Treatment of Large Non-Muscle-Invasive Bladder Cancer: The Potential Role of Neoadjuvant Intravesical Chemotherapy.

INTRODUCTION: The endoscopic resection of large and bulky bladder cancers represents a challenge. To reduce the tumor and make it more easy to resect, we used neoadjuvant short and intensive intravesical mitomycin (MMC) therapy. METHODS: Patients with large bladder tumors were evaluated for this study. At cystoscopy, the surgeon evaluated the feasibility of complete resection. In patients where this was not possible, biopsies from the tumor, bladder mucosa, and prostatic urethra were taken. These patients then underwent a short and intensive cytoreductive schedule of intravesical MMC. This was then followed by TUR-BT. RESULTS: Fifteen patients were included in our study. The mean age was 74 years (range: 56-82; SD ±6 years). Mean tumor size was 51 mm (range: 35-65; SD ±8 mm). After neoadjuvant treatment, complete resection was then feasible in all patients. The mean tumor volume after the chemo-resection had reduced to 34 mm (range: 10-50; SD ±13 mm). No adverse effects were reported. CONCLUSION: Intravesical cytoreductive neoadjuvant MMC as an initial treatment of large NMIBC can be considered safe, effective, and feasible.

Unilateral positive biopsies in low risk prostate cancer patients diagnosed with extended transrectal ultrasound-guided biopsy schemes do not predict unilateral prostate cancer at radical prostatectomy.

UNLABELLED: Focal therapy is an emergent therapeutic option for prostate cancer. Focal therapy includes a variety of therapeutic approaches ranging from lesion treatment to sub-total gland treatment. In this context, an accurate selection of patients having unilateral prostate cancer is closely related to the success of these strategies, especially when a hemi-ablative approach is considered. As prostate cancer is often multifocal, the critical issue is whether it is possible to preoperatively predict a clinically significant unifocal and/or unilateral lesion with sufficient accuracy to recommend focal or hemi-ablative therapy, relying on clinical characteristics and pathological data derived from the biopsy. Our study clearly demonstrates that the prediction of unilateral prostate cancer is not accurate, based on preoperative variables (predictive accuracy 52.3%). Our study is the first study based on an extended biopsy template. Even in patients diagnosed with extended biopsy, the accuracy of the available predictors is far from the ideal prediction. To date, there is no way of correctly identifying patients who will harbour unilateral prostate cancer based on routinely available variables. OBJECTIVE: o establish the predictors of unilateral prostate cancer in a population of patients with low risk prostate cancer, diagnosed with extended biopsy and submitted to radical prostatectomy, potentially candidates for focal therapy. PATIENTS AND METHODS: The study included 321 consecutive patients with low risk (clinical stage T1, Gleason score 3 + 3 or less, prostate-specific antigen [PSA] < 10 ng/mL) unilateral prostate cancer diagnosed after extended biopsy who were subsequently treated with radical prostatectomy between 2002 and 2009 at a single institution. We evaluated the rate of unilateral prostate cancers at final pathology following radical prostatectomy, defined as pT2a or pT2b stage. Univariable and multivariable logistic regression analyses were used to identify predictors of unilateral prostate cancers. Predictive accuracy was assessed with estimates of the area under the receiver operating characteristic curve, which were subjected to 200 bootstraps to reduce overfit bias. RESULTS: At final pathology only 29.3% patients harboured unilateral prostate cancer. No significant differences in terms of age, preoperative PSA, prostate volume and percentage of positive cores were recorded between patients with unilateral prostate cancer and patients with more advanced stage (all P ≥ 0.07). Patients harbouring unilateral prostate cancer had a smaller number of positive biopsy cores (2.8 vs 3.2, P = 0.056) compared with patients with stage pT2c or higher at final pathology. Patients with unilateral prostate cancer had a higher rate of Gleason sum 6 compared with patients with more advanced pathological stage (pT2c or higher: 85.1% vs 65.6%; P = 0.002). On multivariable analyses, only the percentage of positive cores (odds ratio 0.57; P = 0.047) was an independent predictor of unilateral prostate cancer at radical prostatectomy, after controlling for age, PSA at diagnosis and prostate volume (all P ≥ 0.3). The newly developed model for identifying the presence of unilateral prostate cancer failed to achieve accurate prediction (area under the curve 52.3%). When only patients with a single positive core were considered, no differences in PSA and prostate volume were detected (all P ≥ 0.5) and a similar rate of unilateral prostate cancer was demonstrated (33.3% vs 28.4%; P = 0.5). CONCLUSIONS: In patients with unilateral low risk prostate cancer at biopsy, only one-third showed unilateral prostate cancer at radical prostatectomy. The number of cores and the number of positive cores represented independent predictors of unilateral prostate cancer. However, the accuracy of the multivariable model in predicting unilateral prostate cancer is low (52.3%), thus making prediction of unilateral prostate cancer extremely inaccurate. These results need to be taken into account in those cases where focal therapy is considered as a treatment of prostate cancer.

Does the transrectal ultrasound probe influence prostate cancer detection in patients undergoing an extended prostate biopsy scheme? Results of a large retrospective study.

OBJECTIVE: • To compare the prostate cancer detection rate and tolerance profile between a transrectal biopsy made with a 'side fire' (SF) and an 'end fire' (EF) ultrasound probe. PATIENTS AND METHODS: • We selected patients undergoing first biopsy and re-biopsy of the prostate with a 14- and 18-core template using EF and SF transrectal probes, respectively. • We compared the cancer detection rate between the two probes on first biopsy and re-biopsy and gauged patient tolerance using a visual analogue scale (VAS). RESULTS: • A total of 1705 patients were included in the first biopsy group, while 487 were in the re-biopsy group. • The overall detection rate of first biopsy was 37.2%; the overall detection rate of re-biopsy was 10.1%. • No significant difference was found between the two probes in the first biopsy and re-biopsy sets (38% vs 36.5%, P= 0.55; 10.8% vs 9.3%, P= 0.7). • The lack of any significant association between the type of probe used and prostate cancer detection was confirmed by univariable and multivariable analyses in both the first biopsy and re-biopsy sets after accounting for prostate-specific antigen values, per cent free prostate-specific antigen, digital rectal examination, and prostate and transition zone volumes. • The patient tolerance profile of the SF group was significantly better than that of the EF group (mean VAS 1.78 ± 2.01 vs 1.45 ± 2.21; P= 0.02). CONCLUSION: • The prostate cancer detection rate does not depend on the type of probe used. However, the SF transrectal probe is associated with a better patient tolerance profile.

Preoperative circulating sex hormones are not predictors of positive surgical margins at open radical prostatectomy.

PURPOSE: To examine the association between positive surgical margins (PSMs) and preoperative circulating estradiol (E(2)), total testosterone (tT), and sex hormone-binding globulin (SHBG) in patients undergoing retropubic radical prostatectomy (RRP). METHODS: A cohort of 665 non-screened patients who underwent RRP at a single institute was studied. Serum tT, E(2), and SHBG were measured the day before surgery (8-10 AM: ) in all cases. Logistic regression models tested the association between predictors [e.g., PSA, clinical stage, biopsy Gleason sum, body mass index (BMI), tT, E(2), and SHBG] and PSM. Circulating tT was included in the model as both a continuous variable and a categorized variable [according to the definition of hypogonadism (<3 ng/ml)]. RESULTS: PSMs were found in 175 patients (26.3%) within the whole cohort of men and in 78 (16.2%) of the pT2 patients. Patients with PSMs had significantly higher PSA, a higher proportion of more advanced clinical stage, and a lower rate of well-differentiated biopsy Gleason sum than those without PSMs (all P ≤ 0.03). Conversely, no significant differences were found regarding age, BMI, preoperative tT, E(2), and SHBG between patients with and without PSMs. At multivariate analysis, tT, hypogonadism, E(2), and SHBG were not significantly associated with PSMs, after accounting for routinely available preoperative parameters. CONCLUSIONS: In contrast to previously published data, preoperative tT was not an independent predictive factor for PSM at RRP. Likewise, hypogonadism, E(2), and SHBG did not achieve independent predictor status for PSM, after accounting for routinely available preoperative parameters.

Prostate saturation biopsy following a first negative biopsy: state of the art.

INTRODUCTION: Saturation prostate biopsy (SPBx) has been initially introduced to improve prostate cancer (PCa) detection rate (DR) in the repeat setting. Nevertheless, the optimal number and the most appropriate location of the cores, together with the timing to perform a second PBx and the eventual modification of the PBx protocols according to the different clinical situations, are matters of debate. The aim of this review is to perform a critical analysis of the literature about the actual role of SPBx in the repeat setting. MATERIALS AND METHODS: We performed a systematic review of the literature since 1995 up to 2011. Electronic searches were limited to the English language, using the MEDLINE database. The key words 'saturation prostate biopsy' and 'repeated prostate biopsy' were used. RESULTS: SPBx improves PCa DR if clinical suspicion persists after previous biopsy with negative findings and provides an accurate prediction of prostate tumor volume and grade, even if the issue about the number and locations of the cores is still a matter of debate. CONCLUSIONS: At present, SPBx seems to be really necessary in men with persistent suspicion of PCa after negative initial biopsy and probably in patients with a multifocal high-grade prostatic intraepithelial neoplasia or atypical small acinar proliferation. In the remaining situations, adopting an individualized scheme is preferable.

Leydig cell tumor of the spermatic cord in an adolescent affected by congenital adrenal hyperplasia.

We report the first case of a patient with extratesticular Leydig cell tumor associated with congenital adrenal hyperplasia. An 18-year-old congenital adrenal hyperplasia patient presented with a palpable and asymptomatic right extratesticular mass. Color Doppler sonography confirmed the presence of a capsulated and vascularised lesion. Sieric tumor markers were negative. The patient underwent surgical scrotal exploration through an inguinal right incision. The mass, 18 mm in size and located within the spermatic cord, was removed and final pathology diagnosed a benign Leydig cell tumor.

The role of transrectal saturation biopsy in tumour localization: pathological correlation after retropubic radical prostatectomy and implication for focal ablative therapy.

OBJECTIVE: • To evaluate the accuracy of an initial 24-core prostate biopsy scheme (PBx24) in predicting unilateral prostate cancer (PCa) in radical prostatectomy (RP) specimens. PATIENTS AND METHODS: • Between 2005 and 2008, 203 consecutive patients underwent PBx24 followed by RP for PCa. The area under the curve (AUC) was used to evaluate the accuracy of unilateral PCa on PBx24 to predict unilateral PCa in RP specimens. • The positive predictive value (PPV) and negative predictive value (NPV) were also calculated. Moreover, in patients with unilateral PCa on biopsy, univariable and multivariable logistic regression analyses tested the relationship between the presence of unilateral PCa in an RP specimen and the variables: age, prostate-specific antigen (PSA), total prostate volume, clinical stage, primary Gleason grade, secondary Gleason grade and the number of positive cores. RESULTS: • PCa cores were unilateral in 115 patients (56.7%) on biopsy. Of those, only 26 (22.6%) had unilateral PCa in the RP specimen (AUC, 72.9%; PPV, 22.6%; NPV, 98.8%). In patients with clinically low-risk tumours, only 17 of 63 (27%) had a unilateral PCa on PBx24 and in the RP specimen (AUC, 59.1%; PPV, 27.0%; NPV, 100.0%). • None of the examined variables was an independent predictor of the presence of unilateral PCa in the RP specimen (all P > 0.05). CONCLUSIONS: • Initial PBx24 is not sufficiently accurate to be dependable as a method of predicting tumour laterality in RP specimens. Therefore, the use of PBx24 to guide hemi-ablation therapy of PCa may lead to mistreatment in a considerable proportion of patients. • Moreover, none of the routinely available clinical and pathological characteristics appears to improve the ability of unilateral PCa on biopsy to predict unilateral PCa in the RP specimen.

Anaesthesia in transrectal prostate biopsy: which is the most effective technique?

BACKGROUND: Prostate biopsy (PBx) techniques have changed significantly since the original Hodge's scheme, with an increase in the number and location of cores. These improvements have been realized in part because of the introduction of different local anaesthesia techniques. We critically analysed the literature discussing the role of anaesthesia techniques for use during PBx to find which technique provides the best pain relief for the patient and safety for the urologist. METHODS: We performed a literature review by searching the Medline database for articles published between January 2000 and March 2010. Electronic searches were limited to the keywords 'transrectal prostate biopsy' and 'anaesthesia'. RESULTS: Pain and discomfort perceived during PBx are the result of different anatomic factors: the introduction to and movement of the transrectal ultrasound probe in the rectum and the needle piercing the rectum and the prostate capsule. The anaesthesia techniques currently available can be divided into two groups: local (i.e. intrarectal lubricant agents, periprostatic nerve blocks, caudal blocks, pudendal nerve blocks, and their different combinations) and systemic (i.e. oral/intravenous drug administration and sedoanalgesia). CONCLUSIONS: The most effective anaesthesia technique for transrectal PBx performed in outpatient settings is the periprostatic nerve blocks with 1 or 2% lidocaine 10 ml, which is associated with intrarectal lubricant agents, especially in younger people. Nevertheless, the current choice of the anaesthesia technique still depends both on patient characteristics (age, prostate size, number and location of cores, anxious personality, need for re-biopsy) and, above all, the urologist's experience and habits.

Early detection of urothelial premalignant lesions using hexaminolevulinate fluorescence cystoscopy in high risk patients.

BACKGROUND: To evaluate fluorescence cystoscopy with hexaminolevulinate (HAL) in the early detection of dysplasia (DYS) and carcinoma in situ (CIS) in select high risk patients. METHODS: We selected 30 consecutive bladder cancer patients at high risk for progression. After endoscopic resection, all patients received (a) induction BCG schedule when needed, and (b) white light and fluorescence cystoscopy after 3 months. HAL at doses of 85 mg (GE Healthcare, Buckinghamshire, United Kingdom) dissolved in 50 ml of solvent to obtain an 8 mmol/L solution was instilled intravesically with a 12 Fr catheter into an empty bladder and left for 90 minutes. The solution was freshly prepared immediately before instillation. Cystoscopy was performed within 120 minutes of bladder emptying. Standard and fluorescence cystoscopy was performed using a double light system (Combilight PDD light source 5133, Wolf, Germany) which allowed an inspection under both white and blue light. RESULTS: The overall incidence was 43.3% dysplasia, 23.3% CIS, and 13.3% superficial transitional cell cancer. In 21 patients, HAL cystoscopy was positive with one or more fluorescent flat lesions. Of the positive cases, there were 4 CIS, 10 DYS, 2 association of CIS and DYS, 4 well-differentiated non-infiltrating bladder cancers, and 1 chronic cystitis. In 9 patients with negative HAL results, random biopsies showed 1 CIS and 1 DYS. HAL cystoscopy showed 90.1% sensitivity and 87.5% specificity with 95.2% positive predictive value and 77.8% negative predictive value. CONCLUSION: Photodynamic diagnosis should be considered a very important tool in the diagnosis of potentially evolving flat lesions on the bladder mucosa such as DYS and CIS. Moreover, detection of dysplasic lesions that are considered precursors of CIS may play an important role in preventing disease progression. In our opinion, HAL cystoscopy should be recommended in the early follow-up of high risk patients.

Is extended and saturation biopsy necessary?

Prostate biopsy (PBx) techniques have significantly changed since the original Hodge's 'sextant scheme', which should now be considered obsolete. The feasibility of carrying out a biopsy scheme with a high number of cores in an outpatient setting is a result of the great improvement and efficacy of local anesthesia. Peri-prostatic nerve block with lidocaine injection should be considered the 'gold standard' because it provides the best pain relief to patients undergoing PBx. The optimal extended protocol should now include the sextant template with an additional 4-6 cores directed laterally (anterior horn) to the base and medially to the apex. Saturation biopsies (i.e. template with > or = 20 cores, including transition zone) should be carried out only when biopsies are repeated in patients where there is a high suspicion of prostate cancer. Complementary imaging methods (such as color- and power-Doppler imaging, with or without contrast enhancement, and elastography) could be used in order to increase the accuracy of biopsy and reduce the number of unnecessary procedures. Nevertheless, the routine use of these methods is still under evaluation.

Elasto-sonography of the testis: preliminary experience.

OBJECTIVES: We report our experience in elastosonography, a new developed ultrasonographic diagnostic dynamic technique used to provide an estimation about tissue stiffness. METHODS: 41 patients who presented with scrotal pain, painless enlargement of the scrotum or testicular nodules and infertility were submitted to ultrasound examination (US), color Doppler ultrasonography (CDU), elastosonography examination (E). During ultrasonography examination we obtained conventional B-mode images. Lesion size was defined by the major diameter The color Doppler examination was performed to evaluate the vascular pattern. Subsequently we obtained elasticity images, with the patient in supine position. We used Hi Vision 8500 (Hitachi-Tokyo, Japan) ultrasonography machine with SonoElastography imaging option and we scanned with 7,5 MHz linear probe. To obtain images that were appropriate for analysis, we applied the probe with only light pressure, which we defined as a level of pressure that maintained contact with the skin and permitted imaging conditions for which the association between pressure and strain was essentially proportional. RESULTS: In 38 cases elastosonography confirmed the US and CDU findings. In the remaining 3 cases it allowed a better characterization of 2 small benign tumors and of an intratesticular haematoma. CONCLUSION: In our preliminary experience elastosonography can provide additional informations by an higher definition in those cases where there are solid testicular lesions smaller than 10 mm. Infact elastosonography resulted helpful in the determination of 2 small lesions diagnosticated after surgery as Sertoli tumor and adenomatoid tumor of the testis, respectively in a third case the elastosonography identified an intraparenchimal hematoma (confirmed after surgical exploration )in the differential diagnosis with a solid tumor. Further systematic experience is needed for better characterization of testicular lesions with this newly developed technique.

Diagnosis of high-grade prostatic intraepithelial neoplasia: the impact of the number of biopsy cores at initial sampling on cancer detection after a saturation re-biopsy.

OBJECTIVES: To evaluate factors that may predict prostate cancer (PCa) detection after initial diagnosis of high-grade prostatic intraepithelial neoplasia (HGPIN) on 6-24 cores prostatic biopsies (PBx). MATERIAL AND METHODS: We retrospectively evaluated 193 patients submitted from 1998 to 2007 to prostate re-biopsy after initial HGPIN diagnosis in three urologic departments. HGPIN diagnosis was obtained on initial systematic PBx with 6 to 24 random cores. All patients were re-biopsied with a "saturation" PBx with 18-26 cores with a median time to re-biopsy of 12 months. All slides were reviewed by expert uro-pathologists. RESULTS: Plurifocal HGPIN (pHGPIN) was found in 103 patients and monofocal HGPIN (mHGPIN) in 90. Seventy-two and 121 patients were submitted to > 12-core initial biopsy and < or = 12-core, respectively. Overall PCa detection at re-biopsy was 28.4%. PSA (6.7 vs 8.5 ng/ml; p = 0.029) and age (64 vs 68 years; p = 0.005) were significantly higher in patients with PCa at re-biopsy. PCa detection was significantly higher in patients who underwent a < or = 12-core initial PBx than in those with > 12-core (35.5% vs 16.8%; p = 0.03), and in patients with pHGPIN than in those with mHGPIN (34.9% vs 21%; p = 0.035). At multivariable analysis, PSA value (p = 0.007; HR:1.18), prostate volume (p = 0.01; HR:0.966), age (p < 0.001; HR:1.15), pHGPIN (p = 0.003; HR:2.97) and < or = 12-core initial biopsy (p = 0.012; HR:3.62) were independent predictors of PC detection. We further analysed the 2 groups of patients submitted to < or = 12-core and > 12-core initial PBx. Plurifocal HGPIN and older age at biopsy were independent predictors in patients with < or = 12-core initial PBx. On the contrary, in patients with > 12-core initial biopsy, higher PSA values and lower prostate volume were independent predictors of PC detection. CONCLUSIONS: PCa detection on saturation re-biopsy after initial diagnosis of HGPIN is significantly higher in patients submitted to < or = 12-core than those submitted to > 12-core initial PBx. In patients with < or = 12-core initial biopsy pHGPIN and older age were predictors of PCa detection at re-biopsy. In patients with > 12-core initial biopsy, higher PSA values and lower prostate volume was associated to an increased risk of PCa detection at re-biopsy.

Quantitative sensory testing of peripheral thresholds in patients with lifelong premature ejaculation: a case-controlled study.

INTRODUCTION: The main functional factors related to lifelong premature ejaculation (PE) etiology have been suggested to be penile hypersensitivity, greater cortical penile representation, and disturbance of central serotoninergic neurotransmission. AIMS: To quantitatively assess penile sensory thresholds in European Caucasian patients with lifelong PE using the Genito-Sensory Analyzer (GSA, Medoc, Ramat Yishai, Israel) as compared with those of an age-comparable sample of volunteers without any ejaculatory compliant. METHODS: Forty-two consecutive right-handed, fully potent patients with lifelong PE and 41 right-handed, fully potent, age-comparable volunteers with normal ejaculatory function were enrolled. Each man was assessed via comprehensive medical and sexual history; detailed physical examination; subjective scoring of sexual symptoms with the International Index of Erectile Function; and four consecutive measurements of intravaginal ejaculatory latency time with the stopwatch method. All men completed a detailed genital sensory evaluation using the GSA; thermal and vibratory sensation thresholds were computed at the pulp of the right index finger, and lateral aspect of penile shaft and glans, bilaterally. MAIN OUTCOME MEASURES: Comparing quantitatively assessed penile thermal and vibratory sensory thresholds between men with lifelong PE and controls without any ejaculatory compliant. RESULTS: Patients showed significantly higher (P < 0.001) thresholds at the right index finger but similar penile and glans thresholds for warm sensation as compared with controls. Cold sensation thresholds were not significantly different between groups at the right index finger or penile shaft, but glans thresholds for cold sensation were bilaterally significantly lower (P = 0.01) in patients. Patients showed significantly higher (all P < or = 0.04) vibratory sensation thresholds for right index finger, penile shaft, and glans, bilaterally, as compared with controls. CONCLUSIONS: Quantitative sensory testing analysis suggests that patients with lifelong PE might have a hypo- rather than hypersensitivity profile in terms of peripheral sensory thresholds. The peripheral neuropathophysiology of lifelong PE remains to be clarified.

Initial extended transrectal prostate biopsy--are more prostate cancers detected with 18 cores than with 12 cores?

PURPOSE: We retrospectively investigated the detection rates of prostate cancer, high grade prostatic intraepithelial neoplasia and atypical glands suggestive of carcinoma by initial 18 and 12-core prostate biopsy. MATERIALS AND METHODS: A total of 3,460 consecutive patients with prostate specific antigen between 2.5 and 15 ng/ml underwent 12 (1,684) or 18 (1,776) core prostate biopsy under local anesthesia at 2 departments that adopted the same indications for performing biopsy. Biopsies were evenly distributed throughout the prostate in 6 sectors. In the 12-core prostate biopsy group 2 samples were obtained from each sector and in the 18-core prostate biopsy group 1 additional core was taken from each sector. RESULTS: The cancer detection rate in patients who underwent 18-core prostate biopsy was not different from the rate in those who underwent 12-core prostate biopsy (39.9% and 38.4%, p = 0.37), nor did the detection of atypical glands suggestive of carcinoma differ significantly between the 2 groups (2.9% and 3.3%, respectively, p = 0.33). However, 18-core prostate biopsy detected a significantly higher percent of cases of high grade prostatic intraepithelial neoplasia (20.0% vs 12.9%, p = 0.001). The cancer detection rate was higher with 18 than with 12-core prostate biopsy in patients with a prostate volume of 55 cc or greater (31.5% vs 24.8%, p = 0.01) but not in those with a prostate volume of less than 55 cc (54.3% and 53.0%, respectively, p = 0.7). Moreover, we determined that patients with positive digital rectal examination findings do not need 18-core prostate biopsy as opposed to 12-core prostate biopsy. CONCLUSIONS: Compared with 12-core prostate biopsy, 18-core prostate biopsy detects significantly more cases of high grade prostatic intraepithelial neoplasia. However, 18-core prostate biopsy detects a significantly higher number of cancer only in patients with a prostate volume of 55 cc or greater.

Thulium laser enucleation of the prostate (ThuLEP): Results, complications, and risk factors in 139 consecutive cases.

OBJECTIVES: To report our experience with the emerging technique of thulium laser enucleation of the prostate (ThuLEP) for the treatment for prostate hyperplasia. PATIENTS AND METHODS: Our inclusion criteria were an International Prostate Symptom Score (IPSS) of >15 and a quality-of-life (QoL) score of >3 in patients with confirmed bladder outflow obstruction, no longer responsive to medical therapy, with a significant post-void residual urine volume (PVR; >100 mL), with or without recurrent urinary tract infection and/or acute urinary retention. Patients with neurogenic bladder, urethral strictures, bladder stones, and previously failed transurethral prostate surgery were excluded. RESULTS: In all, 139 men were included in the study. The mean age was 67.8 years. The IPSS and QoL score improved by 17.6 and 2.6, respectively. The flow rate increased from a mean of 9.6 mL to 31.2 mL and the PVR decreased from a mean of 131 mL to 30 mL. On univariate and multivariate analyses, operating time was a predictive factor for haemoglobin drop during the operation. Heparin prophylaxis was the only risk factor identified for postoperative bleeding. Two patients (0.01%) required blood transfusion. One patient (0.007%) required re-intervention for bleeding control, and two patients developed urethral and bladder neck strictures (0.01%). CONCLUSION: ThuLEP is safe and reproducible. Whilst it significantly reduces intraoperative bleeding as compared to transurethral resection of the prostate, operating time and perioperative heparin prophylaxis may still lead to a Hb drop and constitute a risk factor for postoperative bleeding. Therefore, a potential risk of deep vein thrombosis requiring heparin prophylaxis should be carefully considered and balanced with the expected clinical benefit of the operation.

Detection and diagnosis of prostate cancer: what's new.

OBJECTIVE: Prior the widespread use of PSA screening in asymptomatic men, prostate cancer was historically detected by a simple digital rectal examination. Although the gold standard for prostate cancer still remains prostate biopsy, current researches in the area of detection and diagnosis of prostate carcinoma are focusing on identification of better sampling protocols, biologic markers and imaging strategies in order to detect disease at an earlier stage. We reviewed all the recent literature on the detection of clinically meaningful prostate cancer. METHODS: A systematic review of the literature using Medline up to 2005 was performed. Electronic searches were limited to the English language using the keywords prostate cancer, diagnosis, transrectal ultrasound, prostate biopsy. Unpublished information known by the authors and that were considered of interest to the readers were also included. RESULTS: The prostate biopsy technique has extremely changed from the original Hodge's sextant biopsy protocol. Several authors have already reported high rates of false negative biopsy using sextant protocols. The optimal protocol should, nowadays, include six standard sextant biopsies with additional biopsies weighted more laterally (anterior horn) and medially to the apex. Repeat biopsies should also be based on an extended scheme and should include the transition zone especially in patient with at initial negative biopsy. To increase accuracy of prostatic biopsy and reduce unnecessary prostate biopsy, TRUS, power Doppler imaging (PDI), colour Doppler TRUS (CDUS), and 3-dimensional Doppler (3DD) can be successfully adopted, but their routine use is still controversial. Several types of local anaesthesia are now available and can be safely performed to reduce the pain of multi-sites biopsy protocol. CONCLUSION: Extended biopsy schemes should be performed not only at first biopsy but especially at repeated biopsy for premalignancy lesions. The widespread use of local anesthesia makes the procedure more comfortable.

Atypical small acinar proliferation (ASAP) on extended prostatic biopsies: predictive factors of cancer detection on repeat biopsies.

OBJECTIVE: To evaluate the clinical and histopathologic factors that may help to predict cancer detection by means of extended repeated prostate needle biopsies in patients with Jumma atypical small acinar proliferation (ASAP) results on initial prostate biopsy. MATERIALS AND METHODS: From 1998 to September 2003, 105 out of 121 (86%) patients with a diagnosis of ASAP after a first set of 10 to 12 systematic biopsies, were rebiopsied using the same technique plus additional biopsies on the ASAP site (mean number of repeat biopsy samples, 12.6). The median time until a second and third biopsy was 7.04 months (95% confidence interval [CI], 5.5-8.5), and 13.3 months (95% CI, 8.8-17.7; 19 patients), respectively. Each histological slide was reviewed blindly by a single experienced pathologist (M.F) who differentiated highly suspicious (ASAPH) and not highly suspicious (ASAPB) lesions for cancer. RESULTS: On initial biopsy, a concomitant HGPIN was present in 18 patients (17%) with ASAP The overall cancer detection rate in those who underwent two or three sets of biopsies was 39% (41/105); it was 35% (37/105) and 21% (4/19) in second and third biopsies, respectively. The overall cancer detection rate was higher in patients who had ASAP associated with HGPIN (50%) compared with patients who had isolated ASAP (37%) (p = 0.3). Statistical analysis showed that levels of prostate-specific antigen (PSA), PSA density, prostatic volume, digital rectal examination results, transrectal ultrasound findings, time until rebiopsy (less vs. more than 6 months), and histological level of suspicion were not significant predictors of prostate cancer at the time of rebiopsy. In particular, the cancer detection rate was not significantly higher in patients with ASAPH than those with ASAPB (49% vs. 33%, respectively; p = 0.11). In a univariate analysis, the mean prostate volume was statistically different in patients with cancer compared with those without (56.4 +/- 6.3 and 78.9 +/- 5.3 respectively; p = 0.009), but only in the group of patients who had isolated ASAP In these patients, the rate of cancer detection was significantly higher in patients who had a prostatic volume less than 60 mL (56%) than in patients with a prostatic volume greater than or equal to 60 mL (27%) (p = 0.03). CONCLUSIONS: Patients with an initial ASAP diagnosis after extended biopsies had an overall cancer detection rate less than 40% after two sets of extended biopsy. ASAPH lesions did not indicate a significantly higher risk of cancer than ASAPB lesions on repeated extended biopsies. Despite the extended rebiopsy plus the additional biopsies targeted to the ASAP lesion, the detection rate was lower for patients with a larger prostate than those with a smaller prostate.

[Diagnostic value of ultrasound-guided anastomotic biopsies in patients with high PSA (> or = 0,4 ng/ml) after radical prostatectomy]. / Il ruolo diagnostico delle biopsie eco-guidate della anastomosi vescico-uretrale nei pazienti con un aumento del PSA (> or = 0,4 ng/ml) dopo prostatectomia radicale.

OBJECTIVES: The authors report their experience on the use of a high number of biopsies for the diagnosis of a vesicourethral anastomosis tumor recurrence in patients who underwent radical prostatectomy with a PSA elevation. METHODS: Sixty-five patients with PSA > or = 0.4 ng/ml after radical prostatectomy received 6 to 8 transrectal ultrasound (TRUS) guided biopsies of the vesicourethral anastomosis. RESULTS: The biopsy scheme with 6 random anastomotic biopsies plus additional biopsies through TRUS detectable lesions was able to diagnose a local recurrence in more than 60% of the cases. In presence of a post-operative PSA < 1.0 ng/ml and in absence of ultrasound detectable or palpable lesions a local neoplastic recurrence was detected in 58% of the cases. In presence of a palpable or ultrasound visible lesions, the detection rate increases to 80% of the cases.

[Role of ultrasonography-guided prostatic biopsy of hypoechoic areas associated with systematic biopsies in patients with normal and high PSA levels]. / Il ruolo delle biopsie prostatiche mirate sulle aree ipoecogene associate alle biopsie a sestanti nei pazienti con PSA elevato e nella norma.

OBJECTIVE: The aim of the study is to evaluate the need to perform directed biopsies to hypoechoic areas at transrectal ultrasound associated with a prostatic mapping in patients with normal and elevated levels of PSA. MATERIALS AND METHODS: Since January 1987, 517 consecutive patients (mean age: 65.5 +/- 5.2 yrs) underwent selective prostatic biopsies of hypoechoic areas and systematic sextant biopsies with 10 samples in patients with a prostatic volume < 60 g and 12 samples in prostatic volume > 60 g. RESULTS: The median PSA value was 7.2 +/- 4.6 ng/ml (SD). 52% of the patients had a positive digital rectal examination. Cancer was detected in 47% of the patients (245/517), in 18% (14/78) of patients with PSA level < 4.0 ng/ml, in 42% (109/256) with PSA level from 4 to 10 ng/ml, in 66% (122/183) with PSA > 10 ng/ml. The PSA value was statistically higher (PSA = 14.9 +/- 17) in patients with positive prostatic biopsies compared to patients with negative biopsies (PSA = 8.5 +/- 8.3 ng/ml) (p > 0.0001). The PPV (positive predictive value) of the hypoechoic lesions was 36% (187/517). Cancer was detected only in directed biopsies of the hypoechoic areas regardless of PSA value in the 20% of patients (49/245). Sextant biopsies were positive with negative directed biopsies in 24% (58/245) of the patients, while both directed and sextant biopsies were positive in 56% (138/245) of the patients. COMMENTS: The hypoechoic lesion is the prostatic area in which prostatic cancer is most likely to be located in spite of the fact that the PPV of a hypoechoic area is less than 40%. The combination of sextant and lesion-directed biopsies maximizes the detection rate using the lowest possible number of biopsy cores. In the case of a TRUS visible lesion, the optimal number and placement of added systematic biopsies is yet to be defined. Due to the multifocality of prostate cancer, in the future, it is probable that, by adding more biopsies to the sextant standard scheme, the necessity of biopsying single small hypoechoic lesions will no longer be necessary.

[Role of prostate fossa ultrasonography in the diagnosis of local recurrence after radical prostatectomy in case of PSA failure]. / Il ruolo dell'ecografia della loggia prostatica nella diagnosi delle recidive locali dopo prostatectomia radicale in caso di rialzo del PSA.

OBJECTIVES: The aim of this study is to verify the diagnostic accuracy of transrectal ultrasound (TRUS) of vesico-urethral anastomosis in patients with PSA elevation (> or = 0.2 ng/mL) after radical prostatectomy, who received 4-6 random anastomotic biopsies of the prostatic fossa plus additional biopsies directed to TRUS detectable lesions. MATERIAL AND METHODS: Since 1992 up to now, 102 patients (mean age: 68.3 +/- 5.4 years) with PSA elevation after radical prostatectomy underwent TRUS of the vesico-urethral anastomosis and 4-6 TRUS-guided random biopsies plus 1-2 additional biopsies directed to TRUS detectable lesions. Pathologic stage was B (ASS classification) in 60% of cases, C in 36% and D in 4% (patients without hormonal treatment who underwent TRUS-guided biopsy because of TRUS detectable or palpable lesion). RESULTS: The mean PSA at biopsy time was 2.1 +/- 4.6 (SD) ng/mL (range: 0.2-31.6 ng/mL) with median PSA of 0.9 ng/mL. DRE was positive in 37% of cases, while TRUS was positive in 73%. Recurrent adenocarcinoma was detected in 51% of all patients and in 45% (26/57) of patients with PSA < 1.0 ng/mL. TRUS sensitivity was higher (80%) than DRE (50%), but specificity was lower (37% vs 81%). The positive predictive value of TRUS detectable lesion was 60%. TRUS sensitivity and specificity increase with PSA elevation and sonographic aspects of prostatic fossa are statistically correlated with histology when PSA > 1.2 ng/mL. CONCLUSIONS: TRUS of the vesico-urethral anastomosis seems to be more sensitive but less specific than DRE for prostatic cancer local recurrence. More than half of TRUS detectable lesions is positive at biopsy. TRUS and TRUS-guided biopsy accuracy are directly correlated with PSA elevation.