Thrombospondin-1 expression in bladder cancer: association with p53 alterations, tumor angiogenesis, and tumor progression.

BACKGROUND: Thrombospondin-1 (TSP) is a 430-kd glycoprotein that is an important component of the extracellular matrix and is known to be a potent inhibitor of angiogenesis (i.e., formation of new blood vessels) both in vitro and in vivo. Several reports suggest that TSP possesses tumor suppressor function, possibly through its ability to inhibit tumor neovascularization. It has recently been shown that TSP expression is enhanced by the product of the p53 gene (also known as TP53). PURPOSE: We examined the role of TSP expression in tumor recurrence and overall survival in patients with invasive bladder cancer. We also examined the relationship between alterations in p53 protein expression, TSP expression, and tumor angiogenesis. METHODS: Tumors from 163 patients (with a median follow-up of 7.7 years) who underwent radical cystectomy for invasive transitional cell carcinoma of the bladder (63 patients with organ-confined disease and no lymph node involvement, 48 patients with extravesical extension of the disease and no lymph node involvement, and 52 patients with metastasis to regional lymph nodes) were examined for TSP expression by immunohistochemistry, utilizing monoclonal antibody MA-II, which recognizes an epitope in the amino-terminal region of TSP. For each tumor, microvessel density counts and p53 protein expression status (via immunohistochemistry) were also determined. TSP expression was graded as low, moderate, or high without knowledge of clinical outcome, p53 status, and microvessel density count; tumors with moderate and high TSP levels were considered as one group. Groups of patients were compared by Kaplan-Meier product limit estimates of overall survival, the complement of cumulative incidence curves for recurrence-free survival, and the stratified logrank test. Reported P values are two-sided. RESULTS: TSP expression was significantly associated with disease recurrence (P = .009) and overall survival (P = .023). Patients with low TSP expression exhibited increased recurrence rates and decreased overall survival. TSP expression was an independent predictor of disease recurrence (P = .002) and overall survival (P = .01) after stratifying for tumor stage, lymph node status, and histologic grade, but it was not independent of p53 status. TSP expression was significantly associated with p53 expression status (P = .001) and microvessel density counts (P = .001). Tumors with p53 alterations were significantly more likely to demonstrate low TSP expression, and tumors with low TSP expression were significantly more likely to demonstrate high microvessel density counts. Results of an analysis of variance were compatible with the hypothesis that p53 affects tumor angiogenesis by regulating the level of TSP expression. CONCLUSIONS AND IMPLICATIONS: These data support the concept that TSP may possess a tumor-inhibitory function. TSP may act, in part, through the regulation of tumor neovascularity. These results may also provide insight into one mechanism by which p53 exerts its tumor suppressor effects, i.e., through the control of tumor angiogenesis.

Effect of p21WAF1/CIP1 expression on tumor progression in bladder cancer.

BACKGROUND: Altered expression of p53 protein is an important predictor of progression in bladder cancer. The action of p53 on cell cycle regulation is mediated, in part, through expression of the cyclin-dependent kinase inhibitor p21WAF/CIP1 (p21). Loss of p21 expression may, therefore, contribute to tumor progression. We sought to determine the relationship between p21 expression in bladder cancer and disease progression. METHODS: Tumor specimens were obtained from 242 patients who underwent cystectomy for bladder cancer. Median follow-up was 8.5 years (range, 0.1-11.8 years). Nuclear p21 status was determined by immunohistochemistry and was then analyzed in relationship to the probability of tumor recurrence, overall survival, and tumor p53 status. Reported P values are two-sided. RESULTS: Nuclear p21 expression was detected in the tumors of 156 (64%) of the 242 patients. Patients with p21-positive tumors had a decreased probability of tumor recurrence (P<.00001) and an increased probability of overall survival (P<.00001) in comparison with patients with p21-negative tumors. In a multivariable analysis, p21 expression was an independent predictor of tumor recurrence (P = .0017) and of survival (P = .006) when assessed with tumor grade, tumor stage, lymph node status, and p53 status. p21 expression was associated with p53 status (P<.001); 56% of tumors with p53 alterations showed loss of p21 expression, whereas 79% of tumors expressing wild-type p53 were p21 positive. Patients with p53-altered/p21-negative tumors demonstrated a higher rate of recurrence and worse survival compared with those with p53-altered/p21-positive tumors (P<.0001). Patients with 53-altered/p21-positive tumors demonstrated a similar rate of recurrence and survival as those with p53-wild type tumors. CONCLUSION: Loss of p21 expression is a statistically significant and independent predictor of bladder cancer progression. Maintenance of p21 expression appears to abrogate the deleterious effects of p53 alterations on bladder cancer progression.

Malignant transformation in a nontumorigenic human prostatic epithelial cell line.

The human prostatic epithelial cell line BPH-1 is normally nontumorigenic in nude mice. The present report demonstrates that this cell line can be permanently transformed by its microenvironment to become tumorigenic. The establishment of a series of tumorigenic sublines based on this parental cell line is described. BPH-1 cells were induced to form tumors either by recombination with human prostatic carcinoma-associated fibroblasts (CAFs) or by exposure to carcinogenic doses of testosterone and estradiol (T+E2) after recombination with rat urogenital sinus mesenchyme. Epithelial cells isolated from these tumors were established as cell strains in culture. When regrafted to nude mouse hosts epithelial cells isolated from CAF- or T+E2-induced tumors were found to be consistently tumorigenic even in the absence of CAF or T+E2. The T+E2-induced cell strains have been designated BPH1(TETD)-A and -B and the CAF-induced strains are designated BPH1(CAFTD)-01 through -08. In vitro, the cells had an epithelial morphology with a less well-defined cobblestone pattern than the parental line. They express SV40 large T antigen, confirming their derivation from the parental BPH-1 line. The BPH1(CAFTD) strains formed colonies in soft agar, whereas the parental BPH-1 cells and the BPH1(TETD) sublines did not. There was no immunocytochemically detectable expression of androgen (AR), alpha-estrogen (ERalpha), or progesterone (PR) receptors by the parental BPH-1 cell line or by any of the tumor-derived cell strains. The cells uniformly coexpressed both basal and luminal cell-type cytokeratins and the basal cell marker p63. When grafted beneath the renal capsule of athymic mouse hosts, all of the tumor-derived cell strains consistently formed tumors. These were predominantly poorly or moderately differentiated squamous or adenosquamous tumors, similar in organization to the primary tumors from which the cell strains were derived. The cell strains continued to express both basal- and luminal-type cytokeratins in vivo. Some of the cell strains also coexpressed vimentin. E-cadherin expression was absent from many of the cells, although patches of cells expressing this marker were seen. The cells continued to express SV40T antigen. These cell strains, which are all derived from a common nontumorigenic progenitor, represent a useful resource for examining genetic and phenotypic changes during carcinogenesis.

Carcinoma-associated fibroblasts direct tumor progression of initiated human prostatic epithelium.

The present study demonstrates that fibroblasts associated with carcinomas stimulate tumor progression of initiated nontumorigenic epithelial cells both in an in vivo tissue recombination system and in an in vitro coculture system. Human prostatic carcinoma-associated fibroblasts grown with initiated human prostatic epithelial cells dramatically stimulated growth and altered histology of the epithelial population. This effect was not detected when normal prostatic fibroblasts were grown with the initiated epithelial cells under the same experimental conditions. In contrast, carcinoma-associated fibroblasts did not affect growth of normal human prostatic epithelial cells under identical conditions. From these data, we conclude that in this human prostate cancer model, carcinoma-associated fibroblasts stimulate progression of tumorigenesis. Thus, carcinoma-associated fibroblasts can direct tumor progression of an initiated prostate epithelial cell.

The consequences of chromosomal aneuploidy on gene expression profiles in a cell line model for prostate carcinogenesis.

Here we report the genetic characterization of immortalized prostate epithelial cells before and after conversion to tumorigenicity using molecular cytogenetics and microarray technology. We were particularly interested to analyze the consequences of acquired chromosomal aneuploidies with respect to modifications of gene expression profiles. Compared with nontumorigenic but immortalized prostate epithelium, prostate tumor cell lines showed high levels of chromosomal rearrangements that led to gains of 1p, 5, 11q, 12p, 16q, and 20q and losses of 1pter, 11p, 17, 20p, 21, 22, and Y. Of 5700 unique targets on a 6.5K cDNA microarray, approximately 3% were subject to modification in expression levels; these included GRO-1, -2, IAP-1,- 2, MMP-9, and cyclin D1, which showed increased expression, and TRAIL, BRCA1, and CTNNA, which showed decreased expression. Thirty % of expression changes occurred in regions the genomic copy number of which remained balanced. Of the remainder, 42% of down-regulated and 51% of up-regulated genes mapped to regions present in decreased or increased genomic copy numbers, respectively. A relative gain or loss of a chromosome or chromosomal arm usually resulted in a statistically significant increase or decrease, respectively, in the average expression level of all of the genes on the chromosome. However, of these genes, very few (e.g., 5 of 101 genes on chromosome 11q), and in some instances only two genes (MMP-9 and PROCR on chromosome 20q), were overexpressed by > or =1.7-fold when scored individually. Cluster analysis by gene function suggests that prostate tumorigenesis in these cell line models involves alterations in gene expression that may favor invasion, prevent apoptosis, and promote growth.

Minichromosome maintenance protein 2 expression in prostate: characterization and association with outcome after therapy for cancer.

The minichromosome maintenance (MCM) proteins are highly conserved proteins essential for initiating and regulating eukaryotic DNA replication. Recent studies have demonstrated the potential use of MCM proteins as markers of proliferation. We characterized the pattern of Mcm 2 staining in benign and malignant prostate tissues and examined the role of Mcm 2 expression in disease-free survival after surgery in men with localized prostate cancer. Tumors from 92 patients who underwent radical prostatectomy for prostate cancer (median follow-up of 54 months) were examined for Mcm 2 expression by immunohistochemistry using a monoclonal antibody. Prostate tissue from five men without histopathological evidence of prostate cancer was also stained for Mcm 2. Mcm 2 expression was quantified by calculating a labeling index, and patients were grouped according to degree of staining. An analysis of the association between Mcm 2 expression with traditional clinicopathological characteristics of prostate cancer was carried out. A Cox proportional hazards analysis was performed to determine whether Mcm 2 staining was a significant independent predictor of disease-free survival. Mcm 2 expression is low (<2%) and limited to the basal cell layer in nonmalignant prostate glands. Mcm 2 expression is consistently increased in malignant glands and is significantly associated with disease-free survival in univariate (P = 0.002) and multivariate (P = 0.01) analyses. Patients with high Mcm 2 expression exhibited shorter disease-free survival. Mcm 2 expression was not associated with any traditional clinical or pathological factors and therefore is an independent predictor of survival in these patients with prostate cancer. These data support evidence that Mcm 2 may serve as a novel proliferation marker in the prostate. Mcm 2 expression is an independent predictor of disease-free survival after definitive local therapy and has potential as a molecular marker for clinical outcome in prostate cancer.

Immunohistochemical detection of thrombospondin-1 in formalin-fixed, paraffin-embedded tissue.

Thrombospondin-1 (TSP) is a 450-KD glycoprotein that was initially discovered in the platelet alpha-granule. It now appears that TSP is intimately involved in the regulation of a variety of cellular functions and cell-to-cell interactions. Recently, it has been demonstrated that TSP functions as a p53-dependent inhibitor of angiogenesis in cultured fibroblasts from Li-Fraumeni patients and therefore may be an important factor involved with tumor invasion and metastasis. It has previously been demonstrated that TSP can be detected in frozen tissue sections by immunohistochemical methods. Our objective in this study was to determine the optimal antigen retrieval (AR) protocol for detection of TSP in formalin-fixed, paraffin-embedded tissue by using tissue sections from patients with invasive transitional cell carcinoma of the bladder. The optimal AR protocol was determined utilizing a variety of heating conditions and antigen retrieval buffers. Our results demonstrate that TSP can be reliably detected in paraffin-embedded tissue by immunohistochemical techniques that utilize AR with high-temperature microwave heating and a low-pH Tris-HCI buffer. The importance of this method is that it allows the reliable detection of TSP in archival tissue. This should facilitate further investigation into TSP's role in the regulation of cellular processes, including its influence on tumor angiogenesis and metastasis.

Genetic and epigenetic influences in prostatic carcinogenesis (review).

Prostatic carcinogenesis is a multistep process with well-documented stages. Although prostate cancer is a major cause of mortality many small tumor foci never progress to form clinically significant disease, indicating that the disease process may be regulated at more than one level. Carcinogenesis is accompanied by increasing genetic damage to prostatic epithelial cells, however the pattern of genetic lesions is inconsistent. The differentiation of stromal cells surrounding tumors is more fibroblastic and less muscular than in normal prostate. The present communication reviews the roles of both genetic and, stromally derived, epigenetic effects on prostatic tumorigenesis.

Ventral penile curvature following radical pelvic surgery: a variant of urethral manipulation syndrome.

OBJECTIVES: Urethral manipulation syndrome (UMS) describes ventral penile curvature and urethral stricture disease that develop following repeated episodes of urethral manipulation. We describe a variant of this syndrome, in which the presence of an indwelling catheter following radical pelvic surgery led to a marked penile curvature without clinically apparent urethral stricture disease. METHODS: We identified 4 patients in whom ventral penile curvature developed following radical pelvic surgery. Three patients underwent radical retropubic prostatectomy and the fourth patient underwent radical cystoprostatectomy with creation of a neobladder to the urethra. All were treated with 3 weeks of catheter drainage postoperatively. Each patient reported straight erections prior to surgery. RESULTS: These patients came to prosthesis surgery between 7 months and 3 years after their pelvic procedure. Each patient was noted to have ventral penile curvature when artificial erection was induced. Curvature was secondary to scarring between the anterior corpus spongiosum and the overlying ventral tunica albuginea in the mid- to proximal penile shaft. It was necessary to mobilize the urethra off the corpora and to incise the scarred tunica to obtain a satisfactory result at the time of prosthesis placement. In 3 cases, GoreTex was needed to bridge the corporeal defect. CONCLUSIONS: These cases represent a variant of UMS in which catheter drainage leads to scarring of the ventral tunica albuginea, resulting in ventral penile curvature. In view of the increasing number of radical pelvic procedures being performed, this potential complication must be recognized, as aggressive corporeal reconstruction with urethral mobilization is needed if subsequent prosthesis surgery is undertaken.

Intermittent androgen deprivation for clinically localized prostate cancer: initial experience.

OBJECTIVES: To evaluate the use of intermittent androgen deprivation (IAD) in the treatment of selected patients with clinically localized prostate cancer. METHODS: We report our initial experience with 47 patients (aged 50 to 92 years) treated with IAD for clinically localized prostate cancer (Stage T1c in 3 patients, T2 in 21, T3 in 21, T4 in 1, and unknown in 1). No patient was found to have systemic disease prior to the initiation of therapy. Twenty-seven patients with localized cancers refused local therapy and have been treated with IAD only. Seven patients developed recurrent disease following radiotherapy, 2 following cryotherapy, 8 following radical prostatectomy, and 3 following radical prostatectomy with adjuvant radiotherapy. Mean and median serum prostate-specific antigen (PSA) prior to the start of treatment were 20.5 and 8.4 ng/mL, respectively (range 0.6 to 190). Androgen deprivation was continued 1 to 2 months after serum PSA became undetectable or a nadir level was reached. Therapy was then reinstituted after serum PSA reached a predetermined level. Thirty-three patients have been treated with total androgen blockade and 14 have been treated with a luteinizing hormone-releasing hormone agonist only. RESULTS: Follow-up ranges from 5 to 52 months from the start of treatment (mean 24 months). Patients have received from 1 to 5 treatment cycles (median 2 cycles), with the mean and median cycle lengths being 15 and 14 months, respectively. Eighteen patients are currently on cycle 1, 15 on cycle 2, 11 on cycle 3, 1 on cycle 5, and 1 patient has discontinued treatment after undergoing salvage radical prostatectomy. The mean and median nadir serum PSA on androgen deprivation have been 0.2 and 0.0 ng/mL, respectively. Nadir PSA was reached within an average of 4 months (range 1 to 11) after initiating treatment. The mean serum PSA at the start of cycle 2 was 7.0 ng/mL (range 0.6 to 19.1). Only 1 patient has failed to respond to reinstitution of treatment; this patient was found to have metastatic disease during his second cycle of treatment (time to progression 25 months from the start of IAD). No other patient has demonstrated disease progression during the follow-up period. Patients have spent an average of 47% of the time off of therapy. CONCLUSIONS: IAD appears to be a viable treatment option in selected patients with clinically localized prostate cancer. However, the durability and advantage of IAD, if any, over continuous therapy is unknown at present. Consequently, at the present time IAD should be considered an investigative form of treatment for patients with prostate cancer.

Horseshoe kidney with a retrocaval ureter.

Horseshoe kidney and retrocaval ureter are two uncommon congenital anomalies of the genitourinary system that have rarely been reported to occur in the same patient. In each case previously reported, the isthmus of the horseshoe was positioned posterior to the inferior vena cava and anterior to the aorta. In no case was the diagnosis of both anomalies made preoperatively. We report a case of simultaneous horseshoe kidney and retrocaval ureter diagnosed by preoperative imaging studies and discuss the diagnostic evaluation and surgical management of this rare entity.

Traumatic pyeloduodenal fistula: a case report and review of the literature.

A case of a traumatic pyeloduodenal fistula secondary to a gunshot wound is reported. After initial conservative management failed, the fistula tract was surgically excised without removal of the involved kidney. Previous treatments of pyeloduodenal fistulas secondary to gunshot wounds have involved nephrectomy. We present the first case of a pyeloduodenal fistula secondary to gunshot wound managed without nephrectomy along with a review of the literature regarding traumatic pyeloduodenal fistula.

Technique of radical cystectomy and simultaneous repair of an abdominal aortic aneurysm.

Surgical repair of an abdominal aortic aneurysm in conjunction with radical cystectomy and orthotopic urinary diversion can be safely performed without morbidity secondary to excessive blood loss, operative time, or vascular graft infection. The techniques required for this combined procedure and a case report are discussed.

Bilateral emphysematous pyelonephritis: a case report and review of the literature.

Emphysematous pyelonephritis is a rare, rapidly progressive, life-threatening infection of the renal parenchyma. It most commonly is unilateral, is found almost exclusively in diabetics, is associated with gas-forming coliform bacteria, and is characterized by the presence of gas within the renal parenchyma. Early aggressive therapy (combined medical and surgical) is the hallmark of successful treatment. A high index of suspicion coupled with radiographic imaging is essential to make a timely diagnosis and guide therapeutic intervention. Bilateral emphysematous pyelonephritis is an even more rare phenomena, with only 14 reported cases in the English literature and is associated with a high patient mortality. We herein present an additional case and review the literature as it pertains to bilateral emphysematous pyelonephritis. Appropriate care requires aggressive combined medical and surgical therapy in an attempt to preserve renal function without increased mortality.

Lower urinary tract reconstruction in the female using the Kock ileal reservoir with bilateral ureteroileal urethrostomy: update of continence results and fluorourodynamic findings.

OBJECTIVES: To update continence results and present fluorourodynamic data in 17 female patients undergoing orthotopic lower urinary tract reconstruction with the Kock ileal urethrostomy following cystectomy. METHODS: Continence results, voiding pattern, and overall patient satisfaction were evaluated by means of patient survey. Fluorourodynamic data and abdominal leak point pressures were obtained in 6 patients. RESULTS: Complete daytime urinary continence was reported in 93% of patients, whereas complete nighttime continence was reported by 87% of patients. Fluorourodynamic studies demonstrated excellent neobladder capacity with low reservoir pressure in all cases. Abdominal leak point pressure measurements confirmed normal urethral sphincter function. CONCLUSIONS: Excellent results with respect to urinary continence, voiding pattern, patient satisfaction, and reservoir function can be expected in women undergoing orthotopic lower urinary tract reconstruction.

Prospective pathologic analysis of female cystectomy specimens: risk factors for orthotopic diversion in women.

OBJECTIVES: To prospectively evaluate our previously established pathologic risk factors in women undergoing cystectomy for bladder cancer and to determine if these criteria identify appropriate female candidates for orthotopic diversion. METHODS: Prospective pathologic evaluation was performed on 71 consecutive female cystectomy specimens removed for primary transitional cell carcinoma of the bladder. The histologic grade, pathologic stage, presence of carcinoma in situ, number, and location of tumors were determined. In addition, final pathologic analysis of the bladder neck and proximal urethra was performed and compared with the intraoperative frozen-section analysis of the distal margin (proximal urethra). RESULTS: Tumor at the bladder neck and proximal urethra was seen in 14 (19%) and 5 (7%) cystectomy specimens, respectively. Bladder neck tumor involvement was found to be the most significant risk factor for tumor involving the urethra (P <0.001). All patients with urethral tumors demonstrated concomitant bladder neck tumors. However, more than 60% of patients with bladder neck tumors had a normal (tumor-free) proximal urethra. Furthermore, no patient with a normal bladder neck demonstrated tumor involvement of the urethra. Intraoperative frozen-section analysis of the distal surgical margin was performed on 47 patients: 45 without evidence of tumor and 2 patients with urethral tumor involvement. In all cases, the intraoperative frozen-section analysis was correctly confirmed by final permanent section. CONCLUSIONS: We prospectively demonstrate that bladder neck tumor involvement is a significant risk factor for urethral tumor involvement in women. However, despite bladder neck tumor involvement, a number of women undergoing cystectomy for bladder cancer have a normal urethra and may be candidates for orthotopic diversion. Furthermore, our data demonstrate that intraoperative frozen-section analysis of the distal surgical margin accurately and reliably evaluates the proximal urethra and currently determines which patients undergo orthotopic diversion at our institution.

Long-term side effects of treatment for testis cancer.

Patients newly diagnosed with testis cancer can now expect excellent results with respect to long-term, disease-free survival after treatment. Given the young age of presentation for many of these patients, the long-term consequences of curing testis cancer have become a major concern. Surgery, radiation, and chemotherapy for testis cancer have all been associated with potential long-term side-effects. Consequently, new treatment regimens have been directed toward minimizing these possible side-effects while at the same time maintaining high cure rates (i.e., limiting the size of radiation fields, decreasing the number of chemotherapy cycles, eliminating bleomycin). Patients and physicians must be made aware of the potential adverse side effects of treatment for testis cancer. At the present time, however, it appears that the beneficial effects of such treatment, with respect to overall and disease-free survival, far outweigh the limited probability of persistent treatment-related side effects in patients newly diagnosed with testis cancer.

Evaluation of asymptomatic microscopic hematuria.

Asymptomatic microscopic hematuria continues to be a common cause for urologic referral. Depending on the population under investigation, the condition is reported in 0.2% to 21.1% of subjects. Many possible etiologies exist for the presence of asymptomatic microscopic hematuria, ranging from insignificant lesions to potentially life-threatening lesions that may require urgent treatment. A cause for asymptomatic microscopic hematuria can be determined in 32% to 100% of patients undergoing a full urologic evaluation, with 3.4% to 56% of these patients having either moderately or highly significant lesions at the time of diagnosis. Consequently, full urologic evaluation is warranted in the majority of patients referred to a urologist with asymptomatic microscopic hematuria. In patients in whom no diagnosis is reached after initial evaluation, follow-up is necessary, although the extent and timing of such follow-up have not been adequately investigated. The ultimate goal of evaluating any patient with asymptomatic microscopic hematuria is the discovery of a significant lesion at an early stage when it is amenable to curative therapy and prior to that lesion causing significant morbidity. No randomized, prospective studies have compared the outcomes of patients with asymptomatic microscopic hematuria undergoing full evaluation with those of patients undergoing surveillance only. The data obtained in high-risk groups undergoing urinary dipstick screening for bladder cancer suggest that the bladder tumors discovered when evaluating all patients with asymptomatic microscopic hematuria may be more amenable to treatment than those normally encountered, thereby possibly reducing the mortality and morbidity associated with bladder cancer in these patients. These findings support the evaluation of patients with asymptomatic microscopic hematuria in a cost-conscious medical environment.

Benign prostatic hyperplasia: clinical overview and value of diagnostic imaging.

The term benign prostatic hyperplasia has traditionally been used to describe a constellation of obstructive and irritative voiding symptoms that occur in men as they age. Such symptomatology may be due to a variety of causes, including prostatic enlargement. Thus, the term lower urinary tract symptoms has replaced BPH to describe this symptom complex. The evaluation and treatment of LUTS continues to be a significant part of urology practice in the United States, as well as a significant component of medical resource utilization. Currently, indication for treatment in patients with LUTS is most often based on subjective measurements of symptom severity and bother. Consequently, imaging does not play a major role in the evaluation of such patients. Recent data suggest that the size of the prostate gland may predict which patients with LUTS will develop progressive symptoms and complications. Moreover, both prostate size and the histologic composition of BPH may help to select patients for specific treatment options. Thus, radiologic imaging may eventually play a larger role in the diagnosis and treatment of LUTS in the future. After review of the literature, it appears that routine upper urinary tract imaging in patients with LUTS or BPH is not warranted. Selective use of such imaging tests in patients with BPH and either hematuria, laboratory evidence of renal insufficiency (elevated BUN or creatinine), or a history of urinary tract infection, urolithiasis, previous urinary tract surgery, or congenital or acquired renal disease remains indicated. Local imaging of the prostate can be performed with either MR imaging or TRUS. Although MR imaging provides excellent resolution of internal prostatic anatomy, information with respect to the ratio of glandular to stromal tissue in the prostate, and an accurate estimate of prostate volume, its use in patients with BPH is limited by its high cost and limited availability. In contrast, TRUS remains an important tool in the evaluation of patients with prostatic disease. Similar to MR imaging, TRUS provides excellent images of internal prostatic anatomy and an accurate estimate of prostate volume prior to treatment. In addition, this imaging modality is noninvasive, cost-efficient, easily adapted to office use, and able to provide guidance for transrectal prostate biopsy.

The prostatic gland: malignancies other than adenocarcinomas.

Many rare variants of prostatic carcinoma have been described and characterized in recent years. Accurate diagnosis of these variants is necessary in order to determine appropriate therapy. Unusual tumors arising in the prostate raise questions of histogenesis, and may carry a better or worse prognosis than typical adenocarcinoma. Virtually the entire spectrum of cellular differentiation has been observed within prostatic epithelium, and rare neoplasms exhibit these unusual forms of differentiation as the chief component of the tumor. Except in sarcoma (marked prostatic enlargement), imaging plays a limited role in the diagnoses of these entities. Biopsy and histologic diagnoses are essential and the role of imaging is restricted to the evaluation of locoregional and distant spread of the disease.