Prostate cancer in patients with an abnormal digital rectal examination and serum prostate-specific antigen less than 4.0 ng/mL.

OBJECTIVES: To evaluate men with abnormal digital rectal examination (DRE) findings and a serum prostate-specific antigen (PSA) level less than 4.0 ng/mL who underwent prostate biopsy. METHODS: A total of 986 patients undergoing prostate biopsy were documented to have DRE findings suspicious for prostate cancer and a serum PSA level of less than 4.0 ng/mL. We examined the serum PSA level, age, and race to see which patient characteristics were statistically significant predictors of prostate cancer on biopsy. The pathologic findings of the biopsy and prostatectomy specimens were examined to determine which patients had serendipitously diagnosed prostate cancer. RESULTS: The positive predictive value of an abnormal DRE was 8.8%. The PSA level and increasing age were statistically significant predictors of a positive biopsy, but race was not. Well-differentiated cancer (Gleason score 6 or less) was diagnosed in 72.8% of the biopsies. Also, 87.5% of the patients undergoing radical prostatectomy had pathologic Stage T2 disease. Using specific pathologic criteria, prostate cancer was diagnosed serendipitously in 19% of the biopsies and in 43% of the radical prostatectomy specimens. CONCLUSIONS: Higher serum PSA levels even if less than 4.0 ng/mL were associated with dramatic increases in prostate cancer detection. Age was also a statistically significant predictor of cancer. Although the overall positive predictive value of the DRE was poor, most patients diagnosed with prostate cancer had an abnormality on the DRE that corresponded either to the location of cancer detected on biopsy or had cancer volumes on prostatectomy specimens large enough to be palpable.

Race is not a predictor of prostate cancer detection on repeat prostate biopsy.

PURPOSE: We evaluated men undergoing repeat prostate biopsies for persistently increased serum prostate specific antigen (PSA) levels to determine if race was a predictor of cancer detection. MATERIALS AND METHODS: Between July 1995 and June 2002, 401 men had undergone 2 or more transrectal ultrasound guided prostate biopsies at our institutions. Clinical information was gathered using our prostate biopsy database and retrospectively reviewed. Race, age, serum PSA, PSA velocity, total number of biopsies performed, total number of previous negative cores and the presence of high grade prostatic intraepithelial neoplasia (HGPIN) or atypical small acinar proliferation (ASAP) on prior biopsy were evaluated to determine if they were predictors of subsequent cancer detection. Multivariate analysis was performed using a time dependent covariate Cox proportional hazards model. RESULTS: Of the 401 men undergoing repeat prostate biopsy, 91 (22.7%) were diagnosed with prostate cancer. In total there were 180 (44.9%) black men and 221 (55.1%) white men. Cancer was diagnosed in 49 black men (27.2%) and 42 white men (19.0%, p = 0.06). On multivariate analysis serum PSA, HGPIN, ASAP and PSA velocity were predictors of prostate cancer detection (p = 0.006, <0.0001, 0.001 and 0.0004, respectively). Race was not found to be a predictor of prostate cancer detection on repeat prostate biopsy (p = 0.16). In the evaluation of clinical data for racial differences, black men had a significantly higher incidence of HGPIN on prior biopsy compared to white men (p = 0.02). Serum PSA, PSA velocity, presence of ASAP on prior biopsy, age, number of biopsies performed and number of previous negative cores were not statistically different between black and white men. CONCLUSIONS: Race is not a predictor of prostate cancer detection in men undergoing repeat prostate biopsies. With the exception of HGPIN, all other clinical parameters were similar between black and white men. Serum PSA, PSA velocity, HGPIN and ASAP were found to be significant predictors of subsequent prostate cancer detection.

Selective operative management of major blunt renal trauma.

BACKGROUND: We reviewed the management and outcomes of patients at our Level I trauma center suffering major blunt renal trauma diagnosed and staged by CT scan. METHODS: We retrospectively reviewed the cases of 26 patients with blunt trauma at our institution who were initially hemodynamically stable and diagnosed with grade 4 or 5 renal injuries by CT scan. Patients were broken down into two groups based on whether they were managed conservatively or surgically. Patient characteristics and morbidity were analyzed. RESULTS: There were 14 patients managed conservatively and 12 patients managed surgically. There was no statistically significant difference in morbidity between the two groups. The only statistically significant predictor of failure of conservative management was a coexisting solid organ intra-abdominal injury. CONCLUSIONS: Conservative management of major blunt renal trauma is appropriate in hemodynamically stable patients.

Ureteral injury due to penetrating trauma.

OBJECTIVES: We sought to evaluate the diagnosis and management of penetrating ureteral injuries at our trauma center. METHODS: We retrospectively reviewed the cases of 12 patients with ureteral injuries secondary to penetrating ureteral trauma. RESULTS: From January 1995 to December 2000, a total of 12 patients were diagnosed and treated for penetrating ureteral injuries. The diagnosis was made acutely in nine patients, and a delayed diagnosis was made in three patients. Hematuria was present in the nine patients diagnosed acutely, and these patients had either preoperative or intraoperative imaging. All patients underwent exploratory laparotomy, and ureteral injuries were missed in the three patients without radiologic imaging or hematuria. Repair of the ureteral injuries was highly successful, and patients diagnosed acutely had decreased morbidity. CONCLUSIONS: Traumatic ureteral injuries from penetrating trauma are uncommon, and a high index of suspicion is necessary to diagnose ureteral injuries when hematuria is not present and imaging is nondiagnostic.

Do concerns about more advanced pathological features increase the likelihood of neurovascular bundle resection in black men undergoing radical prostatectomy?

PURPOSE: Traditionally black men undergoing radical prostatectomy have presented with higher serum prostate specific antigen (PSA) levels, Gleason grade and pathological stage compared to white men. We evaluated men undergoing radical prostatectomy at our institutions to determine if race was an independent predictor of neurovascular bundle resection and if racial differences existed with regard to clinical and pathological outcomes in men undergoing a nerve sparing procedure. MATERIALS AND METHODS: Between July 1995 and March 2000, 316 men underwent radical retropubic prostatectomy for clinically localized prostate cancer. Patient data were gathered prospectively and reviewed with regard to age, race, preoperative serum PSA, operative procedure, pathological findings and patient followup. Racial differences were analyzed by the chi-square test or student's t statistic. Predictors of neurovascular bundle resection were evaluated using multiple logistic regression. RESULTS: Of the 316 men who underwent a radical retropubic prostatectomy, 126 were black and 190 were white. Overall, a nerve sparing procedure was performed in 77 (40.5%) white men and 44 (34.9%) black men. When evaluating only potent men preoperatively, a nerve sparing prostatectomy was performed in 69.3% of white men and 58.6% of black men. There was no statistically significant racial difference with regard to the proportions of men undergoing a nerve sparing procedure. Predictors of neurovascular bundle resection during radical prostatectomy were preoperative erectile function, serum PSA level before prostate biopsy, biopsy Gleason score and number of cores positive for cancer. In men undergoing a nerve sparing radical prostatectomy there were no significant racial differences with regard to age, preoperative serum PSA, Gleason score, pathological stage, postoperative potency, continence or disease-free survival (mean followup 44 months). CONCLUSIONS: At our institutions a similar proportion of black and white men undergo nerve sparing radical prostatectomy, which appears to produce similar clinical outcomes in black and white men.

The prevalence of men with National Institutes of Health category IV prostatitis and association with serum prostate specific antigen.

PURPOSE: We evaluated the prevalence and relationship of serum prostate specific antigen (PSA) levels in a screening population of men diagnosed with National Institutes of Health (NIH) category IV prostatitis. MATERIALS AND METHODS: In September of 2001, 300 men were randomly selected from our prostate cancer awareness screening program to be evaluated for NIH category IV prostatitis. After informed consent was obtained all patients completed the NIH prostate cancer awareness survey and had a serum sample obtained for PSA before examination. Expressed prostatic secretions were obtained from 227 of the 300 participants. Patients were classified according to findings on examination of the expressed prostatic secretions. The records were entered into our data base and subsequently reviewed. RESULTS: The prevalence of NIH category IV prostatitis was 32.2% in our population of men. Patient age, American Urological Association symptom scores and clinical prostate gland size did not differ between men with or without evidence of prostatitis on expressed prostatic secretion examination. Men with NIH category IV prostatitis had a mean serum PSA level of 2.3 which was significantly higher (p <0.0004) than those without prostatitis (mean PSA 1.4). CONCLUSIONS: These data suggest that NIH category IV prostatitis is fairly prevalent (32.2%) among men in the general population who present for prostate cancer screening and appears to contribute to increased serum PSA levels in some men.

Treatment of chronic prostatitis lowers serum prostate specific antigen.

PURPOSE: We evaluated men with documented chronic prostatitis and elevated serum prostate specific antigen (PSA) to determine whether treatment with antibiotics and anti-inflammatory drugs lowers serum PSA. MATERIALS AND METHODS: We retrospectively reviewed the records of 95 men who presented with serum PSA greater than 4 ng./ml. and were subsequently diagnosed with chronic prostatitis with greater than 10 white blood cells per high power field in expressed prostatic excretions. Patients meeting these criteria were treated with a 4-week course of antibiotics and a nonsteroidal anti-inflammatory agent. In all patients followup PSA was determined within 2 months of treatment. RESULTS: Mean PSA decreased 36.4% from 8.48 ng./ml. before to 5.39 after treatment (p <0.001). In 44 patients (46.3%) serum PSA decreased to below 4 ng./ml. (mean 2.48) and these patients no longer had an indication for biopsy. In the remaining 51 patients serum PSA remained elevated at greater than 4 ng./ml. and they underwent double sextant transrectal ultrasound guided biopsy. Pathological study showed prostate cancer in 13 cases (25.5%), chronic inflammation in 37 (72.5%) and only benign prostatic hypertrophy in 1 (1.05%). PSA in the 13 patients with prostate cancer decreased with treatment only 4.8% from 8.32 to 7.92 ng./ml. (p >0.05). Followup PSA at a mean of 11.4 months was determined in 19 of the 44 men who responded to treatment. Mean PSA increased only 4.5% from 2.35 to 2.46 ng./ml. (p >0.05) during this followup interval. CONCLUSIONS: In almost half of the patients diagnosed with elevated PSA and chronic prostatitis serum PSA normalized with treatment and there was no longer an indication for transrectal ultrasound guided biopsy. Our study suggests that chronic prostatitis is an important cause of elevated PSA and when it is identified, treatment can decrease the percent of negative biopsies.