Extracorporeal shock wave lithotripsy under intravenous sedation for treatment of urolithiasis.

BACKGROUND: In contrast to treatment with oral or intramuscular analgesics, extracorporeal shock wave lithotripsy (E.S.W.L.) can be performed with patients under sedation too. Besides the advantage of increased shock energy, patients tend to have more constant breathing excursions and are more idle during treatment, potentially increasing the stone-free ratio (S.F.R.) after treatment. METHODS: This study presents the results of 310 patients who underwent 400 E.S.W.L. procedures under sedation, with a stationary lithotripter. RESULTS: After one procedure, the S.F.R. was 54.8% (170/310). A second treatment was successful in 42.1% (32/76), a third treatment in 21.4% (3/14). Therefore, 66.1% (205/310) of patients eventually became stone-free. Kidney stones were successfully treated in 65.4% (161/246), ureteral stones in 68.8% (44/64) of cases. Patients with stones ≤15 mm were successfully treated in 67.4% (194/288), patients with stones >15 mm in 50% (11/22) of cases. Considering each procedure individually, 45.3% (181/400) of procedures were successful after 3 weeks. Extending follow-up to 3 months is important, since 26.7% of stones (24/90) eventually still disappeared, increasing S.F.R. to 51.3% after one procedure. Complications occurred after 5.5% E.S.W.L.-procedures. CONCLUSIONS: E.S.W.L. is a well-tolerated, non-invasive procedure that produces reasonable stone clearance of both upper and lower urinary tract calculi. Performing the procedure whilst patients are intravenously sedated results in an acceptable S.F.R. Strong selection based on unfavourable factors could increase the chance on successful treatment and spare patients a pointless procedure. However, considering E.S.W.L.'s elegant nature, sometimes a more tolerant approach seems justifiable.

On the standardization of total prostate-specific antigen: an exercise with two reference preparations.

In this study, 112 serum samples were analyzed for total prostate-specific antigen with three well-established assays i.e. Tandem R and Tandem E (both from Hybritech Inc., San Diego, USA) and Prostatus Free/Total from Wallac Oy, Turku, Finland. Thirty-two samples were collected from prostate cancer patients, 32 from patients with benign prostate hyperplasia and 48 from men participating in a screening study for prostate cancer. The aim of the study was to compare the results before and after recalculation with the data obtained with two reference preparations for total prostate-specific antigen: Stanford 90:10 PSA Calibrator and Certified Reference Material 613 Prostate-Specific Antigen. Comparing the actual results revealed almost perfect correlations between Tandem R and Tandem E and between both Tandem assays and Prostatus. We observed statistically significant differences in accuracy between Tandem R and Tandem E: y(Tandem E)= 1.05 x(Tandem R)+0.07 and between Tandem E and Prostatus: y(Prostatus)= 0.94 x(Tandem E)+0.02 In both comparisons prostate-specific antigen values ranged from 0-40 microg/l. Recalculation with both reference preparations did not solve these discrepancies. One exception was the combination Tandem R and Tandem E. The application of either reference preparation solved the differences in accuracy here. In conclusion, even after recalibration, assays for total prostate-specific antigen are still not completely interchangeable.

The changing pattern of prostate cancer at the time of diagnosis: characteristics of screen detected prostate cancer in a population based screening study.

PURPOSE: We describe the clinical and pathological features of prostate cancer diagnosed through serum prostate specific antigen (PSA), digital rectal examination and transrectal ultrasonography in a population based randomized screening study. MATERIALS AND METHODS: Between November 1993 and June 1997, 20,632 volunteers 55 to 76 years old were included in the study. In the screening arm 9,776 men underwent digital rectal examination, transrectal ultrasound and serum PSA determination. Biopsies were taken if the digital rectal examination and/or transrectal ultrasound findings were abnormal or if PSA was 4 ng/ml or greater. A total of 2,262 men underwent biopsy and 474 cases of prostate cancer were diagnosed. RESULTS: The pretreatment data were complete in 459 men, of whom 78% had clinically organ confined disease. Bone or lymph node metastases were seen in 8 cases (1.7%). Of 172 men who underwent radical prostatectomy 2 had lymph node metastases. Overall 66.3% of men treated with radical prostatectomy had organ confined disease. CONCLUSIONS: Comparison of the characteristics of prostate cancer detected through screening of the general population with those in a population based cohort of men in which there was no organized screening revealed stage reduction, primarily with regard to number of metastatic cases. Whether this stage reduction will lead to a decrease in disease specific mortality remains unknown until the study is completed and the end point of prostate cancer specific mortality is evaluated.

Evaluation of prostate needle biopsies in a population-based screening study: the impact of borderline lesions.

BACKGROUND: The finding of isolated high grade prostatic intraepithelial neoplasia (PIN) or borderline lesions (lesions suspicious for malignancy) in prostate needle biopsies warrants repeat biopsies. The reported frequency of these lesions in prostate needle biopsies varies considerably. The authors evaluated the frequency and clinical impact of high grade PIN and borderline lesions in sextant prostate needle biopsies obtained from screened participants in the European Randomized study of Screening for Prostate Cancer (ERSPC). METHODS: A total of 8763 participants in the Rotterdam section of the ERSPC ages 55-75 years were screened systematically for prostate carcinoma. Systematic sextant prostate needle biopsies were prompted by an abnormal digital rectal examination and/or abnormal transrectal ultrasonography findings at serum prostate specific antigen (PSA) levels > or = 1.0 ng/mL or a PSA level > or = 4.0 ng/mL. Repeat biopsies were obtained within 6 months after initial biopsy. RESULTS: Of 1824 biopsied men, 384 (21.1%) were found to have prostate carcinoma on initial biopsy. Twelve participants (0.7%) had isolated high grade PIN and 43 (2.4%) had borderline lesions. Repeat biopsies yielded no carcinoma in 7 participants with initial high grade PIN and 15 tumors (38.5%) in 39 participants with borderline lesions. CONCLUSIONS: In prostate needle biopsies obtained from a screened population, indications for repeat biopsy such as high grade PIN and borderline lesions do not represent large diagnostic subsets. Borderline lesions comprise the most important indication for a repeat biopsy. The low frequency of equivocal biopsy diagnoses in the current study supports the clinical applicability of sextant needle biopsies in population-based screening for prostate carcinoma.

New developments in the standardization of total prostate-specific antigen.

OBJECTIVE: Analytical evaluation of the calibration of three recently launched assays for the measurement of total prostate-specific antigen, i.e., IMx Total PSA (Abbott), Elecsys PSA (Roche), and IMMULITE 3rd Generation PSA (DPC). DESIGN AND METHODS: For accuracy assessment two reference materials were applied namely, Stanford 90:10 PSA Calibrator and Certified Reference Material 613 Prostate-Specific Antigen. Dilutions of these preparations were analyzed with all assays. In addition, clinical specimens from known prostate cancer or benign prostate hyperplasia patients and samples taken from an ongoing prostate cancer screening study were used for comparison. RESULTS: Application of the Stanford Calibrator revealed results well within 10% of the calculated values for all assays. Regarding the CRM Calibrator only the IMx Total PSA proved to approach the line of identity. The IMMULITE results differed about 40% and the Elecsys about 18% from the calculated values. The comparison with clinical specimens showed statistically different results for the combination IMMULITE-IMx and for IMMULITE-Elecsys. The regression lines for both collections were: y(IMx) = 0.86x(IMMULITE) +0.12 (n = 104, r = 0.970, Sy/x = 0.883 microg/L) and y(Elecsys) = 0.98x(IMMULITE) +0.38 (n = 97, r = 0.976, Sy/x = 0.733 microg/L). In the lower measuring range (PSA <5.0 microg/L) as measured with the screening samples (n = 43), these differences were less pronounced. CONCLUSION: In analytical sense a difference was found for both reference preparations in the assays studied. Clinically, despite improvements in methodology, results for total prostate-specific antigen are still not interchangeable. The possible consequences need to be elaborated.

Repeat screening for prostate cancer after 1-year followup in 984 biopsied men: clinical and pathological features of detected cancer.

PURPOSE: We describe the yield of a repeat examination and biopsy procedure 1 year after initial biopsy was negative. We also assessed the parameters responsible for the failure to diagnose these cancers at the primary screening. MATERIALS AND METHODS: We screened 8,103 men randomized to the screening arm of the Rotterdam section of the European Randomized Study of Screening for Prostate Cancer using prostate specific antigen measurement, digital rectal examination and transrectal ultrasound. At the primary screening biopsy of 1,875 men was positive for prostate cancer in 374. Of the remaining 1,501 men 984 underwent repeat screening. RESULTS: Biopsy at repeat screening diagnosed prostate cancer in 49 of 442 men (11%), a rate significantly lower than the 19.9% true positive biopsy rate at the primary screening. Pathological characteristics of the tumors diagnosed were not significantly different in the 2 groups. However, prostate volume in men diagnosed with prostate cancer was significantly greater at repeat versus primary screening (mean 42.6 versus 34.9 cc, p = 0.003). The clinical characteristics were more favorable because of an increased proportion of stage T1C tumors. Prostate volume in men with stage T1C cancer was significantly greater than in those with palpable or visible tumors in whom prostate specific antigen values were in the same range. CONCLUSIONS: The most important factor responsible for the failure to diagnose these cancers at the primary screening was significantly greater prostate volume. Tumor characteristics were not significantly different in the groups. If prostate cancer screening were to become a routine health care policy, efforts would have to be made to improve the chances of diagnosing prostate cancer in larger prostates by repeat biopsy or by increasing the number of cores obtained.

Comparison of prostate-specific antigen corrected for total prostate volume and transition zone volume in a population-based screening study.

OBJECTIVES: To compare the discriminatory potential between prostate cancer and benign conditions of the prostate in a population-based screening study, of serum prostate-specific antigen levels (PSA) and PSA corrected for both the total prostate volume (PSA-D) and the transition zone volume (PSA-T). METHODS: In a randomized population-based screening study (Rotterdam section of the European Randomized Study of Screening for Prostate Cancer), in which 10,865 men have been screened, the biopsy results of 1202 men with PSA levels of 4 ng/mL or more were evaluated. Planimetric and prolate ellipsoid volumes of the total prostate as well as of the transition zone were measured. The measured volumes were compared with the volumes of 57 radical prostatectomy specimens through Spearman's rank correlation coefficient and agreement tests. A receiver operating characteristic (ROC) curve analysis was done of sensitivity and specificity of biopsy indications through PSA and PSA corrected for the volumes measured with transrectal ultrasound. RESULTS: In the 1202 men studied, 361 cases of prostate cancer were diagnosed. Both PSA-D and PSA-T showed a significantly higher area under the ROC curve (0.77 and 0.79, respectively) than PSA alone (area 0.65). There was no significant difference between PSA-D and PSA-T. The use of a PSA-D threshold value of 0. 10 ng/mL/cc would have avoided 28% of biopsies at the cost of 10% of detectable cancers. A PSA-D threshold of 0.15 ng/mL/cc would have avoided 73.8% of biopsies at the cost of not diagnosing 43.8% of detectable cancers. CONCLUSIONS: The planimetrically obtained prostate volume showed a more favorable agreement with the radical prostatectomy volume than the prolate ellipsoid volume. The discriminatory potential of the corrected PSA value is better at predicting the results of needle biopsy of the prostate when compared with PSA alone. The use of the transition zone volume for this correction results in a higher discriminatory potential when compared to the use of the total prostate volume; however, the observed difference was not statistically significant.

Complications of transrectal ultrasound-guided systematic sextant biopsies of the prostate: evaluation of complication rates and risk factors within a population-based screening program.

OBJECTIVES: Screening for prostate cancer to reduce the mortality and morbidity from this disease has become an important issue in recent years. Of all procedures used to diagnose prostate cancer, biopsy of the prostate is the cause of most complications. To evaluate the safety of the screening procedure, we have studied the complications and risk factors for complications within the screened population of the European Randomized Study of Screening for Prostate Cancer (ERSPC), Rotterdam section. METHODS: Between June 1994 and July 1996, 1687 transrectal ultrasound-guided systematic sextant biopsies were performed after screening 6198 men through prostate-specific antigen level, digital rectal examination, and transrectal ultrasonography. RESULTS: From these 1687 biopsies, 302 cases of prostate cancer were diagnosed. Mild complications such as hematuria and hematospermia were reported frequently with rates of 23.6% and 45.3%, respectively. More severe complications were far less frequently seen. Fever, usually of low grade, was seen after 4.2% of biopsies. Seven men (0.4%) were admitted to a hospital after biopsy. Risk factors for complications could not be identified. CONCLUSIONS: Review of the literature concerning transrectal biopsies of the prostate shows that the complication rates within this screened population are comparable to those reported within referred patients. The admittance rate is slightly lower. Transrectal ultrasound-guided systematic sextant biopsy of the prostate is a safe procedure for the diagnosis of prostate cancer within the general population; however, identification of risk factors for complications might further improve the safety of the screening procedure.

Halothane hepatitis and the anaesthesiologist.

There is no longer any doubt that liver dysfunction following surgery and anaesthesia may sometimes be attributable to the inhalational anaesthetic agent halothane. Much controversy still surrounds the entity of halothane hepatitis, which continues to vex the practising anaesthesiologist. The incidence, causation, pathogenesis and diagnosis of halothane hepatitis are presented, and the safety and practicality of halothane administration in the presence of liver dysfunction are discussed.

[Peri-operative management of a patient with insulinoma. A case report]. / Peri-operatiewe hantering van 'n pasiënt met insulinoom. 'n Gevalbespreking.

Insulinoma is a rare tumour of the islet cells of the pancreas and was first described by Harris in 1924. It can be benign or malignant. This report emphasizes the medical, surgical and anaesthetic aspects of the treatment in a case of insulinoma.

Precautions against intra-ocular pressure changes during endotracheal intubation--a comparison of pretreatment with intravenous lignocaine and diazepam.

Endotracheal intubation after administration of succinylcholine is associated with a rise in intraocular pressure (IOP). That this is likely to have harmful effects in patients with penetrating eye injuries is self-evident. The efficacy of various means of abolishing these effects is debatable. This study evaluates pretreatment with intravenous lignocaine and diazepam in the prevention of high IOP during a standard induction-intubation sequence. Sixty patients were randomly divided into a control group receiving pretreatment with saline and two study groups receiving pretreatment with lignocaine and diazepam respectively. IOP, pulse rate and systolic blood pressure were recorded after induction, after intubation and after return of spontaneous respiration. Statistical analysis of the data showed that diazepam diminished the rise in IOP, while lignocaine had little effect (P less than 0,05). It is concluded that pretreatment with diazepam 0,05 mg/kg is beneficial in reducing the ocular risks of endotracheal intubation.