Results of the spanish section of the European Randomized Study of Screening for Prostate Cancer (ERSPC). Update after 21 years of follow-up. / Resultados de la rama española del Estudio Randomizado Europeo de Screening del Cáncer de Próstata (ERSPC). Actualización tras 21 años de seguimiento.

INTRODUCTION AND OBJECTIVE: The objective of the European Randomized Study of Screening for Prostate Cancer (ERSPC) is to assess whether prostate cancer (PCa) screening leads to an improvement of cancer-specific survival. This multicenter study (eight European countries) has recruited more than 180,000 asymptomatic men. After a follow-up period of 16 years, it has been shown that PSA screening reduces PCa mortality by 20%, and that it does not affect all-cause mortality. This article provides updated the results of the Spanish arm of the ERSPC after 21 years of follow-up. MATERIALS AND METHODS: The study invited 18,612 men (aged 45 - 70) of the Spanish section (Getafe and Parla, Madrid) to participate. They were randomly assigned to the intervention arm (serum PSA-based screening) and to the control arm (follow-up without intervention). The diagnoses of PCa were recorded, as well as the PCa-specific and all-cause mortality rates. A comparison between the survival curves of both arms of the study and detailed analysis of the causes of death were performed. RESULTS: The study finally included 4,276 men (2,415 intervention arm, 1,861 control arm). The median age, serum PSA and follow-up time were 57 years, 0.9 ng/ml and 21.1 years, respectively. There were 285 cases with PCa diagnosis, 188 (7.8%) from the intervention arm and 97 (5.2%) from the control arm (p<,001). A total of 216 (75.8%) presented organ-confined disease. There were 994 deaths were recorded; 544 (22.5%) in the intervention arm and 450 (24.2%) in the control arm. No significant differences were detected between the arms of the study in terms of cancer-specific (p=.768) or all-cause (p=.192) mortality rates. The main cause of death was malignant tumors (492 patients, 49.5% of overall mortality), and the most frequent sites were lung and bronchus (29.5%), colon and rectum (14.8%), and hematologic (9.8%). Only 20 patients (0.4% of the patients recruited) died from PCa, with no significant difference between study arms. CONCLUSIONS: In this update of the results of the Spanish section of the ERSPC study after 21 years of follow-up, we have not detected a benefit of PCa screening in terms of overall and cancer-specific survival.

[Selective bladder sparing with transrectal resection of muscle-infiltrating tumors]. / Preservación vesical selectiva mediante resección transuretral de los tumores músculo-infiltrantes.

OBJECTIVE: To disclose te ability of TUR as monotherapy in muscle invasive bladder cancer. MATERIAL AND METHODS: 27 patients with muscle-invasive bladder cancer recruited throughout 1991-1999 were allocated into a protocol based on TUR. 30-45 days after the first TUR a second procedure was performed. The number of recurrences and progressions was registered. Progression-free survival and survival were analyzed using Kaplan-Meier estimates. RESULTS: Two patients were excluded due to persistence of muscle-invasive disease after the second resection. 8 subjects (32%) were lost in follow-up. 17 were eventually evaluable. 12 patients (70.5%) had recurrences. Eventually, 4 more cystectomies were undertaken for invasive recurrences (4/17, 23.5%). During the study period, 3 deaths were recorder (3/17, 17.6%). The actuarial probability of progression at 93 months was estimated on 60%. CONCLUSIONS: 75% of patients retained their bladders. The proportion of patients lost in follow-up was very high. Patients must commit to a close surveillance.

[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.

[Adverse effects of transrectal prostatic biopsy. Analysis of 303 procedures]. / Efectos adversos de la biopsia prostática transrectal. Un análisis de 303 procedimientos.

INTRODUCTION AND OBJECTIVE: Prostate biopsy is a basic step towards prostate cancer (Pca) diagnosis, but usually not free from complications. In this article we have reviewed the adverse effects of this procedure in our setting. MATERIAL AND METHODS: We studied in a prospective fashion the complications arising from transrectal prostate biopsy with the aid of a questionnaire fulfilled by 303 patients who underwent this procedure, within the context of a Pca screening program. All biopsies were transrectal ultrasound guided and randomly taken (sextant). A cleaning enema was applied the night before, and 100 mg of intramuscular tobramycin were administered prior of the procedure. RESULTS: Ninety patients (29.7%) had no adverse effects at all, and 136 (44.9%) reported at least one minor complication (hematuria, hemospermia, or autolimited dysuria). Lastly 77 (25.4%) presented with major complications--urinary retention, fever, need for medical assistance (primary or hospital care) or treatment. Thirty-five patients (11.5%) reported to present with fever after biopsy, 145 (47.8%) hematuria, 95 (31.3%) hemospermia, 77 (25.4%) rectal bleeding, 67 (22.1%) urinary difficulty, and 9 (2.9%) urinary retention. Up to 39 (12.8%) needed to visit their G.P., and 19 of them were referred to Hospital, where only 6 (1.9%) were admitted longer than 24 hours. No intensive care unit admittances or deaths were reported. CONCLUSIONS: The rate of post-transrectal biopsy adverse effects is high in our experience. This phenomenon could be explained, in part, due to data collecting by means of a self-administered questionnaire. Probably the high fever rate presented here could be diminished with other type of antibiotic prophylaxis.

[Differential traits of prostatic cancer detected through an early screening program versus the one detected during urologic consultation]. / Rasgos diferenciales del cáncer de próstata procedente de un programa de detección precoz frente al detectado en una consulta de urología.

OBJECTIVE: To compare some features of prostate cancers (PCa) detected in a screening program, versus cancers diagnosed in an outpatient clinic. MATERIAL AND METHODS: Retrospective study of 393 patients with biopsy evidence of PCa: 93 (23.7%) from a screening campaign, and 300 (76.3%) detected in an outpatient Urology clinic. Features studied at the moment of diagnosis were age, PSA, digital rectal examination (DRE), transrectal ultrasound (TRUS) characteristics and volume stimation, PSA density (PSAD), clinical stage and Gleason score. A comparison was established between the two groups of patients taking into account the mentioned parameters. RESULTS: A higher age, PSA and DPSA values were found among cancers detected out of the screening program. A greater probability of abnormal DRE and a more advanced clinical stage was also noted. In the screening group, 78.5% of the cancers were localized and 8.6% metastatic. In the outpatient clinic group, the proportions were 50.7% and 26%, respectively. No differences were found with respect to TRUS findings, prostate volume, or Gleason score. CONCLUSIONS: Cancers detected in screening programs are found in earlier stages. Nevertheless, results from long term randomized studies are necessary to verify if these data really mean that a disease-specific mortality reduction can be achieved.

[Clinical significance of prostatic intraepithelial neoplasia]. / Significado clínico de la neoplasia intraepitelial prostática.

OBJECTIVE: To determine the value of high grade prostatic intraepithelial neoplasia (with or without the influence of certain risk factors) in predicting prostate cancer in subsequent biopsies. METHODS: The study comprised 41 patients from a prostate cancer screening program with high grade prostatic intraepithelial neoplasia. Subsequent biopsies were reviewed and the probability of detecting prostate cancer was calculated. We analyzed the influence of age, DRE and transrectal US findings, PSA levels and PSA density on the results of the repeat biopsies. RESULTS: The patients were aged 50 to 83 years (mean 62.8 +/- 1.6 SD, median 61). Only 27 of the 41 patients with high grade prostatic intraepithelial neoplasia accepted a repeat biopsy. Of these, prostate cancer was demonstrated in 11 (40.7%; all cases were clinically localized at the time of diagnosis) and 16 showed no changes (59.3%) on repeat biopsy. By univariate and multivariate analysis, patient age, DRE and transrectal US findings, PSA levels and PSA density were not found to be predictors of cancer in the subsequent biopsies. CONCLUSIONS: The finding of high grade prostatic intraepithelial neoplasia in the prostate biopsy carries a high probability of detecting cancer in subsequent biopsies. We therefore advocate performing a repeat biopsy in these patients.

[Usefulness of ultrasonography in the assessment of acute pyelonephritis]. / Utilidad de la ecografía en la evaluación de la pielonefritis aguda.

OBJECTIVE: The diagnosis of acute pyelonephritis (APN) is based fundamentally on the clinical and bacteriological findings. Radiology is useful in ruling out obstructive causes that often require surgical management. The present study analyzed the role of renal ultrasonography (US) in patients with clinical symptoms, signs and history compatible with APN that have normal plain abdominal x-rays. METHODS: 87 patients who consulted our emergency services with symptoms and signs compatible with APN were reviewed. Patients who referred renal colic and those with a previous history of urological disease other than uncomplicated recurrent urinary tract infection were excluded. Patients with a plain abdominal x-ray compatible with lithiasis were excluded. Renal US evaluation was performed by the urologist to rule out hydronephrosis. RESULTS: 37 (42.5%) of the 87 patients had an abnormal US scan. These patients were evaluated again by US or IVP, or both (one case). Obstructive uropathy was demonstrated in only 5 cases (5.8%). These foregoing 5 patients were treated by surgery. CONCLUSIONS: In our series, renal US evaluation indicated surgical treatment in 5.8% of patients with clinical features of APN and a plain abdominal x-ray with no evidence of lithiasis. This incidence is likely to be lower in the outpatient setting. It is difficult to propose a standard approach in the management of these patients. It may therefore be more reasonable to utilize US and IVP in those patients who do not respond to antibiotic therapy.

[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.

[Transrectal echography in tuberculous prostatitis]. / Ecografía transrectal en la prostatitis tuberculosa.

Tuberculous prostatitis is diagnosed incidentally, when the pathologist is studying a specimen of transurethral resection of the prostate or a prostatic biopsy. There is scant literature on the role of transrectal ultrasound in the diagnosis of this pathology. A case of tuberculous prostatitis is presented, with special reference to the transrectal ultrasound pattern. A complete review of the references on the imaging techniques in this pathology is done.