Value of early second session shock wave lithotripsy in treatment of upper ureteric stones compared to laser ureteroscopy.

PURPOSE: The safety and efficacy of early second session shock wave lithotripsy (SWL) compared with laser ureteroscopy (URS) for the treatment of upper ureteric stones were evaluated. METHODS: From January to October 2019, 108 patients with upper ureteric stones (< 1.5 cm and ≤ 1000 Hounsfield unit (HU)) were randomized into SWL and laser URS groups. The second SWL session was performed within 48-72 h of the first session. Using plain abdominal X-ray and ultrasonography, patients were evaluated 48-72 h after the first SWL session and one week after the second and third SWL sessions or one week after URS. The procedure was considered a success when no additional procedures were needed to clear the stone. To determine the stone-free rate (SFR), noncontrast computed tomography of the urinary tract was performed three months postoperatively. RESULTS: In the SWL group, the success rates were 92.6% and 94.4% after the second and third sessions. The SFR was 96.2% in the laser URS group. The success rates were not significantly different between the second and third SWL sessions versus the laser URS (p = 0.418 and 0.660, respectively). Operative and fluoroscopy times were significantly longer in the SWL group (p = 0.001), and JJ stent insertions were needed after laser URS. CONCLUSION: Ultraslow full-power SWL treatment of patients with upper ureteric stones (< 1.5 cm and ≤ 1000 HU) with an early second session is safe and effective compared to laser URS. Patients who do not respond to early second SWL session should be shifted to another treatment modality.

Ultraslow full-power shock wave lithotripsy protocol in the management of high attenuation value upper ureteric stones: A randomized comparative study.

OBJECTIVES: To evaluate the efficacy and safety of ultraslow full-power shock wave lithotripsy protocol in the management of high attenuation value upper ureteric stones compared with slow-rate, power-ramping shock wave lithotripsy. METHODS: This was a randomized trial enrolling patients with a single high attenuation value (≥1000 HU) upper ureteric stones between January 2019 and July 2019. Ultraslow full-power shock wave lithotripsy (54 patients) was applied at a rate of 30 shock waves/min with power ramping from 6 to 18 kV for 100 shock waves, then a safety pause for 2 min, followed by ramping 18-22 kV for 100 shock waves, then a safety pause for 2 min. Then, full power (22 kV) was maintained until the end of the session. Slow-rate, power-ramping shock wave lithotripsy (47 patients) was applied at a rate of 60 shock waves/min with power ramping from 6 to 10 kV during the first 500 shock waves, then from 11 to 22 kV during the next 1000 shock waves, then maintained on 22 kV in the last 1500 shock waves. Up to three sessions were carried out with a follow up 3 months after the last session. The primary outcome was the stone-free rate. Perioperative data of the two protocols were compared. RESULTS: There was no significant difference in preoperative data. The stone-free rate was significantly higher in ultraslow full-power shock wave lithotripsy after single (92.6% vs 23.4%) and multiple (96.3% vs 63.8%) sessions. Most complications were mild, with no significant difference between both groups (9.3% vs 12.8%; P = 0.573). Logistic regression analysis identified ultraslow full-power shock wave lithotripsy protocol as the only significant independent factor for the stone-free rate (odds ratio 12.589, P = 0.025). CONCLUSION: Ultraslow full-power shock wave lithotripsy for high attenuation value upper ureteric stones is associated with a significantly higher stone-free rate, and with mild complications that are comparable to those of standard shock wave lithotripsy.

Percutaneous nephrostomy versus JJ ureteric stent as the initial drainage method in kidney stone patients presenting with acute kidney injury: A prospective randomized study.

OBJECTIVE: To compare percutaneous nephrostomy tube versus JJ stent as an initial urinary drainage procedure in kidney stone patients presenting with acute kidney injury. METHODS: Between January 2017 and January 2019, 143 patients with acute kidney injury secondary to obstructive kidney stone were prospectively randomized into the percutaneous nephrostomy tube group (71 patients) and JJ stent group (72 patients) at Beni-Suef University Hospital, Beni-Suef, Egypt. Exclusion criteria included candidates for acute dialysis, fever (>38°C), pyonephrosis, pregnancy and uncontrolled coagulopathy. The period required for serum creatinine normalization, failure of insertion, operative and fluoroscopy time were recorded. Definitive stone management for proximal ureteral stones >1.5 cm consisted of percutaneous nephrolithotomy for the percutaneous nephrostomy group and ureteroscopic laser lithotripsy for the JJ stent group. For stone size <1.5 cm, ureteroscopy or shockwave lithotripsy was carried out for both groups. Percutaneous nephrolithotomy was carried out for renal stones >2 cm, and shockwave lithotripsy for stones <2 cm. Distal and mid ureteral stones were treated by ureteroscopy. RESULTS: The percutaneous nephrostomy group had shorter operative time (P = 0.001). There was no significant difference in the recovery period for normalization of serum creatinine between both groups (P = 0.120). Procedural failure, ureteric mucosal injury and perforations increased in the case of male sex, stone size >1.5 cm and upper ureteric stones in the JJ stent group. Procedural failure, pelvic perforations and intraoperative bleeding increased in case of male sex, mild hydronephrosis and stone size >2.5 cm in the percutaneous nephrostomy group. Suprapubic pain, urethral pain and lower urinary tract symptoms were significant in the JJ stent group. The presence of a JJ stent directed us toward ureteroscopy (P = 0.002) and the presence of a percutaneous nephrostomy directed us toward percutaneous nephrolithotomy (P = 0.001). CONCLUSIONS: Percutaneous nephrostomy facilitates subsequent percutaneous nephrolithotomy, especially when carried out by a urologist, and it has a higher insertion success rate, a shorter operative time and a lesser incidence of postoperative urinary tract infection than a JJ stent. A JJ stent facilitates subsequent ureteroscopy, but operative complications can increase in the case of proximal ureteral stones >1.5 cm.

Ultraslow full-power shock wave lithotripsy versus slow power-ramping shock wave lithotripsy in stones with high attenuation value: A randomized comparative study.

OBJECTIVES: To compare the efficacy and safety of ultraslow full-power versus slow rate, power-ramping shock wave lithotripsy in the management of stones with a high attenuation value. METHODS: This was a randomized comparative study enrolling patients with single high attenuation value (≥1000 Hounsfield unit) stones (≤3 cm) between September 2015 and May 2018. Patients with skin-to-stone distance >11 cm or body mass index >30 kg/m2 were excluded. Electrohydraulic shock wave lithotripsy was carried out at rate of 30 shock waves/min for group A versus 60 shock waves/min for group B. In group A, power ramping was from 6 to 18 kV for 100 shock waves, then a safety pause for 2 min, followed by ramping 18-22 kV for 100 shock waves, then a safety pause for 2 min. This full power (22 kV) was maintained until the end of the session. In group B, power ramping was carried out with an increase of 4 kV each 500 shock waves, then maintained on 22 kV in the last 1000-1500 shock waves. Follow up was carried out up to 3 months after the last session. Perioperative data were compared, including the stone free rate (as a primary outcome) and complications (secondary outcome). Predicting factors for success were analyzed using logistic regression. RESULTS: A total of 100 patients in group A and 96 patients in group B were included. The stone-free rate was significantly higher in group A (76% vs 38.5%; P < 0.001). Both groups were comparable in complication rates (20% vs 19.8%; P = 0.971). The stone-free rate remained significantly higher in group A in logistic regression analysis (odds ratio 24.011, 95% confidence interval 8.29-69.54; P < 0.001). CONCLUSIONS: Ultraslow full-power shock wave lithotripsy for high attenuation value stones is associated with an improved stone-free rate without affecting safety. Further validation studies are required using other shock wave lithotripsy machines.

Outcome of Botulinum Toxin-A intraprostatic injection for benign prostatic hyperplasia induced lower urinary tract symptoms: A prospective multicenter study.

INTRODUCTION: Our aim was to determine the factors predicting the outcome of intraprostatic injection of Botulinum Toxin-A (BTX-A) in the treatment of benign prostatic hyperplasia (BPH)-induced lower urinary tract symptoms (LUTS) and to evaluate its efficacy and safety. METHODS: Between September 2016 and May 2018, 45 Egyptian patients, with BPH-induced LUTS were included; the indication was a failure of medical treatment, unfit, or refusing surgical intervention. Measurements of prostate size by TRUS, total PSA level before and 12 weeks after injection. IPSS, uroflow, and postvoiding residual urine (PVR) were measured before injection, 2, 4, 8 and 12 weeks postinjection. 100 U BTX-A vial was diluted with 10 mL of saline then injected into the transition zone at base and midzone of the prostate by TRUS. RESULTS: The mean patients' age was 64.4 ± 6.6 years. Mean baseline IPSS 24.06 decreased to 18.75 at 2 weeks and progressively decreased to 16.37 at 12 weeks (P < 0.001), Q max of 9.08 mL/s. increased to 10.44 at 2 weeks and 11.44 at 12 weeks (P < 0.001), mean prostate volume was 67.44cc; decreased to 66.06cc (P < 0.001) at 12 weeks and mean residual urine was 82.62 mL and decreased to 57.66 mL at 12 weeks. DISCUSSION: Intraprostatic injection of BTX-A as modality treatment of LUTS/BPH significantly improve IPSS, Q max , PVR, and decrease prostate volume. We can suspect better results with this line of treatment in patients with IPSS ≤ 22 and Q max ≤ 10 mL/min and prostate volume ≤ 56.5cc.

PCA3-based nomogram for predicting prostate cancer and high grade cancer on initial transrectal guided biopsy.

BACKGROUND: To develop a validated prostate cancer antigen 3 (PCA3) based nomogram that predicts likelihood of overall prostate cancer (PCa) and intermediate/high grade prostate cancer (HGPCa) in men pursuing initial transrectal prostate biopsy (TRUS-PBx). METHODS: Data were collected on 3,675 men with serum prostate specific antigen level (PSA) ≤ 20 ng/ml who underwent initial prostate biopsy with at least 10 cores sampling at time of the biopsy. Two logistic regression models were constructed to predict overall PCa and HGPCa incorporating age, race, family history (FH) of PCa, PSA at diagnosis, PCA3, total prostate volume (TPV), and digital rectal exam (DRE). RESULTS: One thousand six hundred twenty (44%) patients had biopsy confirmed PCa with 701 men (19.1%) showing HGPCa. Statistically significant predictors of overall PCa were age (P < 0.0001, OR. 1.51), PSA at diagnosis (P < 0.0001, OR.1.95), PCA3 (P < 0.0001, OR.3.06), TPV (P < 0.0001, OR.0.47), FH (P = 0.003, OR.1.32), and abnormal DRE (P = 0.001, OR. 1.32). While for HGPCa, predictors were age (P < 0.0001, OR.1.77), PSA (P < 0.0001, OR.2.73), PCA3 (P < 0.0001, OR.2.26), TPV (P < 0.0001, OR.0.4), and DRE (P < 0.0001, OR.1.53). Two nomograms were reconstructed for predicted overall PCa probability at time of initial biopsy with a concordance index of 0.742 (Fig. 1), and HGPCa with a concordance index of 0.768 (Fig. 2). CONCLUSIONS: Our internally validated initial biopsy PCA3 based nomogram is reconstructed based on a large dataset. The c-index indicates high predictive accuracy, especially for high grade PCa and improves the ability to predict biopsy outcomes.

The utility of PSA velocity in prediction of prostate cancer and high grade cancer after an initially negative prostate biopsy.

BACKGROUND: Prostate specific antigen kinetics (PSAK) including prostate specific antigen velocity (PSAV) and PSA doubling time (PSADT) are used as predictors of prostate cancer (PCa) therapeutic outcome, disease prognosis, and cancer-specific mortality. However controversy persists regarding use of these parameters in cancer detection. Our aim is to evaluate PSAV as a predictor of PCa and intermediate/high grade PCa (HGPCa). METHODS: We included 682 patients that underwent repeat transrectal ultrasound guided biopsy after initial negative biopsy. Univariate and multivariate analyses as well as area under the receiver operating characteristic curve (ROC-AUC) were performed to assess predictive accuracy regarding detection of PCa and intermediate/HGPCa (Gleason score ≥ 7). RESULTS: PCa was detected in 179/682 (26.24%) patients. Our univariate analysis suggested that age, total prostate volume (TPV), atypical small acinar proliferation (ASAP) and PSA indices in the form of PSA at the time of repeat biopsy (PSA2), PSAV, PSA density (PSAD2) and percent free PSA at time of repeat biopsy (%FPSA2) were all predictors of overall PCa and intermediate/HGPCa. Meanwhile, our multivariate model showed that factors associated with overall PCa and intermediate/HGPCa were age, PSAV and TPV. CONCLUSIONS: In men pursuing a second biopsy after an initial negative biopsy, PSAV was an independent predictor of overall PCa, intermediate and high grade cancer.

Identification of the variables associated with pain during transrectal ultrasonography-guided prostate biopsy in the era of periprostatic nerve block: the role of transrectal probe configuration.

OBJECTIVE: To identify the different factors that are associated with pain perceived during transrectal ultrasonography (TRUS)-guided prostate biopsy (PBx), with special focus on the role of transrectal probe configuration. PATIENTS AND METHODS: We analysed prospective data on 1114 patients undergoing TRUS-guided PBx at our institute from January 2007 to August 2010. Patients completed questionnaires based on a 10-point visual analogue pain scale related to the consecutive steps of PBx: probe insertion, application of periprostatic nerve block (PPNB) and the obtaining of PBx cores. The variables of interest were age, prostate volume, DRE findings, number of previous biopsies, probe type and the number of retrieved cores. All variables were correlated to pain scores using multivariate regression analysis. RESULTS: At the probe insertion step, end-fire probes were more painful than side-fire probes. The Siemens G50 with metal, short plastic and long plastic needle guides (Siemens, Munich, Germany) had higher pain scores than the B&K probe (Bruel & Kjaer Medical, Copenhagen, Denmark; P = 0.09, 0.008 and 0.003, respectively). For pain at the PPNB application step, all G50(TM) guide subtypes and the Sonoline Prima probe (Siemens) had higher pain scores than the B&K probe, but this only reached statistical significance for the G50(TM) probe with short plastic guide (P = 0.03). On obtaining PBx cores, all G50(TM) subtypes had higher pain scores when compared with the B&K probe (P = 0.59, 0.38 and 0.69, respectively). CONCLUSIONS: The probe design and needle guide affect pain during each step of TRUS-guided PBx. Both the B&K and Sonoline Prima probes caused less pain when compared with the G50(TM) probe, regardless of needle guide.

Type of transrectal ultrasonography probe influences prostate cancer detection rates on repeat prostate biopsy.

UNLABELLED: It is known that the end-fire probe detects more prostate cancer on initial prostate biopsy, but there is no literature looking at the influence of type of probe on repeat biopsy. Given that the literature on the influence of ultrasonography probe on repeat prostate biopsy is non-existent, the present study adds information which may help urologists improve their chances of detecting prostate cancer on prostate biopsy. Determining which type of probe to use on a prostate biopsy is a simple external factor that may help improve patient management. OBJECTIVE: To determine if the type of transrectal ultrasonography (TRUS) probe used during repeat prostate biopsy influences prostate cancer detection rates. PATIENTS AND METHODS: We conducted a retrospective chart review of 680 men undergoing repeat prostate biopsy at our institution between 2000 and 2010. Patient mean (range) age was 64.2 (39-95) years. The median (range) prostate-specific antigen (PSA) level was 5.5 (0.37-33.8) ng/mL and median (range) free PSA was 17 (5-45) %. Patient age, PSA, prostate volume, number of biopsy cores, time interval between initial and repeat biopsy, digital rectal examination and pathological findings were all included in a multivariate logistic regression analysis. RESULTS: The use of an end-fire probe on repeat biopsy significantly increased prostate cancer detection (odds ratio [OR] 1.59, 95% confidence interval [CI]: 1.03-2.46). The time interval between 1(st) and 2(nd) biopsy was also significant (OR 1.46, 95% CI: 1.11-1.09). On univariate analysis, white race (OR 0.66, 95% CI: 0.44-0.99), increasing prostate volume (OR 0.70, 95% CI: 0.55-0.89), and higher free PSA (OR 0.54, 95% CI: 0.34-0.84) were associated with a decreased risk of cancer. When evaluating the different permutations of using an end-fire or side-fire probe on initial or repeat biopsy, there was no difference in prostate cancer detection regardless of order of use of an end-fire or side-fire probe. CONCLUSIONS: An end-fire probe is associated with improved prostate cancer detection rates on both initial and repeat biopsy. The order of probe use does not appear to matter.

Hospitalization patterns in HD patients in the Kingdom of Saudi Arabia: A comprehensive cohort study.

INTRODUCTION: The rate of hospitalization represents a morbidity indicator in HD patients. The study aimed to evaluate hospitalization patterns in a large HD cohort. METHODS: All DaVita-KSA HD patients from October 2014 to December 2019 were included. Demographical and clinical characteristics and hospitalization data were recorded. Less than 24 h admission was excluded. Overall and cause-specific hospitalization rates were calculated. RESULTS: During the follow-up period, 3982 patients with a mean age of 52.5 ± 16.8 years, 2667 hospitalizations were recorded in 34.1% of the patients and 45.6% had repeated admissions. Infectious causes accounted for 26.6% of all recorded causes vs. 15.6% for cardiovascular complications. The median hospital stay length was 11 days, while the overall annual hospitalization rate of 34.9% and the annual duration of 3.7 days per patient. Hospitalized patients had a higher risk of mortality (p < 0.001). CONCLUSION: Infectious complications were the leading cause of hospitalization and had the longest hospital stay.

Statin use and risk of prostate cancer in a population of men who underwent biopsy.

PURPOSE: We determined the association between statin use and prostate cancer in men who underwent prostate biopsy. MATERIALS AND METHODS: We performed a retrospective cohort study of men who underwent prostate biopsy from 2000 to 2007 at Cleveland Clinic. Statin use was determined using outpatient pharmacy records, and clinical and pathological outcomes were obtained. Multivariate logistic regression analysis to determine the effects of statins (and duration of use) was performed after adjusting for age, body mass index, African-American race, number of cores taken and prostate volume. RESULTS: We analyzed data from 4,204 patients, and we identified 3,182 (75.7%) not on statins and 1,022 on statins. Men diagnosed with prostate cancer on statins compared to those not taking statins were less likely to have digital rectal examination positivity (5.3% vs 8.9%, OR 0.7, p <0.01), Gleason score 7 or greater prostate cancer (61.4% vs 72.4%, OR 0.78, p = 0.02) and high volume prostate cancer (27.2 vs 31.4, p <0.01). Moreover statin users had lower prostate specific antigen compared to nonstatin users (5.13 vs 5.98, p = 0.03). Multivariate analysis adjusted risk ratios for prostate cancer diagnosis, high grade prostate cancer (Gleason score 7 or greater) and 3 or more cores positive in statin users were 0.92 (95% CI 0.85-0.98), 0.76 (95% CI 0.67-0.85) and 0.86 (95% CI 0.75-0.97) and only high grade prostate cancer persisted with length of use. CONCLUSIONS: Statin use was associated with a decreased risk of prostate cancer, less frequent high grade prostate cancer and lower volume of prostate cancer, suggesting that statin use has a protective effect against prostate cancer.

Office based transrectal saturation biopsy improves prostate cancer detection compared to extended biopsy in the repeat biopsy population.

PURPOSE: Multiple studies have shown significant prostate cancer detection for repeat biopsy. However, the best approach regarding core number and location remains controversial. Transrectal saturation biopsy is believed to increase cancer detection but to our knowledge no studies comparing it to 12 to 14-core extended biopsy have been published. We compared saturation and extended repeat biopsy protocols after initially negative biopsy. MATERIALS AND METHODS: A total of 1,056 men underwent prostate biopsy after initially negative biopsy. The extended biopsy group included 393 men with 12 to 14-core repeat biopsy. The saturation biopsy group included 663 men with 20 to 24-core repeat biopsy. We analyzed demographics and prostate cancer between the 2 groups. We compared prostate cancer detection in patients with previous atypical small acinar proliferation and/or high grade prostatic intraepithelial neoplasia as well as the risk of detecting clinically insignificant tumors. RESULTS: Prostate cancer was detected in 315 of the 1,056 patients (29.8%). Saturation biopsy detected almost a third more cancers (32.7% vs 24.9%, p=0.0075). In patients with a benign initial biopsy saturation biopsy achieved significantly greater prostate cancer detection (33.3% vs 25.6%, p=0.027). For previous atypical small acinar proliferation and/or high grade prostatic intraepithelial neoplasia there was a trend toward higher prostate cancer detection rate in the saturation group but it did not attain statistical significance (31.2% vs 23.3%, p=0.13). Of 315 positive biopsies 119 (37.8%) revealed clinically insignificant cancer (40.1% vs 32.6%, p=0.2). CONCLUSIONS: Compared to extended biopsy, office based saturation biopsy significantly increases cancer detection on repeat biopsy. The potential for increased detection of clinically insignificant cancer should be weighed against missing significant cases.

Multifocal high grade prostatic intraepithelial neoplasia is a risk factor for subsequent prostate cancer.

PURPOSE: The risk of under diagnosed or development of subsequent prostate cancer and the treatment of patients diagnosed with high grade prostatic intraepithelial neoplasia remain controversial. We evaluated the relationship between high grade prostatic intraepithelial neoplasia on initial biopsy and the future presence of prostate cancer. MATERIALS AND METHODS: From December 1997 to February 2008 a total of 328 men underwent a second prostate biopsy after being initially diagnosed with high grade prostatic intraepithelial neoplasia. Men with prostate cancer or atypia on initial biopsy were excluded from study. Another 335 men without high grade prostatic intraepithelial neoplasia, prostate cancer or atypia underwent a second prostate biopsy based on clinical suspicion alone. A Cox proportional hazards model was used to estimate the effect of high grade prostatic intraepithelial neoplasia on the subsequent diagnosis of prostate cancer after adjustment for prostate specific antigen, age, presence of inflammation, abnormal digital rectal examination and number of cores obtained at biopsy. High grade prostatic intraepithelial neoplasia was also stratified into multifocal disease and laterality. Adjusted Kaplan-Meier plots were generated to estimate the rates of prostate cancer. RESULTS: High grade prostatic intraepithelial neoplasia alone on initial prostate biopsy had a significant effect on the subsequent diagnosis of prostate cancer (HR 1.89; 95% CI 1.39, 2.55; p <0.0001). Stratifying high grade prostatic intraepithelial neoplasia into multifocal and bilateral disease significantly increased the hazard ratios to 2.56 (95% CI 1.83, 3.60) and 2.20 (95% CI 1.51, 3.21), respectively, resulting in estimated 3-year cancer rates of 29.0% and 37.0% compared to 12.5% and 18.9%, respectively, following benign biopsy. CONCLUSIONS: Multifocal and bilateral disease are adverse features of high grade prostatic intraepithelial neoplasia that significantly increase the risk of prostate cancer despite adjusting for other clinical indicators such as prostate specific antigen and abnormal digital rectal examination.

Development and validation of a nomogram for predicting a positive repeat prostate biopsy in patients with a previous negative biopsy session in the era of extended prostate sampling.

OBJECTIVE: To create a nomogram for predicting the probability of a positive biopsy in men with one or more previous negative biopsies, as the false-negative rate of prostate biopsy in contemporary series remains substantial, and there is a need to identify those with a negative result but with a high risk of having unrecognized prostate cancer. PATIENTS AND METHODS: The study included 408 patients from Cleveland Clinic who had one or more repeat biopsies after an initial negative biopsy from 1999 to 2008. Another 470 men with the same criteria were used to validate the nomogram. Nomogram variables included age, family history of prostate cancer, body mass index, findings on a digital rectal examination, prostate-specific antigen (PSA) level, PSA slope, total prostate volume, months from initial negative biopsy session, months from previous negative biopsy, cumulative number of negative cores previously taken and history of high-grade intraepithelial neoplasia or atypical small acinar proliferation. We calculated the nomogram predicted probability in each patient. These predicted outcomes were compared with the actual biopsy results. The area under the receiver operating characteristic (ROC) curve was calculated as a measure of discrimination. RESULTS: The mean number of previous negative biopsies was 1.5, and the mean number of cores per session was 19.1. Of the original development data, 129 men (31.6%) had prostate cancer. A nomogram was constructed that had a concordance index of 0.72, which was greater than any single risk factor. In the validation group the area under the ROC curve was 0.62. CONCLUSIONS: Our nomogram for predicting a positive repeat biopsy can provide important additional information to aid the urologist and patient with a negative biopsy in evaluating clinical options.

A nomogram for predicting upgrading in patients with low- and intermediate-grade prostate cancer in the era of extended prostate sampling.

STUDY TYPE: Diagnostic (exploratory cohort). LEVEL OF EVIDENCE: 2b. OBJECTIVE: To develop a nomogram to predict the probability that the pathological Gleason sum (GS) will be higher than that indicated by the biopsy, suggesting a higher risk for the patient presumed to be at low risk, as a substantial proportion of patients with low and intermediate grade on biopsy are upgraded on interpretation of the radical prostatectomy (RP) specimens, but a similar clarification of accurate Gleason scoring is not available in patients with no surgical histology. PATIENTS AND METHODS: The study included 1017 patients who had RP after biopsy showing GS 6 and 7 (3 + 4) from 2000 to 2007. Nomogram predictor variables included age, race, digital rectal examination, prostate-specific antigen (PSA) level, number of cores taken, number of positive cores, maximum percentage cancer in any core, number of previous biopsies, prostate volume, clinical stage, high-grade prostatic intraepithelial neoplasia, atypical small acinar proliferation, inflammation and perineural invasion. We calculated the nomogram-predicted probability in each patient. The area under the receiver operating characteristic curve was calculated as a measure of discrimination, and the calibration was assessed graphically. RESULTS: The mean age of the patients was 60 years, the mean PSA level 6.62 ng/mL; 336 patients were upgraded (33%), 623 remained the same (61.3%) and 58 were downgraded (5.7%). A nomogram for predicting the possibility of upgrading was constructed that had a concordance index of 0.68. The nomogram was well calibrated. CONCLUSIONS: Our nomogram for predicting upgrading provides important additional information for deciding on treatment to both the urologist and the patient with low- and intermediate-grade prostate cancer. It might prove useful when the possibility of a more aggressive Gleason variant can change the management, and is especially meaningful when management options other than surgery are selected based on the inability to recognize the true pathological actual GS.

Does transrectal ultrasound probe configuration really matter? End fire versus side fire probe prostate cancer detection rates.

PURPOSE: We compared prostate cancer detection rates for the 2 most commonly used transrectal ultrasound prostate biopsy probes, end fire and side fire, to determine whether the probe configuration affects detection rates. MATERIALS AND METHODS: We evaluated 2,674 patients who underwent initial prostate biopsy between 2000 and 2008 with respect to prostate specific antigen, biopsy technique and pathological findings. Patients were divided into 1,124 in whom biopsies were performed with an end fire probe and 1,550 in whom biopsies were performed with a side fire probe. RESULTS: There was a significant difference in the overall cancer detection rate in the end vs side fire arms (45.8% vs 38.5%, p <0.001). In the subsets of patients with prostate specific antigen greater than 4 to 10 ng/ml or less and greater than 10 ng/ml a significant difference persisted (46.4% vs 38.9% and 61.7% vs 49.1%, p <0.004 and <0.015, respectively). There was also a significant difference in detection rates between probes in those who underwent 8 to 19 biopsy cores (p <0.009). Biopsies of greater than 20 cores failed to attain statistical significance (p >0.105). We also found that prostate volume, patient age, prostate specific antigen and hypoechoic findings were independent variables for predicting cancer detection on multivariate analysis (p <0.001). CONCLUSIONS: The type of probe significantly affects the overall prostate cancer detection rate, particularly in patients with prostate specific antigen greater than 4 ng/ml and/or nonsaturation (8 to 19 cores) prostate biopsy. This may be because the end fire probe allows better mechanical sampling of the lateral and apical regions of the peripheral zone, where cancer is most likely to reside. We set the stage for a randomized, controlled trial to confirm our observations.

Prostate biopsy clinical and pathological variables that predict significant grading changes in patients with intermediate and high grade prostate cancer.

OBJECTIVE: To identify the clinical and pathological variables that predict pathological changes in the significant proportion of men with prostate cancer who have an intermediate- or high-grade biopsy Gleason score (GS) of >or=7 and who are upgraded or downgraded on interpretation of radical prostatectomy (RP) pathological specimens, as GS is critical in treatment decisions. PATIENTS AND METHODS: We retrospectively evaluated 1129 patients who had RP after a biopsy showing a GS of >or=7, at our institution, from 2000 to 2007. Complete relevant clinical information was available for all patients. A multivariable logistic regression analysis was used to identify predictors of pathological grading changes. RESULTS: The overall mean age was 61 years, with median prostate-specific antigen (PSA) level of 6 ng/mL. Of the 1129 patients, the surgical GS was upgraded in 296 (26.2%), downgraded in 210 (18.6%), and remained the same in 623 (55.2%). Factors predicting a surgical GS upgrade were a higher PSA level (P = 0.005), presence of perineural invasion (P = 0.043), absence of inflammation (P < 0.001), and absence of associated high-grade prostatic intraepithelial neoplasia (P = 0.02). In an analysis of pathological variables the number of positive cores (P = 0.033) was predictor of upgrading. Large prostate volume (P = 0.004) and low maximum percentage cancer in any core (P = 0.001) were predictors of downgrading. CONCLUSION: Men with a higher PSA level, perineural invasion and high-volume cancer at biopsy are most likely to be upgraded, while men with a large prostate volume and low-volume cancer at biopsy are more likely to be downgraded. These findings have implications for men with prostate cancer managed without confirmation by RP of their true GS.

Prostate cancers diagnosed at repeat biopsy are smaller and less likely to be high grade.

PURPOSE: We investigated whether prostate cancer diagnosed on initial prostate biopsy had worse pathological outcomes compared to that diagnosed on repeat prostate biopsy. MATERIALS AND METHODS: We reviewed 905 newly diagnosed prostate cancer cases from 2000 to 2007. Patients were stratified by the number of previous biopsies, including the initial biopsy in 690, and 1 and 2 or greater negative previous biopsies in 142 and 73, respectively. We analyzed Gleason sum, number of cores taken, percent of positive cores and bilaterality of prostate cancer. Clinically insignificant cancers were defined according to prostate specific antigen density 0.4 ng/ml or less, 3 or fewer positive cores, 50% or less of maximum cancer in any core and Gleason sum 6 or less. RESULTS: Prostate cancer was diagnosed in 57%, 23% and 21% of cases in the initial, and 1 and 2 or greater negative previous biopsies groups, respectively. Initial prostate biopsy showed a higher number and percent of positive cores, and the maximum percent of prostate cancer involved in a core. However, the Gleason pattern distribution differed significantly in the 3 groups with the highest percent (14%) of Gleason sum 8 or greater in the subset with 2 or greater negative previous biopsies (p <0.01). On multivariate analysis accounting for prostate specific antigen, digital rectal examination, age and biopsy schema the number of previous biopsies was an independent predictor of the number and percent of positive cores, maximum prostate cancer involved in a core, and bilaterality (p <0.01). Only prostate specific antigen, digital rectal examination and age but not the number of previous biopsies independently predicted Gleason sum (p <0.01). CONCLUSIONS: Prostate cancer diagnosed on initial prostate biopsy had higher volume. However, there were a significant number of high grade prostate cancers detected on the third or greater prostate biopsy, underscoring the importance of repeat prostate biopsy in the setting of increased or increasing prostate specific antigen despite negative previous prostate biopsy.