rectal examination (DRE), prostate volume, ultrasound nodule and previous pathological diagnosis were compared with the pathology results of the successive biopsies of the gland. RESULTS: Incidence of atypical acini was 4%. A total of 46.7% of patients undergoing a repeat biopsy presented prostate cancer. We did not find significant differences in the clinical variables studied between patients with or without a definite cancer diagnosis. Patients initially diagnosed with acinar atypia with associated high grade PIN presented a higher incidence of cancer in the repeat biopsy than patients with isolated acinar atypia (p=0.007). A total of 94.3% of all neoplasms diagnosed were detected in the 2nd and 3rd biopsy. CONCLUSIONS: Patients with atypical acini are at high risk of having prostate cancer not detected in the first biopsy. They should, therefore, undergo a second biopsy as soon as possible. There is only a very small probability of detecting cancer after the 3rd biopsy.

[Pediatric renal transplantation from young children donors (aged < or = 6 years). Complications and functional clinical course]. / Trasplante renal pediátrico con injertos de donantes infantiles de corta edad (< or = 6 años). Complicaciones y evolución funcional.

GOALS: To evaluate functional results and complications in a group of pediatric patients who received kidney transplants from donors aged 6 years or less. MATERIAL & METHODS: Thirty-four consecutive renal transplants were reviewed. Of 34 patients, 19 (55.8%) received kidneys from donors aged below 3 years (Group A) and 15 (44.2%) from donors aged 3-6 years (Group B). Long-term functional patient and graft survival results along with complications were compared in both groups. RESULTS: Seven patients in group A (36.7%) had vascular complications, in comparison to 3 in group B (20%, p<0.05). Kidneys preserved in Eurocollins (EC) solution had more vascular complications (35.3%) in comparison to University of Wisconsin (UW) solution kidneys (23.5%, p<0.05). Ten-year graft survival rate in group A was significantly lower in comparison to group B (35.5% vs 58.6%, p<0.05). In relation to preservation solution type used, 10-year graft survival rate was also significantly better in UW group (26.8% vs 63%, p<0.001). CONCLUSIONS: The exclusion of donors younger than 3 years and the utilization of optimal preservation solutions produces a decrease in figures of vascular complications and a significant improvement in graft survival rates.

Hydrodynamic and biochemical effects of isolated hypothermic renal perfusion depending on the pump model and perfusion solution.

OBJECTIVES: To evaluate hydrodynamic, biochemical, and histological consequences of hypothermic isolated renal perfusion using a new computerized perfusion system. MATERIALS AND METHODS: The device that allowed us to obtain on renal hydrodynamics during perfusion included multiple parts. The organ was perfused at 4 degrees C with a constant flow either using a classic roller pump or a pump designed in our laboratory to employ vacuum or atmospheric pressure sequentially to achieve a truly pulsatile wave (vacuum-powered tubular pump). The study included 16 minipigs with Eurocollins or Belzer perfusion solutions sampled at predefined interval and histological studies of the organs performed. RESULTS: There was a significant difference in weight increase between the two types of pumps; those perfused with Eurocollins showed greater values than those with Belzer solution. Onset of nitric oxide (NO) in the perfusion solution increased inversely with the renal vascular resistance. The highest NO levels were observed with the Belzer solution and vacuum pump. CONCLUSIONS: Changes in renal hydrodynamics, as induced by perfusion wave form and solution type, may be recorded in real time using a computerized system. A vacuum pump with the Belzer solution achieved the best experimental results.

[Incidence of high grade prostatic intraepithelial neoplasm in transrectal biopsy of the prostate]. / Incidencia de la neoplasia intraepitelial prostática de alto grado en las biopsias transrectales de la próstata.

OBJECTIVE: To analyze the incidence of high grade prostatic intraepithelial neoplasia (PIN) in the transrectal prostate biopsies of patients from the Urology department. METHODS: From 1995 to 1999, 2018 patients aged 46-92 years (mean 68 +/- 10) had a transrectal biopsy. Thirty-six percent had a suspicious DRE and the mean serum PSA was 31.7 +/- 152.9 ng/ml. The anatomopathological diagnoses were: a) cancer, b) benign pathology, c) high grade PIN and d) glandular atypia. Statistical analysis using the chi square and Mann-Whitney tests was performed to compare the following variables: age, DRE, PSA, PSAf/PSAt ratio and the finding of a suspicious node on ultrasound. RESULTS: The incidence of high grade PIN in this series was 8% and the incidence of prostate cancer was 38.6%, PIN grade 3 was diagnosed in 94 patients and PIN grade 2 in 67, and was associated with glandular atypia in 13 patients. Patients with prostate cancer were older and showed statistically significant higher PSA, percentage of suspicious DRE, sonographically suspicious nodes, and a lower PSAf/PSAt ratio than the other diagnoses (p < 0.001). Comparison of patients with high grade PIN and those with benign pathology showed no differences for age, DRE, PSA levels and PSAf/PSAt ratio. However, a significantly lower incidence of sonographically suspicious nodes was found (p < 0.001). CONCLUSIONS: The incidence of high grade PIN was 8%. High grade PIN does not cause sufficient changes in the clinical variables analyzed to suspect this lesion before it is confirmed by the pathological findings.

[Differences in survival of patients with bladder cancer depending on depth of muscle infiltration]. / Diferencias en la supervivencia de los pacientes con cáncer de vejiga según la profundidad de la infiltración muscular.

OBJECTIVE: To study the survival of patients with bladder cancer and infiltration into the muscle who undergo radical cystectomy, documenting any survival difference based on the depth of muscle infiltration (pT2a vs. pT2b). MATERIAL AND METHOD: 109 patients with infiltration into the muscle (T2) in the TUR were treated with radical cystectomy between 1986 and 1996; 39 patients were excluded due to infra-staging and 2 died in the immediate postoperative: 68 patients were eligible for the study. Median follow-up was 51 months. At the time of analysis 44 were alive (2 with tumoral disease and one with a second non-urological tumour), 21 had died (4 for causes other than vesical tumour) and 3 patients were considered lost to follow-up at 3, 31 and 111 months. Survival analysis was performed using the Kaplan-Meier method, and the variables were compared with the log-rank test. RESULTS: The 3- and 5-year overall survival of our series was 76% and 62%, while cancer specific survival was 80% and 70% respectively. Cancer specific survival at 5 years by stages was: pT0-83%, pT1-80%, pT2a-66% and pT2b-60% (p = 0.52). The cystectomy specimen (pT0) showed no residual tumour in 15 (22%) patients, and 5-year cancer specific survival in this group was 83% vs. 66% in patients with residual cancer (p = 0.24). CONCLUSIONS: Patients with pT2a and pT2b bladder cancer showed no differences in survival and we believe they should be all included in the same prognostic group (pT2). pT0 patients are a subgroup of patients with significant survival rates in which radical cystectomy should be considered as overtreatment, and a more conservative protocol should be preferred.

[Radical cystectomy in the treatment of cancer of the bladder]. / La cistectomía radical en el tratamiento del cáncer de vejiga.

OBJECTIVE: To analyze retrospectively the efficacy of radical cystectomy alone in the treatment of transitional cell carcinoma of the bladder. METHODS: 125 patients who underwent radical cystectomy were evaluated. The mean follow-up was 62 months. At the time of the study, 65 patients were alive (3 with bladder tumor and 1 with a second primary) and 60 patients had died (50 from bladder cancer and 10 from other causes). Nine patients were lost to follow-up. The Kaplan-Meier method was used for the survival analysis and the log-rank test for the comparison of the variables. RESULTS: The overall survival at 5 years was 50% and the cancer-specific survival was 56%. By tumor stage, the cancer-specific survival at 3 and 5 years were respectively: 83% and 85% for pT1, 78% and 70% for pT2, 52% and 42% for pT3, 24% and 12% for pT4 and 14% for pN+ (p < 0.0001). No differences were found between stages pT2a (73% and 68%) and pT2b (71% and 53%) (p = 0.2). The survival was significantly higher in patients with no residual tumor in the cystectomy specimen (pT0) (93% and 83%) than in those with residual tumor (60% and 53%) (p = 0.03). CONCLUSIONS: Radical cystectomy alone in the treatment of transitional cell carcinoma of the bladder was found to be effective in patients with tumor stage pT2. It is less effective in patients with tumor in the advanced stages (pT3 or pT4) or lymph node invasion. Radical cystectomy is an overtreatment in patients with no residual tumor in the cystectomy specimen.

[Usefulness of free PSA/total PSA ratio in the diagnosis of prostatic cancer in symptomatic patients with PSA levels ranging from 2.5 to 20 ng/ml]. / Utilidad del cociente PSA libre/PSA total en el diagnóstico del cáncer de próstata en pacientes sintomáticos con niveles de PSA entre 2,5 y 20 ng/ml.

OBJECTIVE: To evaluate the value of free PSA/total PSA ratio (fPSA/tPSA) to boost total PSA (tPSA) specificity in the diagnosis of prostate cancer in a series of symptomatic patients. MATERIAL AND METHOD: Prospective study on 334 patients presenting symptoms compatible with PBH and tPSA (ProStatus, Wallace Oy, Turku, Finland) between 2.5 and 20 ng/ml, and mean age 67.2 +/- 7 (49-87). Patients were divided into 3 groups: Group I (normal DRE and tPSA between 2.5 and 10 ng/ml)--189 patients. Group II (normal DRE and tPSA between 10 and 20 ng/ml)--78 patients. Group III (suspicion DRE and sPSA between 2.5 and 20 ng/ml)--67 patients. For each group, the sensitivity, specificity and ROC curves were calculated for several cut-off values of the lPSA/tPSA ratio. RESULTS: Group I--Prostate cancer was diagnosed in 11% (20/189) patients. Significant differences were found only in the lPSA/tPSA ratio (p = 0.01). Using 27% as the cut-off value, cancer would have been diagnosed in 95% (19 of 20) patients, decreasing the total number of negative biopsies by 21% (39 of 189). Group II--Prostate cancer was diagnosed in 19% (15/78) patients. The only significant differences found were in prostate volume (p = 0.02). Using 30% as the cut-off value, 93% (14 of 15) patients with cancer would have been diagnosed, decreasing the total number of biopsies by 6.5% (5 of 78) and the number of negative biopsies by 8% (5 of 63). Group III--Prostate cancer was detected in 72% (48/67) patients. Significant differences were found in lPSA/tPSA ratio (p = 0.003), prostate volume (p = 0.02) and presence of ultrasound nodes (p = 0.004). Using 25% as the cut-off value, 96% (46 of 48) of patients with cancer would have been diagnosed, decreasing the total number of biopsies by 13% (9 of 67) and the number of negative biopsies by 47% (9 of 19). CONCLUSIONS: We advise use of lPSA/tPSA ratio only in patients with normal DRE and tPSA between 2.5 and 10 ng/ml. Biopsing patients with lPSA percent equal to or lower than 27% would have prevented 23% of negative biopsies while still maintaining a diagnostic sensitivity of 95%.

Need for intravenous urography in patients with primary transitional carcinoma of the bladder?

OBJECTIVE: To assess the need for and the efficacy of intravenous urography in the detection of a synchronous upper tract urothelial tumor (UTUT) in patients with primary bladder tumor. MATERIALS: Between 1986 and 1996, 793 patients were diagnosed as having primary tumor of the bladder with pathological confirmation of transitional cell carcinoma. All patients underwent intravenous urography prior to transurethral resection. The mean age of the patients was 66.4 years, and 87.7% of them were male. Of these patients, 72% had superficial tumors, while the remaining 28% had infiltrative tumors. Histological classification of the tumors was: grade I, 10%; grade II, 45%, and grade III, 45%. A chi(2) test was used for statistical analysis. RESULTS: The incidence of upper tract urothelial tumors was 1.1% (9 patients), although intravenous urography only diagnosed 6 cases (0.7%). No differences were seen between patients with or without UTUT with regard to histological grade (p = 0.7), multiple bladder tumors (p = 0.7) and tumor infiltration (p = 0.9). In 5.8% of the patients an unsuspected associated pathology was detected which required treatment in 1.4% of the cases. CONCLUSIONS: Due to the low incidence of UTUT (1.1%) in our series and to the fact that intravenous urography was effective in diagnosing synchronous UTUT in only 66.6% of cases, we do not consider that this procedure should be routinely performed in the diagnostic workup of patients with primary transitional cell tumor of the bladder.

[The diagnostic effectiveness of repeat echo-guided transrectal biopsy as a function of the clinical and anatomicopathological findings]. / Rentabilidad diagnóstica de la biopsia transrectal ecodirigida repetida en función de los hallazgos clínicos y anatomopatológicos.

OBJECTIVE: To evaluate the incidence of false negatives in our series of ultrasound-guided prostate biopsies. MATERIAL AND METHOD: 106 patients (79% with high PSA and the remainder with suspicion digital rectal examination) with cancer-free transrectal biopsy underwent at least a second biopsy limited to the peripheral area: mean age 68 +/- 6.4 years, mean number of biopsy punctures 5 +/- 1, 95% patients with biopsies from both lobes. Re-biopsy indication was the result of persistently high PSA in 84 patients (13 with glandular atypia and 3 with PIN 3), or suspicion digital rectal examination in 22 patients (4 with glandular atypia and 2 with PIN 3). Second biopsy was performed in 89% patients, third in 10% and fourth in just one patient. RESULTS: 14% patients were found to have cancer, tumour diagnosis being made on the second biopsy in 93.3% cases. In patients with suspicion digital rectal examination only, cancer was detected in 31%, and 7.3% patients with high PSA had cancer; 40% patients with PIN 3 and 18% patients with glandular atypia had cancer. In patients with high PSA only, PSA (p = 0.6) and PSAD (p = 0.3) levels and the presence of changes in the ultrasound (p = 0.8) were not enough to detect cancer patients. Deobstructive prostate surgery was performed in 15 patients after re-biopsy, cancer being found in the transitional area in 20% cases. CONCLUSIONS: Our recommendation is that all patients with suspicion digital rectal examination, high grade PIN or glandular atypia should undergo re-biopsy which should include the transitional area. Due to the low incidence of cancer in patients with persistently high PSA and the inefficiency of biochemical and ultrasound parameters to detect patients with cancer, we suggest that each case should be assessed on an individual basis.

[Incidence of prostatic cancer in symptomatic patients with non-suspicious rectal palpation and PSA levels greater than 10 ng/ml]. / Incidencia de cáncer de próstata en los pacientes sintomáticos con tacto rectal no sospechoso y niveles de PSA mayores de 10 ng/ml.

OBJECTIVE: To evaluate the overall incidence of prostate cancer in patients with symptoms of prostatism, no suspicious DRE and PSA > 10 ng/ml. MATERIAL AND METHOD: 397 eligible patients based on the above criteria, mean age 69.3 +/- 7.7 years and mean PSA level of 21.3 +/- 29.3 ng/ml, underwent ultrasound-guided transrectal biopsy of the peripheral and central areas. Patients with no cancer in the biopsy and surgery indication underwent prostate surgery. Incidence of cancer in the transitional area was evaluated in these patients. RESULTS: Biopsy was found to be positive for cancer in 15.4% patients. Patients with prostate cancer had PSA concentrations (p = 0.06) and PSAD (p < 0.0001) lower than cancer-free patients. Thirteen (21%) of these patients underwent radical prostatectomy; an extracapsular tumour was found in 46% of the surgical specimens. Of the 336 patients with benign histology in the biopsy, 94 (28%) underwent prostate surgery. Cancer in the transitional zone was found in 15% cases (5 T1a and 8 T1b), with significant differences between PSA (0.03) and PSAD (0.04) concentrations between patients with BPH or T1b tumour in the surgical specimen but not among patients with BPH and T1a cancer. CONCLUSIONS: Approximately 30% of these patients had prostate cancer, half of them found in the transitional area. PSA and PSAD did not show enough diagnostic strength to identify these patients. Most patients with cancer had clinically significant tumours. Therefore, we believe that prior to deciding the course of therapy these patients should undergo another series of biopsies including the transitional area, mainly in those with long-term life expectancy.

[Upper urothelium tumor in patients treated with radical cystectomy for transitional carcinoma of the bladder]. / Tumor de urotelio superior en pacientes sometidos a cistectomía radical por carcinoma transicional de vejiga.

OBJECTIVE: To evaluate the incidence and characteristics of tumours in the upper endothelium (TUE) that develop in patients with transitional carcinoma of the bladder treated with radical cystectomy. MATERIAL AND METHOD: Between 1986 and 1996, 160 evaluable patients who underwent cystectomy due to transitional cancer of the bladder were reviewed and found to be infiltrant in 96% cases. Follow-up either until death or to the date of the study, was carried out with intravenous urography (IVU) in the first 6 months with additional urographies at least every two years. RESULTS: Five (3.1%) patients showed progress of the upper endothelium tumour, which was multifocal in 3 patients and infiltrant also in 3. No association was seen in these patients with in situ carcinoma of the bladder, or urethral invasion by the primary tumour: only one patient had tumour involvement of end ureters. After three months from diagnosis, tumour-related mortality was 50%. Incidence of upper endothelium tumours in patients with infiltrant tumour of the bladder was lower (1.9%) than in patients with surface tumour of the bladder (16.6%). CONCLUSION: Based on data from our series, the incidence of TUE was 3.1% with a mean time interval between cystectomy and TUE diagnosis of 25.4 months. IVU was diagnostic only in 40% cases. No risk factors were identified in our patients, and mortality due to advanced stage of TUE at three months was 50%. The high percentage of patients with advanced TUE in our series warrants the addition of an annual IVU in the follow-up of these patients.

[Hemorrhagic prostatic cyst following ultrasound guided biopsy. A case report]. / Quiste hemorrágico de próstata después de biopsia ecodirigida. A propósito de un caso.

OBJECTIVE: To describe a case of a hemorrhagic prostatic cyst following ultrasound-guided biopsy of the prostate gland. METHODS/RESULTS: We reviewed our series of 77 patients submitted to re-biopsy of the prostate; only one case (1.3%) of hemorrhagic post-biopsy prostatic cyst was found. The ultrasound features, differential diagnosis and management of these cystic lesions are discussed. CONCLUSIONS: Hemorrhagic post-biopsy prostatic cyst is rare in our series (1.3%). A history of a previous biopsy in the area of the cystic lesion, the results of punction-aspiration of the cystic content and biopsy of the prostate gland provide data that are necessary to make the diagnosis.

[Incidental prostatic cancer]. / Cáncer incidental de próstata.

OBJECTIVE: To evaluate the incidence of incidental prostate cancer and PSA ability to predict its presence. MATERIAL AND METHOD: Retrospective study of 862 patients undergoing prostate surgery between 1994 and 1997, both inclusive. Digital rectal examination provided no suspicion of neoformation. Mean age was 68 +/- 7.5 years. Mean PSA, 8.3 +/- 10 ng/ml (Hybritech). 15% patients had previously undergone at least one ultrasound-guided biopsy in the peripheral area. 55% patients underwent retropubic surgery and the remaining 45% prostate transurethral resection. Ultrasound prostate volume for both patient groups was 107 +/- 63 cc and 45 +/- 25 cc, respectively. RESULTS: Incidental cancer was found in 6% patients; 65% were T1a and 35% T1b. Mean PSA concentration in cancer patients was almost significantly (p = 0.05) higher than in patients with BPH. Patients with PSA > 10 ng/ml presented a significantly higher incidence of cancer (p = 0.02). Patients with previous prostate biopsy showed a cancer incidence rate of 12% versus 5% patients with no previous biopsy (p = 0.001). CONCLUSIONS: Incidence of incidental prostate cancer was 6%. PSA was not a good predictor of incidental cancer. Patients with PSA > 10 ng/ml, showed higher incidence of cancer. Younger patients with PSA > 10 ng/ml, and at least one negative biopsy of the peripheral area should undergo biopsy of the transitional area prior to surgery.

[Clinical and ultrasonographic characteristics of prostatic cancer diagnosed with transrectal biopsy]. / Características clínicas y ecográficas del cáncer de próstata diagnosticado mediante biopsia transrectal.

OBJECTIVE: To analyze the clinical, ultrasound and pathological characteristics of patients with prostate cancer diagnosed by ultrasound-guided transrectal biopsy who consulted for lower urinary tract symptoms compatible with benign hyperplasia of the prostate. METHODS: From 1994 to 1998 ultrasound-guided transrectal biopsy of the prostate was performed in 1,548 patients aged 49-90 years (mean age 70 +/- 7). Of these, 613 (40%) were diagnosed with cancer. Biopsy was performed in 161 patients (60%) with elevated PSA but no suspicion of cancer on digital rectal examination, and 452 patients with a suspicious DRE. Only 10 of these 452 patients (2%) had a PSA value within the normal ranges. Ninety-seven percent of the patients with cancer were diagnosed at the first biopsy. RESULTS: The DRE findings were compatible with locally advanced cancer in 25% of the patients. An echogenic nodule was detected in 79%; the nodule was hypoechoic in 93% of the cases. Ninety-four percent of the patients with a suspicious DRE versus 37% of those with a normal DRE showed a nodule on ultrasound (p < 0.001). According to the ultrasound and DRE findings, 41% of the patients had a localized cancer. Cancer was diagnosed in 70% of the patients with a nodule; 51% of the cases had high grade carcinoma (score 8, 9 or 10). Sixty percent of the patients with a suspicious DRE had high grade cancer versus 30% of the patients with a normal DRE (p < 0.001). Twenty-three percent of the patients underwent radical prostatectomy. Only 34% of the patients had a localized tumor. CONCLUSIONS: Most of the tumors of the prostate diagnosed in patients who presented with lower urinary tract symptoms compatible with BHP were high grade and locally advanced and therefore not susceptible to cure. PSA determination and digital rectal examination at the primary care level can be useful in detecting prostate cancer in the early stages without significantly increasing costs.