Assessment of a clinical pathway for investigation of haematuria that reduces the need for cystoscopy.

AIM: To evaluate prospectively a clinical pathway for investigation of haematuria that involves an initial screening using a urinary biomarker of bladder cancer (Cxbladder Triage™ (CxbT)) in combination with either a renal ultrasound or a computed tomography imaging. Only test-positive patients are referred for specialist assessment and flexible cystoscopy. METHODS: The clinical outcomes of 884 patients with haematuria who presented to their general practitioner were reviewed. Outcome measurements included the findings of laboratory tests, imaging, cystoscopies, specialist assessment and histology. RESULTS: Forty-eight transitional cell carcinomas (TCC) and three small cell carcinomas were diagnosed in the study cohort. The clinical pathway missed a solitary, small, low-risk TCC. When combined, imaging and CxbT had a sensitivity of 98.1% and a negative predictive value of 99.9% to detect a bladder cancer. Follow-up for a median of 21 months showed no further new cases of bladder cancer had occurred in the patient cohort. Review of all new bladder cancers diagnosed in the 15 months following the study showed that none had been missed by haematuria assessment using the clinical pathway. CONCLUSIONS: The combination of CxbT and imaging reliably identifies patients with haematuria who can be managed safely in primary care without the need for a secondary care referral and a flexible cystoscopy.

Assessment of the influence of transrectal and transperineal prostate biopsies on erectile function: A prospective observational single-center study.

OBJECTIVES: To assess the impact of transrectal versus transperineal prostate biopsy on erectile function. METHODS: This was a single-center, observational, prospective study of consecutive patients who underwent a prostate biopsy (transrectal or transperineal/fusion biopsy). Study participants completed the International Index of Erectile Function-5 questionnaire before the procedure, and 3 and 6 months after. Prostatic biopsies were carried out following the standard procedure for both techniques. RESULTS: The study included 135 male patients with a mean age of 63.5 years. At baseline, 28 patients (21%) presented normal erectile function, whereas 107 patients (82%) presented erectile dysfunction, which was severe in four (3%), moderate in 49 (36%) and mild in 54 (40%), with an overall mean International Index of Erectile Function-5 score of 17.70. After 3 months, the rates were 29%, 3%, 27% and 38%, respectively (mean International Index of Erectile Function-5 score 17.95). At 6 months, the rates were 30%, 6%, 28% and 34%, respectively (mean International Index of Erectile Function-5 score of 17.77). No significant differences between pre- and post-biopsy International Index of Erectile Function-5 scores at 3 and 6 months were observed, even when analyzing transrectal and transperineal separately. The number of biopsy cores and number of previous biopsies did not influence the International Index of Erectile Function-5 scores. CONCLUSIONS: Our findings suggest that prostate biopsy technique, number of biopsy cores and history of previous biopsy do not significantly impact erectile function in the medium term up to 6 months.

Prospective comparison of the novel visual prostate symptom score (VPSS) versus the international prostate symptom score (IPSS), and assessment of patient pain perception with regard to transrectal ultrasound guided prostate biopsy.

OBJECTIVE: To compare the International Prostate Symptom Score (IPSS) and novel Visual Prostate Symptom Score (VPSS) in patients with lower urinary tract symptoms (LUTS), to correlate scores with uroflowmetry and prostate volume and assess patient perceptions regarding pain prior to, and after prostate biopsy. MATERIALS AND METHODS: Patients with LUTS who had an indication for transrectal ultrasound (TRUS) biopsy were included. Patients completed the IPSS-, VPSS- and prostate biopsy pain assessment questionnaires. Assessment included uroflowmetry, post- void residual volume and prostate volume (measured with TRUS). RESULTS: One hundred men were included. There were statistically significant correlations between the VPSS score and IPSS score (correlation coefficient (r) = 0.802); VPSS and Qmax (r = -0.311); VPSS and. Qave (r = -0.344); prostate volume with VPSS (r = 0.194) and Qmax (r = -0.260). The VPSS was quicker to complete than the IPSS (mean 100 vs. 165 seconds). The mean anticipated pain score before biopsy was 2.8 (range 0-6), and after biopsy (experienced pain) it was 1.8 (range 0-5). The pain during biopsy was less than expected in 67% of patients. CONCLUSION: In men with LUTS scheduled to undergo prostate biopsy, the VPSS score correlated positively with the IPSS score. Men with limited education take less time to complete the VPSS. Patient's perception of expected pain or discomfort during TRUSguided prostate biopsy was significantly higher than the pain actually experienced during biopsy. Men with lower education level had significantly higher expectation of pain prior to biopsy, but similar pain during biopsy.

Prospective comparison of the novel visual prostate symptom score (VPSS) versus the international prostate symptom score (IPSS), and assessment of patient pain perception with regard to transrectal ultrasound guided prostate biopsy

OBJECTIVE: To compare the International Prostate Symptom Score (IPSS) and novel Visual Prostate Symptom Score (VPSS) in patients with lower urinary tract symptoms (LUTS), to correlate scores with uroflowmetry and prostate volume and assess patient perceptions regarding pain prior to, and after prostate biopsy. Materials and methods: Patients with LUTS who had an indication for transrectal ultrasound (TRUS) biopsy were included. Patients completed the IPSS-, VPSS- and prostate biopsy pain assessment questionnaires. Assessment included uroflowmetry, post- void residual volume and prostate volume (measured with TRUS). RESULTS: One hundred men were included. There were statistically significant correlations between the VPSS score and IPSS score (correlation coefficient (r) = 0.802); VPSS and Qmax (r = -0.311); VPSS and. Qave (r = -0.344); prostate volume with VPSS (r = 0.194) and Qmax (r = -0.260). The VPSS was quicker to complete than the IPSS (mean 100 vs. 165 seconds). The mean anticipated pain score before biopsy was 2.8 (range 0-6), and after biopsy (experienced pain) it was 1.8 (range 0-5). The pain during biopsy was less than expected in 67% of patients. CONCLUSION: In men with LUTS scheduled to undergo prostate biopsy, the VPSS score correlated positively with the IPSS score. Men with limited education take less time to complete the VPSS. Patient's perception of expected pain or discomfort during TRUSguided prostate biopsy was significantly higher than the pain actually experienced during biopsy. Men with lower education level had significantly higher expectation of pain prior to biopsy, but similar pain during biopsy

The global burden of major infectious complications following prostate biopsy.

We present a systematic review providing estimates of the overall and regional burden of infectious complications following prostate biopsy. A directly standardized prevalence estimate was used because it reflects the burden of disease more explicitly. Complications included sepsis, hospitalization, bacteraemia, bacteriuria, and acute urinary retention after biopsy. There were 165 articles, comprising 162 577 patients, included in the final analysis. Our findings demonstrate that transrectal biopsy was associated with a higher burden of hospitalization (1·1% vs. 0·9%) and sepsis (0·8% vs. 0·1%) compared to transperineal biopsy, while acute urinary retention was more prevalent after transperineal than transrectal biopsy (4·2% vs. 0·9%). The differences were statistically non-significant because of large heterogeneity across countries. We also demonstrate and discuss regional variations in complication rates, with Asian studies reporting higher rates of sepsis and hospitalization.

The Continuing Story of the Cost-Effectiveness of Photoselective Vaporization of the Prostate versus Transuretheral Resection of the Prostate for the Treatment of Symptomatic Benign Prostatic Obstruction.

BACKGROUND: In 2008, a UK assessment of technologies for benign prostatic obstruction concluded negatively about photoselective vaporization of the prostate (PVP), and the 2010 National Institute for Health and Care Excellence guidance caused several UK institutions to abandon PVP. OBJECTIVE: To reassess the costs and effects of PVP versus transurethral resection of the prostate (TURP) on the basis of most recent data. METHODS: The same model was used as in 2008. Transition probabilities were estimated using a Bayesian approach updating the 2008 estimates with data from two meta-analyses and data from GOLIATH, the latest and largest trial comparing PVP with TURP. Utility estimates were from the 2008 assessment, and estimates of resource utilization and costs were updated. Effectiveness was measured in quality-adjusted life-years gained, and costs are in UK pounds. The balance between costs and effects was addressed by multivariate sensitivity analysis. RESULTS: If the 2010 National Institute for Health and Care Excellence analysis would have updated the cost-effectiveness analysis with figures from its own meta-analysis, it would have estimated the change in quality-adjusted life-years at -0.01 (95% confidence interval [CI] -0.05 to 0.01) instead of at -0.11 (95% CI -0.31 to -0.01) as in the 2008 analysis. The GOLIATH estimate of -0.01 (95% CI -0.07 to 0.02) strengthens the conclusion of near equivalence. Estimates of additional costs vary from £491 (£21-£1286) in 2008 to £111 (-£315 to £595) for 2010 and to £109 (-£204 to £504) for GOLIATH. PVP becomes cost saving if more than 32% can be carried out as a day case in the United Kingdom. CONCLUSIONS: The available evidence indicates that PVP can be a cost-effective alternative for TURP in a potentially broad group of patients.

Assessment of vascular perfusion kinetics using contrast-enhanced ultrasound for the diagnosis of prostatic disease in dogs.

Vascular perfusion was assessed in 10 dogs without prostatic abnormalities and 26 dogs with prostatic disease using contrast-enhanced ultrasound. The time to reach peak contrast intensity (TTP) and peak perfusion intensity (PPI) were measured, and histological biopsies were collected from each dog. Biopsies confirmed normal prostate (n = 10), benign prostatic hyperplasia (n = 11), mixed benign pathology (n = 9), prostatitis (n = 1), prostatic malignancy [adenocarcinoma (n = 4); leiomyosarcoma (n = 1)]. In normal dogs, mean PPI was 16.8% ± 5.8 SD, and mean TTP was 33.6 ± 6.4 s. Benign conditions overall were not statistically different from normal dogs (p > 0.05); for benign prostatic hyperplasia, mean PPI was 16.9 ± 3.8%, and mean TTP was 26.2 ± 5.8 s; for mixed benign pathology mean PPI was 14.8 ± 7.8%, and mean TTP was 31.9 ± 9.7 s; for prostatitis, PPI was 14.2%, and TTP was 25.9 s. The malignant conditions overall had perfusion values that differed from the normal dogs (p < 0.05), although evaluation of the data for individual malignancies did not demonstrate a consistent trend; for adenocarcinomas, the PPI was numerically higher with a mean of 23.7 ± 1.9%, and the mean TTP was 26.9 ± 4.8 s, whilst for the dog with leiomyosarcoma values were numerically lower with a PPI of 14.1% and TTP of 41.3 s. Contrast-enhanced ultrasound appears to offer some ability to document differences in perfusion that may differentiate between malignant and benign lesions, although studies with larger numbers of animals are required to confirm this contention.

Systematic lateral prostate biopsy--are the benefits worth the costs?

PURPOSE: We quantified the additional benefit of routinely adding 4 lateral biopsies to the initial sextant and transrectal ultrasound lesion targeted biopsy pattern in terms of cancer detection. We related this to costs. MATERIALS AND METHODS: Prospective data were accrued on 1,010 consecutive patients referred for initial transrectal ultrasound directed prostate biopsy between June 16, 2000 and September 1, 2005. Costs were estimated for the pathology and clinical departments in terms of staff time. RESULTS: Of 1,010 patients 494 (48.9%) were diagnosed with prostate adenocarcinoma. In these cases 411 cancers (83%) were found in medial samples, including 107 (22%) isolated to medial cores alone and 304 (62%) in medial and lateral cores. Only 55 patients (5.4%) had cancer isolated to systematic lateral cores. Of these cancers 30 (3%) were defined as clinically significant based on Gleason grade 7 or greater, or Gleason grade 6 involving more than 5% of any core. There was a 24% increase in biopsy related costs and a 36% increase in pathology costs associated with the 4 additional lateral biopsies. CONCLUSIONS: Medial sextant and targeted biopsy directed at transrectal ultrasound identified lesions detects 94.6% of the prostate cancer that is detected with a 10 core biopsy protocol. The latter detects an extra 3% of clinically significant prostate cancer, while increasing costs by 30%. It is important to consider the absolute benefits of systematic lateral prostate biopsy in light of this additional expense when selecting an appropriate transrectal ultrasound biopsy regimen for a patient suspected of harboring prostate cancer.

Prostate-specific antigen in the assessment of organ donors.

Transplantation is limited worldwide by the shortage of organs, thus, donors of older ages are necessary to be used to meet the increasing demand for transplants. To minimize the transmission of cancer from this population, it is mandatory to rule out the presence of neoplasms. We present our experience with analysis of the prostate-specific antigen (PSA) for male donors older than 50 years of age. Eleven (5.9%) had PSA levels >6 ng/mL, 2 had prostate cancer. In 7 donors with high PSA levels postextraction study of the whole prostate gland showed carcinoma in 1 and prostate infarction in 1; the other 5 were reported as normal or having benign prostatic hypertrophy (BPH). Donors with high PSA levels are suitable for transplantation if urgent pathological studies do not find prostate cancer. Nevertheless, in most donors, increased PSA levels are secondary to causes other than malignant tumors, thus, the risk of transmission of prostate cancer with transplants is minimal. In conclusion, measurements of PSA levels alone prior to extraction are not sufficient to diagnose cancer in organ donors. We conclude that this analysis must be restricted to donors with a past history of prostate disease. Meanwhile, better tests to avoid false-positive results are required.

Standardized assessment to enhance the diagnostic value of prostate volume; Part I: Morphometry in patients with lower urinary tract symptoms.

BACKGROUND: The diagnostic value of prostate volume results has been evaluated in patients with prostate problems of benign cause. METHODS: For 247 patients, automated volume results were compared to manual results of planimetric reference volume and of the classical ellipsoid formula. Also, transition zone volume was estimated and growth curves of the prostate and prostate dimensions over age were investigated. RESULTS: Application of automated volume determination gives accurate results compared to the reference volume (Pearson correlation, R = 0.938). The ellipsoid volume results were slightly less correlated (R = 0.921). Average growth of the entire prostate was 1.7% per year, for the transition zone the growth was 4.3%. Compared to growth rates for a community-based population, comparable growth rates were found for our group that had higher mean prostate volume. CONCLUSIONS: The results indicate that the age of onset of volume growth is the determining factor in developing benign prostate enlargement not a change in growth rate.

Standardized assessment to enhance the diagnostic value of prostate volume; Part II: Correlation with prostate-specific antigen levels.

BACKGROUND: Standardized estimations of prostate volumes are used for interpretation of prostate specific antigen (PSA) levels. METHODS: In 243 patients with clinically benign diagnosis, automated and reference prostate volumes and transition zone volumes are correlated to PSA levels. Besides, growth curves of PSA level when aging are determined. RESULTS: The strongest correlation was found with multiple regression analysis between PSA and transition zone volume and rest volume (R = 0.854). Mean PSA density was 0.092 ng/mL2, its labelling quality for benign disease was 91% (threshold = 0.15 ng/mL2). An average growth factor for PSA levels of 2.9% per year was obtained. CONCLUSIONS: The contribution per unit tissue to PSA level was for the transition zone 1.9 times higher than for the rest volume. Average growth of PSA per year is in consonance with the increase in normal levels of age specific PSA ranges, although only weak correlations were found between PSA and age and PSA density and age.

[Screening for the early diagnosis of prostatic carcinoma in Ossola: results after 1 year of effort]. / Screening per la diagnosi precoce del carcinoma prostatico nell'Ossola: risultati dopo 1 anno di lavoro.

Data concerning 1 year calls activity in the early diagnosis of the prostate cancer are published. Taking into consideration the results of the screening the Authors wonder whether its costs are justified.

Comparison of the cost-effectiveness of various therapies for common prostatic disorders.

Diseases of the prostate currently represent a major health problem worldwide. As the age of the male population increases in the future, so will the number of patients suffering from these disorders and the cost for treatment increase. Currently, benign prostatic hyperplasia (BPH) and prostate cancer are common in men over 50 years of age. In men after puberty, prostatic infections (prostatitis) are common. Each condition carries with it controversy regarding the most cost-effective treatment. Treatment for these disorders can include surgical intervention, drug therapy, or no treatment at all. In the United States, surgery is the usual treatment of BPH in men over 65 years of age, but most patients with BPH are asymptomatic and require no intervention. Aside from acute urinary retention or backpressure that compromises renal function, the indications to perform surgery are questionable. While some alpha-adrenergic antagonists are used to temporarily relieve symptoms, many patients with BPH will eventually require surgery. Transurethral resection of the prostate is the surgical treatment of choice in selected patients with BPH, accounting for over 90% of surgery performed in this area. The risk-to-benefit ratio for this procedure is favourable and cost-saving steps can be taken by the physician. Open prostatectomy, both suprapubic and retropubic, is performed to treat large prostates. However, both hospital stay and overall morbidity is higher for open prostatectomy than for transurethral prostatic resection. Radical prostatectomy and radiotherapy are commonly performed to treat patients with cancer of the prostate. For patients with the early stages of the disease, administering no treatment is also acceptable. Each therapeutic method has its advocates, and overall survival rates are similar for all treatments. Radiotherapy, however, is less expensive. We review the magnitude of these diseases, therapies available and relevant cost-effectiveness studies. When this sort of scientific information is not taken into account, the physician's decision of which therapy to choose is sometimes blinded by the prejudices and fears of the patient.