Optimizing prostate biopsy.

Prostate biopsy (PBx) techniques have changed significantly since the original Hodge's scheme. Although the use of transrectal ultrasound (TRUS) guided (PBx) is considered the gold standard for the diagnosis of prostate cancer (Pca), the strategies for initial and repeat biopsies remain controversial. Even with the widespread application of extended prostate biopsy (ePBx) protocols, the false negative rate remains substantial and early PCa detection remains limited. Optimization of the PBx procedures reduce the likelihood of facing a "repeat biopsy dilemma". The aim of this review is to provide an evidence-based update on current methods of PBx and discuss the strategies to optimise biopsy procedures.

Detecting prostate cancer by intracellular macrophage prostate-specific antigen (PSA): a more specific and sensitive marker than conventional serum total PSA.

BACKGROUND: Serum prostate-specific antigen (PSA) is a standard method and a widely used marker for prostate cancer, but it has a poor specificity for early detection. Herein we demonstrate that intracellular macrophage PSA (imPSA) enables screening and differentiation between benign and malignant prostate disease. MATERIALS AND METHODS: The efficacy of intracellular macrophage PSA in circulating and tissue macrophages was therefore investigated in a double-centre study of 38 prostate cancer patients and 36 healthy controls by fluorescent-activated cell sorting analysis and immunohistology. RESULTS: Both methods uncovered the existence of PSA-positive macrophages specific for patients with prostate cancer. In addition, we demonstrate the superiority of our new test over standard serum total PSA in a blinded double-centre trial. ImPSA had a marked higher sensitivity and specificity than serum total PSA (imPSA: sensitivity 92%, specificity 92%, positive predictive value 92%; serum total PSA: sensitivity 79.5%, specificity 87.5%, positive predictive value 26.8%). CONCLUSION: In this study, we demonstrate that imPSA is a new prostate cancer screening method that is highly sensitive and more specific than standard PSA testing.

Biomarkers for early prostate cancer detection.

In the 1990s the discovery of prostate-specific antigen (PSA) revolutionized early prostate cancer detection. Since that time, PSA has become an indispensable marker for diagnosis and follow up of prostate cancer patients. Despite its remarkable performance, PSA is not cancer specific. High PSA levels are found in both cancerous and healthy tissue, particularly in benign prostate disease, resulting in significant numbers of false positive cases. Hence, there is a need for new markers that better differentiate benign from malignant lesions and indolent from aggressive cancers to decrease the potential over treatment of prostate cancer. With recent advances in biotechnology, many promising blood biomarkers have been identified and are currently under investigation. This article reviewed the literature searching for emerging biomarkers for early prostate cancer detection.

[Artificial neural networks for decision making in urologic oncology]. / Réseaux neuronaux artificiels pour la prise de décision en cancérologie urologique.

This chapter presents a detailed introduction regarding Artificial Neural Networks (ANNs) and their contribution to modern Urologic Oncology. It includes a description of ANNs methodology and points out the differences between Artifical Intelligence and traditional statistic models in terms of usefulness for patients and clinicians, and its advantages over current statistical analysis.

[Biological markers of prostate cancer]. / Marqueurs biologiques du cancer de la prostate.

Screening for prostate cancer is currently based on the assessment of blood prostate specific antigen (PSA). Although PSA was shown to be an adequate tool in prostate cancer screening, beginning from 4.0 ng/mL, its specificity is less significant. In men with a PSA between 4.0 and 10 ng/mL its predictive value is low. Therefore, there is a need for new instruments likely to improve the specificity of blood PSA levels between 4.0 and 10 ng/mL and the screening for prostate cancer in subjects with low PSA. Recent data are reviewed.

[Prostate cancer in the elderly patient]. / Cancer de la prostate du sujet âgé.

Although malignant tumours occur at all ages, cancer disproportionately strikes individuals in the age group 65 years and older. The increasing statistical life expectancy of men together with the introduction of prostate specific antigen (PSA) as a screening tool have both contributed to a rising number of elderly men with a diagnosis of prostate cancer. Age is generally considered to be a key prognostic factor in terms of therapeutic decision making, perhaps as important as PSA level and Gleason score. Even in men over 70 years, treatment without curative intent may deprive frail patients of years of life. When considering local treatment, strong consideration should be given to radical surgery. Modern radical prostatectomy is associated with low perioperative morbidity, excellent clinical outcomes as well as long term disease control. Besides, overdiagnosis has led to the concept of expectant management for screening-detected small-volume, low grade disease, with intention of providing therapy for those men experiencing disease progression.

Mucinous adenocarcinoma in defunctionalized bladders.

Primary adenocarcinoma of the bladder accounts for less than 2% of all bladder cancers. There is no report of such a case in a defunctionalized bladder. All reported cases of carcinoma in defunctionalized bladders were either squamous cell, signet ring cell, or transitional cell carcinoma, detected within an average of 5 years after urinary diversion, and all have been associated with chronic inflammation of the bladder. We report on 2 cases of adenocarcinoma that developed in defunctionalized bladders 30 and 8 years after ileal loop diversion for prune belly syndrome and neurogenic bladder, respectively.

False-positive serum prostate-specific antigen values in a patient with non-Hodgkin lymphoma of the kidney.

Prostate-specific antigen (PSA) is the clinically most useful tumor marker for prostate cancer. Although false-positive elevations have been reported due to disease processes outside the prostate gland with the use of the polyclonal assay, such false-positive test results have been exceedingly rare with the use of the monoclonal assay. We report the case of a patient diagnosed with a B-cell lymphoma of the kidney and a significant elevation of serum PSA levels by monoclonal assay in the absence of either inflammatory or malignant prostate disease. PSA returned to normal during lymphoma-specific chemotherapy with a cyclophosphamide, mechlorethamine, vincristine, procarbazine, prednisone regimen. Possible explanations and clinical implications are discussed.

Transurethral microwave thermotherapy: what role should it play versus medical management in the treatment of benign prostatic hyperplasia?

Both transurethral microwave thermotherapy (TUMT) and medical management by alpha-blockade or 5-alpha-reductase inhibition are increasingly being considered as alternatives to surgery for treatment of patients with benign prostatic hyperplasia (BPH). We review current evidence supporting the effectiveness and safety of TUMT and medical management. Factors for consideration in appropriately selecting patients for TUMT versus medical management are suggested. Available data indicate that TUMT confers greater long-term benefits than medical management as judged by symptom score and peak urinary flow rate improvements. TUMT-associated morbidity is comparatively low. Alpha-blockade affords more rapid relief than TUMT for patients with BPH; however, other strategies such as the use of temporary intraurethral endoprostheses during the acute post-TUMT recovery period may diminish or abolish the differences in time-course of symptom and flow rate improvement between TUMT and alpha-blockade. 5-Alpha-reductase inhibition with finasteride offers a favorable side-effect profile, although the magnitude of symptom and flow rate improvements is modest, and maximal effects of finasteride do not become manifest until after several months of treatment. As TUMT continues to evolve, increasing attention is being accorded the delivery of high thermal doses and precise targeting of the thermal energy delivered. The development of alpha-blockers with a more favorable side-effect profile continues to be a major focus of investigation. The potential clinical utility of combination therapy with TUMT and alpha-blockade is currently under investigation.

Radical retropubic prostatectomy for localized carcinoma of the prostate in a large metropolitan hospital: changing trends over a 10-year period (1984-1994). Dallas Outcomes Research Group for Urological Disorders.

OBJECTIVES: To analyze changing trends in the surgical treatment for localized carcinoma of the prostate in a large metropolitan community hospital over a 10-year period from 1984 to 1994. METHODS: The records of all 428 patients who underwent radical prostatectomy for localized carcinoma of the prostate from January 1, 1984, to January 1, 1994, at a large metropolitan community hospital (Baylor University Medical Center, Dallas, Tex) were retrieved and data abstracted in a predefined computerized database by a urology resident who was not part of the patient's surgical team. The abstracted data included attending surgeon, date of surgery, patient's age, clinical stage at presentation and pathologic stage, prostate-specific antigen (PSA), perioperative events, such as duration of surgery, blood loss, transfusion, duration of hospital stay, comorbidities according to the Charlson comorbidity index, and others. The data were analyzed in regard to changes over the 10-year period and stratified by a variety of parameters. RESULTS: The number of radical prostatectomies performed increased by fourfold from 1984 to 1993. The distribution of clinical stage and the incidence of pathologic upstaging noted in the 428 cases were similar to other series reported in the literature. The average age of patients decreased from 67 to 63 years over the 10 years (average calculated in increments of 15 cases in ascending order). Similarly, over time the average duration of surgery, average blood loss, average use of transfusion, and the average duration of hospital stay decreased. When the cases were grouped by individual attending surgeon, whose numerical surgical experience during that time period ranged from 1 to 76 cases, no correlation was noted between the numerical experience and these outcomes. CONCLUSIONS: As opposed to the national Medicare experience recently reported by the Prostate Patients Outcome Research Team, the increase in the number of cases performed was mostly due to patients under the age of 70 years, considered reasonable candidates for radical prostatectomy. Independent of numerical experience of individual attending surgeons, duration of surgery, blood loss, transfusion rates, and duration of hospital stay decreased during this period. This might indicate a learning effect due to continuing education, exchange of ideas, published technical improvements in the surgical procedure, and other factors, ultimately benefiting the patient by improving outcomes.

Neoadjuvant and adjuvant alpha-blockade improves early results of high-energy transurethral microwave thermotherapy for lower urinary tract symptoms of benign prostatic hyperplasia: a randomized, prospective clinical trial.

OBJECTIVES: Improved long-term results with respect to symptoms, voiding function, and quality of life (QOL) in patients with lower urinary tract symptoms (LUTS) of benign prostatic hyperplasia (BPH) are achieved with targeted high-energy transurethral microwave thermotherapy (TUMT) compared with alpha-blocker treatment alone. However, maximal improvement after TUMT is not attained until 3 to 6 months after treatment. Measures to provide earlier symptom relief and improved voiding function and QOL would add to the clinical utility of TUMT. The objective of the present study was to determine whether neoadjuvant and adjuvant alpha-blockade is capable of accelerating a post-TUMT decrease in LUTS of patients with BPH. METHODS: In this randomized, prospective study of 81 patients with LUTS of BPH, 41 underwent TUMT with neoadjuvant and adjuvant tamsulosin (0.4 mg daily) treatment, and 40 had TUMT alone. International Prostate Symptom Score (IPSS), peak urinary flow rate (Qmax), and QOL score were determined before treatment and at periodic intervals thereafter up to 12 weeks after TUMT. RESULTS: Mean IPSS values in the TUMT plus tamsulosin group at 2 weeks (14.0, 95% confidence interval [CI] 13.1 to 14.9) and 6 weeks (8.6; 95% CI 7.7 to 9.5) were 15% and 24% lower, respectively, than those at 2 weeks (16.5, 95% CI 15.6 to 17.4) and 6 weeks (11.3, 95% CI 10.4 to 12.2) in the TUMT-alone group (P<0.0005). However, by the final evaluation at 12 weeks, no significant difference between the groups in mean IPSS was evident. A similar temporal pattern of difference between the two study groups was also observed in QOL score. No significant between-group difference in mean Qmax was evident after TUMT. Urinary retention 1 week or more in duration occurred in 5 (12%) of 40 TUMT-alone group patients compared with 1 (2%) of 41 TUMT plus tamsulosin group patients. CONCLUSIONS: Neoadjuvant and adjuvant alpha-blocker treatment results in significantly greater early symptom reduction and QOL score improvement after TUMT, adding to the clinical utility of this minimally invasive treatment modality. In addition, post-TUMT complications such as urinary retention may be reduced.

Transperineal radiofrequency interstitial tumor ablation of the prostate: correlation of magnetic resonance imaging with histopathologic examination.

OBJECTIVES: Radiofrequency (RF) energy has recently been employed to destroy human tissue in vivo. The purpose of this study was to investigate the safety of this approach in localized carcinoma of the prostate (CaP) and specifically, the predictability of lesions obtained with radiofrequency interstitial tumor ablation (RITA). METHODS: Using RITA, a total of 21 lesions were induced in 10 patients with localized CaP (mean age 70.4 years). RF was delivered transperineally under transrectal ultrasound (TRUS) guidance. All patients underwent endorectal magnetic resonance imaging (MRI) before and after treatment. Radical prostatectomy was performed in all patients 1 to 7 days after RITA. Three of the patients were treated with local anesthesia only. The predictability of the thermal lesion was assessed by correlating the findings of intraoperative TRUS, pre- and post-RITA endorectal MRI, and the histologic examination of the specimen. RESULTS: Postoperatively, patients were catheterized for an average of 1.8 days (1 to 3 days). Lesions of 2 x 2 x 2 cm were targeted. Average lesion diameters obtained on MRI were 2.08 +/- 0.23 x 2.09 +/- 0.36 x 2.28 +/- 0.21 cm. Average lesion diameters defined by coagulative necrosis at histologic examination were 2.20 +/- 0.23 x 2.10 +/- 0.31 x 2.38 +/- 0.14 cm. There were no statistically significant differences (P = 0.377) between average lesion volume on MRI (5.37 +/- 1.83 cm3) and average lesion volume at histology (5.86 +/- 1.63 cm3). No complications or adverse events were noted. CONCLUSIONS: In this Phase I study, RITA was shown to be safe and feasible, and to result in lesions that were predictable in size and location. MRI accurately visualized and verified the area of coagulative necrosis as documented at histology. The procedure is technically simple and can even be performed under local anesthesia.

Postradical prostatectomy TRUS-guided anastomotic biopsy. Where do we stand today?

The issue of performing tissue sampling from the vesicourethral anastomotic area postradical prostatectomy (transrectal ultrasound-guided biopsy) after radical surgical treatment of local disease has failed, still remains controversial. We review a selection of articles that evaluate this procedure as well as newer diagnostic modalities and we discuss how this technique may have a position in our treatment dilemmas in cases with biochemical failure of undetermined origin.

Transurethral microwave thermotherapy: an alternative to medical management in patients with benign prostatic hyperplasia?

Transurethral microwave thermotherapy (TUMT) is being increasingly considered as an alternative to medical management with alpha-blockers or finasteride in patients with lower urinary tract symptoms (LUTS) of benign prostate hyperplasia (BPH). Enduring clinical benefits have been demonstrated after a single 1-hour microwave treatment session under topical anesthesia, and the associated morbidity is low. Optimal results are obtained with the delivery of high thermal doses and accurate targeting of microwave energy. Extensive evidence from randomized clinical trials supports the safety and efficacy of both microwave treatment and medical management, but randomized trial data have only recently become available directly comparing these two approaches to BPH treatment. These data indicate that greater long-term improvements in symptoms, peak urinary flow rates, and quality of life are attained with microwave treatment than with alpha-blockade. Furthermore, the actuarial rate of treatment failure is markedly lower in patients undergoing microwave v alpha-blocker treatment. However, the onset of action of alpha-blocker treatment is more rapid. The principal limitations of alpha-blockade are side effects and lack of efficacy leading to treatment failure in some patients. The maximal effects of finasteride are modest and require a period of months to be manifested, although the side effect profile and tolerability of this agent are favorable. Neoadjuvant and adjuvant alpha-blocker therapy can accelerate symptom and flow rate improvement after TUMT. In contrast to medical management, microwave treatment is highly versatile, allowing patients over a broad range of baseline symptom severities and prostate sizes to be treated with a high probability of success.

Prostate biopsy.

Transrectal ultrasound guided (TRUS) prostate biopsies is the standard method in the diagnosis of prostate cancer. The use of prostate specific antigen (PSA) and digital rectal examination for prostate cancer screening has led to a dramatic increase in the number of TRUS guided biopsies. Frequently urologists are faced with the dilemma of treating a patient with a high suspicion of prostate cancer, but an initial set of negative biopsies. In this review we focus on the current knowledge of prostate biopsies, the indication to perform a biopsy, the impact of prostate volume in the number of cores taken, the technique of an initial and repeat biopsies and when to stop.

[Chemoprevention of prostate cancer]. / Chemoprävention des Prostatakarzinoms.

Despite advances in the detection and management of prostate cancer, this disease remains a major cause of morbidity and mortality in men. Increasing attention has focused on the role of chemoprevention for prostate cancer, i.e., the administration of agents that inhibit one or more steps in the natural course of prostate carcinogenesis. We review prostate cancer chemoprevention studies in Europe. Published studies were identified in a search of MEDLINE. Information about ongoing studies was provided by author access to protocols. A variety of chemoprevention studies have focused on the role of dietary factors, vitamins, and trace elements in prostate cancer. Some of these studies have been prospective, randomized, and double-blinded, while others have used retrospective or epidemiological approaches. Large-scale randomized studies are also evaluating the role of 5alpha-reductase inhibitors, which inhibit the conversion of testosterone to the more potent androgen dihydrotestosterone. Robust evidence is lacking for the value of chemopreventive agents in prostate cancer. Current evidence does suggest that vitamin E and selenium may have a role in prostate cancer chemoprevention. Data from two studies, one examining the type 1 5alpha-reductase selective inhibitor finasteride and the other using the dual 5a-reductase inhibitor dutasteride, will determine the benefits of androgen inhibition strategies for prostate cancer chemoprevention.

[Prevention of temporary prostatic obstruction after high-energy microwave thermothery by placement of prostatic bridge catheter]. / Prévention de l'obstruction prostatique temporaire après thermothérapie micro-ondes haute énergie par mise en place d'un tuteur prostatique.

OBJECTIVES: The clinical utility of a novel intraurethral prostatic bridge-catheter (PBC) was evaluated for prevention of temporary prostate obstruction following targeted high-energy transurethral microwave thermotherapy (TUMT) in patients with benign prostatic hyperplasia (BPH). MATERIAL AND METHODS: High-energy TUMT was administered to 54 BPH patients under topical urethral anesthesia followed by placement of a PBC, which remained indwelling up to 1 month. Patient evaluation included determination of peak urinary flow rate (Qmax), International Prostate Symptom Score (IPSS), and quality of life (QOL) score at baseline, immediately following TUMT and PBC placement, and at periodic intervals thereafter up to 1 month. Results were compared retrospectively with those of 51 patients who underwent TUMT followed by standard temporary urinary catheterization, generally for 24 h. RESULTS: Immediately following TUMT and PBC placement significant improvements (p < 0.0005) were observed in mean Qmax, IPSS and QOL score of 59.3%, 33.5% and 23.6% respectively, compared with baseline values. Further improvements were demonstrable up to 1 month, at which time mean Qmax, IPSS and QOL score had improved 79.0%, 54.9% and 56.5%, respectively, vs baseline means (p < 0.0005). In a retrospective comparison at baseline and 14 days between PBC recipients (PBC group) and a cohort of TUMT patients who had undergone temporary standard catheterization and subsequent catheter removal (standard catheterization group), mean baseline Qmax, IPSS and QOL score were similar between the two groups. However, at the 14 day follow-up evaluation in the PBC group mean Qmax was 101.8% higher, and IPSS and QOL score were 47.9% and 51.1% lower, respectively, than the corresponding values in the standard catheterization group (p 0.0005). The PBC was well tolerated and remained in situ throughout the entire 1 month follow-up period in 48/54 (88.9%) patients. Early PBC removal was performed in 3/54 patients (5.6%) because of urinary retention and in 3/54 patients (5.6%) due to PBC migration. During the acute post-TUMT recovery period, PBC recipients experienced impairment in sexual function which, though statistically significant, was comparatively small in magnitude. CONCLUSION: PBC provides an efficacious and well-tolerated option for preventing prostatic obstruction in the acute post-TUMT period. This approach avoids the inconvenience and infection risk of standard indwelling catheters or intermittent self-catheterization. PBC insertion and removal are rapid, facile and non-traumatic. PBC placement may prove useful in improving the early results of TUMT.

Is transurethral microwave thermotherapy an alternative to medical therapy for patients with benign prostatic hyperplasia?

Scientific evidence supports the safety and efficacy of transurethral microwave thermotherapy (TUMT) as well as medical therapy for management of patients with benign prostatic hyperplasia (BPH). TUMT is being increasingly considered as an alternative to medical management with alpha-blockers or finasteride in patients with lower urinary tract symptoms of BPH. Enduring clinical benefits have been demonstrated after a single 1-hour microwave treatment session under topical anesthesia, and associated morbidity is low. Optimal results are obtained with the delivery of high thermal doses and accurate targeting of microwave energy. Extensive evidence from randomized clinical trials supports the safety and efficacy of both microwave treatment and medical management. Randomized clinical trial data have only recently become available directly comparing these two approaches to BPH treatment. These data indicate that greater long-term improvements in symptoms, peak urinary flow rates, and quality of life are attained with microwave treatment as compared with alpha-blockade. Furthermore, the actuarial rate of treatment failure is markedly lower in patients undergoing microwave vs. alpha-blocker treatment. However, the onset of action with alpha-blocker treatment is more rapid. Limitations of alpha-blockade are side effects and lack of efficacy leading to treatment failure in some patients. Maximal effects of finasteride are modest and require a period of months to be manifested, although the side effect profile and tolerability of this agent are favorable. Neoadjuvant and adjuvant alpha-blocker therapy can accelerate symptom and flow rate improvement after microwave treatment. In contrast to medical management, microwave treatment is highly versatile, allowing patients over a broad range of baseline symptom severities and prostate sizes to be treated with a high probability of success. Compared with medical management, microwave treatment also appears to possess greater versatility, allowing patients who fall within a broad range of baseline symptom severities and prostate sizes to be treated with a high probability of success.