Pathological upgrading and upstaging at radical prostatectomy in Jamaican men with low-risk prostate cancer.

Several studies suggest race-based health disparities in men with low-risk prostate cancer (PCa), with African American males having poorer oncological outcomes. We sought to determine the prevalence and predictors of pathological upgrading and upstaging in Jamaican men with low-risk PCa treated with radical prostatectomy (RP). Data on 141 men who met the National Comprehensive Cancer Network criteria for low-risk PCa and underwent RP at a single institution were reviewed. All men had a transrectal ultrasound-guided biopsy. Pre-operative clinical and final pathological data were obtained. Data were summarised as means and standard deviations or percentages as appropriate. Bivariate analyses such as independent samples t-tests and chi-square tables were conducted and logistic regression models were estimated to predict upgrading (>Gleason 6) and upstaging (p ≥ T3). The mean age was 59.5 ± 7.8 years with mean prostate specific antigen (PSA) of 6.6 ± 2 ng/mL. A total of 48.3% of men were upgraded and 11.4% were upstaged. Bivariate analyses indicated that PSA (p = 0.008) and percentage positive cores (p = 0.002) were associated with upgrading. PSA (p = 0.042) and percentage positive cores (p = 0.003) were significantly associated with upstaging. The odds of upgrading increased with increased PSA levels (OR 1.40, 95% CI 1.05-1.87, p = 0.021) or increased percentage positive cores (OR 8.27, 95% CI 2.19-31.16, p = 0.002). The odds of upstaging increased with increased PSA levels (OR 1.4, 95% CI 1.01-1.96, p = 0.046) and with increased percentages positive cores (OR 11.4; 95% CI 2.06-63.09, p = 0.005). Jamaican men with low-risk PCa are at high risk of pathological upgrading and upstaging at RP. These findings should be taken into consideration when discussing treatment options with these patients.

Prostate Cancer Knowledge, Prevention, and Screening Behaviors in Jamaican Men.

Screening is the only effective method of reducing prostate cancer mortality. Several reports have documented poor prostate cancer awareness and screening practices in Jamaican men. The Jamaica Cancer Society provides the most organized and largest form of screening in Jamaica and hosts an annual mass screening clinic on Prostate Cancer Awareness Day in September. We sought to determine the knowledge and attitudes towards screening and risks and prevention of prostate cancer. The study represented a cross-sectional analysis of 55 men presenting for screening on Prostate Cancer Awareness Day, September 2014 in Kingston, Jamaica. Information on prostate cancer knowledge and attitudes towards screening was obtained using interviewer-administered questionnaires (The Integrative Model of Prostate Cancer Disparity (PIPCaD). Prostate specific antigen (PSA) and digital rectal examination (DRE) were obtained from all patients. Mean PSA of participating men was 1.5 ± 1.48 ng/ml. Fifteen percent of men surveyed had a family history of prostate cancer. Prostate cancer knowledge was moderate, with at least 84 % of men responding correctly to 5 of 10 questions referring to prostate cancer risk and prevention. Most men had a favorable attitude towards screening. Starch formed the major portion of the diet in 68 % of men and 35 % of men engaged in no physical activity. Jamaican men surveyed have moderate prostate cancer knowledge and a positive attitude towards screening and prostate cancer prevention activities. However, the application of activities for potential prevention of modifiable risk factors is poor.

Prostate Cancer Screening in Jamaica: Results of the Largest National Screening Clinic.

Prostate cancer is highly prevalent in Jamaica and is the leading cause of cancer-related deaths. Our aim was to evaluate the patterns of screening in the largest organized screening clinic in Jamaica at the Jamaica Cancer Society. A retrospective analysis of all men presenting for screening at the Jamaica Cancer Society from 1995 to 2005 was done. All patients had digital rectal examinations (DRE) and prostate specific antigen (PSA) tests done. Results of prostate biopsies were noted. 1117 men of mean age 59.9 ± 8.2 years presented for screening. The median documented PSA was 1.6 ng/mL (maximum of 5170 ng/mL). Most patients presented for only 1 screen. There was a gradual reduction in the mean age of presentation for screening over the period. Prostate biopsies were requested on 11% of screening visits; however, only 59% of these were done. 5.6% of all persons screened were found to have cancer. Of the cancers diagnosed, Gleason 6 adenocarcinoma was the commonest grade and median PSA was 8.9 ng/mL (range 1.5-1059 ng/mL). Older men tend to screen for prostate cancer in Jamaica. However, compliance with regular maintenance visits and requests for confirmatory biopsies are poor. Screening needs intervention in the Jamaican population.

A delayed foreskin-sparing approach to the management of penile fractures in uncircumcised Jamaican men.

INTRODUCTION: The traditional surgical approach to penile fracture is to perform a circumferential subcoronal degloving incision emergently to repair the injury. This approach necessitates circumcision to avoid foreskin complications. We present four men who had a delayed foreskin-sparing approach and discuss its advantages. PRESENTATION OF CASE: Four of five uncircumcised patients who had suspected penile fractures secondary to coital injury, and without suspicion of concomitant urethral injury, had a delayed exploration, seven days after injury, utilizing an incision directly over the palpable haematoma, at the location of the tunical defect, thereby resulting in foreskin preservation. Two of 5 patients had repair under general anaesthesia, one under local anaesthesia and surgery was cancelled in another because upon reassessment at seven days he had normal erections and a normal penile examination. At follow up, all men had good functional and cosmetic outcomes. DISCUSSION: Uncircumcised patients with penile fractures, without suspicion of urethral injury, may undergo a delayed repair without prophylactic circumcision since there is minimal risk of foreskin complications. Delayed repair decreases the incidence of negative explorations by fostering a conservative approach in mimicking conditions such as superficial vein lacerations. It also enables the use of local anaesthesia in an elective ambulatory setting. CONCLUSION: Delayed repair of penile fractures results in foreskin preservation, facilitates elective ambulatory care under local anaesthesia and decreases the incidence of negative surgical explorations.

Bilateral complete ureteral duplication with calculi obstructing both limbs of left double ureter.

INTRODUCTION: A woman with bilateral complete ureteral duplication with stones simultaneously obstructing both limbs of the left double ureter is presented. A search of the English medical literature suggests that this is the first reported case. Based on the initial difficulty accessing the stones via ureteroscopy we make recommendations regarding how this rare problem should be approached if encountered. PRESENTATION OF CASE: A 37-year old woman with left-sided flank pain was discovered on CT scan to have bilateral complete ureteral duplication and three stones obstructing both limbs of the left double ureter. Ureteroscopy was initially unsuccessful due to the very small calibre and unyielding nature of the ureters and both ureteral limbs were stented. Repeat ureteroscopy was easily achieved after pre-stenting and the impacted stones were completely cleared with intracorporeal laser lithotripsy. DISCUSSION: The smaller calibre of both double ureters and their presence in a common adventitial sheath distally, made initial attempts at ureteroscopy difficult. Stenting both limbs increased ureteral compliance, passively dilated both ureters and allowed for improved manoeuvrability and retrograde passage of the ureteroscope. Based on the experience with this first reported case it is recommended that pre-stenting should be routinely performed prior to any attempt at ureteroscopy in cases of stones complicating completely duplicated ureters. CONCLUSION: We report the first recorded case of bilateral complete ureteral duplication with stones simultaneously obstructing both limbs of the double ureter and recommend that routine pre-stenting be done prior to ureteroscopy to allow easy uncomplicated retrograde passage of the ureteroscope.

Current state of prostate cancer treatment in Jamaica.

Prostate cancer is the commonest cancer in Jamaica as well as the leading cause of cancer-related deaths. One report suggested that Jamaica has the highest incidence rate of prostate cancer in the world, with an age-standardised rate of 304/100,000 per year. The Caribbean region is reported to have the highest mortality rate of prostate cancer worldwide. Prostate cancer accounts for a large portion of the clinical practice for health-care practitioners in Jamaica. The Jamaica Urological Society is a professional body comprising 19 urologists in Jamaica who provide most of the care for men with prostate cancer in collaboration with medical oncologists, radiation oncologists, and a palliative care physician. The health-care system is structured in two tiers in Jamaica: public and private. The urologist-to-patient ratio is high, and this limits adequate urological care. Screening for prostate cancer is not a national policy in Jamaica. However, the Jamaica Urological Society and the Jamaica Cancer Society work synergistically to promote screening as well as to provide patient education for prostate cancer. Adequate treatment for localised prostate cancer is available in Jamaica in the forms of active surveillance, nerve-sparing radical retropubic prostatectomy, external beam radiation, and brachytherapy. However, there is a geographic maldistribution of centres that provide prostate cancer treatment, which leads to treatment delays. Also, there is difficulty in affording some treatment options in the private health-care sectors. Androgen deprivation therapy is available for treatment of locally advanced and metastatic prostate cancer and is subsidised through a programme called the National Health Fund. Second-line hormonal agents and chemotherapeutic agents are available but are costly to most of the population. The infrastructure for treatment of prostate cancer in Jamaica is good, but it requires additional technological advances as well as additional specialist services.

Metastatic primary neuroendocrine carcinoma of the genitourinary tract: A case report of an uncommon entity.

PATIENT: Male, 59. FINAL DIAGNOSIS: Neuroendocrine carcinoma of urinary bladder. SYMPTOMS: Dysuria • hematuria. MEDICATION: - CLINICAL PROCEDURE: MRI • cystoscopy. SPECIALTY: Urology • oncology. OBJECTIVE: Rare disease. BACKGROUND: Neuroendocrine carcinomas of the genitourinary tract are rare but distinct and important entities because they are very aggressive tumors and are usually advanced or metastatic at the time of diagnosis. A high index of suspicion must be held by the pathologist viewing the specimen, as it can easily be misdiagnosed as a high grade urothelial carcinoma. Specific, proven treatment algorithms have been formulated over the years for the latter, whilst neuroendocrine carcinomas of the genitourinary tract are rare and treatment regimes have not yet been proven to show a significant improvement in survival in the majority of cases, so accurate diagnosis is important. CASE REPORT: We report the case of a 59-year-old man who presented with a short history of dysuria and frank hematuria. Imaging and cystoscopy revealed a large exophytic mass in the base of the urinary bladder, which extended into the bladder neck. Metastatic deposits were already present in his liver and vertebrae. Histology revealed a neuroendocrine carcinoma. CONCLUSIONS: A comprehensive review of the existing literature regarding this rare but aggressive tumor is presented, including advances in classification, pathogenesis, and treatment.

Pathological outcome and biochemical recurrence-free survival after radical prostatectomy in African-American, Afro-Caribbean (Jamaican) and Caucasian-American men: an international comparison.

OBJECTIVE: To compare pathological and biochemical outcomes of radical prostatectomy (RP) among African-American (AA), Afro-Caribbean (AC; Jamaican) and Caucasian-American (CA) men using an international cohort of patients who underwent RP in the USA and Jamaica. MATERIALS AND METHODS: A retrospective review was performed of men who underwent RP for clinically organ-confined (OC) prostate cancer between 2000 and 2011 at Columbia University Medical Center (New York, USA) and the University Hospital of the West Indies (Kingston, Jamaica) between 2000 and 2007. Men who had received neoadjuvant or adjuvant (within 3 months) therapy were excluded. Clinicopathological variables were compared among the three groups, focusing on age, stage, PSA level, Gleason sum (GS) and margin status. Multivariate analysis was performed to determine the predictors of biochemical recurrence (BCR; PSA >0.2 ng/mL), and Kaplan-Meier analysis was performed to determine BCR-free survival rates in AA, AC and CA men. RESULTS: A total of 483 men underwent RP for clinically OC disease (CM, n = 309, AA, n = 93 and AC, n = 81). The mean patient age was 59 years, with AA men being younger than CA men (58 vs 60 years, P< 0.05). The mean (range) follow-up was 49 (13-133) months with no significant difference among the groups. The men in the AC cohort had a higher mean PSA level than AA and CA men (8.8 vs 6.2 and 5.0 ng/mL, respectively, P< 0.05) and more clinical GS ≥7 (44%) tumours than AA (8%) and CA men (0%; P< 0.01). On multivariate analysis, controlling for stage, grade, PSA level and margins, AA and AC race were independent predictors of BCR. AA and AC men had significantly lower 5-year BCR-free survival (76 and 74%, respectively) than CA men (98% [P < 0.001]). CONCLUSIONS: This international comparison of clinicopathological outcomes in AA, AC and CA men undergoing RP shows that AA and AC men present similarly with more aggressive disease features than CA men and have lower 5-year BCR-free survival. Both AA and AC race are significant predictors of BCR, independently of stage, grade, PSA level and margin status. Further research is needed to elucidate and correct the mechanisms behind the observed difference in outcome among these populations.

Bone mineral density in Jamaican men on androgen deprivation therapy for prostate cancer.

BACKGROUND: Androgen deprivation therapy (ADT) has been reported to reduce the bone mineral density (BMD) in men with prostate cancer (CaP). However, Afro-Caribbeans are under-represented in most studies. The aim was to determine the effect of androgen deprivation therapy (ADT) on the bone mineral density (BMD) of men with prostate cancer in Jamaica. METHODS: The study consisted of 346 Jamaican men, over 40 years of age: 133 ADT treated CaP cases (group 1), 43 hormone-naïve CaP controls (group 2) and 170 hormone naïve controls without CaP (group 3). Exclusion criteria included metastatic disease, bisphosphonate therapy or metabolic disease affecting BMD. BMD was measured with a calcaneal ultrasound and expressed in S.D. units relative to young adult men (T score), according to the World Health Organization definition. Patient weight, height and BMI were assessed. RESULTS: Mean ± sd, age of patients in group 1 (75± 7.4 yrs) was significantly greater than groups 2 and 3 (67 ± 8.1 yrs; 65±12.0 yrs). There was no significant difference in weight and BMI between the 3 groups. . The types of ADT (% of cases, median duration in months with IQR) included LHRH (Luteinizing hormone releasing hormone) analogues (28.6%, 17.9, IQR 20.4), oestrogens (9.8%, 60.5, IQR 45.6) anti-androgens (11.3%, 3.3, IQR 15.2) and orchiectomy (15.7%, 43.4, IQR 63.9). Unadjusted t score of group 1, mean ± sd, (-1.6± 1.5) was significantly less than group 2 (-0.9±1.1) and group 3 (-0.7±1.4), p <0.001. Ninety three (69.9%), 20 (45%) and 75 (42%) of patients in groups 1, 2 and 3 respectively were classified as either osteopenic or osteoporotic (p<0.001). Adjusting for age, there was a significant difference in t scores between groups 1 and 2 as well as between groups 1 and 3 (p<0.001). Compared with oestrogen therapy and adjusting for duration of therapy, the odds of low bone mineral density (osteopenia or osteoporosis) with LHRH analogue was 4.5 (95%CI, 14.3 to 3.4); with anti-androgens was 5.9 (95%CI, 32.7 to 5); with orchiectomy was 7.3 (95%CI, 30 to 5.8) and multiple drugs was 9.2 ((95%CI, 31 to 7.1). CONCLUSIONS: ADT is associated with lower BMD in Jamaican men on hormonal therapy for prostate cancer.