The Role of Educational Level and Cognitive Status in Men Undergoing Artificial Urinary Sphincter Implantation.

OBJECTIVE: To examine the relationship between education level, cognitive function of patients and the success/ revision rates of artificial urinary sphincter (AUS) implantation in men with postprostatectomy incontinence. METHODS: Between January 2010 and March 2018, 163 patients (mean age, 68 ± 6.8 years) with moderate-to-severe stress urinary incontinence who underwent AUS implantation were retrospectively examined. Demographic data, body mass index, comorbidities, surgical technique, previous strictures, and radiation therapy were recorded. Incontinence was measured by daily pad use and evaluated by International Consultation on Incontinence Questionnaire-short form. Patients' overall improvement was assessed using the Patient Global Impression of Improvement questionnaire. Education level was determined using the International Standard Classification of Education. Cognitive status was assessed using the Mini-Mental State Examination. Treatment success was defined as the need for ≤1 pad/day at last follow-up. RESULTS: AUS was successful in 77.3% of patients. The International Consultation on Incontinence Questionnaire-short form score improved significantly from 19.9 ± 2.9 to 4.4 ± 5.4 (P = .001). The median outcome reported subjectively on the Patient Global Impression of Improvement scale was 2.1 ± 1.5 (1-7) and self-reported as "much better." Patients' education level had statistically no significant relationship with AUS success and revision rates. Similarly, there was no significant relationship between cognitive status, educational level and the need for revision of AUS (P >.05). However, patients with moderate cognitive impairment and a body mass index >30 showed significantly lower AUS success rates (P <.05). CONCLUSION: AUS implantation is safe and effective treatment option especially for nonobese and cognitively intact patients of all educational levels.

Bilateral intra-abdominal testicular tumor: Case report.

INTRODUCTION: Bilateral intra-abdominal testis is a very rare clinical entity. These testes may develop cancer in an adult patient with empty scrotum. CASE PRESENTATION: A case of a huge intra-abdominal solid mass in a 32-year-old gentleman is presented. Physical examination revealed an empty scrotum. Laboratory investigations, imaging studies, laparotomy and histopathological examination showed that the solid mass was a mixed germ cell tumor of the left testis. The contra-lateral testis also had a tumor. Resection of the solid mass and contra-lateral orchiectomy was performed. Adjuvant chemotherapy was given. Six months after surgery, his follow-up parameters were all within normal limits. DISCUSSION: Since bilateral intra-abdominal testis tumor is a very rare clinical entity, there are no patient management guidelines available. Management strategies differ significantly among groups and they are based mainly on the experience reflected in the context of anecdotal case reports. CONCLUSION: Surgical exploration and adjuvant chemotherapy seems as a reasonable treatment option in the setting of bilateral intra-abdominal testis tumor in an adult patient.

Factors affecting complication rates of retrograde flexible ureterorenoscopy: analysis of 1571 procedures-a single-center experience.

PURPOSE: To evaluate the factors affecting complication rates of flexible ureteroscopy and laser lithotripsy (FURSL). MATERIALS AND METHODS: Data on a total of 1395 patients, with 1411 renal units underwent 1571 procedures with FURSL for renal and/or proximal ureteral stones between April 2012 and January 2016, were retrospectively analyzed. Complications were assessed using the Satava and modified Clavien systems. Univariate and multivariate analyses were done to determine predictive factors affecting complication rates. RESULTS: The mean patient age in the total procedures was 45.68 ± 14.00 years (range 2-86 years), and the mean stone size was 15.15 ± 8.32 mm (range 5-75 mm). The overall success rate was 95.6 %. A total of 209 (13.3 %) cases suffered from complications with intraoperative complications rates of 5.9 % and postoperative complication rates of 7.3 %. Univariate analysis revealed no significant difference in complication rates in respect of age, gender, body mass index, use of ureteral access sheath, operation time, bleeding disorder, solitary kidney, preoperative stenting, American Society of Anesthesiologists score, repeated procedure or location of stones (all p value >0.05). Complication rates were determined to be significantly affected by stone size (p = 0.026), multiplicity (p = 0.028) and the presence of congenital renal abnormality (p < 0.01). The only significant factor in multivariate analysis was the presence of congenital renal abnormalities (p = 0.02). CONCLUSIONS: The results of the current study indicated that stone size, stone number and the presence of congenital renal abnormalities were factors affecting complication rates after FURSL, although congenital renal abnormality was the only independent predictor among these risk factors.

Surgical Drains Do Not Decrease Complication Rates But Are Associated with a Reduced Need for Imaging After Kidney Transplant Surgery.

BACKGROUND: Perigraft collections and wound complications are common after kidney transplantation. The aim of this study was to determine whether intraoperative drain placement had an effect on the risk of these complications. MATERIAL AND METHODS: Adult patients who underwent kidney transplantation in our center between January 2006 and December 2014 were included. Information regarding absence/presence of drain, imaging studies, and complications (perigraft collection and wound complications) were collected. The effect of drains on outcomes was analyzed using logistic regression after adjustment for baseline characteristics. RESULTS: Baseline characteristics were similar for 'drain' (n=374) and 'no drain' (n=283) groups. Forty-eight percent (n=317) of the patients were imaged. Fewer patients with a drain (40%) were imaged to diagnose a perigraft collection compared to those without a drain (60%, p<0.001). Perigraft collections and wound complications were detected in 28% (n=186) and 14% (n=90) of the cohort, respectively. Presence of a drain was associated with a significantly lower rate of perigraft collections (odds ratio 0.62, 95% CI [0.43-0.88], p=0.011). However, risk of wound complications was similar for those with a drain versus without a drain (odds ratio 0.67, 95% CI 0.42-1.07, p=0.096). Among the 225 patients with a complication, the subsequent intervention rate was the same for those with or without a drain (adjusted odds ratio 1.23, 95% CI 0.61-2.46. p=0.562). CONCLUSIONS: Drain placement is not associated with a significant reduction in wound complications following kidney transplant and does not reduce the risk of clinically significant perigraft collections. Since it is associated with reduced need for imaging to diagnose collections, it has the potential to reduce transplant costs.

A comparison of standard PCNL and staged retrograde FURS in pelvis stones over 2 cm in diameter: a prospective randomized study.

The aim of the study was to compare percutaneous nephrolithotomy (PCNL) and staged retrograde flexible ureteroscopy (FURS) methods used in the treatment of kidney stones of 2 cm or more in diameter. The study comprised a total of 60 patients with a diagnosis of kidney pelvic stones more than 2 cm in diameter, for whom surgery was planned between January 2013 and January 2014. The patients were randomly allocated to two groups as staged retrograde FURS (Group A) and PCNL (Group B). Comparison of the groups was made with respect to operating time, number of procedures, total treatment time, length of hospital stay, stone-free rates and complications according to the Clavien-Dindo classification. In Group A, the total operating time of multiple sessions was 114.46 min. In Group B, a single session of PCNL was applied to all patients and the mean operating time was 86.8 min (p = 0.014). Mean total treatment time was 2.01 weeks in Group A and 1 week in Group B (p < 0.01). The mean total hospitalization time was 3.66 days in Group A and 3.13 days in Group B (p = 0.037). At the end of the sessions, clinically insignificant residual fragments were observed in ten patients of Group A and one patient of Group B (p = 0.03). No statistically significant difference was determined between the groups in terms of stone-free rates or complications. Although current technology with FURS is effective on large kidney stones, it has no superiority to PCNL due to the need for multiple sessions and long treatment time.

Management of renal cysts.

BACKGROUND AND OBJECTIVES: Renal cysts have a high prevalence in the general population, and their estimated incidence increases with age. Renal cyst aspiration (usually with sclerotherapy) or open/laparoscopic decortication is a generally effective and safe method in the treatment of symptomatic simple renal cysts. The success rates of laparoscopic decortication and percutaneous aspiration-sclerotherapy were compared to assist in the decision making for the procedure. METHODS: A total of 184 patients with symptomatic simple renal cysts were treated with either laparoscopic decortication in 149 cases or percutaneous aspiration-sclerotherapy in 35 cases. The follow-up period was approximately 35 months, and the symptomatic and radiologic success rates of the 2 techniques were compared retrospectively. RESULTS: Laparoscopic decortication was found to have high success rates, a low recurrence rate, and minimal morbidity. Percutaneous aspiration-sclerotherapy is an outpatient procedure with a minimally higher recurrence rate. CONCLUSION: When a symptomatic cyst is encountered and treatment of the cyst is indicated, laparoscopic decortication is a more efficient method that offers better results than percutaneous aspiration-sclerotherapy.

Management of calyceal diverticular calculi: a comparison of percutaneous nephrolithotomy and flexible ureterorenoscopy.

To compare the outcomes in patients who have been treated with flexible ureterorenoscopy (f-URS) and percutaneous nephrolithotomy (PNL) in managing stone-bearing caliceal diverticula. Between April 2007 and October 2013, we performed a retrospective analysis of 54 evaluable patients (28 women and 26 men) with symptomatic stone-bearing caliceal diverticula, who underwent PNL (n = 29) or F-URS (n = 25) in four referral hospitals in Turkey. The groups were compared with respect to demographics, stone location/size, success rate, stone-free status, symptom-free status, complication rates, and hospital stay. The average stone burden preoperatively was significantly larger in patients who were treated with PNL, with the average size for f-URS being 154 ± 77 mm(2) and that for PNL being 211 ± 97 mm(2) (p = 0.023). Symptom-free rates, success rates, stone-free rates and clinically insignificant residual fragments were similar between the groups (p = 0.880 vs. p = 0.537 vs. p = 0.539, and p = 0.877, respectively). There was no statistical difference between the groups for minor complications (p = 0.521) but no major complication (Clavien III-V) occured in the f-URS group; although there were three major complications (10.3 %) (Clavien III) in the PNL group (p < 0.001). Hospitalization time per patient was 1.04 ± 0.20 days in the f-URS group, while it was 3.86 ± 1.94 days in the PNL group (p < 0.001). Even though this study clearly shows that both techniques have high overall success and symptom-free rates with similar complication rates for stone-bearing calyceal diverticulum, major complication rates may suggest consideration of the invasiveness of PNL. The f-URS procedure is advantageous with respect to a shorter hospital stay and absence of major complications. Therefore, it should be emphasized that the location of the stone and diverticula is an important factor for the selection of the procedure.

Red cell distribution width as a predictor of prostate cancer progression.

BACKGROUND: The aims of this study were to investigate the utility of red blood cell distribution width (RDW) as a simple and readily available marker in prostate cancer, as well as to evaluate RDW as a predictor of progression in prostate cancer patients. MATERIALS AND METHODS: We evaluated 62 newly diagnosed prostate cancer patients who underwent transrectal ultrasound (TRUS)-guided biopsy and 62 healthy controls of mean age 64 (range, 45-75) years at the Urology Clinic of Bozok University Hospital. Data collection was performed using our laboratory information system database to retrieve findings regarding RDW, hemoglobin, prostate- specific antigen (PSA), and age. The RDW values were compared between the healthy control group and prostate cancer patients. A high risk of progression as defined as a Gleason score (GS) >6, total number of cores positive for cancer >33%, each core containing >50% cancer cells, and a prostate-specific antigen (PSA) level >10 ng/ mL. Patients were classified according to risk of progression, as well as divided into subgroups according to the RDW quartile. RESULTS: The mean RDW value of prostate cancer patients was 14.6, compared with 13.7 in the healthy control group (p=0.001). A higher RDW was associated with an increased risk of progression, whereas a lower RDW value was correlated with a low risk of progression. CONCLUSIONS: RDW is an easily derived measure that might, in combination with other markers, help predict prostate cancer risk and progression. We suggest that RDW may be used in combination with other parameters in the assessment of prostate cancer.

Transurethral resection of a bladder leiomyoma: A case report.

Benign mesenchimal tumour of the human bladder is rare. Insulin potentiation therapy mimics malignant tumours both clinically and radiologically. We present a patient we treated with transurethral resection (TUR) only. A 27-year old male patient presented to our clinic with frequency, dysuria and recurrent urinary tract infections. Magnetic resonance (MRI) revealed an endovesical bladder mass of 7 × 8 cm. We performed TUR in the same session for both diagnosis and treatment. The diagnosis was endovesical leiomyoma. Six months to a year after the operation, the MRI did not reveal disease recurrence. Even though TUR is recommended for smaller and endovesical tumours, we believe larger intravesical tumours may also be managed by TUR.

Sex-specific hormone receptors in urothelial carcinomas of the human urinary bladder: a comparative analysis of clinicopathological features and survival outcomes according to receptor expression.

OBJECTIVES: To investigate the expression of sex-specific hormone receptors in normal bladder urothelium and urothelial carcinomas (UCs) of the bladder, and to analyze clinicopathological features and survival outcomes according to receptor expression. METHODS: We evaluated the clinical data and tumor specimens of 139 patients with bladder cancer (BC). In addition, 72 samples of normal urothelium were included. Immunohistochemistry was performed using streptavidin-biotin peroxidase method, a monoclonal androgen receptor (AR), and an estrogen receptor-ß (ERß) antibody on paraffin-embedded tissue sections. Expression levels of each receptor were assessed by evaluating 500 tumor cells for each case and the percentage of positively-stained nuclei was recorded. RESULTS: None of the 58 male control cases showed any AR and ERß expression. Five (35, 71%) of the 14 female control cases expressed ERß. Of the 139 patients with UCs, 71 (51, 07%) expressed AR (62 male vs. 9 female; P = 0.413) and 44 (31, 65%) (39 male vs. 5 female; P = 0.402) showed ERß expression (P < 0.001). No significant relationship was found between ERß expression levels and tumor grades, and stages (P = 0.441; P = 0.247). AR expression was significantly lower in T2-tumors (21%) than in Ta-tumors (60%) and T1-tumors (60%) (P < 0.001). It was significantly higher in low-grade papillary UCs (64%) compared with high-grade papillary UCs (44%) and infiltrative high-grade UCs (17%) (P = 0.039; P < 0.001). Data of 79 patients with noninvasive BC were eligible to present, with a median 29 months follow-up. AR expression level did not influence recurrence-free survival (RFS) and progression-free survival (PFS) (P = 0.095; P = 0.110). No significant association was found between ERß expression level and RFS (P = 0.293). PFS in patients with lower ERß-expressing tumors was significantly better than that in patients with higher ERß-expressing tumors (P = 0.035). Multivariate analysis confirmed this significant influence on PFS (P = 0.025). CONCLUSIONS: Although ERß expression had no impact on histopathological tumor characteristics, decrease in its expression may be associated with better PFS rates in patients with noninvasive BC. Conversely, loss of AR expression was associated with higher grade UCs and invasive UCs, but had no prognostic effect on survival. Finally, sex-specific hormone receptors alone cannot be responsible for gender differences in BC rates because they were expressed in similar rates in both sexes.

Comparison of outcomes for adjustable bulbourethral male sling and artificial urinary sphincter after previous artificial urinary sphincter erosion.

OBJECTIVES: To compare the outcomes of the adjustable bulbourethral male sling and artificial urinary sphincter (AUS) in patients with recurrent postprostatectomy incontinence after previous AUS erosion. METHODS: Sixteen patients with recurrent postprostatectomy incontinence who had undergone either adjustable bulbourethral male sling placement (group 1, n = 8) or AUS implantation (group 2, n = 8) were included in the study. The preoperative evaluations included history, physical examination, International Consultation on Incontinence Questionnaire-short form, pad test, cystoscopy, and urodynamic studies. The follow-up examinations were performed at 1, 3, 6, and 12 months postoperatively and annually thereafter. RESULTS: The mean follow-up was 10 months (range 7-19) and 22 months (range 6-38) for groups 1 and 2, respectively (P = .009). Of the 16 patients, 6 were cured, 1 with the sling and 5 with the AUS (cure was defined as no pads daily); 3 were improved, 1 with the sling and 2 with the AUS (improvement was defined as no more than 2 pads daily), and 7 had treatment failure, 6 with the sling and 1 with the AUS. No intraoperative complication was seen in either group. Readjustment of sling tension was done in 4 patients who had persistent incontinence. No reoperation, excluding the readjustments, was required in group 1; however, 3 patients had transient perineal pain. The AUS was removed for recent erosion at 6 and 12 months postoperatively in 1 cured patient and 1 patient with treatment failure, respectively. Ultimately, 50% of the patients (25% with the sling and 75% with the AUS) were cured or improved. CONCLUSIONS: The results of our study have shown that AUS implantation results in better outcomes than placement of the adjustable bulbourethral male sling as secondary therapy.

Uroflow findings in older boys with tubularized incised-plate urethroplasty.

AIM: To analyze uroflow findings in older boys with tubularized incised-plate urethroplasty (TIPU). MATERIALS AND METHODS: 79 toilet-trained patients who had TIPU were evaluated by studying their voiding history, a physical examination, suprapubic ultrasound and uroflowmetry, both pre- and postoperatively. The obstructive urinary flow pattern (OUFP) was accepted as low maximum urinary flow rate with plateau, staccato or intermittent shape. RESULTS: The mean age was 7 years (range 5-11). The mean follow-up was 30 months (range 6-36). Of the 79 patients, 70 recovered. A permanent OUFP was found in 10 of 63 patients, as follows: 7 were detected in the 6th month after operation, and 1 each in the 9th, 18th and 36th months.Ten patients had no voiding abnormality and significant residual urine. The mean interval from initial surgery to presentation with an OUFP was 10.5 months. CONCLUSIONS: An occult urethral obstruction develops in some asymptomatic children with TIPU and commonly occurres in the first year after operation.

Post-surgical high-flow priapism treated by embolization.

Perineal and penile traumas are the commonest cause of high-flow priapism. The clinical symptom of this disease is generally a prolonged, painless, and semirigid penile erection without any other urogenital symptoms. In contrast, high-flow priapism is a quite uncommon condition after transurethral surgery and it may be presented with an unusual clinical manifestation. Herein, we report the first case of priapism associated with massive urethral hemorrhage requiring blood transfusion after internal urethrotomy. High-flow priapism was successfully treated by autologous clot embolization and the priapism associated with massive urethral hemorrhage resolved.

The prognostic importance of prostate specific antigen in the monitorisation of patients undergoing maximum androgen blockade for metastatic prostate cancer.

INTRODUCTION: The changes in serum prostate specific antigen (PSA) concentrations can be used as a prognostic factor in patients undergoing maximum androgen blockade for metastatic prostate cancer. MATERIAL AND METHOD: A total of 149 patients followed up in our department were classified into 4 groups on the basis of PSA changes: group 1; those with normalisation of PSA levels within the first 3 months, group 2; those with normalisation PSA between months 3 and 6, group 3; those with a decrease in PSA but not reaching normal range, group 4; those with no decrease. The gleason scores and the number of bone metastases were also compared between the groups. RESULT: The time to progression was significantly delayed in group 1 (mean: 23.3 months) compared to those with group 2 (mean: 16.9 months) (P<0.02). The time to progression in group 3 (mean: 8.45 months) was significantly shorter compared to the first two groups (P<0.001). Also, in patients with gleason scores 5-7 (grades 2) and gleason scores over 7 (grade 3) and group 1, the time to progression (mean: 21.2 months) was significantly delayed compared to those with the same gleason scores but with group 2 (mean: 13.4 months) (P<0.001). CONCLUSION: The decrease in PSA level is more important than gleason scores in determining the time to progression. Early normalisation of PSA delays the time to progression, and when combined with gleason scores, PSA is an important prognostic factor in predicting the success of the therapy.

Significance of fibrosis around and/or at external urinary sphincter on pelvic magnetic resonance imaging in patients with postprostatectomy incontinence.

OBJECTIVES: To determine the clinical importance of fibrosis on pelvic magnetic resonance imaging in patients with postprostatectomy incontinence (PPI) due to sphincteric incompetence. METHODS: Urethral and periurethral fibrosis was determined by pelvic magnetic resonance imaging in patients who did (n = 22) or did not (n = 14) have urinary incontinence after transurethral resection, transvesical prostatectomy, or radical retropubic prostatectomy. The relation between fibrosis and the duration of incontinence, pad weight, symptom score, cystoscopy findings, and urodynamic findings was examined. RESULTS: Fibrosis was seen in all patients (22 of 22) in the study group and in 4 of 14 patients in the control group (P <0.001). All the patients with severe fibrosis had undergone radical retropubic prostatectomy (P <0.001). Similar to the etiology for incontinence, no relation was found between the severity of fibrosis and the duration of incontinence, pad weight, symptom score, cystoscopy findings, or urodynamic findings. However, the duration of incontinence was shorter in patients with mild fibrosis, clinically. CONCLUSIONS: The results of our study have shown that the incidence of fibrosis is much greater in patients with PPI than in patients without PPI. Consequently, we believe that fibrosis plays an important role in the development of PPI because it may have a negative effect on external urethral sphincter function.

An alternative noninvasive approach for the treatment of high-flow priapism in a child: duplex ultrasound-guided compression.

We are presenting a 5-year-old boy with a traumatic high-flow priapism developed after a straddle injury and successfully treated by compression and simultaneous monitoring with a duplex ultrasound probe. We believe that this may be an alternative method against conventional treatment modalities including conservative follow-up, sympathomimetic drug administration, percutaneous embolization of the fistula, and surgical ligation.

Subureteral dextranomer/hyaluronic acid copolymer injection for vesicoureteral reflux in transplant candidates.

BACKGROUND AND PURPOSE: Endoscopic subureteral injection of tissue-augmenting substances has become an alternative to antibiotic prophylaxis and open surgery for the management of vesicoureteral reflux (VUR). Several injectable materials have been tried for this purpose. In this study, we tried to determine the efficacy of dextranomer/hyaluronic acid copolymer (Dx/HA) injection for the treatment of VUR in renal-transplant candidates. PATIENTS AND METHODS: A total of 21 transplant candidates (29 ureteral units; 13 females, 8 males) with a mean age of 20.2 years (range 14-26 years) underwent endoscopic correction of VUR with Dx/HA. Diagnosis of VUR was made by voiding cystourethrography. The efficacy of the treatment was assessed with voiding cystourethrography at 3 months and 1 year postoperatively. Renal transplantation with living related donor organs was performed in 11 of the 21 patients. RESULTS: Endoscopic treatment was performed without complication in all cases. Higher success rates were obtained in patients with low-grade reflux, the overall success rate in the series being 82.7%. The mean follow- up after renal transplantation was 21.8 months (range 5-45 months). In one patient, reflux recurred after renal transplantation and was treated successfully by a repeat Dx/HA injection. The urine cultures of all patients remained sterile. CONCLUSION: Transplant candidates with VUR can be treated with Dx/HA, which cured the majority of our patients after one or two treatments with few low side effects. Endoscopic subureteral injection of Dx/HA has become an alternative treatment for VUR in transplant candidates. Long-term results are needed before making a final statement about its value.

Rib resection for live-donor nephrectomy.

INTRODUCTION: Living-related kidney transplants yield more favorable results than cadaveric kidney transplant. Although multiple techniques have been described for living-related donor nephrectomy, operation is generally performed subcostally in lateral decubitis position or by an 11th or 12th rib resection. Recently laparoscopic donor nephrectomy is getting popular. The aim of this study is to determine the rib resection increase the morbidity or not. MATERIALS AND METHODS: Between 1997 and 2004 in our center 118 living donor nephrectomies were performed. 15 of these patients did not come to follow-up controls. This study consists of 103 patients: 11th rib resection (30 patients) determined as group I, 12th rib resection (52 patients) determined as group II, subcostal incision (21 patients) determined as group III. All these three groups were compared with each other according to operation time, pleural or peritoneal defect, pneumothorax, blood transfusion, wound infection, length of hospital stay, postoperative analgesic requirement, return to threshold activities and incisional hernia. RESULTS: Patients whose 11th rib was removed had the shortest operation time. But pain due to surgery continued more than others in this group of patients. The risk of developing incisional hernia was seen most in patients who had subcostal incision. In this group of patients incidence of incisional hernia was 4 (19%). None of the patients had wound infection. We also did not experience any pneumothorax and blood transfusion requirement. Peritoneal or pleural opening occurred in 4 out of 103 patients accidentally and there was no difference between groups. There was also no difference between groups in terms of returning back to daily activation. CONCLUSION: Morbidity of nephrectomy done with removal of 12th rib was less compared with other groups. Resection of 11th should be reserved for patients with high residing kidneys and also for those with a polar artery of the upper pole.

The prognostic importance of prostate-specific antigen in monitoring patients undergoing maximum androgen blockage for metastatic prostate cancer.

The changes in serum prostate-specific antigen (PSA) concentrations can be used as a prognostic factor in patients undergoing maximum androgen blockage for metastatic prostate cancer. A total of 149 patients followed in our department were classified into 4 groups on the basis of PSA changes: group 1, those with normalisation of PSA levels within the first 3 months; group 2, those with normalisation of PSA between months 3 and 6; group 3, those with a decrease in PSA, but not reaching normal range; group 4, those with no decrease. The gleason scores and the number of bone metastases were also compared between the groups. Again time to progression in patients with Gleason scores 5-7 (grade 2) and over 7 (grade 3) whose PSA levels decreased between first and 3rd months (mean 21.2 months) were significantly longer than the patients with same gleason scores whose PSA levels decreased between 3rd and 6th months (mean 13.4 months) (p< 0.001). The decrease in PSA level is more important than gleason scores in determining the time to progression. Early normalisation of PSA delays the time to progression and when combined with gleason scores, PSA is an important prognostic factor in predicting the success of the therapy.