Interpolation to define clinical tumor stage in prostate cancer using clinical description of digital rectal examination.

AIM: This study aims to assess characteristics of patients with prostate cancer for whom clinical T stage category (cT) was not documented in the medical record and assess whether specialists had concordant conclusions regarding cT based on digital rectal examination (DRE) notes. METHODS: Data from the Prostate Cancer Outcome Registry - Victoria (PCOR-Vic) were interrogated. Four specialists independently assigned cT to DRE notes. Words, or part thereof, associated with agreement between clinicians were identified. RESULTS: Of the 10 587 men, cT was documented in 8758 (82.7%) cases. Multivariate analysis indicated that poor cT documentation was associated with older patient age (odds ratio [OR] 0.80, 95% confidence interval [CI] 0.66-0.99 if 75.1-85 years; OR 0.50, 95%CI 0.36-0.72 if >85 years); diagnosis via transperineal compared to transrectal ultrasound-guided biopsy (TRUS) (OR 0.68, 95%CI 0.51-0.91); diagnosed in a private hospital (OR 0.85, 95%CI 0.75-0.96); and a diagnostic Gleason score of >8 compared to ≤6 (OR 0.59, 95%CI = 0.48-0.73). cT was more likely documented in men diagnosed via transurethral resection of prostate (OR 2.06, 95%CI 1.64-2.58) compared to TRUS and/or if receiving treatment in a radiotherapy center (OR 3.44, 95%CI 2.80-4.23 for external beam radiotherapy; OR 3.57 95%CI 2.44-5.23 for brachytherapy and OR 1.34, 95%CI 1.06-1.69 for combination surgery and radiotherapy) compared to those undergoing radical prostatectomy. Agreement in cT assignment ranged from kappa of 0.158 to 0.582. Stem word components in DRE notes associated with poorest level of agreement were "abnorm," "hard," "nodul" and those with highest level of agreement were terms "benign" and "smooth." CONCLUSIONS: Mode of diagnosis/subsequent treatment, and cancer characteristics were associated with cT documentation. Third party interpretation of clinical notes is problematic.

Impact of multiparametric magnetic resonance imaging on risk group assessment of patients with prostate cancer addressed to external beam radiation therapy.

PURPOSE: To investigate the impact of multiparametric magnetic resonance imaging (mpMRI) on risk group assessment of patients with prostate cancer (PCa) initially addressed to external beam radiation therapy (EBRT). MATERIALS AND METHODS: We prospectively performed mpMRI (3.0Tsystem) in 44 patients addressed to EBRT, using a multiparametric protocol (high-resolution multiplanar T2-weighted, diffusion-weighted and dynamic contrast-enhanced imaging). Risk group was assessed in accordance with the National comprehensive cancer network (NCCN) categories, by combining prostate-specific-antigen level, Gleason score and the T-stage as established by digital rectal examination (clinical risk assessment; c-RA) versus mpMRI (mpMRI-risk assessment; mpMRI-RA). The agreement between c-RA and mpMRI-RA was investigated using Cohen's kappa. RESULTS: Patients were included in very low/low risk, intermediate risk, high risk, very high risk and metastatic NCCN categories in 10 (22.7%), 18 (40.9%), 15 (34.1%), 1 (2.3%) and 0 cases using c-RA vs. 8 (18.2%), 14 (31.8%), 14 (31.8%), 4 (9.1%) and 4 (9.1%) cases using mpMRI-RA, respectively, with only moderate agreement (k=0.43). mpMRI-RA determined risk downgrading in 2/44 patients (4.5%), and risk upgrading in 16/44 patients (36.3%). After mpMRI, EBRT remained indicated in all patients. CONCLUSION: mpMRI changed clinical risk stratification in about 41% of patients with PCa, with potential impact on EBRT planning.

Prospective investigation of change in the prostate-specific antigens after various urologic procedures.

PURPOSE: Prostate-specific antigen (PSA) is the most important marker in the diagnosis and follow-up of patients with prostate cancer. The primary objective of this study was to evaluate the effect of various urologic procedures in prostatic area on serum free and total PSA levels. SUBJECTS AND METHODS: A series of 62 patients (8 after digital rectal examination [DRE], 12 after transrectal ultrasonography [TRUS], 11 after rigid cystoscopy, 13 after prostatic massage, 8 after TRUS-guided prostate biopsy, and 10 after transurethral resection of prostate [TURP]) were enrolled in the study. Blood samples were taken from each patient before procedure and at 10, 30, 60, and 120 minutes after procedures. RESULTS: Prostate massage, rigid cystoscopy, TURP, and TRUS-guided prostate biopsy caused statistically significant rise in total and free PSA levels in the serum. There was no significant increase in total and free PSA levels in the serum after DRE and TRUS. The mean differences were greater for free PSA level in the serum for TURP, TRUS-guided prostate biopsy, prostate massage, and rigid cystoscopy. CONCLUSION: Total and free PSA levels in the serum are altered by prostate massage, rigid cystoscopy, TRUS-guided prostate biopsy, and TURP. The PSA rises were related to the stimulation strength of the procedures. The total and free PSA levels were increased significantly from 10 minutes after procedures, except DRE and TRUS, and were increased to maximal level at 60 minutes after procedures.

Un mayor cociente de la longitud del segundo y el cuarto dedo de la mano está en relación con mayor incidencia de Cáncer de próstata en biopsia de próstata / High digit ratio predicts prostate cancer in prostate biopsy

OBJETIVO: Analizar la validez del cociente entre las longitudes del 2º y 4º dedos (2D/4D) de la mano izquierda como predictor de cáncer de próstata en hombres sometidos a biopsia transrectal ecodirigida de próstata. MÉTODOS: Recogimos prospectivamente los datos de 204 pacientes consecutivos referidos para biopsia de próstata transrectal por elevación de PSA o tacto rectal sospechoso entre enero 2008 y junio 2009. El mismo médico realizó todas las exploraciones físicas, medidas y biopsias transrectales. La determinación 2D/4D se realizó mediante un pie de rey en la mano izquierda. Se determinó en todos los pacientes un perfil hormonal (testosterona y SHBG) entre las 07:00 y las 11:00. Las variables edad, tacto rectal, PSA, PSA libre, densidad del PSA, testosterona y SHBG, diagnóstico anatomopatológico y 2D/4D se analizaron prospectivamente. RESULTADOS: Las variables edad y SHBG estuvieron directamente relacionadas con la presencia de neoplasia. El volumen de próstata correlacionó inversamente con la presencia de neoplasia. La ratio 2D/4D >0,95 (OR (IC 95%) 4,4 (1,491-13,107) se relacionó con la presencia de cáncer de próstata (CP). No se encontraron diferencias en el CP respecto al PSA, PSA libre, densidad del PSA, tacto rectal y testosterona. CONCLUSIONES: Los hombres sometidos a biopsia de próstata con 2D/4D >0,95 tienen cuatro veces más probabilidades de presentar CP que aquellos con una ratio digital ≤0,95(AU)

OBJECTIVES: To analyze the validity of the ratio between the second and fourth finger (digit ratio; 2D/4D) of the left hand as a predictor for prostate cancer (PCa) in a group of men undergoing prostate biopsy. METHODS: We prospectively recruited 204 consecutive patients referred for transrectal prostate biopsy due to PSA elevation or abnormal digital rectal examination between January 2008 and June 2009. The same physician performed all clinical examinations, digit ratio measurements and transrectal biopsy in all cases. Digit ratio determination was done with a Vernier caliper in the left hand. Patients underwent determination of hormone profile (testosterone and sexual hormone binding globulin (SHBG)) between 7:00AM and 11:00AM.Age, digital rectal examination, PSA, free PSA, PSA density, testosterone and SHBG, pathological report and D2 and D4 measurements were recorded prospectively. RESULTS: Variables age and SHBG were directly related to PCa. Prostate volume was inversely related to neoplasia. 2D/4D ratio >0,95 (OR (CI 95%) 4,4 (1,491-13,107) was related to neoplasia. No differences in PCa were seen regarding PSA, free PSA, PSA density, digital rectal examination and testosterone. CONCLUSION: High digit ratio predicts PCa in men undergoing prostate biopsy. Digit ratio >0,95 has 4-fold risk of PCa compared to men with digit ratio <0.95(AU)

[Practical approach to constipation in adults]. / Praktyczne zasady postepowania w zaparciach u doroslych.

The authors present epidemiology etiology pathophysiology management, and treatment of constipation including proper qualification for surgery. Constipations can be divided into more common - primary and less frequent - secondary The latter may occur due to organic lesions of the large bowel, in the course of metabolic and endocrine disorders, or neurological and psychiatric diseases. Constipation may also be a side effect of multiple medications. In turn, primary constipation is either a slower movement of contents within the large bowel or twice as likely pelvic floor dysfunction with the inability to adequately evacuate the contents from the rectum. Symptoms such as infrequent defecation and decreased urge to defecate indicate rather colonic inertia whereas prolong straining even in case of loose stools, and feeling of incomplete evacuation are typical of obstructed defecation. Digital rectal examination reveals common anorectal defects presenting with constipation such as tumors, anal fissures and strictures, and rectocele, or less frequent changes such as rectal intussusception and enterocele. Proctologic examination should include the assessment of the anal sphincter tone and the pelvic floor movement. Barium enema or colonoscopy are necessary to confirm or exclude colorectal organic lesions, mostly in patients with alarm features. More accurate differentiation between slow transit constipation and obstructed defecation is possible with tests such as colonic transit time, defecography and anorectal manometry Treatment of constipation, irrespective of the cause, is initiated with lifestyle modification which includes exercise, increased water intake and a high-fiber diet. Pharmacologic treatment is started with osmotic agents followed by stimulant laxatives. In turn, biofeedback therapy is a method of choice for the treatment of defecation disorders. There is a small group of patients with intractable slow-transit constipation and descending perineum syndrome who require surgery Surgical treatment is also indicated in patients with symptomatic rectocele, and advanced rectal intussusception. Enterocele can be corrected during perineopexy performed for the descending perineum.

Achieving fecal continence in patients with spina bifida: a descriptive cohort study.

PURPOSE: Fecal incontinence is a major problem in patients with myelomeningocele. We evaluate the results of a stratified approach aimed at obtaining fecal pseudo-continence in patients with myelomeningocele. MATERIALS AND METHODS: We conducted a cross-sectional descriptive study of last file data in 80 patients 5 to 18 years old with myelomeningocele followed at our center. Beginning at birth patients with myelomeningocele were seen at least annually by the pediatric gastroenterologist, a member of the multidisciplinary "spina team." Constipation was treated with diet and osmotic laxatives. Starting at age 5 years, treatment was targeted at achieving pseudo-continence. A toilet training scheme was started, associated with induced defecation by digital stimulation. Retrograde tap water enemas were used in patients with unsatisfactory results. If retrograde enemas were unsuccessful, an antegrade continence enema procedure was proposed. For children unable to sit on a toilet regular manual evacuation of stools was advised. RESULTS: Eight of the 80 patients were fecal continent. Pseudo-continence was achieved in 50 of the 72 incontinent patients (69%), including 5 of 5 following only a strict toilet scheme, 21 of 24 (87.5%) performing retrograde enemas, 16 of 20 (80%) performing orthograde enemas through an antegrade continence device and 8 of 10 performing regular manual evacuation of stools. In 4 of the 20 patients (20%) performing orthograde enemas complications led to closure of the antegrade continence device. Treatment failed and was stopped in 17 patients. Success of treatment was not related to level of spinal lesion or degree of mobility. CONCLUSIONS: Fecal pseudo-continence was achieved in 58 of 80 patients (72.5%) with myelomeningocele.

Can pain during digital rectal examination help us to decide the necessity and the method of anesthesia for transrectal ultrasound guided prostate needle biopsy?

OBJECTIVE: Transrectal ultrasound (TRUS) guided prostate biopsy is well tolerated by patients but the lack of an effective marker to predict pain prevents us from determining pre-procedurally which patient group needs local anesthesia for biopsy and probe pain. Thus in this study, we investigated predictor factors for prostate biopsy and probe insertion pain. MATERIALS AND METHODS: 71 patients who were undergoing prostate biopsy without anesthesia were included in the study retrospectively. Pain had been assessed with visual analogue scale (VAS 0-10). Digital rectal examination (DRE) pain was analyzed for biopsy and probe insertion pain. RESULTS: DRE pain was related to both probe pain and biopsy pain. CONCLUSION: Although level of pain during DRE determines patients in need of local anesthesia, since the number of patients with moderate-severe pain is rather big, it seems efficient in determining the patients in need of additional anesthesia due to probe pain.

Can pain during digital rectal examination help us to decide the necessity and the method of anesthesia for transrectal ultrasound guided prostate needle biopsy?

OBJECTIVE: Transrectal ultrasound (TRUS) guided prostate biopsy is well tolerated by patients but the lack of an effective marker to predict pain prevents us from determining pre-procedurally which patient group needs local anesthesia for biopsy and probe pain. Thus in this study, we investigated predictor factors for prostate biopsy and probe insertion pain. MATERIALS AND METHODS: 71 patients who were undergoing prostate biopsy without anesthesia were included in the study retrospectively. Pain had been assessed with visual analogue scale (VAS 0-10). Digital rectal examination (DRE) pain was analyzed for biopsy and probe insertion pain. RESULTS: DRE pain was related to both probe pain and biopsy pain. CONCLUSION: Although level of pain during DRE determines patients in need of local anesthesia, since the number of patients with moderate-severe pain is rather big, it seems efficient in determining the patients in need of additional anesthesia due to probe pain.