Microwave transurethral applicator with helix-loaded-dipole-antenna (HLDA) for prostate treatment.

Three designs of transurethral applicators have been analysed to find the one that is best able to selectively heat the desired volume of prostate. A helix-loaded-dipole-antenna (HLDA) inserted into a Foley type catheter was found to be the most promising design. A change in the heat deposition pattern of the antenna depending on prostate size is possible by moving the position of the antenna within a Foley catheter. A number of prototypes of HLDA were manufactured and tested to optimize their design. These tests were performed in solid and liquid phantoms and in laboratory animals. Intra-operative measurements of intra-prostatic temperature distribution were also performed. A comparison of the HLDA with other commercially available transurethral applicators and the published data showed that the present design has a higher linear homogeneity coefficient and a better heat deposition in the prostate.

Carcinoma of the kidney, testis, and rare urologic malignancies.

The purpose of this symposium was to provide a forum for discussion on current information on the etiology and diagnosis of, and therapy for, tumors of the kidney, testis, and several uncommon malignancies of the genitourinary tract. The most recent contributions in epidemiology and molecular genetics were discussed with specific reference to their importance for clinical practice. Contemporary treatment approaches with the emphasis on multidisciplinary patient management of tumors commonly seen in the clinic as well as those that are only rarely diagnosed by urooncologists were presented. Major stress was given to the management optimization as it pertains to short- and long-term quality of life issues of patients treated for these tumors. Methods to reduce treatment toxicity including carcinogenic potential of chemotherapy, radiotherapy, or their combination were found to be of nearly equal importance to patient survival. Symposium participants reached consensus on a number of important points: 1) The management of patients with several malignancies discussed requires the presence of a multidisciplinary team of specialist who are interested in diagnosis and treatment of genitourinary tumors; 2) Patients managed in such an environment are expected to have optimal survival and the best possible quality of life; 3) Real advances in the management of patients can be best obtained through well-designed prospective clinical trials; and 4) There is a need for timely introduction of relevant advances in epidemiology and molecular genetics to clinics.

[Preliminary experiences with the use of the Holmium-YAG laser in the treatment of soft tissues and of cystine calculi in children]. / Premières expériences avec l'utilisation du laser Holmium-YAG dans le traitement des tissus mous et des calculs de cystine chez l'enfant.

INTRODUCTION: Experience of the use of the Holmium: Yttrium-Aluminium-Garnet (Ho:YAG) laser in children has been limited. However, the Ho:YAG laser has been in clinical use in urology for several years but has mainly been used for the treatment of renal stones and benign prostatic hyperplasia. Due to its unique combination of vaporization and coagulation, the Ho:YAG laser allows a precise cutting action. The depth of penetration in water and tissue is limited to < 0.5 mm and therefore provides a safety margin. The Ho:YAG laser can be used in children, as the energy can be delivered via fibers that range from 200 to 1000 mu in diameter. MATERIALS AND METHODS: We used the Ho:YAG laser in 5 children (2-15 years): one child (2 years) with bladder exstrophy had a urethral stricture after bladder neck reconstruction, two children (6 years and 14 years) had ureteropelvic junction (UPJ) stenosis and refused open surgery and two children (5 years and 15 years) suffered from cystine stones (ESWL failed). The urethral stricture was incised in a retrograde fashion. We performed an antegrade incision of the UPJ with the Ho:YAG laser in the 6-year-old child and a retrograde incision in the 14-year-old child. We removed the stones in antegrade fashion in the 5-year-old child and in retrograde fashion in the 15-year-old child. RESULTS: All children now have more than 12 month's follow-up. There were no immediate or late complications. The boy with urethral stricture remained free of recurrence, the boy with UPJ stenosis obtained improved drainage on the excretory renogram and the two children with cystine stones remained stonefree. CONCLUSION: We have shown that the safety and efficacy of the Ho:YAG laser is also reproducible in urologic pathology in children. In addition, due to its vaporizing quality, the Ho:YAG laser is more effective in the treatment of cystine stones and allows minimaly invasive treatment in children.

Acute obstruction of the renal collecting system: the intrarenal resistive index is a useful yet time-dependent parameter for diagnosis.

The aim of this study was to determine whether the intrarenal resistive index (RI) can be used for the diagnosis of acute obstruction in patients with renal colic and to determine whether the index is time-related. Seventy patients referred to the Emergency Department with acute renal colic and without known associated renal disease underwent duplex Doppler ultrasonography to determine the intrarenal RI at the symptomatic and asymptomatic side. The age range of the patients was 18-72 years. An RI greater than 0.68 and/or an interrenal difference in RI greater than 0.06 and/or an increase in RI of more than 11% compared with the normal side proved reliable cut-off values to diagnose acute renal obstruction. In addition, time dependency of the increase in RI was noted. No significant differences were observed within the first 6 h after the onset of symptoms. From 6 to 48 h, however, the mean RI in the affected kidney (0.70 +/- 0.06; mean +/- SD) was significantly different from that in the normal kidney (0.59 +/- 0.04) (P < 0.001). In the same period the mean difference in RI was 0.08-0.13 (P < 0.001). After 48 h the sensitivity of RI dropped substantially. It is concluded that renal duplex Doppler ultrasonography is useful for diagnosing acute renal obstruction between 6 and 48 h after the onset of symptoms.

Is intravenous urography still used in patients with prostatism?

The value of intravenous urography in patients with prostatism was retrospectively evaluated. One thousand four hundred ninety five intravenous urograms of male patients referred by the department of urology were reviewed. Based on the clinical information, only patients with complaints of prostatism as a single symptom were selected. Patients with associated symptoms (i.e. hematuria, urinary infection) were excluded. Forty seven patients could be included based on these criteria. In 29 of 47 cases (61.7%) no abnormalities were found. Abnormalities found in 18 cases included dilatation of the excretory system, urinary calculi, congenital anomaly, acquired small kidney, renal cysts and retroperitoneal fibrosis. In 5 cases (10.1%) the intravenous urography necessitated further treatment and/or follow up. In 3.1% prostatism was the indication for the examination. The number of relevant abnormalities at intravenous urography performed for prostatism is low and this is in accordance with results reported in literature. These results provide further evidence for the continuously changing indications for intravenous urography.

Impalpable invisible stage T1c prostate cancer: characteristics and clinical relevance in 100 radical prostatectomy specimens--a different view.

PURPOSE: We analyzed 100 consecutive radical prostatectomy specimens to evaluate the extent and clinical relevance of the stage T1c cancers discovered. MATERIALS AND METHODS: All cases were diagnosed by systematic prostatic puncture biopsies because of abnormal prostate specific antigen (PSA) or PSA density. Surgical specimens were examined with the whole organ multiple step-section technique (4 mm.) to identify primary tumor location (peripheral or transition zone cancer), tumor volume, tumor volume divided by prostate volume (percent tumor volume), Gleason score, pathological T stage and positive surgical margins. Tumors smaller than 0.5 cm.3 and without unfavorable pathology (Gleason score 7 or more, or positive surgical margins) were considered insignificant. RESULTS: Median patient age, PSA, tumor volume and Gleason score were 64 years, 8.8 micrograms./l., 1.6 cm.3 and 6, respectively. Of the specimens 46 (46%) had transition zone cancer that was clinically undetectable due to anterior location, while peripheral zone cancers were small, diffuse, anterolateral or in large glands with low percent tumor volume. Transition zone cancer showed greater PSA, PSA density, tumor volume and percent tumor volume than peripheral zone cancer (p = 0.08, 0.03, 0.0002 and 0.0004, respectively), yet with similar Gleason score (p = 0.4). Of the tumors 34 (34%) were locally advanced (stage pT3 and/or positive surgical margins, mostly anterior in 16 transition zone cancers, and apical or posterolateral in 18 peripheral zone cancers), whereas 22 were insignificant (6 transition and 16 peripheral zone cancers). Prostatic puncture biopsies with a core cancer length of less than 3 mm. could have predicted 18 of 19 insignificant tumors but underestimated 13 (33%) and 6 (17%) significant transition and peripheral zone cancers. CONCLUSIONS: The majority of our stage T1c tumors were significant with a distinguished high incidence of transition zone cancer. Therefore, they were large but occult. Transition zone cancer behaved differently than peripheral zone cancer, and warranted considerations during treatment of stage T1c prostate carcinoma.

Free-to-total prostate specific antigen ratio as a single test for detection of significant stage T1c prostate cancer.

PURPOSE: We investigated whether impalpable, invisible (stage T1c) but significant prostate cancer can be detected better by determining the free-to-total prostate specific antigen (PSA) ratio of equivocal PSA serum levels. MATERIALS AND METHODS: The specificity of free-to-total PSA ratio using research monoclonal enzyme immunoassays was compared to that of PSA greater than 4.0 ng./ml. in 117 consecutive patients with PSA 3 to 15 ng./ml. (Hybritech Tandem-R assay) due to untreated benign prostatic hypertrophy or prostate cancer. Of the patients 77% underwent adenectomy or radical prostatectomy with thorough pathological evaluation of surgical specimens. RESULTS: Benign prostatic hypertrophy had a greater median free-to-total PSA ratio than stages T1c and T2 or greater prostate cancer (0.16 versus 0.09 and 0.11 ng./ml., p = 0.0001 and p = 0.0268, respectively). In stage T1c prostate cancer, areas under receiver operating characteristic curves were 0.58 and 0.84 for PSA and free-to-toal PSA ratio, and free-to-total PSA ratio correlated with prostate volume (r = 0.49, p = 0.005) and Gleason score (r = -0.37, p = 0.036). Pathologically, 84% of stage T1c cancers were significant and comparable to stage T2 or greater cancers. CONCLUSIONS: Free-to-total PSA ratio enhances the efficacy of PSA measurement by improving specificity for detecting impalpable, invisible but significant stage T1c prostate cancer.

Detection of prostate specific antigen in pancreas and salivary glands: a potential impact on prostate cancer overestimation.

PURPOSE: We explored the immunohistochemical expression of prostate specific antigen (PSA) in pancreas and salivary glands. MATERIALS AND METHODS: We investigated 62 specimens from male and female subjects, representing normal cases and several pathological conditions of pancreas and salivary glands. Two commercially available monoclonal antisera for PSA and 1 for prostatic acid phosphatase were used. RESULTS: A consistently positive reaction for PSA and prostatic acid phosphatase, independent of patient sex, was noted in ductal cells of normal pancreas and normal salivary glands, as well as pleomorphic adenoma, adenocarcinoma and all oncocytic epithelial cells of Warthin's tumor. Reaction was absent in normal stromal and acinar cells, and squamous carcinoma. CONCLUSIONS: PSA is detectable in normal and cancer tissues far from the prostate. Therefore, we may not entirely rely on specificity of PSA alone to diagnose metastatic prostate cancer.

[The significance of focal hypoechoic lesions in the peripheral zone of the prostate]. / De betekenis van een focaal hyporeflectief letsel in de perifere zone van de prostaat.

Hypoechoic lesions in the peripheral zone of the prostate gland are one of the commonest abnormalities at transrectal ultrasonography (TRUS). 90% of all carcinomas originating in the peripheral zone present as a hypoechoic lesion. Hypoechogenicity though is not specific, as many benign lesions are also hypoechoic. In this retrospective study, based on TRUS alone 57% of the hypoechoic lesions showed carcinoma in the biopsy core (43% of the biopsy cores were benign). The number of positive biopsies increased up to 75% when the hypoechoic lesion was palpable at digital rectal examination. 5.2% of the hypoechoic cancers would have been missed when non-palpable lesions would not have had a biopsy. When the hypoechoic lesion was associated with increased serum concentration of prostate specific antigen (PSA > 4 ng/ml) 74% of the biopsies were positive. 20% to 25% of all hypoechoic cancers would not have had a biopsy. The positive predictive value was 85% when the hypoechoic lesion was palpable at digital rectal examination and the PSA-concentration was > 4 ng/ml (and 90% when volume-adjusted PSA-parameter would have been applied).

Morphologic and neuroendocrine features of adenocarcinoma arising in the transition zone and in the peripheral zone of the prostate.

We examined retrospectively 107 step-sectioned radical prostatectomy specimens. The index tumor in each specimen was designated a transition zone carcinoma (TZCa) or a peripheral zone carcinoma (PZCa) based on its location. All tumor sections were immunohistochemically stained with chromogranin A (ChrA). A semiquantitative ChrA score (0 to 3) was assessed. ChrA-positive neuroendocrine cells were found in 83% of the index tumors. The ChrA score was significantly related to the Gleason score, the volume of the tumor, and the pathologic stage. Twenty-two percent of the index tumors were designated TZCas; 75% of these demonstrated neuroendocrine differentiation versus 85% of the PZCas. A high ChrA score of > or = 2 was found in 46% of PZCas and in only 33% of TZCas. Capsular transgression, seminal vesicle involvement, positive surgical margins, and lymph node metastasis were seen in the TZCa group in 33%, 17%, 29%, and 4%, respectively versus 58%, 20%, 48%, and 6% in the PZCa group. These findings were associated with a higher mean tumor volume in the TZCa group compared with the PZCa group. The average Gleason score of 4.5 in the TZCa group was significantly (P < 0.0001) lower than the Gleason score 6.2 in the PZCa group. Multicentricity was found in 62% of TZCas and in 49% of PZCas. Eighty-seven percent of the second tumors in the prostates with a primary TZCa were located in the peripheral zone. We conclude that the frequently occurring neuroendocrine cells population enlarges with tumor progression, especially in PZCas.(ABSTRACT TRUNCATED AT 250 WORDS)

Peripherally localized benign hyperplastic nodules of the prostate.

Approximately one-half of needle-core biopsy samples performed for palpable and/or ultrasonographically hypoechoic focal lesions of the prostate reveal carcinoma. A fraction of the negative biopsy samples are related to benign hyperplastic nodules, localized in the peripheral zone of the prostate. The present study examines the morphology of this particular lesion in surgical specimens obtained after cystoprostatectomy and radical prostatectomy performed for bladder and (small) prostate cancer, respectively. Peripheral hyperplastic nodules occur in 18.5% of this population and are unifocal in one-half of the cases. The mean diameter is 4 (+/- 1.3) mm. Peripheral hyperplastic nodules are characteristically localized posteriorly in the peripheral zone, between the midline and the lateral border of the prostate and often in the vicinity of the boundary of the transition zone. Histologically, they resemble glandulostromal hyperplastic nodules as observed in classic benign nodular hyperplasia of the transition zone. Cystic transformation may occur. The nodules are sometimes surrounded by condensed stroma and atrophic glands. Atypical adenomatous hyperplasia is rarely noticed in this lesion. No pure stromal (leiomyomatous) nodules without glands are seen. The peripheral hyperplastic nodule should be included in the differential diagnosis of focal lesions of the peripheral zone.

Cooled microwave transrectal applicator with adjustable directional beam for prostate treatment.

A new intracavitary applicator design for microwave hyperthermia, particularly for transrectal prostate treatment, is presented. It includes an exchangeable multisection antenna that enables us to create a required longitudinal heating pattern, a cooling system to shift the maximum temperature away from the surface and a microwave reflecting system embedded in the cooling system that allows one to shape the irradiation beam in a transverse direction. Independent control of the longitudinal and transverse irradiation patterns of the applicator along with the cooling system, enable precise heating of selected tissues. Results of SAR measurements, E-field measurements and steady state temperature distributions, in solid and liquid tissue-equivalent phantoms are presented. Clinical performance of this applicator was evaluated earlier in patients heated intraoperatively and in a phase I clinical study. The applicator was found capable of effectively heating a tissue volume extending radially 3-25 mm from the applicator surface, angularly defined by configuration of reflecting system and longitudinally determined by specific choice of the multisection antenna.

Morphologic and immunohistochemical changes in prostate cancer after preoperative hormonal therapy. A comparative study of radical prostatectomies.

BACKGROUND: Estramustine phosphate (EMP) and flutamide (FL) were used as reversible preoperative hormonal drugs in the surgical treatment of patients with localized prostate cancer. METHODS: The authors descriptive and quantitatively examined the morphologic and immunohistochemical changes in 40 of 200 step-sectioned radical prostatectomies, obtained after treatment with EMP (25 patients) and with FL (15 patients). Of these, 28 pretreatment needlecore biopsies were available. RESULTS: Every specimen contained adenocarcinoma. Understaging was found in 50% of the cases and a higher Gleason score in 70%. Benign glands underwent atrophy and squamous metaplasia. Treated tumors showed cytoplasmic vacuolization, nuclear pyknosis, fibrosis and lymphocytic infiltrates. The EMP group had an 84% (P < 0.05) higher mean total regression score than the FL group. Estramustine phosphate induced a 56% (P < 0.05) and a 34% decrease in tumoral prostate specific antigen and prostate specific acid phosphatase intensity scores, respectively, versus 29% and 32% after FL. The mean proliferating cell nuclear antigen (PCNA) labeling index and the mean mitotic index of the EMP group were 52% (P < 0.05) and 70% (P < 0.05) lower than those measured in the FL group. Each FL-treated tumor and 92% of EMP-treated tumors expressed chromogranin A (ChrA); ChrA labeling correlated significantly with PCNA labeling. Seventy-six percent of EMP-treated specimens revealed venous thrombosis. CONCLUSIONS: Estramustine phosphate induces important morphologic and immunohistochemical changes in prostate cancer with an apparent decrease of secretory and proliferative activity when compared with FL-treated tumors. These changes represent pitfalls in the diagnosis and grading of treated carcinomas. Nearly every treated adenocarcinoma of the prostate has neuroendocrine differentiation, showing increasing ChrA labeling with higher tumor stage. A significant correlation between tumor proliferation and neuroendocrine differentiation was noticed in this small cohort of patients. There was a high incidence of periprostatic venous thrombosis after EMP treatment.

Lymph node staging of localized prostatic carcinoma with CT and CT-guided fine-needle aspiration biopsy: prospective study of 285 patients.

PURPOSE: To ascertain the reliability of computed tomography (CT) and CT-guided fine-needle aspiration biopsy (FNAB) in staging of lymph nodes in patients with locally confined prostatic carcinoma. MATERIALS AND METHODS: A total of 285 patients were studied prospectively. FNAB was performed in 43 patients (15%) with lymph nodes suspect for metastasis on CT scans. FNAB findings were correlated with either the findings of the pathologic examination performed after lymph node dissection (LND) or the status of the lymph node at follow-up with CT after hormone therapy. RESULTS: The sensitivity, specificity, and accuracy of CT-guided FNAB were 77.8%, 100%, and 96.5%. If CT only had been performed, these results would have been 77.8%, 96.7%, and 93.7%. CT staging was false-negative in only 10 patients, who had microscopic metastatic deposits in a solitary lymph node. CONCLUSION: Combined CT and FNAB is highly efficient for assessment of lymph node metastasis. Therefore, it could be considered an alternative to surgical or laparoscopic lymphadenectomy in patients scheduled for radical prostatectomy or curative radiation therapy.

Benign hyperplastic nodules that originate in the peripheral zone of the prostate gland.

PURPOSE: To describe a benign nodular lesion in the peripheral zone (PZ) of the prostate gland. MATERIALS AND METHODS: In 1,087 patients, the features of 722 focal lesions in the PZ or central zone of the prostate on transrectal ultrasound (TRUS) scans were retrospectively compared with histologic findings in biopsy samples. RESULTS: In 18 patients (5.5% of the 328 patients with benign lesions), benign hyperplasia was found in a focal, nodular lesion obviously located within the PZ. On TRUS scans, the nodules were well circumscribed, ovoid or round, and slightly hypoechoic (n = 11) or isoechoic (n = 7). The isoechoic lesions were surrounded by an anechoic halo. One nodule was an incidental sonographic finding; the 17 others were felt as firm (n = 11) or soft (n = 6) at digital rectal examination. The ratio of serum prostate-specific antigen (PSA) level to prostatic volume was low (< 0.1), except in one patient (0.24). CONCLUSION: Some sonographic features and the normal PSA values might suggest a benign nodule in the PZ, but TRUS-guided biopsies and histologic correlation are necessary to confirm the diagnosis.

Renal thorium deposition associated with transitional cell carcinoma: radiologic demonstration in two patients.

Abdominal radiography, excretory urography, retrograde pyelography, and computed tomography were performed in two patients who had undergone retrograde pyelography with thorium dioxide (Thorotrast) approximately 40 years ago. Both patients developed a transitional cell carcinoma due to suburothelial thorium deposition. Typical thorium densities were demonstrated at CT in the peripelvicalyceal area as well as in retroperitoneal lymph nodes. Elderly patients in whom radiographic examination reveals retained Thorotrast in the kidney should be followed up because of the high risk of renal carcinoma.