The association of diabetes and positive prostate biopsy in a US veteran population.

BACKGROUND: Several studies have shown a protective effect of diabetes mellitus (DM) on incidence of prostate cancer; however, the data are not consistent. Moreover, whether or not DM is associated with a positive result among patients referred for prostate biopsy due to abnormal PSA and/or abnormal digital rectal examination is not clear. METHODS: A retrospective review of 3162 consecutive men who underwent prostate biopsy between January 2000 and July 2009 at the Atlanta Veterans Affairs Medical Center was performed. Men with positive and negative biopsies were compared for various demographic and clinical factors. The data were analyzed using logistic regression models with results expressed as adjusted odds ratios (ORs) with corresponding 95% confidence intervals (CI). RESULTS: DM was associated with increased odds of positive biopsy in the overall cohort (OR 1.26, 95% CI: 1.01-1.55; P = 0.04). Subjects with DM had higher odds of more aggressive disease (Gleason ≥ 7) than those without the condition (OR 1.31, 95% CI: 0.98-1.74; P = 0.07). Race had no significant impact on these results. CONCLUSIONS: In this large series of prostate biopsies, diabetes is associated with higher odds of positive biopsy and higher Gleason grade. More studies investigating the role of DM and its associated comorbidities in prostate carcinogenesis are needed.

Novel atomic absorption spectrometric and rapid spectrophotometric methods for the quantitation of paracetamol in saliva: application to pharmacokinetic studies.

A novel atomic absorption spectrometric method and two highly sensitive spectrophotometric methods were developed for the determination of paracetamol. These techniques based on the oxidation of paracetamol by iron (III) (method I); oxidation of p-aminophenol after the hydrolysis of paracetamol (method II). Iron (II) then reacts with potassium ferricyanide to form Prussian blue color with a maximum absorbance at 700 nm. The atomic absorption method was accomplished by extracting the excess iron (III) in method II and aspirates the aqueous layer into air-acetylene flame to measure the absorbance of iron (II) at 302.1 nm. The reactions have been spectrometrically evaluated to attain optimum experimental conditions. Linear responses were exhibited over the ranges 1.0-10, 0.2-2.0 and 0.1-1.0 mug/ml for method I, method II and atomic absorption spectrometric method, respectively. A high sensitivity is recorded for the proposed methods I and II and atomic absorption spectrometric method value indicate: 0.05, 0.022 and 0.012 mug/ml, respectively. The limit of quantitation of paracetamol by method II and atomic absorption spectrometric method were 0.20 and 0.10 mug/ml. Method II and the atomic absorption spectrometric method were applied to demonstrate a pharmacokinetic study by means of salivary samples in normal volunteers who received 1.0 g paracetamol. Intra and inter-day precision did not exceed 6.9%.

Medical and minimally invasive therapies for the treatment of benign prostatic hyperplasia.

Over the last decade, management of benign prostatic hyperplasia (BPH) has changed with a substantial decrease in the use of transurethral prostatectomy (TURP) and a simultaneous increase in the use of medical therapy and minimally invasive surgical therapy (MIST). The goal of management of this chronic progressive condition is not only to provide relief of lower urinary tract symptoms (LUTS) but also to reduce the lifetime risk of adverse outcomes. Recent clinical evidence has demonstrated a clear role for medical therapy, particularly with 5-alpha-reductase inhibitors (5ARIs) either alone or in combination with alpha-blockers, to reduce the risk of acute urinary retention and need for surgery and provide symptom relief. Clinical data on MISTs also indicate a more pronounced short-term effect; however, the long-term durability of these therapies remains uncertain. Minimally invasive surgical therapies confer treatment benefits in a single 1-h treatment session under local anesthesia. Recovery times and adverse events are improved compared with TURP, but issues such as hematuria, prolonged catheterization, urinary tract infection and retreatment remain commonly reported issues. Today, urologists are faced with the challenge of identifying the most appropriate treatment option for the long-term management of BPH. The initial choice for any given patient will depend on his presenting circumstances and the influence of treatment risks on these circumstances. Providing patients with informed treatment decisions is a key element of management.

The effect of urethral instrumentation on uroflowmetry.

OBJECTIVE: To evaluate in a prospective study the effect of urethral instrumentation (flexible cystoscopy) on uroflowmetry, and in particular the peak urinary flow rate (Qmax). PATIENTS AND METHODS: Thirty-two consecutive patients (median age 61.8 years, range 24-80) undergoing flexible cystoscopy were included in the analysis. Patients with active urethral stricture disease or urinary infection were excluded. The indications for cystoscopy included haematuria (44%), voiding symptoms (66%), history of bladder cancer (19%), and history of perineal trauma (3%). Patients underwent uroflowmetry immediately before instrumentation. The postvoid residual volume (PVR) was measured by bladder catheterization. After cystoscopy the bladder was completely emptied and then filled with the same volume of sterile normal saline (bladder volume = voided volume + PVR), and the patient underwent a second uroflowmetry. RESULTS: Patients with voiding symptoms (21, 66%) had a median (range) American Urological Association symptom score of 17 (4-34), a Bother score of 16 (1-23), and Quality of Life score of 3 (1-6). The mean Qmax was 16.9 (4.5-36.9) and 13.3 (4.5-39.4) mL/s before and after cystoscopy, respectively (P = 0.029). The mean percentage difference in Qmax was + 27 (- 23 to 139)% higher before than after cystoscopy. After cystoscopy, up to 25% (eight) and 21% (seven) patients had a lower Qmax, from > 15 to < 15 mL/s and from > 12 to < 12 mL/s, respectively. There were no significant differences in the bladder volume and PVR (P = 0.914 and 0.984, respectively). CONCLUSIONS: Urethral instrumentation by flexible cystoscopy significantly alters Qmax. A 'false' mean change in Qmax (favouring improvement) of +27% would result if uroflowmetry data after instrumentation were used at baseline. Therefore, study protocols for benign prostatic obstruction should exclude uroflowmetry data obtained after urethral instrumentation; failure to exclude such data will lead to disproportionately greater improvements in Qmax that are independent of the therapy delivered.

Dietary supplementation with cranberry concentrate tablets may increase the risk of nephrolithiasis.

OBJECTIVES: Cranberry juice has been recommended for patients with recurrent urinary tract infections. However, cranberry juice has a moderately high concentration of oxalate, a common component of kidney stones, and should be limited in patients with a history of nephrolithiasis. Cranberry concentrate tablets are currently available at nutrition stores and are sold as promoters of urinary tract health. After one of our patients with a distant history of calcium oxalate nephrolithiasis developed recurrent stones following self-administration of cranberry concentrate tablets, we sought to investigate the potential lithogenic properties of cranberry supplements. METHODS: Five healthy volunteers on a normal diet provided 24-hour urine collection for pH, volume, creatinine, oxalate, calcium, phosphate, uric acid, sodium, citrate, magnesium, and potassium. Cranberry tablets were administered to these volunteers at the manufacturer's recommended dosage for 7 days. On the seventh day, a second 24-hour urine collection was obtained. RESULTS: The urinary oxalate levels in the volunteers significantly increased (P = 0.01) by an average of 43.4% while receiving cranberry tablets. The excretion of potential lithogenic ions calcium, phosphate, and sodium also increased. However, inhibitors of stone formation, magnesium and potassium, rose as well. CONCLUSIONS: Cranberry concentrate tablets are marketed for urinary tract ailments. Physicians and manufacturers of cranberry products should make an effort to educate patients at risk for nephrolithiasis against ingestion of these dietary supplements.

A randomized prospective trial of intrarectal lidocaine for pain control during transrectal prostate biopsy: the Emory University experience.

PURPOSE: We prospectively evaluated the safety and efficacy of intrarectal lidocaine gel as anesthesia during transrectal prostate biopsy. MATERIALS AND METHODS: Of 63 consecutive men undergoing transrectal prostate biopsy 50 who qualified were enrolled in this study. Indications for the procedure were an abnormal prostate on digital rectal examination and/or elevated serum prostate specific antigen. Patients were randomized into group 1-25 who received 10 cc of 2% intrarectal lidocaine 10 minutes before the procedure and group 2-25 controls. No narcotics, sedation or analgesia was given. Pain during biopsy was assessed using a 10-point linear visual analog pain scale. RESULTS: In groups 1 and 2 median patient age was 63 and 66 years (p = 0.139), and median prostate specific antigen was 6.04 (range 1.07 to 263) and 7.24 (range 1.34 to 51.82) ng./ml. (p = 0.337). Digital rectal examination was normal and abnormal in 17 and 15 group 1, and in 8 and 10 group 2 patients, respectively. Ultrasound showed a median prostate volume of 43.6 cc (range 15.3 to 124) in group 1 and 40.3 (range 19.8 to 132) in group 2 (p = 0.710). Final histological results revealed prostate cancer in 7 men (28%) in each group. The median pain score during transrectal prostate biopsy was 2 (range 1 to 5) and 5 (range 1 to 7) in groups 1 and 2, respectively (p = 0.00001). No adverse events were noted. CONCLUSIONS: Intrarectal lidocaine gel is a simple, safe and efficacious method of providing satisfactory anesthesia in men undergoing transrectal prostate biopsy. We recommend its routine administration in all patients during this procedure.

Prospective multicenter study of transperineal prostatic block for transurethral needle ablation of the prostate.

The choice of anesthesia during thermal therapy of the prostate plays a significant role in the morbidity profile, patient convenience, and cost. We report 39 men with symptomatic benign prostatic hyperplasia who underwent transurethral needle ablation of the prostate under transperineal prostatic block. This method of local anesthesia proved safe, convenient, and satisfactory during the procedure.

A prospective study of transperineal prostatic block for transurethral needle ablation for benign prostatic hyperplasia: the Emory University Experience.

PURPOSE: We evaluate the feasibility, effectiveness and role of transperineal prostate block in providing anesthesia during minimally invasive radio frequency thermal therapy of the prostate. MATERIALS AND METHODS: A total of 38 consecutive patients undergoing transurethral needle ablation for symptomatic benign prostatic hyperplasia were entered in this prospective study. All patients received transperineal prostatic block as the main method of anesthesia. A mixture of equal volumes of 1% lidocaine and 0.25% bupivacaine, each with epinephrine (1:100,000 concentration ratio) was used. Pain control during the instillation of transperineal prostatic block and transurethral needle ablation was assessed using a 10-point linear analog pain scale and questionnaire. RESULTS: Median patient age was 65.5 years (range 47 to 79), with 21% of men in the eighth decade of life. Median American Urological Association symptom score was 25.0 (range 14 to 35), bother score was 20.0 (11 to 28), quality of life score was 4.0 (3 to 6) and peak urinary flow rate was 8.9 cc per second (3.5 to 15.7). Median sonographic prostate volume was 35.0 cc (range 17 to 129). Median volume of anesthetic agent used was 40.0 cc (range 30 to 60) per case (1.1 cc solution per 1 cc prostate tissue). No adverse events were encountered. Median pain score was 3.3 (range 1 to 6) during instillation of transperineal prostatic block and 1.0 (0 to 6) during transurethral needle ablation. Transperineal prostatic block proved highly effective and was a satisfactory method of anesthesia during transurethral needle ablation as judged by postoperative questionnaire. No sedation, narcotic or analgesia was required. All procedures were performed in the outpatient cystoscopy suite or office setting without support of an anesthesia team or conscious sedation monitoring. CONCLUSIONS: Transperineal prostatic block is a safe, convenient, effective and satisfactory method of minimally invasive anesthesia for transurethral needle ablation of the prostate in an outpatient office setting. Elderly patients and those at high surgical risk can be treated safely using this approach. Considerable cost saving is seen secondary to omission of charges related to anesthesia team support, recovery room facility and conscious sedation monitoring.

Analgesia during extracorporeal shock wave lithotripsy using the Medstone STS lithotriptor: a randomized prospective study.

OBJECTIVES: To investigate and compare the effectiveness of three analgesic protocols for pain management during extracorporeal shock wave lithotripsy (ESWL) in a prospective, randomized clinical trial. METHODS: Seventy-four patients were randomized into three groups before ESWL; group A (n = 23) received 10 mg morphine sulfate (MS), group B (n = 25) 60 mg ketorolac tromethamine (KT), and group C (n = 26) topical 2.5% lidocaine/prilocaine gel (Emla). Each method of pain management during ESWL was assessed using a standard 10-point linear pain scale and by the requirement for supplemental analgesia during treatment. Supplemental analgesia was administered intravenously using a patient-controlled analgesic pump. The results were compared between the three groups, as were such parameters as body habitus, stone burden, stone location, number of shock waves, and the presence of ureteral stents. RESULTS: Pain severity averaged 4.6 points on the pain scale for the three groups combined. Pain tended to be more severe in group C (5.4) than in group A (4.3) or group B (4.1); however, the differences were not statistically significant (P>0.05). The amount of supplemental analgesia was similar in all three groups. Stone burden, stone location, and number of shock waves did not influence the severity of pain or analgesic requirement during ESWL. The analgesic requirement was significantly less in patients with ureteral stents (n = 32) than in patients without (n = 42), averaging 10 mg versus 24 mg MS, respectively (P = 0.01). KT was not associated with adverse events such as bleeding. MS was more likely to cause oversedation and nausea or vomiting, necessitating naloxone and antiemetic therapy, respectively. CONCLUSIONS: The use of KT was safe and effective for premedication before ESWL; patients receiving KT before ESWL reported lower pain scores and required less supplemental analgesia requirement than those who received MS or Emla; however, the differences were not statistically significant. Patients receiving Emla recorded the highest pain scores. Patients with ureteral stents had lower pain scores and required less supplemental analgesia.

The effects of transurethral needle ablation and resection of the prostate on pressure flow urodynamic parameters: analysis of the United States randomized study.

PURPOSE: We evaluated the effects of transurethral needle ablation and prostate resection on pressure flow urodynamic parameters in men with benign prostatic hyperplasia (BPH), compared symptomatic and objective parameters of efficacy 6 months after initial treatment, and determined whether urodynamic assessment may predict symptomatic improvement. MATERIALS AND METHODS: We enrolled 121 patients with clinical BPH, American Urological Association symptom index of 13 or greater and maximum urinary flow of 12 ml. per second or less in a randomized study comparing transurethral needle ablation to prostate resection at 7 institutions in the United States. Patients underwent baseline and followup assessments at 6 months, including pressure flow studies. RESULTS: Patients who underwent each procedure had statistically and clinically significant improvement in symptom index, BPH impact index and quality of life score. After needle ablation and prostate resection maximum flow improved from 8.8 to 13.5 (p<0.0001) and 8.8 to 20.8 ml. per second (p<0.0001), detrusor pressure at maximum flow decreased from 78.7 to 64.5 (p = 0.036) and 75.8 to 54.9 cm. water (p<0.001), and the Abrams-Griffiths number decreased from 61.2 to 37.2 (p<0.001) and 58.3 to 10.9 (p<0.001), respectively. At 6 months the differences in transurethral needle ablation and prostate resection were significant in terms of maximum flow (p<0.001) and the Abrams-Griffiths number (p<0.001) but not detrusor pressure at maximum flow or symptom assessment tools. The presence or absence of urinary obstruction at baseline did not predict the degree of symptomatic improvement in either treatment group. CONCLUSIONS: Transurethral needle ablation and prostate resection induce statistically and clinically significant improvement in various quantitative symptom assessment questionnaires at 6 months. The parameters of free flow rates and invasive pressure flow studies also significantly improve after each treatment. However, transurethral prostate resection induces a significantly greater decrease in the parameters of obstruction. Baseline urodynamic parameters do not predict the degree of symptomatic improvement and they may not be helpful in patient selection for transurethral needle ablation.

Transurethral needle ablation (TUNA). A critical review of radiofrequency thermal therapy in the management of benign prostatic hyperplasia.

Radiofrequency thermal therapy of the prostate is a new minimally invasive treatment for symptomatic benign prostatic hyperplasia (BPH). The procedure is called transurethral needle ablation (TUNA). With TUNA, the inner region of the prostate is selectively ablated with temperatures approaching 90-100 degrees C while the prostatic urothelium is preserved. The objective of this article is to discuss the basics of radiofrequency energy, instrumentation, surgical techniques, and to present an update of the clinical results as it applies to the treatment of BPH.

Clinical features and management of anterior intraurethral prostatic cyst.

We report on a symptomatic anterior intraurethral prostatic cyst in a 46-year-old man without clinical evidence of benign prostatic hyperplasia. The anterior location of this cyst makes it unique to all previously reported cases of prostatic cysts which are located posteriorly. Transurethral resection of the cyst with limited resection of the anterior prostatic tissue at the base of the cyst was performed with successful resolution of voiding symptoms. In the absence of lateral lobe hypertrophy, standard transurethral resection of the prostate should be avoided to ensure preservation of erectile and ejaculatory function.

The prostate anesthetic block for outpatient prostate surgery.

With the emergence of minimally invasive techniques for the treatment of benign prostate hyperplasia and the need to reduce health care costs, a simple and effective prostate anesthetic block may allow more procedures to be done in an outpatient or office setting. As based on neuroanatomy studies of the prostate, the perineal approach appeared to be the best way to anesthetize the prostate. This technique was used in 43 patients who underwent interstitial laser coagulation an outpatient or office setting. The perineal prostatic block was effective for pain control whether lidocaine or lidocaine/bupivacaine was used as determined by visual analog scale, linear pain scale, or global pain questionnaire. The use of intravenous (i.v.) sedation did not influence the efficacy of the prostate anesthetic block. Thus, the perineal prostate anesthetic block may be employed in patients undergoing minimally invasive surgery for benign prostatic hyperplasia in the outpatient/office location.

Renal masses presenting 25 and 50 years following blunt renal trauma.

The long-term consequences of blunt renal trauma are not well described. We report on 2 patients with a history of blunt renal trauma who presented with radiographically detected renal masses suspicious for renal tumor. Both patients suffered blows to the kidney during boxing matches followed by flank pain and hematuria. The injuries occurred 25 and 50 years prior to the detection of renal masses. Subsequent nephrectomy and histopathological evaluation revealed benign dystrophic renal tissue. These presentations represent probable long-term sequelae of blunt renal trauma.

A prospective, randomized 1-year clinical trial comparing transurethral needle ablation to transurethral resection of the prostate for the treatment of symptomatic benign prostatic hyperplasia.

PURPOSE: We assess the 1-year efficacy and safety of transurethral needle ablation of the prostate compared to transurethral resection of the prostate for the treatment of symptomatic benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: A prospective, randomized clinical trial of 121 men 50 years old or older with symptomatic BPH was performed at 7 medical centers across the United States. Of the men 65 (54%) were treated with transurethral needle ablation of the prostate and 56 (46%) underwent transurethral resection of the prostate. Mean and percentage changes from baseline and between cohorts for American Urological Association (AUA) symptom score, AUA bother score, quality of life score, peak urinary flow rate and post-void residual urine volume were measured at 1, 3, 6 and 12 months following treatment. Length of procedure, hospitalization, type of anesthesia, post-procedure catheterization, side effects and sexual function were compared. RESULTS: Transurethral needle ablation and resection resulted in a statistically significant improvement in AUA symptom, bother and quality of life scores, peak urinary flow rate and post-void residual. At 1-year followup, needle ablation and resection were equally effective in enhancing quality of life. Needle ablation had less effect on sexual function, with resection being associated with a greater incidence of retrograde ejaculation. Needle ablation could be performed as an outpatient procedure with local anesthesia while resection required anesthesia and hospitalization. Needle ablation was associated with markedly fewer side effects than resection. CONCLUSIONS: Compared to transurethral resection of the prostate, transurethral needle ablation of the prostate is an efficacious, minimally invasive treatment for symptomatic BPH that is associated with few side effects.

Transurethral needle ablation for benign prostatic hyperplasia: 12-month results of a prospective, multicenter U.S. study.

OBJECTIVES: To report the safety and efficacy of the transurethral needle ablation (TUNA) procedure for the treatment of clinical benign prostatic hyperplasia (BPH). METHODS: One hundred thirty patients with BPH were enrolled in two identical protocols and treated by the TUNA procedure. Entry criteria included an American Urological Association symptom index (AUA SI) of 13 points or higher and a peak flow rate of 12 mL/s or less. Patients were followed up for 12 months. Efficacy parameters included the AUA SI, AUA problem index, BPH impact index (BPH II), quality of life (QOL) score, and peak flow rate. At each visit, side effects were elicited. Follow-up data are available for 93 patients at 12 months. All patients were given intraurethral lidocaine augmented by oral and/or parenteral sedation. No patient received spinal or general anesthesia. RESULTS: All patients tolerated the procedure well, and there were no deaths. Forty-one percent of patients (n = 53) had a catheter placed immediately after the procedure. At 12 months, the AUA SI had decreased from 23.7 to 11.9 (P < 0.0001) and the BPH II from 7.5 to 2.5 (P < 0.0001), whereas the peak flow rate had increased from 8.7 to 14.6 mL/s (P < 0.0001). Irritative voiding symptoms were noted in 20 patients (16%) at some point during follow-up. Two patients reported erectile dysfunction, and 1 reported retrograde ejaculation. CONCLUSIONS: In this prospective study of 130 patients with clinical BPH and lower urinary tract symptoms, TUNA provided substantive and lasting improvement according to AUA SI, BPH II, and QOL scores as well as peak flow rate over 1 year. The TUNA procedure was well tolerated, with few major side effects and complications noted. Longer follow-up is needed to document the maintenance of clinical benefit beyond 12 months.

A new technique of intraprostatic fiber placement to minimize thermal injury to prostatic urothelium during indigo interstitial laser thermal therapy.

A new technique of cystoscopic insertion of laser fiber into the prostate is described for interstitial laser thermal therapy in the treatment of benign prostatic hyperplasia. The technique uses the inherent physical properties of the fused silica laser fiber with the assistance of a standard cystoscope to insert the laser fiber into the inner region of the prostate gland. Laser thermal therapy is subsequently maintained within the inner prostate at a distance from the prostatic urothelium. The technique described is simple, safe, and minimizes the potential for thermal injury to the prostatic urothelium.

Surgical challenge of massive bilateral staghorn renal calculi in a spinal cord injury patient.

We report a rare case of massive bilateral staghorn calculi in a spinal cord injury patient with significant renal compromise. The patient was successfully treated with percutaneous nephrolithotomy to achieve a stone-free status. The various options of treatment are discussed with special attention to the technical aspects necessary to achieve complete eradication of the stone burden during percutaneous nephrolithotomy. Furthermore, the importance of treating bladder dysfunction and urinary metabolic abnormalities is emphasized.

New technique of ureteral stent placement for impacted ureteral calculus: the glidewire loop technique.

Impacted ureteral stones pose a challenge during retrograde ureteral stenting. Multiple attempts to bypass the obstruction with conventional guide wires often fail and may result in perforation of the ureter. We describe a new, simple approach to overcome this common problem by utilizing a retrograde glidewire loop technique. The technique described allows safe and successful bypassing and stenting of ureteral obstruction.