A 970 Hounsfield units (HU) threshold of kidney stone density on non-contrast computed tomography (NCCT) improves patients' selection for extracorporeal shockwave lithotripsy (ESWL): evidence from a prospective study.

UNLABELLED: What's known on the subject? and What does the study add? Stone density on non-contrast computed tomography (NCCT) is reported to be a prognosis factor for extracorporeal shockwave lithotripsy (ESWL). In this prospective study, we determined that a 970 HU threshold of stone density is a very specific and sensitive threshold beyond which the likelihood to be rendered stone free is poor. Thus, NCCT evaluation of stone density before ESWL may useful to identify which patients should be offered alternative treatment to optimise their outcome. OBJECTIVE: • To evaluate the usefulness of measuring urinary calculi attenuation values by non-contrast computed tomography (NCCT) for predicting the outcome of treatment by extracorporeal shockwave lithotripsy (ESWL). PATIENTS AND METHODS: • We prospectively evaluated 50 patients with urinary calculi of 5-22 mm undergoing ESWL. • All patients had NCCT at 120 kV and 100 mA on a spiral CT scanner. Patient age, sex, body mass index, stone laterality, stone size, stone attenuation values (Hounsfield units [HU]), stone location, and presence of JJ stent were studied as potential predictors. • The outcome was evaluated 4 weeks after the ESWL session by NCCT. • ESWL success was defined as patients being stone-free (SF) or with remaining stone fragments of <4 mm, which were considered as clinically insignificant residual fragments (CIRF). RESULTS: • Our survey concluded that 26 patients (52%) were SF, 12 (24%) had CIRF and 12 (24%) had residual fragment on NCCT after a one ESWL treatment. • Stones of patients who became SF or had CIRF had a lower density compared with stones in patients with residual fragments [mean (sd) 715 (260) vs 1196 (171) HU, P < 0.001]. • The Youden Index showed that a stone density of 970 HU represented the most sensitive (100%) and specific (81%) point on the receiver-operating characteristic curve. • The stone-free rate for stones of <970 HU was 96% vs 38% for stones of ≥ 970 HU (P < 0.001). A linear relationship between the calculus density and the success rate of ESWL was identified. CONCLUSION: • The use of NCCT to determine the attenuation values of urinary calculi before ESWL helps to predict treatment outcome, and, consequently, could be helpful in planning alternative treatment for patients with a likelihood of a poor outcome from ESWL.

Management of adenocarcinoma of the female urethra: case report and brief review.

INTRODUCTION: We present a case of a differentiated adenocarcinoma of the female urethra, which caused dysuria and voiding dysfunction. MATERIALS AND METHODS: A 54-year-old female presented with dysuria and the sensation of incomplete voiding. RESULTS: An ultrasound-guided biopsy showed a urethral carcinoma. A magnetic resonance imaging (MRI) scan showed a high-stage tumor. The patient had a pelvic exenteration. The patient was free of disease after 2 years of follow up. CONCLUSION: Urethral carcinoma is a rare malignancy. A biopsy is necessary to make a diagnosis. MRI is the best imaging for tumor staging. Small tumors are treated with a single modality option including sparing surgery or radiotherapy. Advanced disease should be treated with a multimodality of options including neoadjuvant radiotherapy given concomitantly with chemotherapy followed by surgery.

The 20-core prostate biopsy protocol--a new gold standard?

PURPOSE: We investigated the ability of a 20-core prostate biopsy protocol to enhance the prostate cancer diagnosis rate. MATERIALS AND METHODS: We compared the diagnosis rate of prostate biopsies in 2 groups of consecutive patients, including group 1-10 cores and group 2-20 cores. The prostate specific antigen range in the 2 groups was 3 to 30 ng/ml and biopsies were performed because of increased prostate specific antigen (more than 3 ng/ml) and/or abnormal digital rectal examination. To analyze the results we divided each group into 3 subgroups according to prostate specific antigen, including group 1-3 to less than 6 ng/ml, group 2-6 or greater to less than 10 ng/ml and group 3-10 or greater to up to 30 ng/ml. Multivariate analysis was performed to assess the difference in the diagnosis rate among the subgroups according to the number of cores taken. RESULTS: The percent of positive biopsies was 39.7% in group 1 and 51.7% in group 2. Multivariate analysis confirmed that the number of biopsies taken was a factor that independently and significantly correlated with the prostate cancer diagnosis. The 20-core biopsy protocol was more efficient than the 10-core protocol in the 3 subgroups with 47.2% vs 28.1% of patients diagnosed in group 1 (OR 3.26, p = 0.001), 40.5% vs 36.1% in group 2 (OR 2.37, p = 0.009) and 69.8% vs 39.7% in group 3 (OR 2.01, p = 0.015). CONCLUSIONS: The 20-core biopsy protocol was more efficient than the 10-core biopsy protocol, especially in patients with prostate specific antigen between 3 and 6 ng/ml. Nevertheless, it is mandatory to confirm whether detected tumors are clinically significant on pathological examination of the radical prostatectomy specimens.

Double J stent reduces the efficacy of extracorporeal shock wave lithotripsy in the treatment of lumbar ureteral stones.

INTRODUCTION: We evaluated the effect of the presence of a double J stent on the efficacy of extracorporeal shock wave lithotripsy (ESWL) in the treatment of lumbar ureteral stones. MATERIAL AND METHODS: Between January 2007 and February 2012, we performed a retrospective cohort study. Forty-four patients were treated by ESWL for lumbar ureteral stones and included into two groups for the analysis: group 1, non-stented (n = 27) and group 2, stented patients (n = 17). Treatment efficacy was evaluated by abdominal X-ray or CT-scan at 1 month. Stone-free patients and those with a residual stone ≤4 mm were considered to be cured. RESULTS: Mean stone size and density in groups 1 and 2 were 8.2mm/831HU, and 9.7 mm/986HU respectively. Both groups were comparable for age, BMI, stone size and density, number, and power of ESWL shots given. The success rates in groups 1 and 2 where 81.5% and 47.1%, respectively (p = 0.017). There was no difference between the groups for stones measuring 8 mm or less (p = 0.574). For stones >8 mm, the success rates were respectively 76% and 22.2% for groups 1 and 2 (p = 0.030). Logistic regression analysis revealed a higher failure rate when a double J stent was associated with a stone >8 mm (p = 0.033). CONCLUSIONS: The presence of a double J stent affects the efficacy of ESWL in the treatment of lumbar ureteral stones. This effect is significant for stones >8 mm. Ureteroscopy should be considered as the first-line treatment in such patients.

The learning curve of transrectal ultrasound-guided prostate biopsies: implications for training programs.

OBJECTIVE: To assess the quality of specimens obtained from prostate biopsies performed by urology residents and evaluate the number of procedures required to perform high-quality transrectal ultrasound (TRUS)-guided prostate biopsies. MATERIALS AND METHODS: Between 2006 and 2009, 770 patients underwent TRUS-guided prostate biopsies in our academic center. During the 6 semesters of this period, 24 residents (4 per semester) performed 1 session of 5.6±1.5 procedures each month for a total of 33.6±9 procedures during the study. The first session was performed with a senior urologist. Prostate cancer detection rate and standards of quality (average length of prostatic core biopsy specimens and absence of prostatic tissue) were retrospectively studied between the beginning and the end of each semester. RESULTS: A total of 12,760 biopsy cores were performed for 770 procedures. Mean patient age (64.5±6.1 years), and median prostate-specific antigen (8.7±3.7 ng/mL) were comparable between the study periods. The average length of biopsy cores significantly improved (+10%) from the first (12±2.7 mm) to the last month (13.2±2.1 mm) with a plateau after 12 procedures. Overall, cancer detection rate was 47% and was stable during the semester (41.3% the first month vs 44.1% the last month; P=.39). On univariate and multivariate analysis the mean length of biopsy specimens was associated with the number of procedures (P<.001) and the number of cores performed (P<.001). CONCLUSION: Twelve procedures are necessary to perform high-quality TRUS-guided prostate biopsies without compromising prostate cancer detection. In current training programs, we strongly recommend that residents have direct supervision for a minimum of 12 cases before they are allowed to perform TRUS-guided biopsies with indirect supervision.

Prostate cancer characteristics in a multiracial community.

OBJECTIVES: To investigate the hypothesis that Northern Africans differ from Caucasians with regard to their PCa characteristics, using our 1988-2006 database we retrospectively reviewed the preoperative and pathological features of consecutive patients subjected to radical prostatectomy (RP) for localized prostate cancer (PCa) and stratified according to their ethnic origin. METHODS: In 727 consecutive patients (616 Caucasians; 61 Blacks originating from Central Africa and the French West Indies; 50 Northern Africans from Morocco, Algeria, Tunisia), we preoperatively analyzed and compared age, clinical stage of the tumour, prostate-specific antigen (PSA), transrectal ultrasound prostate volume, PSA density (PSAD), biopsy Gleason score, number of positive cores (NPC), and percentage of tissue core invaded by cancer (PTIC); postoperatively, we determined the status of the capsule, seminal vesicles, and margins of the RP specimen, as well as Gleason score and prostate weight. Statistical analyses (chi-square test and ANOVA) were performed to compare the results between the three groups of patients. A multivariate analysis was carried out to test the independence of variables. RESULTS: Black patients were the youngest at the time of surgery (by 3-4 yr) and had the highest rates of final Gleason score>or=8. The Northern Africans had more favourable features than did Caucasian and Black patients: mean PTIC was 7.1% versus 14.6% and 12.5%, respectively (p=0.005), mean NPC was 26.4% versus 34.7% and 36.4%, respectively (p=0.034), rates of biopsy and final Gleason score>or=8 were significantly lower (p=0.02 and p=0.028, respectively), and there were positive margins in 26% versus 36% and 35.6%, respectively (p>0.05). CONCLUSIONS: This study showed that a French Black population is the most likely of those studied to have unfavourable PCa characteristics at the time of RP. Albeit in a limited series, we show for the first time that Northern Africans have significantly better features in this regard than Caucasians and Blacks. Although Northern Africans did not have a better pathological stage outcome, they did have a more favourable Gleason score.

Posterior urethral valves in adult with Down syndrome.

Posterior urethral valves (PUVs) in patients with Down syndrome (DS) have been previously described. However, no case of PUVs has been reported in an adult patient with DS. We report on a 40-year-old man with DS, who presented with two severe urinary infections and obstructive symptoms. He was found to have type 3 PUVs associated with bladder neck sclerosis. PUV resection and bladder neck incision were done. Because PUVs seem to be more frequent in patients with DS, complete investigations should be performed, even in adults with DS, in the case of urinary infection or lower urinary tract symptoms.

Construction of a global score quantifying allelic imbalance among biallelic SIDP markers in bladder cancer.

The purpose of this paper is the construction of an adapted statistical test for urinary detection of bladder cancer based on the assessment of allelic imbalance using biallelic Short Insertion/Deletion Polymorphism DNA markers. This test is based on the comparison of several of these markers, analysed from urinary DNA, to the distribution of their analogues in blood, which is taken as reference. A reproductibility study is first performed in blood in order to make a selection among the 23 available markers and 18 are retained. A global score based on the chi2 distribution is then built to test for allelic imbalance among all informative markers for each patient. It avoids the count of DNA abnormalities marker by marker and allows to take into account the degree of abnormality of each marker. That method is preliminarily evaluated on a sample of 53 patients and 27 controls. The estimated specificity (96.3%) on that reduced sample is satisfactory, whereas sensitivity (60.4%) could be improved by an augmentation of the number of tested markers. Several issues regarding the validity of the method are discussed.