PSA levels of 4.0 - 10 ng/ml and negative digital rectal examination: antibiotic therapy versus immediate prostate biopsy

Purpose: The management of mildly elevated (4.0-10.0 ng/ml) prostate specific antigen (PSA) is uncertain. Immediate prostate biopsy, antibiotic treatment, or short term monitoring PSA level for 1-3 months is still in controversy. Material and Methods: We conducted a retrospective chart review of patients in a large community practice (2003 - 2007) who had PSA levels between 4.0-10 ng/mL without any further evidence of infection. Data was gathered regarding patient's age, whether standard antibiotic therapy (10-14 days of ofloxacin or ciprofloxacin) had been administered before the second PSA measurement, results of a second PSA test performed at 1- to 2-month intervals, whether a prostate biopsy was performed and its result. Results: One-hundred and thirty-five men met the study inclusion criteria with 65 (48.1 percent) having received antibiotics (group 1); the PSA levels decreased in 39 (60 percent) of which, sixteen underwent a biopsy which demonstrated prostate cancer in 4 (25 percent). Twenty-six (40 percent) patients of group 1 exhibited no decrease in PSA levels; seventeen of them underwent a biopsy that demonstrated cancer in 2 (12 percent). The other 70 (51.9 percent) patients were not treated with antibiotics (group 2); the PSA levels decreased in 42 (60 percent) of which, thirteen underwent a biopsy which demonstrated prostate cancer in 4 (31 percent). In the other 28 (40 percent) patients of group 2 there was no demonstrated decrease in PSA, nineteen of these subjects underwent a biopsy that demonstrated cancer in 8 (42 percent). Conclusions: There appears to be no advantage for administration of antibacterial therapy with initial PSA levels between 4-10 ng/mL without overt evidence of inflammation.

Laparoscopic removal of local renal cell carcinoma recurrence

Purpose: To describe an entirely laparoscopic technique for excising a recurrence of local renal cell carcinoma (RCC). Materials and Methods: The patient is placed in a full flank position. A 10-mm trocar is inserted using Hasson's technique with three additional ports in the upper abdomen. After lysis of adhesions, the psoas muscle, ureteral and gonadal vein remnants, inferior vena cava or aorta, and renal vessel stumps are dissected and isolated. The specimen, including the mass, the adrenal gland, and the ipsilateral pararenal and paracaval or para-aortic tissue within Gerota's fascia remnants, are excised en bloc and removed inside an Endocatch-II bag. Results: To date we have used this technique for excising RCC recurrences in three patients. Pathologic examination showed clear cell type RCC Fuhrman grade 2 in the specimens of two patients and chromophobe type in one. No patient have had further recurrence after 50, 38 and 12 months of follow-up. Conclusions: An entirely laparoscopic surgical approach for excising local RCC recurrence has not, to our knowledge, been previously described. This method can be effectively applied while adhering to oncologic principles, with minimal blood loss and low morbidity.