[Role of PSA velocity in the detection of prostate cancer. A study of 986 males]. / Papel de la velocidad del PSA en la detección del cáncer de próstata. Un estudio con 986 varones.

OBJECTIVE: To analyze the role of PSA velocity (PSAV) in the detection of prostate cancer (Pca) when compared to other valid alternatives. PATIENTS AND METHODS: From a Pca screening program, 986 men were evaluated in two visits (601 of them agreed for a third visit). Serum PSA was performed in every visit (PSA1, PSA2 and PSA3). All Pca diagnosed after PSA1 were excluded. Criteria for biopsy (PSA2 and PSA3) were PSA > 4 ng/ml, or PSAV > 0.7 ng/ml/year. Diagnostic performance of PSAV was compared with other options (PSA alone, DRE, and PSA density -PSAD-). RESULTS: Median age was 57 years. Median interval between visits were 679 days and 852.5 days respectively. During PSA2, 122 biopsies were indicated (91 performed). After PSA3, 78 were indicated and 24 done. This great proportion of not biopsied men was due to refusal. Seven Pca were detected during PSA2, and 5 during PSA3. Sensitivity of PSAV (two draws) was 0.86, specificity 0.95, missed 1 cancer of 7 and needed 7.5 biopsies per cancer. When three PSA samples available, PSAV missed 2 cancers of 5, and 2.7 biopsies per cancer needed. PSA alone detected 86% of the cancers, multiplying by 2 the number of biopsies needed. Not DRE, nor PSAD improved the diagnostic performance of PSAV when combined with this parameter. CONCLUSIONS: Diagnostic performance of PSAV was found to be unacceptable in our hands. The need for a third biopsy in these studies make them difficult to reproduce. Validation of PSAV is a difficult task to achieve, we think its role remains questioned.

[Reliability of routine cytological diagnosis in bladder cancer]. / Fiabilidad del diagnóstico citológico de rutina en el cáncer vesical.

OBJECTIVES: To establish the reliability of three cystopathologists for cytological diagnosis of primary bladder tumors. METHODS: Pre-operative voided urine specimens of 71 patients with bladder cancer and 55 healthy controls were retrospectively and blindly reviewed by 3 independent cytologists, and their results--positive for bladder cancer, negative or inconclusive--were compared with each other. The estimation of the interobserver agreement was calculated using the weighted kappa-coefficient (k). A multivariative analysis was carried out to identify the factors associated with the disagreement among the three observers. The sensitivity and specificity for each of the participants were calculated in order to clearly identify the origin of the disagreement, in terms of the performance of the diagnostic test in the hands of each observer. A comparison of the overall diagnostic performance was made by plotting sensitivity versus 1-specificity. RESULTS: The weighted k coefficient among observers was 0.46. The multivariative analysis did not identify any variable that could have caused such disagreement. Large differences in sensitivity and specificity were detected between observer number 1 (sens., 0.90, spec., 0.45) and observers number 2 (sens., 0.67, spec., 0.72) and number 3 (sens., 0.71, spec., 0.80), but the overall diagnostic performance (sensitivity vs 1-specificity) was superimposable in the three cases (p = ns). CONCLUSIONS: Simple, reproducible and agreed-on diagnostic criteria should be established to yield reliable results in a group of cytologists. The consideration of individual diagnostic performances can give a false idea of homogeneity between observers. In this field, concordance analysis makes quality control reliable and should be a routine procedure of any pathology department.

[Results of a screening program for prostatic cancer]. / Resultado de un programa de screening para el cáncer de próstata.

OBJECTIVE: To set up the epidemiology of prostate cancer in the geographical area of Getafe, Madrid (Spain) and to detect curable prostate cancer. The results of screening 2.576 men are reported. PATIENTS & METHODS: Patients underwent digital rectal examination (DRE) and PSA determination. Patients with suspicious DRE or PSA greater than 4 ng/ml were further evaluated with transrectal ultrasonography (TRUS) and biopsy. The diagnostic performances of the tests or combinations of tests were determined. RESULTS: Mean age was 59.9 years (median 58 years). Ninety-four patients (3.6 per cent) had abnormal DRE while PSA was higher than 4 ng/ml in 169 patients (6.5% of the total). 6.8 biopsies were needed to prove one cancer. The higher sensitivity corresponded to the PSA (93%). The test of greatest specificity was the rectal examination (97%). Positive predictive value raised to 78.9% when both DRE and PSA were abnormal. Advanced tumor stages were more common (39.4%) than in previous experiences. CONCLUSIONS: PSA should be the first diagnostic test when screening for prostate cancer. Neither the DRE nor the TRUS have any place in patients with PSA below 4 ng/ml. In summary we can't encourage screening programs for prostate cancer so far.

[Does some relation exist in the size and histological composition of the prostate?]. / Existe alguna relación entre el tamaño y la composición histológica de la próstata?

OBJECTIVE: To determine if the histological composition of the prostate-the proportion of glands and stroma-depends on its size. METHODS: Prostate volume was determined by abdominal US; transurethral biopsy of the prostate was performed in 22 patients (mean age 64.8 years) with BPH or bladder tumor. Morphometric analysis of a fragment of the prostate was performed using light and electron microscopy. The stroma-epithelial ratio (SER) and the density of prostatic vascularization (DPV), and the nuclear and cellular areas of 5 epithelial cells in each case, were determined. The ratio of the sum of granular to cellular areas (secreto-cellular ratio), and the nuclear-cytoplasmic ratio (NCR) were determined. The pearson coefficient and linear regression equation that best correlated the prostate volume and the rest of the variables. RESULTS: The mean SER was 4:1 and the DPV was 15.18 vessels/mm2. The cellular and nuclear areas were 79.6 and 21.2 mu2, respectively. The secreto-cellular ratio was 0.083 and the NCR was 0.28. The prostate volume showed no mathematical relationship with SER (r = 0.016, p = 0.9) or DPV (r = 0.026, p = 0.9). Only a random association between the US prostate volume and the cellular and nuclear areas, and the secreto-cellular and NCR could be observed. CONCLUSION: The histological composition of the prostate cannot be determined by the US prostate volume.

[Predictive factors on postoperative quality of life in transurethral resection of prostatic adenoma]. / Factores anticipadores de la calidad de vida postoperatoria en la resección transuretral del adenoma de próstata.

OBJECTIVE: To identify the traits of patients undergoing transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH) that best predict the outcome of the procedure; i.e., quality of life (QOL) changes. METHODS: The prostatic symptoms and the pre- and postoperative QOL of 151 patients submitted to TURP for BPH were evaluated by the IPSS AUA-7 questionnaire. The available preoperative variables (age, symptoms, US prostate size and DRE findings) were correlated with the QOL changes. Thereafter, the relationship between the available postoperative variables and the QOL changes were analyzed. RESULTS: Of the available preoperative variables, symptoms and prostate size were the only factors that significantly influenced the variability of the QOL changes. Multivariate analysis permitted anticipating only 14% of that variability (r2 = 0.14). Analysis of all of the available post-TURP variables showed postoperative symptoms to be the only variable with a statistically significant relationship with the QOL changes. This model provides an explanation for the 60% interindividual variability of the QOL changes (r2 = 0.77, r2 = 0.603; p < 0.001). CONCLUSIONS: We found no mathematical relationship between the preoperative factors and the QOL changes. These changes depended largely upon the postoperative symptoms. The remaining parameters analyzed in this study--including the weight of resected prostatic tissue--showed a weak influence, which suggests that the prostates react differently to TURP.

[Abscessed primary retroperitoneal leiomyoma]. / Leiomioma retroperitoneal primario abscesificado.

OBJECTIVE: To describe a case of primary retroperitoneal leiomyoma presenting as pelvic abscess. METHODS/RESULTS: A patient who had consulted for fever and hypogastric and perineal pain is described. The diagnostic imaging techniques disclosed a heterogeneous pelvic mass compatible with an abscess, which was drained. After the purulent material had been drained, the mass was removed surgically. The pathological analysis of the surgical specimen disclosed a retroperitoneal leiomyoma. CONCLUSION: An abscessed primary retroperitoneal leiomyoma is a very uncommon tumor.

[A bladder nephrogenic adenoma. A case report]. / Adenoma nefrogénico vesical. Descripción de un caso.

OBJECTIVE: To report an additional case of nephrogenic adenoma of the bladder. METHODS/RESULTS: A case of nephrogenic adenoma of the urinary bladder in a 28-year-old female is described. Patient clinical history and diagnostic imaging findings are presented. CONCLUSIONS: Nephrogenic adenoma of the bladder is a rare benign tumor with specific histological features that has been associated with previous surgery, trauma, infections and lithiasis. Although it is currently not considered to be a premalignant lesion, its rate of recurrence is high (37%-49%). The treatment of choice is by transurethral resection and yearly cytological, ultrasound and cystoscopic follow-up evaluation to detect recurrence.

[Echographic diagnosis of female urethral diverticulum]. / Diagnóstico ecográfico del divertículo uretral femenino.

OBJECTIVE: To describe the utility of transrectal ultrasound as an alternative imaging technique in the diagnosis of diverticulum of the female urethra. METHODS/RESULTS: A 35-year-old female that had been initially diagnosed as having a benign tumor of the vagina is described. The voiding cystogram, positive pressure urethrography with a double balloon catheter and urethroscopy were falsely negative for urethral diverticulum of the female urethra. Subsequent evaluation by transrectal ultrasound disclosed on oval-shaped, anechoic lesion located posteriorly to base of the bladder. CONCLUSIONS: Transrectal ultrasound could be the diagnostic imaging technique of choice in patients suspected as having diverticulum of the female urethra.

[Antimicrobial prophylaxis in urology]. / Profilaxis antimicrobiana en urología.

UNLABELLED: Antimicrobial prophylaxis in surgery has proven to be effective in controlled randomized trials. Usage in Urology is known at least since the '30s although its effectiveness has only become known since 1979. METHODS: Review of literature related to surgical antibiotic prophylaxis, more specifically urological surgery, basically from 1991 to 1995, but without overlooking those papers that have become classics due to their impact. RESULTS AND CONCLUSIONS: Efficacy of antimicrobial prophylaxis in urological surgery is nowadays beyond all doubt. Usage is indicated in the presence of sterile urine and dosage must be short, in single dosis in the immediate pre-operative or within 24 hours after the procedure. However, there is a number of issues that deserve to be treated in more detail for better understanding. Those are the establishment of adequate prophylactic regimes in renal transplantation and the use of antimicrobials based on their pharmacokinetic characteristics to optimize the prophylactic purpose.

[Analysis of prognostic factors in superficial bladder tumors]. / Análisis de los factores pronósticos en los tumores vesicales superficiales.

OBJECTIVE: When the traditional prognostic factors (tumor grade, stage, size, number and cytological findings) are used as guidelines for intravesical therapy of superficial bladder tumors and the reported results are compared, it is not uncommon to find unexplainable differences. This study was conducted to determine the prognostic factors for tumor recurrence and progression before instituting any type of adjuvant therapy for superficial bladder tumors. METHODS: 81 consecutive patients with primary superficial bladder cancer (stage Ta-T1, grade 1-3) were entered into a surveillance protocol and controlled for a mean period of 14 months (range 3-44). Patient individual features (sex and age) and tumor characteristics (grade, stage, size, number, cytological findings) were analyzed to determine the risk of tumor recurrence and/or progression. RESULTS: Logistic regression analysis identified age as the only independent prognostic factor for recurrence, which was 6.37 fold (2-42) more frequent for subjects aged 65 years or older. Given the low progression rate (3 cases; 4.8%), a formal risk analysis could not be performed. CONCLUSION: The factors used to predict recurrence (tumor grade, stage, size, number and cytological findings) were not found to be independent in the present series. Certain predictors of tumor aggressiveness-such as age-, which could modify tumor biology, were found to predispose to tumor recurrence.

[Limitations of ultrasonography in the clinical course monitoring of bladder tumors]. / Limitaciones de la ecografía en el control evolutivo de los tumores vesicales.

Ultrasonography is a fairly innocuous test in the follow-up of bladder tumours. Its results, however, can not be superposed to those of cystoscopy. This study aims to identify the risk factors for failure of transabdominal ultrasonography in the FU of bladder tumors. The influence of the primary tumour, sex and age of patients on the ability of ultrasonography to detect relapses was analyzed. Chi square and Student's t tests were used to associate the characteristics of primary tumours and patients to the results of ultrasonography. Student's t test was used to estimate the effect of diagnostic oversight in terms of annual recurrence rate and progression. The characteristics of primary tumours where relapse was detected or overlooked had no influence on the results of ultrasound follow-up as neither did age and sex. No differences were detected in recurrence rate of patients with anticipated (0.57) or overlooked (0.58) tumours. Although differences in progression rates (4.76% and 9% for overlooked and identified tumours, respectively) were substantial, they did not reach statistical significance. There are no features in the original tumour or the patient to anticipate the failure of ultrasound monitoring. Multiple and/or small relapses are overlooked more frequently that single and/or large ones, and tumours located in lateral walls, base and dome may be unnoticed. In spite of oversights, alternate ultrasound/cystoscopic monitoring does not compromise the outcome of the disease.

[Alternatives to the cystoscopic control of bladder neoplasms]. / Alternativas al control cistoscópico de los tumores vesicales.

OBJECTIVE: Cystoscopy is the most sensitive technique for the detection of bladder tumor recurrence, but is the least accepted by the patient. In our Service, 25% of cystoscopies are poorly tolerated. Our experience with alternatives to cystoscopy is described. METHODS: Using cystoscopy as the gold standard, we analyzed the diagnostic yield of cytology, vesicorenal US and the combination of vesicorenal US and cytology. The techniques were compared for sensitivity vs 1-specificity. RESULTS: The sensitivity of the alternative techniques was limited. At best it was 0.81 when US and cytology were used in combination. The specificity was low and the incidence of false negatives was 7.3%. Similarly, the diagnostic yield was better when US and cytology were used in combination (sensitivity vs 1-specificity = 0.77). CONCLUSIONS: No technique, alone or in combination, can replace cystoscopy. However, alternate use of combined US and cytology with cystoscopy is efficient in the follow-up of bladder tumors and can reduce the number of cystoscopies. The delay in the diagnosis of recurrence probably has not negative negative influence on the history of the disease.

[Inguinal hernia containing the urinary bladder. Description of a case]. / Hernia inguinal que contiene vejiga urinaria. Descripción de un caso.

OBJECTIVE: Hernial pathology has a high incidence in the adult population. However, involvement of the urinary tract system in a hernial process constitutes an uncommon finding. This rare condition is analyzed in the present article. METHODS/RESULTS: A case of an inguinal hernia containing urinary bladder is described. No complications were found and surgical treatment was not required. CONCLUSIONS: Inguinal bladder hernia is rare and usually has no associated complications and the symptoms are scanty. Diagnosis is established by ultrasound and cystography. Treatment is by surgery, although in many cases this condition requires no treatment.

[The validity of the IPSS questionnaire in a sample of 262 patients with benign prostatic hyperplasia]. / Validez del cuestionario IPSS en una muestra de 262 pacientes con hiperplasia benigna prostática.

OBJECTIVE: The IPSS is a well-known method for symptom evaluation in patients with prostate disease. The present study analyzes the validity of this self-administered questionnaire in a group of patients from an industrial area in Spain. METHODS: 513 questionnaires (test 1) were sent out to patients with benign prostatic hyperplasia (BPH) who had undergone TUR or adenomectomy. After an interval of 30-60 days, the same questionnaire (test 2) was sent out to all those patients who had correctly answered test 1. The feasibility and reliability of this test in our hands, as well as its ability to discriminate, were determined. Moreover, the relationship between symptoms (S) and quality of life (L) was analyzed. RESULTS: Patient ages ranged from 50 to 86 years (mean 67.6). A) Feasibility (percentage of patients who answered the questionnaire correctly) was 71%. B) Reliability: internal consistency (Cronbach's alpha) was 0.74 and the retest reliability (correlation between the scores of tests 1 and 2) was 0.76 (Pearson's r) and 0.5 (Kendall's T). C) Correlation between symptoms (S) and quality of life (L) was 0.53 (Pearson) and 0.33 (Kendall). D) Discriminating validity (ability of the test alone to diagnose patients with BPH correctly). The patients in the study were compared with a group of 420 "healthy" males from a prostate cancer screening program; the area below the ROC curve was 0.98 (scantily evaluable: healthy patients vs surgical BPH cases). CONCLUSIONS: In our setting, the self-administered IPSS questionnaire had a moderate feasibility (29% of the patients were unable to understand the questionnaire). Our results, in terms of internal consistency and retest reliability, are similar to those of other validation studies conducted in our country (and appreciably worse than those of the original validation studies in the English language). Nevertheless, some items of the questionnaire have an unacceptable retest reliability, particularly those relating to frequency or urgency. Finally, the total symptom (S) score showed a scanty correlation with quality of life (L). We can conclude that although the IPSS questionnaire is a useful method in the assessment of patients with prostate disease, its reliability remains far from optimal.

[Bladder pheochromocytoma: a rare cause of ureterohydronephrosis]. / Feocromocitoma vesical: una causa poco frecuente de ureterohidronefrosis.

OBJECTIVE: To describe a case of bladder paraganglioma with an uncommon form of presentation. The clinical features and diagnostic aspects of this condition are briefly reviewed. METHODS/RESULTS: Herein we describe the clinical history of a young male patient that had been misdiagnosed as having a ureterocele causing ureterohydronephrosis and hypertension, and had undergone nephrectomy. Pathological analysis of the surgical specimen revealed the underlying cause of the patients's condition. CONCLUSIONS: Pheochromocytoma is a rare disease entity whose most common form of presentation is hematuria or that which results from catecholamine produced by the tumor. Lesions located close to the ureteral meatus may cause obstruction. If this condition is not suspected and the findings of diagnostic imaging are inadequately interpreted, its diagnosis and treatment may be delayed, thereby increasing the surgical risk due to its secretory nature.

[A paratesticular myxoid liposarcoma as a simulator of a hernial process. A case report]. / Liposarcoma mixoide paratesticular como simulador de proceso herniario. Descripción de un caso.

OBJECTIVE: To describe a case of paratesticular liposarcoma in a 69-year-old male. The literature is briefly reviewed and the prognostic and therapeutic aspects are discussed. METHODS/RESULTS: The patient was submitted to surgery. Pathological analysis of the surgical specimen disclosed a myxoid liposarcoma with undifferentiated pleomorphic areas. Patient follow up has shown no recurrence or metastasis. CONCLUSIONS: This tumor type develops in scrotal soft tissue, slowly increasing scrotal size, and should be distinguished from inguinoscrotal hernia. Together with physical examination, ultrasonography is generally useful. Treatment is by radical orchiectomy through an inguinal approach; the role of adjuvant therapy remains unclear. It has a good prognosis, with frequent local relapses; metastatic spread is uncommon.

[Relationship between a benign fibroepithelial polyp and a pelvic nephroblastoma: report of a case]. / Relación entre un pólipo fibroepitelial benigno y un nefroblastoma piélico: a propósito de un caso.

The purpose of this paper is to report one case of left pyelic Wilms' tumour in a 17-year old male patient. Pre-operative diagnosis was complicated by a background of prior surgery on the same kidney due to a benign fibroepithelial polyp. The possible concomitences are analyzed while the relevance of an extensive pathoanatomical study to avoid possible diagnostic errors is emphasized.

[Identification of factors conditioning urinary cytology in bladder cancer]. / Identificación de los factores que condicionan la citología urinaria en el cáncer vesical.

OBJECTIVES: To identify the clinical and tumoral aspects related with urinary cytology as a means of validating current criteria or determining the usefulness of this test in the diagnosis of bladder tumors. METHODS: 96 patients that were posteriorly diagnosed as having primary transitional cell carcinoma of the bladder were initially evaluated by urinary cytology. The diagnoses were positive, negative or inconclusive cytology. Any abnormality (for both inconclusive and positive cytologies) were considered as compatible with tumor. To determine the relationship between patient characteristics and tumors, and the results of cytology, standard univariate statistical analysis was performed. To eliminate the confounding factors, a multivariate analysis was performed. RESULTS: Cytology was positive on 44 (45.8%), inconclusive on 22 (23%) and negative on 30 (31.2%) occasions. Age > or = 55 years (p < 0.05), grade (p < 0.05), tumor aspect (p < 0.01) and size (p < 0.001) were associated with a higher frequency of cytologies compatible with tumor. Multiple regression analysis identified tumor size as the only independent variable related with the cytologies compatible with tumor [odds ratio = 8.68 (2.7-26.9)]. CONCLUSIONS: If, as the results of the present analysis suggest, the real effect of cytological analysis in the initial diagnosis of bladder tumors is the anticipation of different features of tumor grade and stage (as patient age, tumor size, aspect and number), its utility would be very limited since other more precise tests (US, cystoscopy...) that provide this information are available.

[Usefulness of cystomanometry in the assessment of urinary irritative symptoms]. / Valor de la cistomanometría en la evaluación de la sintomatología irritativa miccional.

OBJECTIVES: To analyze the value of cystometry in evaluating patients with irritative voiding symptoms with no remarkable previous medical history. METHODS: 79 patients (24 males, 55 females; mean age 49.6 years) with irritative voiding symptoms and no remarkable previous medical history comprised the study. The patients underwent physical and neurourological examination. The urodynamic assessment included uroflowmetry, filling cystometry, pressure/flow study (and urethral pressure in some cases). Uninhibited detrusor contractions were registered. RESULTS: Cystometry failed to detect involuntary detrusor contractions in 68 of the 79 patients (86.1%) with no relevant medical history. Detrusor instability was not found in 41 of 52 women (78.9%) with irritative voiding symptoms and stress incontinence without neurological disease. Involuntary contractions were not observed in 14 of 16 patients (87.5%) with irritative symptoms with a diagnosis of infravesical obstruction. On the other hand, 33 of 68 patients (48.5%) with irritative complaints and a history of neurologic disease showed no hyperreflexia. A statistically significant difference was found between this latter group of patients and those with no remarkable previous medical history (p < 0.001). CONCLUSIONS: Our results indicate that filling cystometry is of little value in the assessment of patients with irritative voiding symptoms and no remarkable previous medical history, but is more useful in patients with irritative symptoms and neurological disease. Careful history-taking and physical examination should detect the underlying problem in the majority of patients.